From the Guidelines
The first-line treatment for cellulitis should be a 5- to 6-day course of antibiotics active against streptococci, such as a cephalosporin, penicillin, or clindamycin, for patients able to self-monitor and who have close follow-up with primary care 1.
Key Considerations
- The choice of antibiotic should be based on the severity of the infection, the presence of methicillin-resistant Staphylococcus aureus (MRSA) risk factors, and local resistance patterns.
- For patients with MRSA risk factors, such as penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or systemic inflammatory response syndrome, an antibiotic effective against both MRSA and streptococci, such as vancomycin, should be considered 1.
- Treatment duration should be individualized based on clinical response, but a 5- to 6-day course is recommended for uncomplicated cases 1.
Antibiotic Options
- Cephalexin 500 mg four times daily for 5-6 days
- Dicloxacillin 500 mg four times daily for 5-6 days
- Clindamycin 300-450 mg three times daily for 5-6 days
- Trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily for 5-6 days for patients with MRSA risk factors
Supportive Measures
- Elevation of the affected area
- Warm compresses
- Pain management It is essential to note that the treatment of cellulitis should be tailored to the individual patient's needs and circumstances, taking into account factors such as the severity of the infection, the presence of underlying medical conditions, and the patient's ability to self-monitor and follow up with primary care 1.
From the Research
First-Line Treatment for Cellulitis
- The first-line treatment for cellulitis should cover Streptococcus and methicillin-sensitive Staphylococcus aureus 2.
- A study found that β-hemolytic streptococci were the dominating cause of cellulitis in all clinical subgroups 3.
- The treatment should be directed against Streptococcus and methicillin-sensitive S. aureus, with expansion for methicillin-resistant S. aureus (MRSA) in cases of cellulitis associated with specific risk factors 2.
- Five days of treatment is sufficient, with extension if symptoms are not improved 2.
Antibiotic Options
- A network meta-analysis found that there were no significant differences in cure rates for cellulitis among the antibiotics analyzed, with cefaclor demonstrating the most favorable profile for curative outcomes 4.
- Ceftriaxone was identified as the least likely to induce diarrhea or vomiting 4.
- Pristinamycin showed the most promising results in achieving cure rates for erysipelas, but with a higher risk of rash 4.
- A systematic review and meta-analysis found that no evidence was found to support the superiority of any one antibiotic over another, and antibiotics with activity against methicillin-resistant Staphylococcus aureus did not add an advantage 5.
Clinical Considerations
- The diagnosis of cellulitis is based primarily on history and physical examination 2, 6.
- Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization 6.
- Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit 6.