From the Guidelines
For facial cellulitis, empiric antibiotic coverage should target Streptococcus and Staphylococcus species, with a recommended treatment duration of 5 days, but extended if the infection has not improved within this time period 1.
Key Considerations
- Facial cellulitis requires prompt treatment due to the risk of spread to central nervous system structures.
- First-line treatment is typically oral cephalexin 500 mg four times daily for 5-10 days.
- Alternatives include dicloxacillin 500 mg four times daily, amoxicillin-clavulanate 875/125 mg twice daily, or clindamycin 300-450 mg four times daily if penicillin allergy is present.
- For more severe cases requiring hospitalization, intravenous options include cefazolin 1-2 g every 8 hours, nafcillin/oxacillin 1-2 g every 4-6 hours, or vancomycin 15-20 mg/kg every 8-12 hours if MRSA is suspected.
Patient Evaluation and Follow-up
- Patients should be advised to return for evaluation if redness spreads, fever develops, or symptoms worsen despite 48 hours of antibiotics.
- Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1.
- Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability, while hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, or for infection in a severely immunocompromised patient 1.
From the Research
Appropriate Antibiotic Coverage for Cellulitis of the Face
- The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus 2
- Appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient 2
- Even with rising rates of community-acquired methicillin-resistant Staphylococcus aureus, coverage for non-purulent cellulitis is generally not recommended 2
- Cephazolin 2 g twice daily has been shown to be effective in treating cellulitis in the home environment, with low re-admission rates 3
- There is no association between the route of antibiotic administration (intravenous or oral) and clinical outcome for patients with cellulitis of similar severity 4
- The duration of antibiotic therapy does not appear to affect outcome, with no additional benefit seen with courses longer than 5 days 4, 5
- No evidence supports the superiority of any one antibiotic over another, including those with activity against methicillin-resistant Staphylococcus aureus 5
- Ceftriaxone has been evaluated as an alternative to antistaphylococcal antibiotics for definitive treatment of methicillin-susceptible Staphylococcus aureus infections, with no difference in efficacy but a lower risk of toxicity 6