What is the treatment for right cheek cellulitis?

Treatment of Right Cheek Cellulitis

For typical non-purulent right cheek cellulitis, start with oral beta-lactam monotherapy such as cephalexin 500 mg four times daily, dicloxacillin 250-500 mg every 6 hours, or amoxicillin for 5 days, as this achieves clinical success in 96% of cases. 1, 2

First-Line Antibiotic Selection

• Beta-lactam monotherapy is the standard of care for uncomplicated facial cellulitis because β-hemolytic streptococci and methicillin-sensitive Staphylococcus aureus are the primary pathogens 1, 3, 4
• Recommended oral agents include:
  • Cephalexin 500 mg four times daily 1, 2
  • Dicloxacillin 250-500 mg every 6 hours 1, 2
  • Amoxicillin (standard dosing) 1, 2
  • Penicillin V 250-500 mg four times daily 1, 2
• MRSA coverage is NOT routinely necessary for typical non-purulent facial cellulitis, even in high-prevalence settings 1, 2, 4

Treatment Duration

• Treat for exactly 5 days if clinical improvement occurs 1, 2
• Extend treatment only if symptoms have not improved within the initial 5-day period 1, 2
• Traditional 7-14 day courses are no longer necessary for uncomplicated cases 1

When to Add MRSA Coverage

Add MRSA-active antibiotics only when specific risk factors are present 1, 2:

• Penetrating trauma to the face 1, 2
• Purulent drainage or exudate 1, 2
• History of injection drug use 1, 2
• Evidence of MRSA infection elsewhere or known MRSA colonization 1, 2
• Systemic inflammatory response syndrome (SIRS) 1, 2

If MRSA coverage is needed, use:

• Clindamycin 300-450 mg every 6 hours (provides single-agent coverage for both streptococci and MRSA, avoiding need for combination therapy) 1, 5
• Alternative: Doxycycline 100 mg twice daily PLUS a beta-lactam (never doxycycline alone, as it lacks reliable streptococcal coverage) 1
• Alternative: Trimethoprim-sulfamethoxazole PLUS a beta-lactam 1

Hospitalization Criteria

Consider hospitalization if any of the following are present 1, 2:

• Systemic inflammatory response syndrome (SIRS): fever >38°C, tachycardia >90 bpm, tachypnea >24 rpm 1
• Hypotension or hemodynamic instability 1, 2
• Altered mental status or confusion 1, 2
• Severe immunocompromise or neutropenia 1, 2
• Concern for deeper or necrotizing infection (severe pain out of proportion to exam, skin anesthesia, rapid progression, bullous changes) 1, 2

For hospitalized patients requiring IV therapy:

• Cefazolin 1-2 g IV every 8 hours (preferred IV beta-lactam for uncomplicated cases) 1
• Vancomycin 15-20 mg/kg IV every 8-12 hours (if MRSA coverage needed) 1

Severe Infections Requiring Broad-Spectrum Coverage

For suspected necrotizing fasciitis or severe cellulitis with systemic toxicity, use mandatory broad-spectrum combination therapy 1:

• Vancomycin 15-20 mg/kg IV every 8-12 hours PLUS piperacillin-tazobactam 3.375-4.5 g IV every 6 hours 1
• Alternative: Linezolid 600 mg IV twice daily PLUS piperacillin-tazobactam 1
• Obtain emergent surgical consultation for diagnostic and therapeutic debridement 1

Adjunctive Measures

• Elevate the head/affected area to promote gravity drainage of edema and inflammatory substances 1, 2
• Consider systemic corticosteroids (prednisone 40 mg daily for 7 days) in non-diabetic adults, though evidence is limited 1, 2
• Treat predisposing conditions such as eczema, chronic edema, or skin lesions 1, 2

Common Pitfalls to Avoid

• Do not extend treatment beyond 5 days if clinical improvement has occurred 1, 2
• Do not automatically add MRSA coverage for typical non-purulent cellulitis without specific risk factors 1, 2, 4
• Do not use doxycycline as monotherapy for cellulitis, as its activity against β-hemolytic streptococci is unreliable 1
• Do not use azithromycin for cellulitis, as it is not indicated for this condition 6
• Reassess in 24-48 hours to verify clinical response, as treatment failure rates of 21% have been reported with some regimens 1