What are the treatment guidelines for facial cellulitis?

From the Guidelines

Facial cellulitis treatment should begin with empiric antibiotic therapy targeting common causative organisms like Streptococcus and Staphylococcus species, with oral antibiotics such as cephalexin 500mg four times daily, amoxicillin-clavulanate 875/125mg twice daily, or clindamycin 300-450mg four times daily for 5 days, as recommended by the Infectious Diseases Society of America 1.

Treatment Guidelines

For mild to moderate cases of facial cellulitis, the following treatment options are recommended:

• Oral antibiotics such as cephalexin, amoxicillin-clavulanate, or clindamycin for 5 days 1
• Supportive measures including warm compresses, elevation of the head while sleeping, adequate hydration, and pain management with acetaminophen or ibuprofen For severe cases or those with systemic symptoms, hospitalization for intravenous antibiotics is necessary, typically with ceftriaxone, ampicillin-sulbactam, or vancomycin if MRSA is suspected 1.

Key Considerations

• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period 1
• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1
• Patients should be monitored closely for complications such as orbital involvement, abscess formation, or systemic spread
• If improvement isn't seen within 48-72 hours, reevaluation is necessary to consider alternative diagnoses, resistant organisms, or need for surgical intervention

Antibiotic Options

• Cephalexin 500mg four times daily
• Amoxicillin-clavulanate 875/125mg twice daily
• Clindamycin 300-450mg four times daily
• Vancomycin 15-20mg/kg every 8-12 hours if MRSA is suspected
• Ceftriaxone 1-2g daily
• Ampicillin-sulbactam 3g every 6 hours It is essential to note that the treatment should be adjusted based on culture results when available, and the patient's clinical response should be closely monitored 1.

From the FDA Drug Label

14 CLINICAL STUDIES 14. 1 Acute Bacterial Skin and Skin Structure Infections

Adults A total of 1333 adults with acute bacterial skin and skin structure infections (ABSSSI) were randomized in two multicenter, multinational, double-blind, non-inferiority trials. Both trials compared SIVEXTRO 200 mg once daily for 6 days versus linezolid 600 mg every 12 hours for 10 days In Trial 1, patients were treated with oral therapy, while in Trial 2, patients could receive oral therapy after a minimum of one day of intravenous therapy. Patients with cellulitis/erysipelas, major cutaneous abscess, or wound infection were enrolled in the trials Patients with wound infections could have received aztreonam and/or metronidazole as adjunctive therapy for gram-negative bacterial coverage, if needed.

The treatment guideline for facial cellulitis is not explicitly stated in the provided drug label. However, the label does mention that patients with cellulitis/erysipelas were enrolled in the trials and treated with SIVEXTRO 200 mg once daily for 6 days or linezolid 600 mg every 12 hours for 10 days 2.

• The primary endpoint in the trials was early clinical response, defined as no increase from baseline lesion area at 48-72 hours after the first dose and oral temperature of ≤37.6°C, confirmed by a second temperature measurement within 24 hours in the ITT population.
• The types of ABSSSI included were cellulitis/erysipelas (41% in Trial 1 and 50% in Trial 2), wound infection, and major cutaneous abscess. However, the label does not provide specific treatment guidelines for facial cellulitis.

From the Research

Treatment Guidelines for Facial Cellulitis

• The majority of non-purulent, uncomplicated cases of cellulitis are caused by β-hemolytic streptococci or methicillin-sensitive Staphylococcus aureus, and appropriate targeted coverage of this pathogen with oral antibiotics such as penicillin, amoxicillin, and cephalexin is sufficient 3.
• For facial cellulitis, β-haemolytic streptococci (BHS) are the leading cause, and most patients exhibit sharply demarcated lesions and systemic symptoms, with narrow-spectrum β-lactam antibiotics and short hospital stay appearing sufficient 4.
• Ceftriaxone has been evaluated as a potential treatment for methicillin-susceptible Staphylococcus aureus (MSSA) infections, with current evidence suggesting no difference in efficacy between ceftriaxone and antistaphylococcal antibiotics (ASAs) for MSSA infection, but with a lower risk of toxicity with ceftriaxone 5.

Antibiotic Choices

• Cephalexin is a cost-effective option for outpatient empiric therapy of cellulitis, but clindamycin becomes more cost-effective at high likelihoods of MRSA infection 6.
• Clindamycin or trimethoprim/sulfamethoxazole (TMP/SMX) may be considered for empiric therapy in cases where the likelihood of MRSA infection is high 6.
• Penicillin or penicillinase-resistant penicillin alone or in combination can cure a significant proportion of patients with facial cellulitis, with supplementary clindamycin used in some cases 4.

Special Considerations

• Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen that can cause severe infections, including nasal septal abscess and facial cellulitis, requiring prompt diagnosis and appropriate medical and/or surgical management 7.
• The rise in community-onset MRSA infections potentially complicates the empiric management of cellulitis, and the threshold at which drugs active against MRSA should be incorporated into empiric therapy is unknown 6.