What is the treatment for purulent cellulitis?

From the Guidelines

Purulent cellulitis should be treated with a combination of antibiotics, wound care, and supportive measures, with a recommended antibiotic course of 5-6 days, as stated in the most recent guideline from the American College of Physicians 1.

Key Considerations

• For mild to moderate cases, oral antibiotics such as cephalexin, dicloxacillin, or clindamycin are typically effective.
• For severe infections or those with MRSA concerns, consider trimethoprim-sulfamethoxazole or doxycycline.
• If the infection is severe or rapidly progressing, intravenous antibiotics like vancomycin, linezolid, or daptomycin may be necessary in a hospital setting.
• Any abscess should be incised and drained.
• The affected area should be elevated, and warm compresses applied several times daily to improve circulation and reduce swelling.
• Adequate pain control with acetaminophen or NSAIDs is important.
• Patients should stay well-hydrated and monitor for signs of worsening infection such as increasing redness, warmth, pain, fever, or red streaking from the site.

Antibiotic Options

• Cephalexin (500 mg four times daily)
• Dicloxacillin (500 mg four times daily)
• Clindamycin (300-450 mg three times daily)
• Trimethoprim-sulfamethoxazole (1-2 double-strength tablets twice daily)
• Doxycycline (100 mg twice daily)

Important Notes

• The 2021 guideline from the American College of Physicians recommends a 5- to 6-day course of antibiotics active against streptococci for patients with nonpurulent cellulitis 1.
• The choice of antibiotic should be based on the severity of the infection, the presence of MRSA, and the patient's ability to self-monitor and have close follow-up with primary care.

From the FDA Drug Label

Vancomycin Hydrochloride for Injection, USP is indicated for the treatment of serious or severe infections caused by susceptible strains of methicillin-resistant (β-lactam-resistant) staphylococci When staphylococcal infections are localized and purulent, antibiotics are used as adjuncts to appropriate surgical measures

The treatment for purulent cellulitis may involve the use of vancomycin as an adjunct to surgical measures, such as drainage or debridement.

• Vancomycin is effective against methicillin-resistant staphylococci and other Gram-positive bacteria that may cause purulent cellulitis.
• The use of vancomycin should be guided by culture and susceptibility results, and it should only be used to treat infections that are proven or strongly suspected to be caused by susceptible bacteria 2.
• Daptomycin may also be considered for the treatment of complicated skin and skin structure infections, including purulent cellulitis, as it has been shown to be effective against Gram-positive bacteria, including MRSA 3.

From the Research

Treatment of Purulent Cellulitis

• The treatment of purulent cellulitis is not directly addressed in the provided studies, as they primarily focus on non-purulent cellulitis.
• However, the studies suggest that 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 4.
• For purulent cellulitis, the treatment may involve antibiotics that cover a broader range of pathogens, including Staphylococcus aureus and Streptococcus species, but the optimal antibiotic regimen is not specified in the provided studies.

Antibiotic Selection

• Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit 5.
• The available trial data do not demonstrate the superiority of any agent, and data are limited on the most appropriate route of administration or duration of therapy 6.
• The use of broad-spectrum antibiotics is not recommended for non-purulent cellulitis, and their use should be limited to cases where there is a high suspicion of resistant organisms or severe infection 7, 8.

Clinical Practice Guidelines

• Implementation of clinical practice guidelines is recommended to limit the use of broad-spectrum antibiotics in uncomplicated cellulitis 7.
• An evidence-based care pathway for cellulitis can improve process, clinical, and cost outcomes by reducing broad-spectrum antibiotic use, pharmacy costs, and total facility costs without an adverse change in length of stay or 30-day readmissions 8.