How should I manage a patient with cellulitis and swelling surrounding a laceration that has a small area of wound dehiscence held with steri‑strips, while the remainder of the wound is sutured and planned for suture removal at a five‑day follow‑up, including antibiotic selection, wound‑care instructions, and red‑flag monitoring?

Management of Laceration with Cellulitis, Swelling, and Partial Wound Dehiscence

For a laceration complicated by cellulitis, swelling, and a small area of wound dehiscence held with steri-strips, prescribe oral beta-lactam monotherapy (cephalexin 500 mg every 6 hours or dicloxacillin 250–500 mg every 6 hours) for 5 days, elevate the affected area, keep the wound clean and dry, and reassess in 48–72 hours for clinical improvement before the planned suture-removal visit. 1, 2

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Antibiotic Selection Algorithm

First-Line Therapy: Beta-Lactam Monotherapy

• Cephalexin 500 mg orally every 6 hours for 5 days provides excellent coverage against beta-hemolytic streptococci and methicillin-sensitive Staphylococcus aureus, the predominant pathogens in typical cellulitis surrounding traumatic wounds. 1, 3
• Dicloxacillin 250–500 mg orally every 6 hours for 5 days is an equally effective alternative with comparable activity against streptococci and MSSA. 1, 4
• Beta-lactam monotherapy achieves approximately 96% clinical success in typical non-purulent cellulitis, making routine MRSA coverage unnecessary in most cases. 1, 2

When to Add MRSA Coverage

Add MRSA-active antibiotics only if any of the following risk factors are present:

• Penetrating trauma (e.g., contaminated object causing the laceration). 1
• Visible purulent drainage or exudate from the wound or surrounding tissue. 1, 2
• Known MRSA colonization or prior MRSA infection. 1
• Systemic inflammatory response syndrome (fever >38°C, heart rate >90 bpm, respiratory rate >24 breaths/min). 1
• Failure to respond to beta-lactam therapy after 48–72 hours. 1

MRSA-Active Regimens (if indicated)

• Clindamycin 300–450 mg orally every 6 hours provides single-agent coverage for both streptococci and MRSA, but use only if local MRSA clindamycin resistance is <10%. 1
• Trimethoprim-sulfamethoxazole 1–2 double-strength tablets twice daily PLUS a beta-lactam (cephalexin or amoxicillin) ensures dual coverage. 1
• Doxycycline 100 mg orally twice daily PLUS a beta-lactam is another combination option. 1

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Treatment Duration

• Treat for exactly 5 days if clinical improvement occurs (reduced warmth, tenderness, erythema; no fever); extend only if symptoms have not improved. 1, 2
• High-quality randomized controlled trial evidence shows 5-day courses are as effective as 10-day courses for uncomplicated cellulitis. 1
• Traditional 7–14-day regimens are unnecessary for uncomplicated cases and promote antimicrobial resistance. 1

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Wound-Care Instructions

Steri-Strip Management

• Leave steri-strips in place until the 5-day follow-up visit; they provide mechanical support for the dehisced area without requiring sutures. 5
• Evidence shows no significant difference in wound dehiscence rates between wounds closed with sutures alone versus sutures plus steri-strips, but steri-strips are appropriate for small areas of dehiscence. 5
• Do not remove steri-strips prematurely; allow them to fall off naturally or remove at follow-up if the wound edges are well-approximated. 5

Wound Hygiene

• Keep the wound clean and dry for the first 24–48 hours; after this period, gentle cleansing with sterile saline or tap water is acceptable. 5
• Avoid iodine- or antibiotic-containing solutions for routine wound cleansing, as sterile normal saline is sufficient. 5
• Do not soak the wound in water (e.g., baths, swimming) until the cellulitis has resolved and the wound is fully healed. 5

Elevation and Edema Management

• Elevate the affected body part above heart level for at least 30 minutes three times daily to promote gravity drainage of edema and inflammatory substances. 1, 6
• Elevation is especially critical during the first few days after injury and accelerates healing. 5

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Red-Flag Monitoring: When to Seek Immediate Care

Instruct the patient to return immediately or seek emergency care if any of the following develop:

Signs of Necrotizing Infection

• Severe pain out of proportion to examination findings—suggests deep fascial involvement. 1
• Skin anesthesia or numbness over the affected area. 1
• Rapid progression of erythema over hours rather than days. 1
• Violaceous bullae, cutaneous hemorrhage, or skin sloughing. 1
• "Wooden-hard" subcutaneous tissue or palpable/visible gas. 1

Systemic Toxicity

• Fever >38°C, tachycardia >90 bpm, hypotension, or altered mental status—indicates systemic inflammatory response syndrome (SIRS) requiring hospitalization. 1, 7

Wound Complications

• Increasing purulent drainage or foul-smelling discharge from the wound. 1
• Expanding erythema beyond the initial marked borders after 48–72 hours of antibiotics. 1
• Complete wound dehiscence with separation of the entire wound edge. 5

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Follow-Up Plan at 5-Day Visit

Clinical Assessment

• Reassess warmth, tenderness, and erythema to confirm clinical improvement; if these signs have resolved, discontinue antibiotics. 1
• Inspect the dehisced area held by steri-strips; if the wound edges are well-approximated and no signs of infection remain, remove the steri-strips. 5
• Remove the remaining sutures from the well-approximated portion of the wound if the wound is healed and no longer requires mechanical support. 5

If No Improvement After 5 Days

• Consider resistant organisms (e.g., MRSA) if the patient has not improved despite appropriate beta-lactam therapy. 1
• Reassess for undrained abscess using bedside ultrasound if clinical uncertainty exists; purulent collections require incision and drainage. 1
• Evaluate for deeper infection (e.g., septic arthritis, osteomyelitis) if pain is disproportionate or located near a bone or joint. 5
• Switch to MRSA-active therapy (clindamycin or TMP-SMX plus a beta-lactam) and reassess in 48 hours. 1

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Common Pitfalls to Avoid

• Do not routinely add MRSA coverage for typical cellulitis surrounding a traumatic wound without the specified risk factors; this overtreats the majority of cases and promotes resistance. 1, 2
• Do not extend antibiotic therapy to 7–10 days automatically; extend only if warmth, tenderness, or erythema have not improved after 5 days. 1
• Do not close infected wounds primarily; the area of dehiscence should remain open and heal by secondary intention if signs of infection persist. 5
• Do not delay surgical consultation if any signs of necrotizing infection, deep abscess, or systemic toxicity develop. 1
• Do not use doxycycline or trimethoprim-sulfamethoxazole as monotherapy for typical cellulitis, as they lack reliable activity against beta-hemolytic streptococci. 1

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Adjunctive Measures to Reduce Recurrence Risk

• Treat predisposing skin conditions such as tinea pedis, eczema, or chronic edema to reduce future cellulitis risk. 1, 8
• Address venous insufficiency or lymphedema with compression therapy once the acute infection resolves. 1
• Ensure tetanus prophylaxis is current; administer 0.5 mL tetanus toxoid intramuscularly if status is outdated or unknown. 5