Cellulitis medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
'''Empiric Therapy''' <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Clin Infect Dis. 2011;52(3):e18-55<ref name="LiuBayer2011">{{cite journal|last1=Liu|first1=C.|last2=Bayer|first2=A.|last3=Cosgrove|first3=S. E.|last4=Daum|first4=R. S.|last5=Fridkin|first5=S. K.|last6=Gorwitz|first6=R. J.|last7=Kaplan|first7=S. L.|last8=Karchmer|first8=A. W.|last9=Levine|first9=D. P.|last10=Murray|first10=B. E.|last11=Rybak|first11=M. J.|last12=Talan|first12=D. A.|last13=Chambers|first13=H. F.|title=Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children|journal=Clinical Infectious Diseases|volume=52|issue=3|year=2011|pages=e18–e55|issn=1058-4838|doi=10.1093/cid/ciq146}}</ref> and Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name=IDSA2005>{{Cite journal | |||
| author = Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade | | author = Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade | ||
| title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections | | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections |
Latest revision as of 15:47, 15 January 2021
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2], Mugilan Poongkunran M.B.B.S [3], Faizan Sheraz, M.D. [4]
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Overview
The mainstay of therapy for cellulitis is antimicrobial therapy. Beta-lactam antibiotics are the usual drugs of choice, since most of the cases of cellulitis are caused either by Staphylococcus aureus or Streptococcus. Supportive therapy includes bed rest, compression stockings, and elevation of the affected limb. If a small abscess is surrounding the affected tissue, it may be treated with incision and drainage.
Medical Therapy
Empiric Therapy Adapted from Clin Infect Dis. 2011;52(3):e18-55[1] and Guidelines for Skin and Soft-Tissue Infections CID 2005[2]== Clinical practice guidelines direct management.[3]
- Empiric therapy depends on the clinical presentation of the cellulitis.[4]
- Non-purulent cellulitis refers to the infection without purulent drainage or exudate and not associated with an abscess.
- Purulent cellulitis is associated with purulent drainage or exudate in the absence of a drainable abscess, and it is associated to Staphylococcus aureus.
- Complicated cellulitis refers to a deeper soft-tissue infection and/or the association significant coexisting diseases (including diabetes mellitus, immunocompromised patients, and obesity), the need for significant surgical intervention or the involvement of the perianal area.
- Patients with complicated cellulitis also present with surgical site infection, necrotizing soft-tissue infection, and signs of systemic toxicity.
- For patients with purulent cellulitis, cultures are recommended and empirical therapy for Community Associated-MRSA (CA-MRSA) should be started.
- For patients with non-purulent cellulitis, empirical therapy for β-hemolytic streptococci should be started; if the patient does not respond to B-lactam antibiotics, empirical coverage for CA-MRSA should be initiated. Per 2014 clinical practice guidelines, antibiotics for outpatients should be "an antimicrobial agent that is active against streptococci...For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (severe nonpurulent; Figure 1), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (strong, moderate)".[4]
- The duration of the therapy should be individualized for the clinical response of each patient; 5-10 days is usually recommended.
- The treatment of cellulitis in neonates usually requires hospitalization and parenteral therapy. Oral therapy is given for completion of the treatment when the pathogen is unknown.
- The optimal dose should be based on determination of serum concentrations and patients with renal insufficiency may require dose adjustment in case of cephalosporins.
- Clindamycin is an alternate therapy for patients at risk of severe hypersensitivity reaction to penicillins and cephalosporins.
- Doxycycline is not recommended for children <8 years of age.
- Studies have shown an increase in treatment failure with TMP-SMX compared to other agents for cellulitis in children, reflecting a decreased efficacy of TMP-SMX against Group A streptococcus.[5]
▸ Click on the following categories to expand treatment regimens.
Non-Purulent Cellulitis ▸ Adults ▸ Children age >28 days Purulent Cellulitis ▸ Adults ▸ Children age >28 days
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Special Considerations Adapted from N Engl J Med 2004;350:904-12.[6]
- For the certain anatomical locations (buccal, facial and periorbital) a specific therapy should be given due to the predisposition of certain bacteria.
- For certain conditions, such as salt or fresh water wound exposure, or if the patient is a butcher, fisherman or veterinarian, an additional antibiotic therapy should be added to the usual regimen in order to cover specific pathogens associated to those circumstances.
▸ Click on the following categories to expand treatment regimens.
Special Considerations ▸ Buccal Cellulitis ▸ Facial Cellulitis ▸ Orbital Cellulitis ▸ Salt Water Wound Exposure ▸ Fresh Water Wound Exposure ▸ Butcher, Fisherman, Veterinarian
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Diabetic Foot Ulcer Adapted from Diabetes Care. 2013;36(9):2862-71.[7] and Clin Infect Dis. 2012;54(12):e132-73.[8]
- Appropriate wound care is essential for the management of all diabetic foot ulcers.
- Uninfected diabetic ulcers do not require antibiotic therapy.
- For acutely infected wounds, empiric antibiotic with efficacy against Gram-positive cocci should be initiated after obtaining a post-debridement specimen for aerobic and anaerobic culture.
- Infections with antibiotic-resistant organisms and those that are chronic, previously treated, or severe usually require broader spectrum regimens.
Empiric Therapy
▸ Click on the following categories to expand treatment regimens.
Uninfected (Grade 1) ▸ No Evidence of Infection Mild (Grade 2) ▸ Acute Infection Without Recent Antibiotic Use ▸ High Risk for MRSA
Moderate to Severe (Grade 3–4) ▸ Chronic Infection or Recent Antibiotic Use ▸ High Risk for MRSA ▸ High Risk for Pseudomonas aureuginosa ▸ Polymicrobial Infection |
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Neutropenic Patients Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[2]
- Patients with neutropenia require an antimicrobial therapy with a broader coverage.
- The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
Microorganism | Duration of Therapy |
▸ Gram-negative Bacteria | 7-14 days |
▸ Gram-positive Bacteria | 7-10 days |
▸ Fungi | Until clinical resolution |
▸ Click on the following categories to expand treatment regimens.
Neutropenia ▸ Gram-Negative Bacteria ▸ Gram-Positive Bacteria ▸ Fungi
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Cellular Immune Deficient Patients Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[2]
- Patients with cellular immunodeficiency require a pathogen-specific antimicrobial therapy.
- The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
Microorganism | Duration of Therapy |
▸ Nocardia spp | 3-12 months |
▸ Atypical mycobacteria | 6-12 months |
▸ Cryptococcus spp | 8-12 weeks |
▸ Histoplasma spp | ≥ 12 months |
▸ Varicella-zoster virus | 7-10 days |
▸ Herpes simplex virus | 7 days |
▸ Cytomegalovirus | 21 days |
Bacteria ▸ Nocardia spp ▸ Atypical mycobacteria Fungi ▸ Cryptococcus spp ▸ Histoplasma spp Viruses ▸ Varicella-zoster virus ▸ Herpes simplex virus ▸ Cytomegalovirus |
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BitesAdapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[2]
- All bite wounds should be cleaned profusely with iodide soap and water.
- Bites are contaminated by a polimicrobial flora and antibiotic prophylaxis treatment is recommended to avoid subsequent infection.
- The route of administration depends on the depth and severity of the wound, as well as the time that has passed since the bite.
▸ Click on the following categories to expand treatment regimens.
Antibiotic Prophylaxis ▸ Any Type of Bite Specific Therapy ▸ Cat Bite ▸ Dog Bite ▸ Human Bite
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Treatment Regimen
- Cellulitis[3]
- Non purulent Cellulitis
- Mild (typical cellulitis/erysipelas with no focus of purulence)
- Preferred regimen (1): Penicillin VK 500 mg PO bid
- Preferred regimen (2): Cephalosporin
- Preferred regimen (3): Dicloxacillin
- Preferred regimen (4): Clindamycin 600-900 mg IV q6-8h
- Moderate (typical cellulitis/erysipelas with systemic signs of infection)
- Preferred regimen (1): Penicillin VK 500 mg PO bid
- Preferred regimen (2): ceftriaxone 1-2 g q4-8h
- Preferred regimen (3): cefazolin
- Preferred regimen (4): clindamycin 600-900 mg IV q6-8h
- Severe infection
- Patients who have failed incision and drainage plus oral antibiotics
- Those with systemic signs of infection such as temperature >38°C,
- Tachycardia (heart rate >90 beats per minute),
- Tachypnea (respiratory rate >24 breaths per minute) or
- Abnormal white blood cell count (<12 000 or <400 cells/µL), or
- Immunocompromised patients
- Preferred regimen: Vancomycin AND piperacillin-tazobactam
- Purulent Celluitits
- Mild (typical cellulitis/erysipelas with no focus of purulence)
- Preferred regimen: Incision and Drainage
- Moderate (typical cellulitis/erysipelas with systemic signs of infection)
- Incision and Drainage
- Empiric regimen : TMP-SMX OR doxycycline
- MRSA : TMP-SMX
- MSSA : Dicloxacillin OR cephalexin
- Severe infection: patients who have failed oral antibiotic regimen or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction.
- Incision and Drainage
- Empiric regimen : Vancomycin OR daptomycin OR linezolid OR televancin OR ceftaroline
- MRSA : Vancomycin OR daptomycin OR linezolid OR televancin OR ceftaroline
- Buccal Cellulitis
- 1. Empiric antimicrobial therapy
- Preferred regimen: Cefuroxime 50 mg/kg IV q8h OR Cefuroxime 10–15 mg/kg PO q12h (maximum dose is 1 g/day) OR Ceftriaxone 50 mg/kg IV q24h
- Alternative regimen: Amoxicillin-Clavulanate 90 mg/kg/day PO q12h
- Note: In case of suspected meningitis, increase Cefuroxime dose to 80 mg/kg IV q8h, or Ceftriaxone dose to 50 mg/kg IV q24h.
Non-Antibiotic Therapy
- Elevation of the affected area facilitates gravity drainage of edema and inflammatory substances. Compressive stockings and diuretic therapy may help patients with edema.
- The skin should be sufficiently hydrated to avoid dryness and cracking without maceration.
References
- ↑ Liu, C.; Bayer, A.; Cosgrove, S. E.; Daum, R. S.; Fridkin, S. K.; Gorwitz, R. J.; Kaplan, S. L.; Karchmer, A. W.; Levine, D. P.; Murray, B. E.; Rybak, M. J.; Talan, D. A.; Chambers, H. F. (2011). "Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children". Clinical Infectious Diseases. 52 (3): e18–e55. doi:10.1093/cid/ciq146. ISSN 1058-4838.
- ↑ 2.0 2.1 2.2 2.3 Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 41 (10): 1373–1406. doi:10.1086/497143. PMID 16231249. Unknown parameter
|month=
ignored (help) - ↑ 3.0 3.1 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
- ↑ 4.0 4.1 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America". Clin Infect Dis. 59 (2): e10–52. doi:10.1093/cid/ciu444. PMID 24973422.
- ↑ Elliott DJ, Zaoutis TE, Troxel AB, Loh A, Keren R (2009). "Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus". Pediatrics. 123 (6): e959–66. doi:10.1542/peds.2008-2428. PMID 19470525.
- ↑ Morton N. Swartz (2004). "Clinical practice. Cellulitis". The New England journal of medicine. 350 (9): 904–912. doi:10.1056/NEJMcp031807. PMID 14985488. Unknown parameter
|month=
ignored (help) - ↑ Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.
- ↑ Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
- ↑ Griffith, David E.; Aksamit, Timothy; Brown-Elliott, Barbara A.; Catanzaro, Antonino; Daley, Charles; Gordin, Fred; Holland, Steven M.; Horsburgh, Robert; Huitt, Gwen; Iademarco, Michael F.; Iseman, Michael; Olivier, Kenneth; Ruoss, Stephen; von Reyn, C. Fordham; Wallace, Richard J.; Winthrop, Kevin (2007). "An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases". American Journal of Respiratory and Critical Care Medicine. 175 (4): 367–416. doi:10.1164/rccm.200604-571ST. ISSN 1073-449X.
- ↑ Wheat, LJ.; Freifeld, AG.; Kleiman, MB.; Baddley, JW.; McKinsey, DS.; Loyd, JE.; Kauffman, CA. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045. Unknown parameter
|month=
ignored (help)