Cellulitis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]
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Overview
Beta-lactam antibiotics against Streptococcus and penicillinase-producing Staphylococcus aureus are the usual drugs of choice. Ancillary measures include elevation of the affected area to reduce fluid accumulation and cool sterile saline dressings to remove purulent debris from open wounds.
Empiric TherapyAdapted from Clinical Practice Guidelines CID 2011[1] and Guidelines for Skin and Soft-Tissue Infections CID 2005[2]
- Empiric therapy would depend on the clinical presentation of the cellulitis.
- 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 with necrotizing fasciitis, septic arthritis, or osteomyelitis.
- 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.
- 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 TMP-SMX less action against Group A streptococcus.[3]
▸ Click on the following categories to expand treatment regimens.
Non-Purulent Cellulitis ▸ Adults ▸ Children age >28 days Purulent Cellulitis ▸ Adults ▸ Children age >28 days Complicated Cellulitis† ▸ Adults ▸ Children age >28 days
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Therapy based on Anatomical Location
A specific therapy should be given for the following anatomical locations due to the predisposition of certain bacteria.
▸ Click on the following categories to expand treatment regimens.
Location ▸ Buccal ▸ Facial ▸ Orbital
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Special Considerations Adapted from N Engl J Med 2004;350:904-12.[4]
For the following conditions, 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 ▸ Diabetic Foot Ulcer ▸ Neutropenic Patients ▸ Sal Water Wound Exposure ▸ Fresh Water Wound Exposure ▸ Butcher, Fisherman, Veterinarian
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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
- ↑ Mathews, CJ.; Weston, VC.; Jones, A.; Field, M.; Coakley, G. (2010). "Bacterial septic arthritis in adults". Lancet. 375 (9717): 846–55. doi:10.1016/S0140-6736(09)61595-6. PMID 20206778. Unknown parameter
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ignored (help) - ↑ 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
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ignored (help) - ↑ 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
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ignored (help)