Cellulitis medical therapy

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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 Staphyloccocus 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


Non-Purulent Cellulitis
Preferred Regimen
Cephalexin 500 mg PO q6h x5-10 days
OR
Dicloxacillin 500 mg PO q6h x5-10 days
OR
Clindamycin 300-450 mg PO q8h
OR
Amoxicillin 500 mg PO q8h
OR
TMP-SMX 80-160 mg/400-800 mg PO q12h
OR
Doxycycline 100 mg PO q12h
OR
Linezolid 600 mg PO q12h
Non-Purulent Cellulitis
Preferred Regimen
Cephalexin 25 mg/kg/day PO divided q6h x 5-10 days
OR
Dicloxacillin 25 mg/kg/day PO divided q6h x 5-10 days
OR
Clindamycin 10-13 mg/kg IV q6-8h (max:40 mg/kg/day)
OR
TMP-SMX 4-6 mg/kg PO q12h (TMP component)
OR
Doxycycline¶ 2 mg/kg PO q12h†
OR
Linezolid 10 mg/kg PO q8h (max: 600mg/dose)
Not recommended for children < 8 years of age
For children ≤45 kg. Children >45 kg receive adult dosing.
Purulent Cellulitis
Preferred Regimen
Linezolid 600 mg PO q12h
OR
Clindamycin 300 - 450 mg PO q8h
OR
Minocycline 200 mg PO 1 dose, then 100 mg PO q12h
OR
Doxycycline 100 mg PO q12h
OR
TMP-SMX 80-160 mg/400-800 mg PO q12h
Purulent Cellulitis
Preferred Regimen
Linezolid 10 mg/kg PO q8h (max: 600mg/dose)
OR
Clindamycin 10-13 mg/kg IV q6-8h (max:40 mg/kg/day)
OR
Minocycline 4 mg/kg PO 1 dose, then2 mg/kg/dose PO q12h
OR
Doxycycline¶ 2 mg/kg PO q12h†
OR
TMP-SMX 4-6 mg/kg PO q12h (TMP component)
Not recommended for children < 8 years of age
For children ≤45 kg. Children >45 kg receive adult dosing.
Complicated Cellulitis
Preferred Regimen
Vancomycin 15-20 mg/kg IV q8-12h
OR
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4mg/kg IV q24h
OR
Telavancin 10mg/kg IV q24h
Alternative Regimen
Clindamycin 600 mg IV/PO q8h
Complicated Cellulitis
Preferred Regimen
Vancomycin 15 mg/kg IV q6h
OR
Linezolid 10 mg/kg IV/PO q8h (max: 600mg/dose)
Alternative Regimen
Clindamycin 10-13 mg/kg IV/PO q6-8h (max:40 mg/kg/day)

Location-specific Therapy

Special Considerations

Orbital Cellulitis

▸ Click on the following categories to expand treatment regimens.

[4]

Orbital Cellulitis

  ▸  Usual pathogens

  ▸  MRSA

Usual pathogens
Preferred Regimen
Nafcillin 2 gm IV q4h
PLUS
Ceftriaxone 2 gm IV q24h
PLUS
Metronidazole 1 gm IV q12h
Alternative Regimen
Vancomycin 1 gm IV q12h
PLUS
Levofloxacin 750 mg IV once daily
PLUS
Metronidazole 1 gm IV q12h
MRSA
Preferred Regimen
Vancomycin 1 gm IV q12h
PLUS
Ceftriaxone 2 gm IV q24h
PLUS
Metronidazole 1 gm IV q12h
Alternative Regimen
Daptomycin 6 mg/kg IV q24h
PLUS
Levofloxacin 750 mg IV once daily
OR
Ceftriaxone 2 gm IV q24h
PLUS
Metronidazole 1 gm IV q12h
  • Bite Wounds (Mammalian).
    • Bite wounds suffered from a mammal often contain polymicrobial sources that are anaerobic in nature.[5]
    • Mild cases can be treated with amoxicillin and clavulanate, and in cases of penicillin allergy cotrimoxazole along with metronidazole is used.
    • In severe cases, piperacillin and tazobactum are used.
  • Acquatic punctures and lacerations.[6]
    • This is seen mainly in professional swimmers and divers both in freshwater and in brackish water.
    • Failure to recognize these wounds and delay treatment may cause a larger morbidity.
    • Wounds in fresh water are treated with doxycycline and ceftazidime (or fluroquinolones).
    • Wounds in brackish water are treated with ceftazidime and levofloxacin.

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

  1. 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 |month= ignored (help)
  2. 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. 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.
  4. Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ; et al. (2011). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary". Clin Infect Dis. 52 (3): 285–92. doi:10.1093/cid/cir034. PMID 21217178.
  5. Abrahamian FM, Goldstein EJ (2011). "Microbiology of animal bite wound infections". Clin. Microbiol. Rev. 24 (2): 231–46. doi:10.1128/CMR.00041-10. PMC 3122494. PMID 21482724. Unknown parameter |month= ignored (help)
  6. Noonburg GE (2005). "Management of extremity trauma and related infections occurring in the aquatic environment". J Am Acad Orthop Surg. 13 (4): 243–53. PMID 16112981.