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

The treatment for cellulitis consists of oral or intravenous antibiotics. The usual drug of choice are beta-lactam antibiotics, as most of the cases of cellulitis are caused either by Staphylococcus aureus or Streptococcus. Bed rest and elevation of the affected limbs are recommended as adjuvant therapy. In patients with edema of the extremities, compressive stockings may be beneficial in treating the fluid accumulation. If a small abscess is surrounding the affected tissue, it can be treated with a simple incision and drainage of the fluid.

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.

▸ 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 - Adults
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 - Children
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 - Adults
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 - Children
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 - Adults
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 - Children
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)

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

  ▸  Buccal

  ▸  Facial

  ▸  Orbital

  ▸  Sal Water Wound Exposure

  ▸  Fresh Water Wound Exposure

  ▸  Butcher, Fisherman, Veterinarian


Buccal Cellulitis
(H. influenzae)
Preferred Regimen
Ceftriaxone 1-2 g IV q24h
Alternative Regimen
Meropenem 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)
OR
Imipenem/cilastatin 250-1000 mg IV (max: 50mg/kg/day)
Adapted from N Engl J Med 2004;350:904-12.[5]
Orbital Cellulitis
Preferred Regimen 1
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
PLUS
Ceftriaxone 2g IV q24h
PLUS
Metronidazole 1g IV q12h
Preferred Regimen 2
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
PLUS
Piperacillin-tazobactam 4.5g IV q8h
Alternative Regimen
(if penicillin or cephalosporin allergic)
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
PLUS
Levofloxacin 750 mg IV q24h
Facial Cellulitis
Preferred Regimen
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
Alternative Regimen
Daptomycin 4 mg/kg IV q24h
OR
Linezolid 600mg IV q12h
Salt Water Wound Exposure
(Vibrio vulnificus)
Preferred Regimen
Doxycycline 200 mg IV initial dose, then 50-100 mg IV q12h
Alternative Regimen
Cefotaxime 1-2 g IV/IM q8-12 (up to 2 g q4-6h)
OR
Ciprofloxacin 400 mg IV q8-12h x 7-14 days
OR
Ciprofloxacin 500-750 mg PO q8-12h x 7-14 days
Fresh Water Wound Exposure
(Aeromonas spp)
Preferred Regimen
Ciprofloxacin 400mg IV q12h
OR
Ceftazidime 0.5 -2 g IV q8h
PLUS

Gentamicin 3-5 mg/kg/day IV/IM divided q6-8h or 4-7 mg/kg IV q24h

Alternative Regimen
Meropenem 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)
OR
Imipenem/cilastatin 250-1000 mg IV (max: 50mg/kg/day)
Butcher, Fisherman, Veterinarian
(Erysipelothrix rhusiopathiae)
Preferred Regimen
Amoxicillin 500 mg PO q8hr
Alternative Regimen
Cefotaxime 1-2 g IV/IM q8-12 (up to 2 g q4-6h)
OR
Ciprofloxacin 400 mg IV q8-12h x 7-14 days
OR
Ciprofloxacin 500-750 mg PO q8-12h x 7-14 days
OR
Imipenem-cilastatin 250-1000 mg IV (max: 50mg/kg/day)

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. 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)
  5. 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)