Sandbox/cellulitis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mugilan Poongkunran M.B.B.S [2]

Cellulitis Microchapters
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Overview

Typically a combination of intravenous and oral antibiotics are administered for the treatment of cellulitis. Bed rest and elevation of the affected limbs are recommended to accompany the antibiotic treatment. In patients with edema of the extremities, compressive stockings may really aid in treating the fluid accumulation. Small abscesses surrounding the affected tissue can be treated with a simple incision and drainage of the fluid. It is advised to drink plenty of fluids during your treatment and recovery.

Non-Antibiotic Therapy

• Elevation of the affected area facilitates gravity drainage of edema and inflammatory substances. The skin should be sufficiently hydrated to avoid dryness and cracking without interdigital maceration.
• Treat underlying conditions such as tinea pedis, lymphedema, and chronic venous insufficiency, that predispose them to developing recurrent cellulitis.
• Compressive stockings and diuretic therapy may help patients with edema.

Medical Therapy

• The antibiotic selection for treatment of cellulitis depends on whether the clinical presentation is purulent or nonpurulent, as purulent cellulitis is potentially attributable to staphylococcus aureus, which should be empirically treated with Beta-lactam antibiotics. Latest reports suggest that this bacterium has acquired resistance (MRSA) and newer drugs are to be used to kill off the pathogen. Reports from the laboratory regarding the sensitivity of the pathogen is a key factor in deciding the therapy.

• Choice of the antibiotic therapy for cellulitis depends on the follwoing factors:
  • Age of the individual: Early hospitalization and parenteral therapy are required for treatment of cellulitis in neonates, except for the mildest of cases.
  • Co-morbid conditions
  • Site of lesion
  • Severity of lesion
  • Pathogen involved (gram positive or negative and aerobic or anaerobic)
  • Strain and resistance of the pathogen

Uncomplicated Cellulitis

• Simple infection without abscesses or drainage should be managed with empiric therapy for infection due to beta-hemolytic streptococci and methicillin sensitive staphylococcus aureus (MSSA).
• Dicloxacillin or first generation cephalosporins like cephalexin are used.
• Patients allergic to penicillin drugs can be given macrolide antibiotics like azithromycin.
• Patients who do not respond to initial therapy, or with signs of systemic illness, or with recurrent infection in the setting of underlying predisposing conditions, or with risk factors for MRSA, or in communities where the prevalence of MRSA is greater, additional empiric coverage for MRSA is considered.
• According to the 2011 clinical practice guidelines, if both methicillin resistant staphylococcus aureus and Streptococcus pyogenes are possible causes, then "options include the following: clindamycin alone (A-II) or TMP-SMX or a tetracycline in combination with a β-lactam (eg, amoxicillin) (A-II) or linezolid alone (A-II)." MRSA is commonly the causative agent of cellulitis in cases presenting with abscesses. In mild cases, treatment will be TMP-SMX with doxycycline and in severe cases, the most cost effective therapy will be vancomycin.

• According to the 2005 clinical practice guidelines, which state that staphylococcus aureus is very uncommon: "Suitable agents include dicloxacillin, cephalexin, clindamycin, or erythromycin, unless streptococci or staphylococci resistant to these agents are common in the community." Another trial confirms that if purulence or diabetes are not present then coverage for staphylococcus aureus is not needed.

• A study of failed treatment concluded that failure is reduced if higher dose antibiotics are used:
  • Vancomycin at least 30 mg/kg/day
  • Clindamycin at least 10 mg/kg/day (450 mg every 8 hours)
  • TMP-SMX at least 5 mg/kg/day of trimethoprim (a single strength pill has 80 mg trimethoprim) (two double strength pills every 12 hours)
  • If levofloxacin is used for treatment, 5 days is as effective as 10 days. However, levofloxacin is ineffective against methicillin-resistant Staphylococcus aureus.

Severe Cellulitis

• In severe cases of the disease, parenteral therapy is advocated.
• Higher generations of cephalosporins such as ceftriaxone, and cefuroxime are used.
• Patients with a penicillin allergy can be given vancomycin and clindamycin.
• In diabetic individuals, broad coverage antibiotics are used. Carbapenams, beta-lactam antibiotics with Beta-lactamase inhibitors are given in a combined regimen for antibiotic coverage.
• The duration of therapy should be individualized depending on clinical response; 5 to 10 days is usually appropriate (7 to 10 days in neonates); longer duration of therapy may be warranted in patients with severe disease.

Empiric Therapy for Cellulitis in Neonates

▸ Click on the following categories to expand treatment regimens.

Age Groups   ▸  Infants 0 to 4 weeks of age   ▸  Infants <1 week of age   ▸  Infants ≥1 week of age

Infants 0 to 4 weeks of age Parental Regimen ▸ Vancomycin 15 mg/kg IV q24h PLUS ▸ Cefotaxime 50 mg/kg IV q12h OR ▸ Gentamicin 2.5 mg/kg IV q18-24h Infants 0 to 4 weeks of age Oral Regimen ▸ Clindamycin 5 mg/kg orally q12h OR ▸ Linezolid 10 mg/kg orally q8-12h Infants <1 week of age (BW 1200 to 2000 g) Parental Regimen ▸ Vancomycin 10 to 15 mg/kg IV q12-18h PLUS ▸ Cefotaxime 50 mg/kg IV q12h OR ▸ Gentamicin 2.5 mg/kg IV q12h Infants <1 week of age (BW 1200 to 2000 g) Oral Regimen ▸ Clindamycin 5 mg/kg orally q12h OR ▸ Linezolid 10 mg/kg orally q8-12h Infants <1 week of age (BW >2000 g) Parental Regimen ▸ Vancomycin 10 to 15 mg/kg IV q8-12h PLUS ▸ Cefotaxime 50 mg/kg IV q8-12h OR ▸ Gentamicin 2.5 mg/kg IV q12h Infants <1 week of age (BW >2000 g) Oral Regimen ▸ Clindamycin 5 mg/kg orally q8h OR ▸ Linezolid 10 mg/kg orally q8-12h Infants ≥1 week of age (BW 1200 to 2000 g) Parental Regimen ▸ Vancomycin 10 to 15 mg/kg IV q8-12h PLUS ▸ Cefotaxime 50 mg/kg IV q8h OR ▸ Gentamicin 2.5 mg/kg IV q8-12h Infants ≥1 week of age (BW 1200 to 2000 g) Oral Regimen ▸ Clindamycin 5 mg/kg orally q8h OR ▸ Linezolid 10 mg/kg orally q8h Infants ≥1 week of age (BW > 2000 g) Parental Regimen ▸ Vancomycin 10 to 15 mg/kg IV q6-8h PLUS ▸ Cefotaxime 50 mg/kg IV q6-8h OR ▸ Gentamicin 2.5 mg/kg IV q8h Infants ≥1 week of age (BW > 2000 g) Oral Regimen ▸ Clindamycin 5 mg/kg orally q6h OR ▸ Linezolid 10 mg/kg orally q8h

Note:

• Treatment of cellulitis in neonates usually requires hospitalization and parenteral therapy. Oral therapy is given for completion of the treatment when the patogen is unknown.
• Optimal dose should be based on determination of serum concentrations.

Empiric Therapy for Cellulitis in Adults and Children > 28 days

▸ Click on the following categories to expand treatment regimens.

MSSA   ▸  Adults   ▸  Children age >28 days

Adults Parental Regimen ▸ Cefazolin 1-2 g IV q8h OR ▸ Oxacillin 2g IV q4h OR ▸ Nafcillin 2g IV q4h Alternative Regimen ▸ Clindamycin 600-900 mg IV q8h Adults Oral Regimen ▸ Dicloxacillin 500 mg orally q6h OR ▸ Cephalexin 500 mg orally q6h Alternative Regimen ▸ Clindamycin 300-450 mg orally q6-8h

Children age >28 days Parental Regimen ▸ Cefazolin 100 mg/kg per day IV in 3-4 doses OR ▸ Oxacillin 150-200 mg/kg per day IV in 4-6 doses OR ▸ Nafcillin 150-200 mg/kg per day IV in 4-6 doses Alternative Regimen ▸ Clindamycin 25-40 mg/kg per day IV in 3-4 doses Children age >28 days Oral Regimen ▸ Dicloxacillin 25-50 mg/kg per day orally in 4 doses OR ▸ Cephalexin 25-50 mg/kg per day orally in 3-4 doses Alternative Regimen ▸ Clindamycin 20-30 mg/kg per day orally in 4 doses

▸ Click on the following categories to expand treatment regimens.

MRSA   ▸  Adults   ▸  Children age >28 days

Adults Parental Regimen ▸ Vancomycin 15-20 mg/kg/dose q8-12h, not to exceed 2 g per dose Alternative Regimen ▸ Linezolid 600 mg IV q12h OR ▸ Ceftaroline 600 mg IV q12h OR ▸ Tigecycline 100 mg IV once, thereafter 50 mg IV q12h OR ▸ Daptomycin 4 mg/kg IV q24h (for skin and soft tissue infections); 6 mg/kg IV once daily (for bacteremia) Adults Oral Regimen ▸ Amoxicillin 500 mg orally q8h PLUS ▸ Trimethoprim-sulfamethoxazole 1 double strength tablet orally q12h Alternative Regimen ▸ Clindamycin 300 to 450 mg q8h OR ▸ Linezolid 600 mg orally q12h OR ▸ Tedizolid 200 mg orally q24h OR ▸ Amoxicillin 500 mg orally q8h PLUS Minocycline 200 mg once, then 100 mg orally q12h OR ▸ Amoxicillin 500 mg orally q8h PLUS Doxycycline 100 mg orally q12h Children age >28 days Oral Regimen ▸ Amoxicillin 25-50 mg/kg per day orally divided in 3 doses PLUS ▸ Trimethoprim-sulfamethoxazole 8-12 mg trimethoprim component/kg per day orally divided in 2 doses Alternative Regimen ▸ Clindamycin 40 mg/kg per day orally divided in 3-4 doses OR ▸ Linezolid <12 years: 30 mg/kg per day orally divided in 3 doses, ≥12 years: 600 mg orally q12h OR ▸ Amoxicillin 25-50 mg/kg per day orally divided in 3 doses PLUS Minocycline 24 mg/kg orally once, then 4 mg/kg per day divided in 2 doses OR ▸ Amoxicillin 25-50 mg/kg per day orally divided in 3 doses PLUS Doxycycline ≤45 kg: 4 mg/kg per day orally divided in 2 doses, >45 kg: 100 mg orally q12h

Note:

• The above antibiotic regimen is NOT for initial empirical treatment of infections involving the face.
• Dose alteration for renal insufficiency may be needed 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.

Special Cases

• Bite Wounds (Mammalian).
  • Bite wounds suffered from a mammal often contain polymicrobial sources that are anaerobic in nature.
  • 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.
  • 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.

References

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