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 and Guidelines for Skin and Soft-Tissue Infections CID 2005

• 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.

▸ 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)

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   ▸  Periorbital   ▸  Orbital   ▸  Perianal   ▸  Facial

Buccal Cellulitis (H. influenzae) Preferred Regimen ▸ Ceftriaxone 1-2 g IV q24h Alternative Regimen ▸ Meropenem OR ▸ Imipenem-cilastatin Periorbital Cellulitis Preferred Regimen ▸ [[ OR ▸ [[ Alternative Regimen ▸ [[ OR ▸ [[ 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 Perianal Cellulitis Preferred Regimen ▸ [[ OR ▸ [[ Alternative Regimen ▸ [[ OR ▸ [[ Facial 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

Special ConsiderationsAdapted from

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

Diabetic Foot Ulcer ▸ Empirical therapy should be started depending on the suspicion of a MRSA infection and the severity of the infection. ▸ Definitive therapy would be directed based on the results of culture and susceptibility tests from wound specimens, as well as the clinical response to the empiric regimen. Neutropenic Patients ▸ Initial therapy consist of empirical broad-spectrum antibiotics. ▸ Definite therapy would depend on the severity of the cellulitis and the isolated pathogen Salt Water Wound Exposure (Vibrio vulnificus) Preferred Regimen ▸ Doxycycline 200 mg IV initial dose, then 50-100 mg IV q12h Alternative Regimen ▸ Cefotaxime OR ▸ Ciprofloxacin Fresh Water Wound Exposure (Aeromonas spp) Preferred Regimen ▸ Ciprofloxacin 400mg IV q12h OR ▸ Ceftazidime PLUS ▸ Gentamicin Alternative Regimen ▸ Meropenem OR ▸ Imipenem-cilastatin Butcher, Fisherman, Veterinarian (Erysipelothrix rhusiopathiae) Preferred Regimen ▸ Amoxicillin 500 mg PO q8hr Alternative Regimen ▸ Ciprofloxacin OR ▸ Cefotaxime OR ▸ Imipenem-cilastatin

Orbital Cellulitis

• Treatment regimens are usually empiric and designed to address the usual pathogens like Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, anaerobes (when intracranial extension is suspected), group A streptococci, and sometimes gram negative bacilli because, in the absence of surgical intervention, reliable culture results are difficult to obtain.

▸ Click on the following categories to expand treatment regimens.

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.
  • 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.

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.