Cellulitis medical therapy
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindvarjhulla, M.B.B.S.
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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.
Medical Therapy
Since the most common causative pathogen of cellulitis is Staphylococcus aureus, a gram positive bacteria, the disease is 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 few factors:
- Age of the individual
- 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
The classifications of cellulitis that are accounted for by different antibiotic therapies are:
Uncomplicated Cellulitis
- In cases of simple infection without abscesses or draining, dicloxacillin, amoxacillin or first generation cephalosporins like cephalexin are used.
- Patients allergic to penicillin drugs can be given macrolide antibiotics like azithromycin.
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)."[1]
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."[2] A mroe recent trial confirms that if purulence or diabetes are not present then coverage for staphylococcus aureus is not needed.[3]
A study of failed treatment concluded that failure is reduced if:[4]
- Higher dose antibiotics are used:
- vancomycin at least 30 mg/kg/day
- clindamycin at least 10 mg/kg/day (450 mg every 8 hours)
- Trimethoprim-Sulfamethoxazole combination 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.[5] However, levoflaxacin 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 ceftrioxone, 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.
Special Cases
- MRSA - Methicillin resistant Staphylococcus Aureus.
- MRSA is commonly the causative agent of cellulitis in cases presenting with abscesses.[6]
- In mild cases, treatment will be trimoxazole with doxycycline.
- In severe cases, the most cost effective therapy will be vancomycin.[7]
- Bite Wounds (Mammalian).
- Bite wounds suffered from a mammal often contain polymicrobial sources that are anaerobic in nature.[8]
- 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.[9]
- 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
- ↑ 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.
- ↑ Stevens DL, Bisno AL, Chambers HF; et al. (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clin. Infect. Dis. 41 (10): 1373–406. doi:10.1086/497143. PMID 16231249. Unknown parameter
|month=ignored (help) - ↑ Pallin DJ, Binder WD, Allen MB, Lederman M, Parmar S, Filbin MR; et al. (2013). "Clinical Trial: Comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole vs. cephalexin alone for treatment of uncomplicated cellulitis: A randomized controlled trial". Clin Infect Dis. doi:10.1093/cid/cit122. PMID 23457080.
- ↑ Halilovic J, Heintz BH, Brown J (2012). "Risk factors for clinical failure in patients hospitalized with cellulitis and cutaneous abscess". J Infect. doi:10.1016/j.jinf.2012.03.013. PMID 22445732.
- ↑ Hepburn, Matthew J (2004-08-09). "Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis". Archives of Internal Medicine. 164 (15): 1669–1674. doi:10.1001/archinte.164.15.1669. ISSN 0003-9926. PMID 15302637. Retrieved 2009-09-01. Unknown parameter
|coauthors=ignored (help) - ↑ Moran GJ, Krishnadasan A, Gorwitz RJ; et al. (2006). "Methicillin-resistant S. aureus infections among patients in the emergency department". N. Engl. J. Med. 355 (7): 666–74. doi:10.1056/NEJMoa055356. PMID 16914702. Unknown parameter
|month=ignored (help) - ↑ Stryjewski ME, Chambers HF (2008). "Skin and soft-tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus". Clin. Infect. Dis. 46 Suppl 5: S368–77. doi:10.1086/533593. PMID 18462092. Unknown parameter
|month=ignored (help) - ↑ 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) - ↑ 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.