Sandbox/Alejandro

Medical Therapy

• 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.
• 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.
• Optimal dose should be based on determination of serum concentrations.
• 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.

Therapy based on Anatomical LocationAdapted from

A specific therapy should be given for the following anatomical location due to an increase predisposition of certain bacteria.

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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.

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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 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 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)