Cellulitis_erysipelas%20(pediatric) Treatment

Choice of Route of Administration for Empiric Treatment

Oral Antibiotics

• If lymphadenopathy, fever and other constitutional signs are not present [eg white blood cells (WBC) <15,000], then may typically treat patient with oral antibiotics on an outpatient basis

Parenteral Antibiotics

• Should be considered in the presence of the following: 
  • If symptoms do not improve or if disease progresses significantly after 48-72 hours of oral antibiotic therapy initiation
  • Presence of systemic toxicity (fever >38˚C, hypotension, tachycardia)
  • Rapid progression or persistence of erythema
  • Immunocompromised patients
• If lymphadenopathy, fever or constitutional signs are present
• Neonates and children <5 years should be admitted and given initial parenteral therapy
• Considered in patients with comorbidities [eg diabetes mellitus (DM), peripheral vascular diseases]

Choice of Antibiotic

• Tailored according to known pathogen, severity of symptoms, site of infection, comorbid condition, and special situations like water (eg salt or freshwater) exposure or animal bites
  
  • Treatment should also address underlying predisposing conditions
• Empiric therapy may be started pending culture results
  
  • For patients with purulent cellulitis, treatment is directed towards Methicillin-resistant S aureus (MRSA) since it is the dominant pathogen in this type of cellulitis; therapy for beta-hemolytic streptococci is likely not needed
  • For patients with nonpurulent cellulitis, treatment is directed towards Methicillin-sensitive S aureus (MSSA) and beta-hemolytic streptococci
    
    • Empiric therapy for MRSA may be needed if patient has signs of systemic infection, is unresponsive to initial therapy, has recurrent infection, or has a previous episode of or is at high risk for MRSA infection

Penicillins (Beta-Lactamase Resistant)

• Eg Dicloxacillin, Flucloxacillin, Nafcillin, Oxacillin 
• Recommended 1st-line therapy for patients with erysipelas, moderate nonpurulent and purulent cellulitis, and MRSA infection
• Recommended antibiotics against mild nonpurulent cellulitis caused by group A Streptococcus or S aureus
  
  • Some authorities recommend antistaphylococcal penicillin alone while others advocate antistaphylococcal penicillin + Penicillin or Amoxicillin
  • Combination may increase adverse effects 
• Recommended for initial treatment of neonates with moderate to severe cellulitis
• Also recommended for recurrent cellulitis

Penicillin G [Intravenous (IV)]

• Used for erysipelas and moderate nonpurulent uncomplicated cellulitis
• Treatment option for patients with recurrent cellulitis
• Observe patient for localized S aureus infection

Aminopenicillin/Beta-Lactamase Inhibitors

• Eg Amoxicillin/clavulanic acid
• Recommended 1st-line therapy for patients with cellulitis or erysipelas near the eyes or nose 
• Considered alternative 1st-line therapy
• Alternative treatment option for patients with severe infection
• Effective and especially useful in the presence of bone or joint infection

Cephalosporins - 1st Generation

• Eg Cefadroxil, Cefalexin, Cefazolin 
• If staphylococcal infection is suspected
• Usually sufficient for mild nonpurulent uncomplicated cellulitis

Cephalosporins - 2nd and 3rd Generation (Parenteral)

• Eg Ceftriaxone, Cefuroxime 
• Usually used empirically in diabetes mellitus (DM) patients who have early mild cellulitis
• Treatment alternative for patients with moderate nonpurulent cellulitis
• Alternative treatment option for patients with severe infection

Macrolides

• Eg Clarithromycin, Erythromycin, Roxithromycin
• May be used if patient is allergic to Penicillin
• Alternative therapy for patients with cellulitis or erysipelas near the eyes or nose
• Macrolide resistance among Group A Streptococci has increased and has become a concern in some countries
• Erythromycin is the main macrolide used unless Erythromycin resistance is widespread in the community
• Also used for prophylactic treatment against recurrent cellulitis
• Studies showed that the efficacy of Roxithromycin for erysipelas was comparable to that of Benzylpenicillin

Oxazolidinones

• Eg Linezolid, Tedizolid
• Alternative to Vancomycin or Teicoplanin in the treatment of MRSA infections in combination with other antibiotics
• Used in patients allergic to Penicillin and for complicated cellulitis and erysipelas

Quinolones

• Eg Ciprofloxacin, Levofloxacin, Moxifloxacin, Ofloxacin
• Those that have enhanced activity against Gram-positive bacteria have been shown to be effective
• Used for cellulitis caused by Vibrio vulnificus
• Not recommended for patients living in MRSA-prevalent regions

Tetracyclines

• Eg Doxycycline, Minocycline
• May be considered for moderate-severe purulent cellulitis, MSSA, and MRSA infections

Other Antibiotics

• Clindamycin
  • Used in patients allergic to Penicillin and cephalosporins
  • Alternative therapy for patients with nonpurulent or purulent cellulitis caused by Methicillin-sensitive S aureus (MSSA) or Methicillin-resistant S aureus (MRSA) infection
  • Alternative treatment option for patients with severe infection

• Co-trimoxazole
  • Used for nonpurulent cellulitis and moderate purulent cellulitis
  • Has very good activity against community-acquired MRSA but not to streptococci

• Dalbavancin
  • Lipoglycopeptide antibacterial with properties similar to Vancomycin that may be considered for complicated cellulitis caused by Gram-positive organisms including MRSA

• Vancomycin
  • Treatment option for patients allergic to Penicillin
  • Combination with Piperacillin/tazobactam or Imipenem/Meropenem is recommended for patients with severe nonpurulent cellulitis
  • Combination with Cefotaxime or Gentamicin is recommended as 1st-line parenteral treatment for neonates with MRSA infections
  • Also used for patients with penetrating trauma, nasal colonization with MRSA, and IV drug use
  • Recommended empirical treatment for neonates with nonpurulent cellulitis in combination Cefotaxime or Gentamicin
• Teicoplanin
  • Used in combination with other antibiotics for the treatment of MRSA infections

Length of Therapy

• It is typically recommended that once erythema, warmth and edema have subsided significantly, patient  may be treated for an additional 10 days with oral antibiotics
• A 5- to 7-day course of antibiotics active against streptococci is recommended for patients with nonpurulent cellulitis
• Antibiotic therapy for neonates is usually administered for 7-14 days; 5-10 days for patients >1 month
  • Treatment duration may be extended for severe cases

Adjunct Therapy
Corticosteroids

• Eg Prednisolone
• When used in combination with antibiotics result to earlier switch from IV to oral antibiotics, shorter hospital stay, reduced healing time of lesions and may lower risk of recurrence

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

• Eg Ibuprofen
• Helps to accelerate resolution of cellulitis when combined with antibiotics