Cellulitis_erysipelas Treatment

Choice of Route of Administration for Empiric Treatment

Oral Antibiotics

• If lymphadenopathy, fever and other constitutional signs are not present [eg White blood cell (WBC) <15,000], then may typically treat patient with oral antibiotics on an outpatient basis
  • Given for uncomplicated cellulitis
• If symptoms do not improve or if disease progresses significantly within the first 24-48 hours, parenteral therapy may be needed

Parenteral Antibiotics

• Should be considered in the presence of the following:
  • Presence of signs of toxicity (fever >100.5°F/38°C, tachycardia, hypotension)
  • Rapid progression of erythema
  • Unresponsive/intolerant to oral antibiotic therapy with significant disease progression after 2 days of initiation
  • Presence of indwelling medical device (eg prosthesis, stents)
• Considered in patients with complicated cellulitis and comorbidities [eg diabetes mellitus (DM), peripheral vascular diseases]
• Consider switching to oral therapy after 48 hours if possible

Choice of Antibiotic

• Tailored according to known pathogen, comorbid condition (eg DM), and special situations like water (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, has a previous episode of or is at high risk for MRSA infection, or with indwelling medical device in close proximity to the location of the lesion
• Increased use of biocides (eg antiseptics and disinfectants) during the COVID-19 pandemic has led to the emergence of antimicrobial-resistant organisms 
  • Empiric antimicrobial stewardship should be guided by the local resistance patterns of pathogens 
  • Recent studies show the potential use of antimicrobial fatty acids in developing antibacterial agents to reduce antibiotic resistance

Penicillins (Beta-lactamase Resistant)

• Eg Dicloxacillin, Flucloxacillin, Nafcillin, Oxacillin
• Recommended 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
• Usually sufficient for uncomplicated cellulitis of an extremity caused by streptococci

Aminopenicillin/Beta-lactamase Inhibitors

• Eg Amoxicillin/clavulanic acid, Ampicillin 
• Recommended 1st-line therapy for patients with cellulitis or erysipelas near the eyes or nose
• Considered 2nd-line alternative for patients with severe infection
• Effective and especially useful in the presence of bone or joint infection

Cephalosporins - 1st Generation

• Eg Cefadroxil, Cefalexin, Cefazolin 
• Usually sufficient for mild nonpurulent uncomplicated cellulitis and treatment option for erysipelas
• Active against streptococci and MSSA
• Cefalexin may be used in patients with erysipelas with beta-lactam allergy

Cephalosporins - 2nd and 3rd Generation (Parenteral)

• Eg Ceftriaxone, Cefuroxime 
• Treatment alternative for patients with moderate nonpurulent cellulitis or severe infection
• Usually used empirically in DM patients who have early mild cellulitis
• Active against streptococci and MSSA
• Aminoglycosides may be added if needed

Cephalosporins - Other Generations

• Eg Ceftaroline, Ceftobiprole
• May be considered for patients with MRSA infections

Macrolides

• Eg Clarithromycin, Erythromycin, Roxithromycin
• May be used if patient is allergic to Penicillin
• 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
• Alternative therapy for patients with cellulitis or erysipelas near the eyes or nose
• 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, Tidezolid
• May be used in patients allergic to Penicillin and for complicated cellulitis and erysipelas, or MRSA infections

Quinolones

• Eg Ciprofloxacin, Delafloxacin, 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
• Used in combination with other antibiotics for MRSA and other Gram-positive or Gram-negative organisms and anaerobes

Tetracyclines

• Eg Doxycycline, Minocycline, Omadacycline, Tigecycline
• May be considered for moderate-severe purulent cellulitis, MSSA, and MRSA infections
• May be used in patients allergic to Penicillin
• Tigecycline may be used for treatment of complicated skin infections
  
  • Clinical efficacy is comparable with standard treatment

Other Antibiotics

• Clindamycin
  
  • Used in patients allergic to Penicillin and cephalosporins
  • Alternative therapy for patients with nonpurulent or purulent cellulitis caused by MSSA or MRSA infection or severe infection

• Co-trimoxazole
  
  • Used for nonpurulent cellulitis and moderate purulent cellulitis
  • Treatment option for patients with erysipelas with beta-lactam allergy
  • Has very good activity against community-acquired MRSA but not to streptococci

• Dalbavancin, Oritavancin, Telavancin
  
  • Lipoglycopeptide antibacterials 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 Ampicillin/sulbactam, Piperacillin/tazobactam, Ticarcillin/clavulanate, or Ceftriaxone/Ciprofloxacin/Levofloxacin plus Metronidazole is recommended for patients with purulent cellulitis caused by MRSA infection and other Gram-positive or Gram-negative organisms and anaerobes
  • 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 intravenous drug use
  • Daptomycin is an alternative option if Vancomycin is unavailable

• Teicoplanin
  
  • Alternative to Vancomycin for patients with cellulitis caused by gram-positive organisms including MRSA

Length of Therapy

Uncomplicated/Purulent/Nonpurulent Cellulitis and Erysipelas

• Patient may be treated with antibiotics for 5 to 14 days depending on clinical response

Complicated Cellulitis

• 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
• Patients with peripheral vascular disease, chronic venous stasis, diabetes mellitus or alcoholic cirrhosis may take 1-2 weeks to improve and often require 3-4 weeks of treatment

Adjunct Therapy

Corticosteroids

• Eg Prednisolone, Prednisone
• Studies showed that when used in combination with antibiotics, healing time of lesions are reduced
• Should be considered in nondiabetic patients
  
  
  

• Immobilization and elevation of affected limb
  
  • Effects: May help to decrease swelling and pain especially if used early in the course of treatment, and may also shorten time to recovery

• Dressings
  
  • Cool sterile saline dressing may be applied
  • Effects: Remove purulent exudate from ulcers or infected abrasions, may help decrease local pain

• Compression stockings
  
  • May help with edema