Cellulitis Empiric Therapy
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The publication of Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections 2014 – Update by the Infectious Diseases Society of America addresses an array of skin and soft tissue infections (SSTIs), emphasizing the clinical skills needed to properly treat the likely pathogens before and after culture results are available. [1]
The empiric treatment of cellulitis in adults begins with the categorization of patients into one of the following categories:
Nonpurulent cellulitis: Includes rapidly spreading superficial cellulitis and erysipelas; typically involves groups A, B, C, and G beta-hemolytic streptococci and, occasionally, methicillin-susceptible Staphylococcus aureus (MSSA) ; these infections are diagnosed clinically, and cultures are not mandatory since there is usually no reliable and easily accessible source of specimen to culture [1, 2, 3, 4]
Purulent cellulitis: Includes cutaneous abscesses, carbuncles, furuncles, and sebaceous cyst infection typically involving S aureus, both MSSA and methicillin-resistant S aureus (MRSA); culture should be performed when possible to determine the pathogen’s presence and resistance pattern [1, 5, 6, 7, 8]
Outpatient therapy with oral antibiotics is indicated for healthy individuals who have no evidence of systemic inflammatory response syndrome (SIRS). [1]
Inpatient therapy with parenteral antibiotics is recommended for patients with associated SIRS, hemodynamic instability, and/or mental status changes. Poor compliance, failure to respond to oral antibiotics, facial involvement, and immune suppression are additional indications for inpatient parenteral therapy until the patient is stable and improving. The initial antibiotic selection should cover MRSA for patients with coexisting penetrating and/or surgical trauma, evidence of MRSA infection elsewhere, known nasal MRSA colonization, and intravenous drug abuse. Coverage should also take into consideration the prevalence of MRSA in the patient’s hospital and community. [1, 6]
Outpatient treatment recommendations are as follows: [1, 4]
Dicloxacillin 500 mg PO q6h*
Cephalexin 500 mg PO q6h*
Amoxicillin/clavulanate 875 mg/125 mg PO q12h*
Clindamycin 300 mg PO q6-8h*
Inpatient treatment recommendations are as follows:
Nafcillin or oxacillin 1-2 g IV q4h**
Cefazolin 1-2 g IV q8h**
Clindamycin 600-900 mg IV q8h**
* Total duration of therapy is typically 5-7 days. Extend therapy if cellulitis is slow to respond. [9]
** Parenteral antibiotics are given 1-3 days until the patient is stabilized and improving; then, transition to oral antibiotics for the duration of therapy. [1]
Considerations are as follows: [5, 6, 7, 8]
If abscess is present, drainage is required.
Drainage of abscess without associated cellulitis may be sufficient therapy.
Consider antibiotics if cellulitis is present.
Gram stain and culture are indicated to determine presence and resistance pattern of pathogen.
Outpatient treatment recommendations (MRSA prevalent) are as follows:
Doxycycline or minocycline 200 mg PO followed by 100 mg PO q12h*
Trimethoprim-sulfamethoxazole (160 mg/800 mg) 1-2 tabs PO q12h*
Linezolid 600 mg PO q12h*§
Clindamycin 300-600 mg PO q6-8h*∞
Inpatient treatment recommendations (MRSA prevalent) are as follows:
Vancomycin 15 mg/kg IV q12h followed by dosage adjustment based on trough levels maintained between 10 and 20 µg/mL and serial renal function**
Daptomycin 4 mg/kg IV q24h (q48h if creatinine clearance [CrCl] < 30 mL/min)**
Linezolid 600 mg IV q12h**
Ceftaroline 600 mg IV q12h (dose reduction required if CrCl ≤50 mL/min)**
* Total duration of therapy is 7-14 days. Extend therapy if cellulitis is slow to respond. [1, 6]
** Parenteral antibiotics given 1-3 days until patient debrided, stabilized, and improving; then, transition to oral antibiotics for the duration of therapy. [1]
§ Expensive
∞ Requires special sensitivity testing (DTEST) to exclude hidden (inducible) resistance. [10]
Once microorganisms are identified based on cultures, treatment is tailored to the patient’s needs. The most common offenders (beta-hemolytic streptococci, MSSA, MRSA) are discussed in Cellulitis Organism-Specific Therapy.
Similarly, empiric therapy in patients with cellulitis involving specific clinical situations (ie, marine exposure, fresh water exposure, nonhuman mammalian bites, human bites, diabetic foot wounds, recurrent cellulitis, facial cellulitis/erysipelas/periorbital cellulitis, surgical site infections, immunosuppressive states, necrotizing cellulitis/Fournier gangrene) is beyond the scope of this article.
Unusual forms of SSTI (ie, clostridial myonecrosis, pyomyositis, cutaneous anthrax, erysipeloid, glanders, tularemia, plague, and bacillary angiomatosis), are discussed in separate Medscape topics.
Overview
What guidelines have been published for cellulitis empiric therapy?
How are adult patients categorized for the empiric treatment of cellulitis?
What are indications for outpatient and inpatient therapy in cellulitis empiric therapy?
What are the indications for organism-specific therapy for cellulitis?
[Guideline] Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline].
Jeng A, Beheshti M, Li J, Nathan R. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore). 2010 Jul. 89(4):217-26. [Medline].
Eriksson B, Jorup-Ronstrom C, Karkkonen K, Sjoblom AC, Holm SE. Erysipelas: clinical and bacteriologic spectrum and serological aspects. Clin Infect Dis. 1996 Nov. 23(5):1091-8. [Medline].
Pallin DJ, Binder WD, Allen MB, Lederman M, Parmar S, Filbin MR, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis. 2013 Jun. 56(12):1754-62. [Medline].
Stryjewski ME, Chambers HF. Skin and soft-tissue infections caused by community-acquired methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2008 Jun 1. 46 Suppl 5:S368-77. [Medline].
[Guideline] Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK, Gorwitz RJ, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011 Feb 1. 52(3):e18-55. [Medline].
Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE, McDougal LK, Carey RB, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006 Aug 17. 355(7):666-74. [Medline].
Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007 Jul 26. 357(4):380-90. [Medline].
Hepburn MJ, Dooley DP, Skidmore PJ, Ellis MW, Starnes WF, Hasewinkle WC. Comparison of short-course (5 days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. 2004 Aug 9-23. 164(15):1669-74. [Medline].
Fiebelkorn KR, Crawford SA, McElmeel ML, Jorgensen JH. Practical disk diffusion method for detection of inducible clindamycin resistance in Staphylococcus aureus and coagulase-negative staphylococci. J Clin Microbiol. 2003 Oct. 41(10):4740-4. [Medline]. [Full Text].
Alfred Scott Lea, MD Associate Professor of Medicine, Department of Medicine, Division of Infectious Diseases, University of Texas Medical Branch School of Medicine
Alfred Scott Lea, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Infectious Diseases Society of America, Texas Medical Association, Harris County Medical Society, American College of Certified Wound Specialists
Disclosure: Nothing to disclose.
George Samuel, MDCM, MSc Fellow in Infectious Diseases, University of Texas Medical Branch School of Medicine
George Samuel, MDCM, MSc is a member of the following medical societies: American College of Physicians, American Society for Microbiology
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London
Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.
Eric S Halsey, MD Head, Virology Department, Naval Medical Research Unit No. 6, Lima, Peru; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences
Eric S Halsey, MD is a member of the following medical societies: Armed Forces Infectious Diseases Society, HIV Medicine Association of America, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.
Isaac P Humphrey, MD Assistant Professor of Internal Medicine, Uniformed Services University of the Health Sciences; Clinical Assistant Professor of Internal Medicine, Wright State University Boonshoft School of Medicine
Isaac P Humphrey, MD is a member of the following medical societies: American College of Physicians
Disclosure: Nothing to disclose.
Cellulitis Empiric Therapy
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