Cellulitis / erysipelas

CAUSATIVE ORGANISMS
  • Streptococci most frequent
  • Staph. aureus less frequent
SEVERITY OF INFECTION
  • MILD: No focal purulence and no systemic signs of infection
  • MODERATE:  Cellulitis/erysipelas with systemic signs of infection (i.e., fever)
  • SEVERE: Failed oral antibiotic, SIRS, immunocompromised, or those with clinical symptoms of deeper infection such as bullae, skin sloughing, hypotension, and end organ dysfunction.
RECOMMENDED TREATMENT
  • Routine blood cultures, cutaneous aspirates, biopsies, and swabs not recommended if does not require hospitalization
  • Blood cultures, cutaneous aspirates, biopsies, and swabs recommended on patients with malignancy receiving chemotherapy, neutropenia, severe cell mediated immunodeficiency, immersion injuries or animal bites, or require hospitalization
  • Elevate affected area if possible and treat predisposing factors  such as edema at site and cutaneous disorders
  • Patient should be hospitalized if (moderate to severe severity):
    • Concern for deeper or necrotizing infection
    • Patient with poor adherence to therapy​​
    • Severely immunocompromised
    • Failed outpatient treatment
    • Severe disease
  • No hospitalization required for individuals with no SIRS, no change in mental status, and no hemodynamic instability (mild severity)​
  • ANTIBIOTICS BY SEVERITY OF INFECTION
    1. MILD - treat for 5 days or more if infection not improved entirely
      1. Amoxicillin/clavulanate 875/125 mg PO BID
      2. Cephalexin 500 mg PO q6h
      3. Clindamycin 300 mg PO QID
      4. Dicloxacillin 500 mg PO QID
    2. MODERATE - treat for 5 days or more if infection not improved entirely
      1. Nafcillin IV 1-2 g q4-6h
      2. Clindamycin 600-900 mg IV q8h
      3. Cefazolin 1gm IV q8h
      4. Vancomycin IV (for patients with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or purulent drainage
    3. SEVERE - treat for 5 days or more if infection not improved entirely
      1. Vancomycin PLUS piperacillin/tazobactam 3.375g IV q8h for severely compromised patient (malignancy on chemo, neutropenia, severe cell mediated immunodeficiency, immersion injuries or animal bites)

recurrent cellulitis

RECOMMENDED TREATMENT
  1. Treat underlying causes​
  • ​​Edema
  • Obesity
  • Eczema
  • Venous insuffiency
  • Toe web abnormalities​
​  2.  Antibiotics if patient has 3-4 episodes of cellulitis per year despite method to treat/control predisposing factors:
  • PO Penicillin or erythromycin BID for 4-52 weeks (continued as long as predisposing factors persist) for STREP infection
  • Clindamycin 150 mg PO daily or Sulfamethoxazole/Trimethoprim 800/160 mg 1 tab PO BID for STAPH​ infections