Cellulitis Organism-Specific Therapy 

Updated: Dec 11, 2014
  • Author: Alfred Scott Lea, MD; Chief Editor: Michael Stuart Bronze, MD  more...
  • Print

Specific Organisms and Therapeutic Regimens

Organism-specific therapeutic regimens for cellulitis are provided below, including those for group A beta-hemolytic streptococci (GABHS) [1] and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). [2, 3, 4, 5, 6, 7]

The Infectious Diseases Society of America (IDSA) published 2014 guidelines for the treatment of cellulitis (see Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America). [8]

GABHS

Outpatient treatment recommendations:

Inpatient treatment recommendations:

  • Nafcillin 2 g IV q4h for 1-3d or
  • Clindamycin 600-900 mg IV q8h

CA-MRSA

Outpatient treatment recommendations:

  • No single agent demonstrates superiority; use sensitivities to guide therapy if available
  • Doxycycline 100 mg PO BID for 10-14d (not for use in pregnant women or in children) or
  • Clindamycin 300-600 mg PO q8h for 10-14d or
  • Trimethoprim-sulfamethoxazole (160 mg/800 mg) DS 2 tablets PO BID for 10-14d or
  • Linezolid 600 mg PO BID for 10-14d
  • Some CA-MRSA strains have inducible resistance, and this may result in treatment failure; a D-test can be performed by microbiology to look for this

Inpatient treatment recommendations:

  • Vancomycin 15 mg/kg IV q12h for 1-3d; draw level 0.5h before 5th dose if checking levels or
  • Daptomycin (creatinine clearance [CrCl] > 30 mL/min): 4 mg/kg IV q24h infused over 30min or
  • Tigecycline 100 mg IV as a single dose; then 50 mg IV q12h

Adjunctive therapy

Elevation of the affected extremity may speed resolution.

Consider surgical consultation in the following cases:

  • Urgent consultation with a surgeon should be sought in the setting of crepitus, circumferential cellulitis, necrotic-appearing skin, rapidly evolving cellulitis, pain disproportional to physical examination findings, severe pain on passive movement, or other findings that raise clinical concern for necrotizing fasciitis
  • Serious concern for necrotizing fasciitis or the presence of necrotic skin should prompt examination of the fascial planes by direct observation; this can be performed at the bedside by an experienced surgeon in most cases
  • Circumferential cellulitis may result in compartment syndrome, and surgical decompression may be necessary; measurement of compartment pressures may be helpful in diagnosis
  • Cellulitis associated with an abscess requires surgical drainage of the source of infection for adequate treatment