Treatment
4
Erysipelas and Cellulitis
Î Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT
routinely recommended (SR-M).
Î Cultures of blood are recommended (SR-M), and cultures and
microscopic examination of cutaneous aspirates, biopsies, or swabs
should be considered in patients with malignancy on chemotherapy,
neutropenia, severe cell-mediated immunodeficiency, immersion
injuries, and animal bites (WR-M).
Î Typical cases of cellulitis without systemic signs of infection should
receive an antimicrobial agent that is active against streptococci
(See Fig. 1/Nonpurulent/MILD) (SR-M). For cellulitis with systemic
signs of infection (See Fig. 1/Nonpurulent/MODERATE) systemic
antibiotics are indicated. Many clinicians could include coverage
against methicillin-susceptible S. aureus (MSSA) (WR-L). For patients
whose cellulitis is associated with penetrating trauma, evidence of
MRSA infection elsewhere, nasal colonization with MRSA, injection
drug use, or SIRS (See Fig. 1/Nonpurulent/SEVERE), vancomycin or
another antimicrobial effective against both MRSA and streptococci
is recommended (SR-M). In severely compromised patients as
defined above (See Fig. 1/Nonpurulent/SEVERE) broad-spectrum
antimicrobial coverage may be considered (WR-M). Vancomycin
plus either piperacillin-tazobactam or imipenem/meropenem is
recommended as a reasonable empiric regimen for severe infections
(SR-M).
Î The recommended duration of antimicrobial therapy is 5 days, but
treatment should be extended if the infection has not improved within
this time period (SR-H).
Î Elevation of the affected area and treatment of predisposing factors,
such as edema or underlying cutaneous disorders, are recommended
(SR-M).
Î In lower extremity cellulitis, clinicians should carefully examine
the interdigital toe spaces because treating fissuring, scaling, or
maceration may eradicate colonization with pathogens and reduce the
incidence of recurrent infection (SR-M).
Î Outpatient therapy is recommended for patients who do not have
SIRS, altered mental status, or hemodynamic instability (See Fig. 1/
Nonpurulent/MILD) (SR-M). Hospitalization is recommended if there
is concern for a deeper or necrotizing infection, for patients with poor
adherence to therapy, for infection in a severely immunocompromised
patient or if outpatient treatment is failing (See Fig. 1/Nonpurulent/
MODERATE or SEVERE) (SR-M).
