Acute cellulitis and erysipelas in adults: Treatment

Official reprint from UpToDate® www.uptodate.com

©2024 UpToDate®

Acute cellulitis and erysipelas in adults: Treatment

Authors: Denis Spelman, MBBS, FRACP, FRCPA, MPH, Larry M Baddour, MD, FIDSA, FAHA
Section Editor: Sandra Nelson, MD
Deputy Editor: Keri K Hall, MD, MS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Dec 2023. | This topic last updated: Dec 15, 2023.

INTRODUCTION

Patients with skin and soft tissue infection may present with cellulitis, abscess, and other
forms of infection [1-3].

This topic will discuss treatment of cellulitis and erysipelas. (Related Pathway(s): Cellulitis
and skin abscesses: Empiric antibiotic selection for adults.)

Clinical manifestations and diagnosis of cellulitis and erysipelas are discussed separately.
(See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and
diagnosis".)

Treatment of skin abscess is discussed elsewhere. (See "Skin abscesses in adults:

Treatment".)

DIFFERENTIATING CELLULITIS FROM ERYSIPELAS

Effective treatment of cellulitis and erysipelas depends on determining the most likely
microorganism causing the infection. Beta-hemolytic streptococci cause most erysipelas
infections and most cellulitis infections, but cellulitis is sometimes caused by
Staphylococcus aureus and occasionally by a multitude of other organisms.

Examination and clinical features cannot always differentiate erysipelas from cellulitis, so
we treat for cellulitis whenever we are uncertain. Both erysipelas and cellulitis manifest as
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Acute cellulitis and erysipelas in adults: Treatment

areas of skin erythema, edema, and warmth. On physical examination, classic erysipelas
presents as a bright red patch of skin with a clearly demarcated raised border ( picture 1
and picture 2). Cellulitis involves deeper layers of the skin, so it classically presents with
indistinct borders that are not raised ( picture 3 and picture 4).

Details regarding the clinical presentation and diagnosis of erysipelas and cellulitis are
found elsewhere. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical
manifestations, and diagnosis", section on 'Cellulitis and erysipelas'.)

DETERMINING THE SITE OF CARE

Cellulitis and erysipelas can both cause rapidly progressive and severe illness. Initial
assessment of these infections should focus on determining the severity of illness and
whether hospitalization is indicated.

Hospitalization is indicated for most individuals who warrant parenteral antibiotics and for
all patients who are suspected to have high-risk "red-flag" conditions.

"Red-flag" conditions that warrant hospitalization — Red-flag conditions warrant

immediate hospitalization, and some require urgent surgical intervention. Findings that
increase suspicion for these conditions include severe sepsis or septic shock, rapidly
progressive infection, or pain out of proportion to exam findings. Because of high
morbidity and mortality, such conditions should be considered as part of the initial
assessment of every individual with skin and soft tissue infection. Diagnosis and
management of these conditions are discussed elsewhere.

● Toxic shock syndrome – (See "Invasive group A streptococcal infection and toxic
shock syndrome: Epidemiology, clinical manifestations, and diagnosis" and "Invasive
group A streptococcal infection and toxic shock syndrome: Treatment and
prevention" and "Staphylococcal toxic shock syndrome".)

● Necrotizing soft tissue infection (eg, necrotizing fasciitis) – (See "Necrotizing soft
tissue infections".)

● Joint involvement (with or without prosthesis) – (See "Septic arthritis in adults"

and "Prosthetic joint infection: Epidemiology, microbiology, clinical manifestations,
and diagnosis" and "Prosthetic joint infection: Treatment".)
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● Involvement of vascular graft – (See "Overview of the evaluation and management
of surgical site infection", section on 'Deep infection associated with implanted
materials'.)

● Pyomyositis – (See "Primary pyomyositis".)

● Clostridial myonecrosis (gas gangrene) – (See "Clostridial myonecrosis".)

● Deep venous thrombosis (DVT) - (See "Clinical presentation and diagnosis of the
nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)

● Compartment syndrome – (See "Acute compartment syndrome of the extremities"

and "Pathophysiology, classification, and causes of acute extremity compartment
syndrome".)

Indications for parenteral therapy — The decision to initiate parenteral therapy is

typically based on the extent and severity of infection and patient comorbidities. Patients
who meet criteria for parenteral therapy are usually admitted to the hospital to ensure
prompt administration and close observation.

For individuals with cellulitis or erysipelas without red-flag conditions, we suggest initial
treatment with parenteral antibiotics in the following circumstances:

● Systemic signs of toxicity such as fever >100.5°F/38°C, hypotension, or sustained

tachycardia (refractory hypotension should prompt consideration of toxic shock
syndrome).

● Rapid progression of erythema (eg, doubling of the affected area within 24 hours; in
particular, expansion over a few hours with severe pain should prompt consideration
of necrotizing fasciitis).

● Extensive erythema.

● High-risk neutropenia [4]. Patients with neutropenia are classified as low- or high-risk
based on scoring mechanisms that consider the anticipated duration of neutropenia,
comorbidities, and severity of illness; such scoring systems are discussed separately.
(See "Overview of neutropenic fever syndromes", section on 'Risk of serious
complications'.)

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Acute cellulitis and erysipelas in adults: Treatment
● Inability to tolerate or absorb oral therapy

For patients with lymphangitis accompanying cellulitis, some UpToDate contributors would
administer parenteral antibiotics because they believe that lymphangitis may be indicative
of imminent bacteremia; there are minimal published data to support or refute this notion.

For immunocompromised patients with low-risk neutropenia or a non-neutropenic form of

immunocompromise, we have a lower threshold for admission for IV antibiotics than we
do for immunocompetent patients. Ultimately, clinical judgment is necessary and should
consider the severity of infection, type of underlying immunocompromise, and ability for
close follow-up in the outpatient setting.

ACUTE CELLULITIS

The pillars of cellulitis treatment are antibiotic therapy and management of exacerbating
conditions, including the point of entry of infection. (See 'Considerations prior to selecting
antibiotics' below and 'Adjunctive treatments' below.)

Considerations prior to selecting antibiotics — At the time of presentation, selection of

empiric antibiotic therapy is based on determining the most likely pathogen. In most
cases, the causative pathogen is never identified. If a pathogen is identified, antibiotics
should be narrowed to target the pathogen.

Factors that should be considered when choosing antibiotics for acute cellulitis include the
severity and location of the cellulitis and whether coverage for methicillin-resistant S.
aureus (MRSA) or atypical organisms is necessary. These issues are discussed in the
sections that follow.

Pathogens to always cover — Empiric antibiotics for cellulitis should always cover beta-
hemolytic streptococci and methicillin-sensitive S. aureus (MSSA), which are the two most
common pathogens of cellulitis [1-3]. Further details regarding the microbiology of
cellulitis are discussed elsewhere ( table 1). (See "Cellulitis and skin abscess:
Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Cellulitis
and erysipelas'.)

Indications for MRSA coverage — Empiric coverage for MRSA is indicated for patients
with severe sepsis, certain MRSA risk factors, and those who have increased morbidity if
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suboptimal antibiotics are administered. Conditions that warrant MRSA coverage include
the following [2,5]:

● Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, sustained

tachycardia)
● Cellulitis with purulent wound drainage
● Known MRSA colonization or infection
● Injection drug use
● High-risk neutropenia

Other risk factors may not be as strongly associated with MRSA infection, so we
individualize the decision for MRSA coverage in such cases. For a complete list of risk
factors for MRSA, refer to the table ( table 2).

Wounds and exposures that warrant specific coverage — A broad range of organisms
can cause cellulitis in individuals with wounds, injuries, or certain environmental exposures
( table 1). Antibiotic regimens for these conditions are distinct and discussed in detail
elsewhere.

● Wounds and injuries

• Diabetic foot ulcers – (See "Clinical manifestations, diagnosis, and management of

diabetic infections of the lower extremities", section on 'Management'.)

• Animal bites – (See "Animal bites (dogs, cats, and other mammals): Evaluation and
management", section on 'Management'.)

• Human bites – (See "Human bites: Evaluation and management", section on

'Infected bites'.)

• Puncture wounds other than bites – (See "Infectious complications of puncture

wounds".)

• Pressure injury or pressure ulcer – (See "Infectious complications of pressure-

induced skin and soft tissue injury".)

• Surgical wound – (See "Overview of the evaluation and management of surgical

site infection".)

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● Environmental exposures

• Water exposure – (See "Soft tissue infections following water exposure".)

• Soil exposure - (See "Infectious complications of puncture wounds".)

• Travel-related skin infections – (See "Skin lesions in the returning traveler" and
"Melioidosis: Epidemiology, clinical manifestations, and diagnosis", section on
'Skin infection'.)

Anatomic site of infection — Cellulitis can occur on any part of the body. Depending on
the location of cellulitis, antibiotic selection and other interventions, including surgery, can
vary.

● Cellulitis of the extremities – The extremities are the most common site of cellulitis.
In the absence of a red-flag condition or other indication for broadened antibiotic
coverage, treatment focuses on beta-hemolytic streptococci and S. aureus. (See '"Red-
flag" conditions that warrant hospitalization' above and 'Selecting an antibiotic
regimen' below.)

If cellulitis involves the hand, hospitalization is typically recommended along with

evaluation by a surgeon. Management of hand infections is discussed in depth
elsewhere. (See "Overview of hand infections".)

● Facial cellulitis – Facial skin infections are more often due to erysipelas than
cellulitis. Treatment of facial cellulitis focuses on beta-hemolytic streptococci and S.
aureus. (See 'Selecting an antibiotic regimen' below.)

If the area around the eye is cellulitic, differentiation of preseptal (periorbital) from
orbital cellulitis is paramount. Preseptal cellulitis is generally a mild infection of the
skin around the eye, whereas orbital cellulitis involves the deeper tissues of the eye
and can lead to loss of vision or even loss of life. Rarely, infections involving the
medial third of the face (ie, the areas around the eyes and nose) can be complicated
by septic cavernous thrombosis, a life-threatening disease. More details regarding
diagnosis and management of preseptal and orbital cellulitis, as well as septic
cavernous thrombosis, are found elsewhere. (See "Preseptal cellulitis" and "Orbital
cellulitis" and "Septic dural sinus thrombosis".)

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● Neck cellulitis – Cellulitis of the neck is uncommon. When present, consideration
should be given to underlying deep neck space infection or submandibular space
infection (Ludwig angina), both of which require urgent evaluation and management.
Diagnosis and management of deep neck space infections are discussed elsewhere.
(See "Deep neck space infections in adults" and "Ludwig angina".)

● Breast cellulitis – Breast cellulitis is usually due to beta-hemolytic streptococci or S.

aureus and is managed similarly to uncomplicated cellulitis, as described below (see
'Selecting an antibiotic regimen' below). Additional considerations regarding the
management of breast cellulitis are found elsewhere. (See "Breast cellulitis and other
skin disorders of the breast", section on 'Treatment'.)

● Cellulitis of the abdominal wall – Most reports of abdominal-wall cellulitis of adults

are in individuals with surgical site infection, abdominal-wall mesh infection, or intra-
abdominal conditions such as appendicitis or colon cancer. In each of these
situations, both surgical intervention and antibiotic therapy are usually necessary for
management [6-17]. Management of these conditions is discussed elsewhere. (See
"Overview of the evaluation and management of surgical site infection" and "Wound
infection following repair of abdominal wall hernia".)

Few reports of idiopathic abdominal-wall cellulitis exist, but the infection is probably
more common than the medical literature suggests. In a case series of 260 patients
with cellulitis and morbid obesity between 1998 and 2003, 24 (9 percent) had
idiopathic abdominal-wall cellulitis [18]. Of those 24 patients, 17 (71 percent) had a
remote history of healed abdominal surgery, 10 (42 percent) had diabetes mellitus, 7
(29 percent) experienced recurrences, and 3 (13 percent) underwent surgical
debridement and/or panniculectomy. Eleven (46 percent) had an underlying
dermatologic condition of the abdominal wall, most commonly lymphedema and/or
intertrigo.

No studies have evaluated treatment of idiopathic abdominal-wall cellulitis. We use

the same approach as for cellulitis in general. (See 'Selecting an antibiotic regimen'
below.)

We suggest treating underlying dermatologic and other contributing conditions, such

as intertrigo, while the patient is receiving antimicrobial therapy.

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Acute cellulitis and erysipelas in adults: Treatment
● Cellulitis of the perineum or genitalia – Skin infections of the perineum and
genitals can be due to cellulitis, folliculitis, or other etiologies. Of most concern is
Fournier gangrene, a polymicrobial necrotizing fasciitis of the perineum that can
involve the lower abdominal wall, the penis and scrotum in men, and the labia in
women. Fournier gangrene is a medical and surgical emergency with a high fatality
rate. Details regarding diagnosis and management of Fournier gangrene are found
elsewhere. (See "Necrotizing soft tissue infections".)

Selecting an antibiotic regimen — The first step when selecting an initial antibiotic
regimen for cellulitis is to determine whether providing coverage beyond beta-hemolytic
streptococci and S. aureus is necessary. Certain conditions, exposures, or anatomic sites
often require broader antibiotic coverage than standard regimens, and antibiotic selection
for those conditions is discussed elsewhere ( table 1). (See '"Red-flag" conditions that
warrant hospitalization' above and 'Considerations prior to selecting antibiotics' above.)

For most patients with cellulitis who don't have features that warrant specific
management, our approach depends on the severity of illness, patient's immune status,
and risk for MRSA, as outlined below and in the algorithm ( algorithm 1). (Related
Pathway(s): Cellulitis and skin abscesses: Empiric antibiotic selection for adults.)

In general, our antibiotic recommendations match those of expert guidelines [2].

Patients with severe sepsis — In the setting of severe sepsis, rapid administration of
empiric broad-spectrum antibiotics is indicated because delay or lack of adequate
coverage increases mortality [19,20]. Of note, patients with septic shock, manifest by
refractory hypotension, may have toxic shock syndrome or another red-flag condition and
should be managed accordingly, as discussed elsewhere. (See '"Red-flag" conditions that
warrant hospitalization' above.)

● Initial therapy – We suggest the following antibiotic regimen for patients with severe
sepsis ( algorithm 1):

• Intravenous vancomycin (see table for dosing ( table 3))

PLUS

Cefepime 2 g intravenously (IV) every eight hours

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Other regimens may be more appropriate in certain situations:

• For patients who are known or suspected of having an infection due to an

organism with an extended-spectrum beta-lactamase (ESBL), we suggest using an
empiric carbapenem (eg, meropenem 1 g IV every eight hours) in conjunction with
vancomycin.

• For patients with reported beta-lactam allergies, empiric antibiotic selection

depends on the type and severity of the reaction ( algorithm 2). Patients with
mild, non-immunoglobulin (Ig)E-mediated reactions to penicillins (eg,
maculopapular rash) can usually safely receive cephalosporins; carbapenems are
typically safe in patients who cannot take penicillins or cephalosporins (see
"Choice of antibiotics in penicillin-allergic hospitalized patients"). For patients who
cannot take any beta-lactam agent, we suggest intravenous vancomycin
( table 3) paired with either levofloxacin (750 mg IV once daily) or aztreonam (2 g
IV every eight hours; dosing up to 2 g every six hours may be reasonable for
weight >120 kg). Note that individuals with a history of life-threatening or
anaphylactic reaction to ceftazidime should not be given aztreonam, but
levofloxacin is generally safe.

● Oral step-down therapy – Once clinical improvement and resolution of sepsis occur,
it is generally appropriate to transition to an oral regimen. If a pathogen is identified
during the course of therapy, antibiotics should be narrowed to coverage specific for
that pathogen.

If a pathogen is not identified, stable patients who are not immunocompromised can
generally be transitioned to one of the narrower oral agents described below. (See
'Immunocompetent patients without severe sepsis' below.)

The rationale for using a spectrum that covers pathogens in addition to streptococci and S.
aureus is the risk of poor outcomes with a narrower spectrum of empiric therapy in
severely ill patients if other pathogens are involved.

Immunocompetent patients without severe sepsis — We typically divide this group of

patients into those who warrant MRSA coverage and those who do not ( algorithm 1).
Indications for MRSA coverage are described above. (See 'Indications for MRSA coverage'
above.)
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Without an indication for MRSA coverage — For most patients, antibiotic regimens
that cover beta-hemolytic streptococci and MSSA are effective, and coverage for MRSA is
not necessary [2,5,21,22]. We suggest one of the following regimens ( algorithm 1):

● Oral antibiotic regimens – Many patients with cellulitis of the lower extremity can be
managed with oral antibiotics in the outpatient setting [23]. For such patients, we
suggest one of the following regimens:

• Dicloxacillin 500 mg orally every six hours

• Flucloxacillin 500 to 1000 mg orally every six hours (not available in the United
States)
• Cephalexin 500 mg orally every six hours
• Cefadroxil 500 mg orally every 12 hours or 1 g orally once daily

● Parenteral antibiotic regimens – Parenteral antibiotics are recommended for higher

risk patients (see 'Indications for parenteral therapy' above). For such patients, we
suggest one of the following regimens:

• Cefazolin 1 to 2 g IV every eight hours

• Nafcillin 1 to 2 g IV every four hours
• Oxacillin 1 to 2 g IV every four hours
• Flucloxacillin 2 g IV every six hours (not available in the United States)

For cefazolin, nafcillin, and oxacillin, we usually favor the higher dosages listed above
(ie, 2 g) for treatment of these infections.

Once there is evidence of clinical improvement, parenteral antibiotics should be

switched to one of the oral regimens listed above [24].

Studies suggest that most patients with cellulitis do not need MRSA coverage:

● A randomized trial of adults with nonpurulent cellulitis in five emergency

departments in the United States noted similar clinical cure rates among those
treated with cephalexin plus TMP-SMX and those treated with cephalexin plus
placebo [21]. In the per-protocol analysis, 182 (84 percent) of 218 individuals in the
cephalexin plus TMP-SMX group achieved cure versus 165 (86 percent) of 193 in the
cephalexin group (difference -2 percent; 95% CI, -9.7 to 5.7 percent). The modified
intention-to-treat analysis suggested a possible trend favoring the cephalexin plus
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TMP-SMX group, but those results are difficult to interpret due to a large number of
patients in both groups who did not complete the full course of therapy.

● Another randomized trial of 153 patients with cellulitis without abscess noted
comparable cure rates among those treated with cephalexin and TMP-SMX (85
percent) and those treated with cephalexin and placebo (82 percent; difference 2.7
percent, 95% CI -9.3 to 15 percent) [22].

With an indication for MRSA coverage — MRSA coverage is indicated if certain

conditions are present (see 'Indications for MRSA coverage' above). We suggest one of the
following regimens ( algorithm 1):

● Oral antibiotic regimens – For many patients, treatment in the outpatient setting
with oral antibiotics is effective [23]. We suggest one of the following regimens:

• TMP-SMX (one to two double-strength tablets orally twice daily; for patients who
weigh more than 70 kg and have normal renal function, we favor two double-
strength tablets twice daily).

• Amoxicillin (875 mg orally twice daily) plus doxycycline (100 mg orally twice daily).

TMP-SMX has activity against both Streptococcus and S. aureus, including MRSA.
Doxycycline provides coverage for S. aureus, including MRSA; amoxicillin is added to it
for streptococcal coverage. Cellulitis cure rates with TMP-SMX range from 78 to 83
percent [25,26], and support for doxycycline is based on observational data, as
discussed elsewhere. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in
adults: Treatment of skin and soft tissue infections", section on 'Oral antibiotic
therapy'.)

Linezolid (600 mg orally every 12 hours) is acceptable if the above agents cannot be
used. Meta-analyses, systematic reviews, and randomized trials suggest that linezolid
has at least equivalent outcomes for skin and soft tissue infections (including MRSA
infections) when compared with intravenous vancomycin [27-30]. The analyses also
found elevated rates of nausea, vomiting, and thrombocytopenia when linezolid was
administered; we suggest weekly complete blood counts for patients receiving
linezolid for longer than two weeks. Linezolid is discussed in more detail elsewhere.
(See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin

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and soft tissue infections", section on 'Linezolid and tedizolid'.)

Clindamycin (450 mg orally every eight hours) may have activity against both
Streptococcus and S. aureus and is an alternative if no other options exist; we avoid
its use due to risk for Clostridioides difficile infection and the possibility of
streptococcal and staphylococcal resistance. Local rates of resistance to clindamycin
should be considered before prescribing, as described below. (See 'Alternatives for
serious beta-lactam allergy' below.)

● Parenteral antibiotic regimen – For patients who meet criteria for parenteral
antibiotics, we suggest the following regimen (see 'Indications for parenteral therapy'
above):

• Intravenous vancomycin (see table for dosing ( table 3))

• Daptomycin 4 to 6 mg/kg IV every 24 hours (alternative)

Vancomycin is the preferred option because of extensive experience with this agent.
When daptomycin is used, we usually favor the higher dose (ie, 6 mg/kg). For patients
who cannot take vancomycin or daptomycin, alternative agents can be used and are
listed in the table ( table 4), and their efficacy is discussed elsewhere. (See
"Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and
soft tissue infections".)

Once there is evidence of clinical improvement, parenteral antibiotics should be

switched to one of the oral regimens listed above.

Alternatives for serious beta-lactam allergy — Although many patients have

reported beta-lactam allergies, most do not have allergies that would prohibit the use of
beta-lactams. In particular, many with penicillin allergies can still take a cephalosporin
( algorithm 2). Evaluation and management of reported penicillin allergies are discussed
in detail elsewhere. (See "Choice of antibiotics in penicillin-allergic hospitalized patients"
and "Allergy evaluation for immediate penicillin allergy: Skin test-based diagnostic
strategies and cross-reactivity with other beta-lactam antibiotics".)

For immunocompetent patients without severe sepsis who have serious allergies that
preclude use of beta-lactams, we suggest one of the following regimens
( algorithm 1):
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● Oral antibiotic regimen – If no indication for parenteral antibiotics is present, we
suggest either of the following:

• TMP-SMX (one to two double-strength tablets orally twice daily).

• Linezolid (600 mg orally every 12 hours). More detail regarding this agent is
discussed above. (See 'With an indication for MRSA coverage' above.)

An alternative is clindamycin (450 mg orally every eight hours), but we generally avoid
it due to risk of C. difficile infection and the possibility of streptococcal and
staphylococcal resistance [25,31]. Local rates of resistance to clindamycin should be
considered before prescribing. Data from the United States Centers for Disease
Control and Prevention (CDC) found that 22 percent of group A Streptococcus isolates
and 47 percent of MRSA isolates were resistant to clindamycin in 2017 [32,33]. In
Australia in 2019, clindamycin resistance was reported in 7 percent of group A
Streptococcus and 30 percent of MRSA isolates [34].

Data suggest that TMP-SMX and clindamycin are equally effective for management of
cellulitis. In one randomized trial of outpatients with cellulitis, 110 (81 percent) of 136
individuals who received clindamycin achieved cure versus 110 (76 percent) of 144
who received TMP-SMX (difference -4.5 percent; 95% CI, -15.1 to 6.1 percent) [25].

We do not recommend macrolides, such as azithromycin, due to high resistance rates

among beta-hemolytic streptococci [2,32,35]. The CDC reported that 23 percent of
group A streptococci were resistant to macrolides in 2017 [32].

● Parenteral antibiotic regimen – For patients with an indication for parenteral

therapy, we suggest intravenous vancomycin ( table 3). (See 'Indications for
parenteral therapy' above.)

For patients who cannot take vancomycin, alternative parenteral agents can be used
and are listed in the table ( table 4).

Once there is evidence of clinical improvement, parenteral antibiotics should be

switched to one of the oral regimens listed above.

Immunocompromised patients without severe sepsis — Patients who have certain

immunocompromising conditions are at risk for a wide range of pathogens. However,
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there is a spectrum of immunocompromising conditions, and some do not substantially

increase risk. Ultimately, choosing an antibiotic regimen for immunocompromised patients
should depend on the type of underlying immunocompromise, severity of infection, and
ability for close follow-up in the outpatient setting.

● Patients with high-risk neutropenia – We hospitalize these patients for prompt

administration of intravenous broad-spectrum antibiotics that cover gram-negative
pathogens (including Pseudomonas spp) in addition to streptococci and S. aureus.
Our preferred regimen is vancomycin plus cefepime ( table 5). (See "Treatment of
neutropenic fever syndromes in adults with hematologic malignancies and
hematopoietic cell transplant recipients (high-risk patients)", section on 'Initial
regimen'.)

● Patients with immunocompromise other than high-risk neutropenia – In our

experience, many patients in this group can be treated with IV or oral therapy using
the same regimens as the immunocompetent population. (See 'Immunocompetent
patients without severe sepsis' above and 'Indications for parenteral therapy' above.)

Some immunocompromising conditions can be associated with specific pathogens

( table 1). For example, patients with cirrhosis can develop cellulitis from enteric
gram-negative bacilli (eg, Klebsiella spp), so some experts select a regimen that
covers those organisms (eg, amoxicillin-clavulanate). As another example, patients
with low-risk neutropenia are at risk for pseudomonal infection, so many experts
administer combination therapy (eg, amoxicillin-clavulanate plus ciprofloxacin).

Ultimately, the decision to broaden coverage beyond beta-hemolytic streptococci and

S. aureus is nuanced and requires clinical judgment.

Duration of antibiotic therapy — The duration of therapy should be individualized

depending on clinical response. In general, five to six days of therapy is appropriate for
patients with uncomplicated cellulitis whose infection has improved [2,36,37]. Extension of
antibiotic therapy (up to 14 days) may be warranted in the setting of severe infection, slow
response to therapy, or immunocompromise.

The above suggested duration is supported by a meta-analysis of eight randomized

controlled trials totaling almost 1500 adults with cellulitis that found no difference in
response rates between short (five to six days) and longer courses of antibiotics (relative
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risk [RR] 0.99, 95% CI 0.96-1.03) [23]. The only trial that assessed outcome beyond 30 days
was a trial of 151 individuals hospitalized with nonpurulent cellulitis who were randomized
to treatment with a 6-day or 12-day course of flucloxacillin [38]. Cure rates were similar
between the groups (74 versus 67 percent); relapse rates after 90 days were higher in the
6-day group (6 versus 24 percent), but most relapses in the 6-day group were in patients
with a history of at least one prior episode of cellulitis.

Adjunctive treatments — When treating cellulitis of the lower extremities, management

of exacerbating conditions and any points of entry for microorganisms is paramount.

Elevation and edema management — Edema, a common manifestation of cellulitis, can

impair antibiotic penetration into infected tissue and prevent resolution of infection. For
lower extremity cellulitis, elevation of the affected limb hastens improvement by allowing
gravity drainage of edema and inflammatory substances [2]. To optimize the effect of
gravity, we instruct patients to elevate the heel of the foot above the knee and the knee
above the hip.

Lymphedema and venous insufficiency are commonly associated with lower extremity
cellulitis, especially in individuals who are obese. In addition to elevation, compression
therapy can be used to treat both lymphedema and venous insufficiency. While
compression therapy has been shown to be effective for preventing recurrences of
cellulitis in individuals with lymphedema, the efficacy of compression therapy during acute
cellulitis is uncertain, and clinical practice varies, including among UpToDate contributors.
Traditionally, compression therapy was felt to be contraindicated during episodes of acute
cellulitis for fear of compromising vascular function, although no data support this
contraindication. Limited data suggest that individualized compression therapy applied by
specialized lymphedema physiotherapists may not be harmful and does not compromise
microcirculation in patients with active cellulitis [39,40]. Compression therapy should be
avoided in individuals with known or suspected arterial insufficiency. Details regarding the
management of lymphedema and venous insufficiency are found elsewhere. (See "Lower
extremity lymphedema" and "Clinical staging and conservative management of peripheral
lymphedema" and "Overview of lower extremity chronic venous disease" and
"Compression therapy for the treatment of chronic venous insufficiency".)

Skin management — Treatment of skin conditions and the point of microorganism entry
can expedite resolution of cellulitis.

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The point of entry of microorganisms should be identified and managed at the time of
diagnosis of cellulitis. Common points of entry include intertrigo in the toe webs of the
feet, tinea pedis, onychomycosis, and lower extremity ulcers. Details regarding diagnosis
and management of these issues are found elsewhere. (See "Intertrigo" and
"Dermatophyte (tinea) infections", section on 'Tinea pedis' and "Onychomycosis:
Management" and "Approach to the differential diagnosis of leg ulcers".)

As cellulitis evolves, skin can begin to weep, blister, flake, or crack. Dermatologists and
wound care specialists can provide assistance with management of these conditions. More
details regarding the cutaneous progression of cellulitis are found below. (See 'Monitoring
response to therapy' below.)

Numerous underlying skin conditions are risk factors for the development of cellulitis
including atopic dermatitis (eczema) and psoriasis. Such conditions should be optimally
managed in conjunction with standard cellulitis treatment. Details regarding skin
conditions that predispose to cellulitis are discussed elsewhere. (See "Cellulitis and skin
abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis", section on
'Epidemiology'.)

Interventions that are not recommended — We do not recommend the following

therapies. These recommendations generally match those of expert guidelines [2].

● Anti-inflammatory medications – We suggest not using nonsteroidal anti-

inflammatory drugs (NSAIDs) or corticosteroids when there is concern for moderate
to severe cellulitis. These drugs can mask signs and symptoms of inflammation in
patients with necrotizing soft tissue infection, and their use may be associated with
delay in diagnosis.

For patients with mild infection, anti-inflammatory medications may reduce

symptoms of pain. While some data suggest that use of NSAIDs or corticosteroids
may hasten healing among patients with cellulitis or erysipelas, these results are
inconclusive and are limited by small sample size [41-43]. (See "Necrotizing soft tissue
infections".)

● Topical antibiotics – Although topical antibiotics are effective for some skin
infections (eg, impetigo, folliculitis), topical antibiotics are unlikely to be effective for
cellulitis or erysipelas due to involvement of the layers of skin below the epidermis.
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Acute cellulitis and erysipelas in adults: Treatment
● Hyperbaric oxygen therapy – For cellulitis, hyperbaric oxygen therapy has not been
shown to be effective [2]. Further information on hyperbaric oxygen therapy is found
elsewhere. (See "Hyperbaric oxygen therapy".)

TREATMENT OF ERYSIPELAS

Management of erysipelas primarily consists of antibiotic therapy along with the

adjunctive therapies described above. (See 'Adjunctive treatments' above.)

Oral antibiotics for erysipelas — Most cases of erysipelas can be managed with oral
antibiotics in the outpatient setting. For patients with unambiguous erysipelas who do not
meet criteria for parenteral antibiotics, empiric oral antibiotics active against beta-
hemolytic streptococci should be administered (see 'Indications for parenteral therapy'
above). We suggest one of the following regimens:

● Penicillin V potassium 500 mg orally every six hours

● Amoxicillin 875 mg orally every 12 hours
● Cephalexin 500 mg orally every six hours
● Cefadroxil 500 mg orally every 12 hours or 1 g orally once daily

For patients with serious beta-lactam allergies that preclude use of the above regimens,
oral options are the same as those listed above for cellulitis. (See 'Alternatives for serious
beta-lactam allergy' above.)

Parenteral antibiotics for erysipelas — We suggest antibiotics that cover beta-hemolytic

streptococci and S. aureus for patients with erysipelas who have an indication for
parenteral therapy (see 'Indications for parenteral therapy' above). Differentiating
erysipelas from cellulitis is not always straightforward, so we believe that adding
staphylococcal coverage is prudent in individuals who are ill enough to warrant parenteral
therapy.

For such patients, appropriate regimens include those described in the above discussion
about antibiotic therapy for cellulitis.

If a microbiologic diagnosis of beta-hemolytic Streptococcus is subsequently established

(eg, by a positive blood culture), then we recommend switching to parenteral aqueous
crystalline penicillin G (2 to 4 million units intravenously [IV] every four to six hours).
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Acute cellulitis and erysipelas in adults: Treatment

For patients in whom outpatient parenteral antibiotic is desired, ceftriaxone (1 to 2 g IV

once daily) is an alternative that allows for convenient once-daily outpatient
administration.

Once there is evidence of clinical improvement, parenteral antibiotics should be switched

to oral antibiotics that cover streptococci. Appropriate oral antibiotics for erysipelas are
described above. (See 'Oral antibiotics for erysipelas' above.)

Duration of antibiotic therapy — In general, the duration of therapy for erysipelas is

analogous to the duration used for cellulitis. (See 'Duration of antibiotic therapy' above.)

MONITORING RESPONSE TO THERAPY

Patients with cellulitis or erysipelas typically have symptomatic improvement within 24 to

48 hours of beginning antimicrobial therapy, although visible improvement of skin
manifestations can take 72 hours or longer [44,45]. In some cases, we monitor patients
remotely by having patients send daily pictures of their infection to our clinic; we advise
patients to take photographs from the same angle and in the same environment, with
particular attention to lighting.

It is useful to document the baseline appearance of the physical findings at the start of
antibiotic therapy. We obtain a baseline digital photograph to help monitor progress. Some
experts outline the area of infection with an indelible marker at the time of treatment
initiation to allow objective monitoring of progress. Other do not outline the infection
because patients sometimes experience unnecessary anxiety if the infection appears to
extend beyond the line as the infection dissipates. In the early stages of treatment,
erythema may expand beyond the initial margins of infection as the infection dissipates.
Deepening of erythema may be observed due to destruction of pathogens that can
enhance local inflammation. These findings should not be mistaken for therapeutic failure.
Clues that the infection is improving include reductions in fever, pain, brightness or
intensity of erythema, peripheral white blood cell count, and other signs of infection.

As cellulitis evolves, skin can begin to weep, blister, flake, or crack. None of these findings
are necessarily indications of worsening infection. As discussed elsewhere, wound care
specialists or dermatologists can help to manage these conditions. (See 'Skin
management' above.)
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Acute cellulitis and erysipelas in adults: Treatment

Residual skin inflammation is a common finding after completion of effective therapy

[38,44]. In a study of 216 patients hospitalized for cellulitis, more than half had residual
inflammation at the end of therapy [45]. Per telephone consultation done approximately
two weeks after completion of therapy, approximately 40 percent still had residual
inflammation and 16 percent had deterioration or required readmission.

REFRACTORY INFECTION

Significant progression of erythema or persistence of systemic symptoms after 24 to 48

hours should prompt a search for possible reasons for treatment failure. Evaluation should
consider multiple possibilities:

● Red-flag condition – Any time cellulitis progresses rapidly or clinical symptoms,

especially pain, seem to be out of proportion to physical exam, red-flag conditions
should be considered. A low threshold for surgical consultation to evaluate for these
conditions is prudent. A list of red-flag conditions is provided above. (See '"Red-flag"
conditions that warrant hospitalization' above.)

● Inadequate dosing or tissue penetration of antibiotics – Conditions at the site of

infection, such as edema or peripheral artery disease, can markedly reduce the ability
of antibiotics to penetrate into soft tissue. To optimize tissue penetration of the
antibiotics, management of these conditions is paramount. (See 'Adjunctive
treatments' above.)

In patients failing oral antibiotics, switching from oral to intravenous antibiotics can
markedly increase antibiotic delivery to the site of infection. This is especially the case
for antibiotics with poor bioavailability (such as some beta-lactam agents) or for
patients whose ability to absorb oral medications is uncertain.

In select situations, using higher antibiotic dosages may be beneficial. Obesity can
increase drug clearance from circulation and thereby limit the amount of antibiotic
that reaches the site of infection [46]. Moreover, certain bacteria, such as
Pseudomonas spp, require higher antibiotic dosages to achieve bacterial killing.
Consultation with a pharmacist may be helpful in these cases.

● Abscess – As cellulitis responds to antibiotic therapy, sometimes the infection can

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Acute cellulitis and erysipelas in adults: Treatment

coalesce to form an abscess below the surface. Abscess should be suspected when
focal tender fluctuance is found on exam, and ultrasound can aid in detection. If
present, surgical consultation for incision and drainage is recommended. Detailed
discussion of skin abscess management is found elsewhere. (See "Skin abscesses in
adults: Treatment".)

● Diagnosis other than cellulitis or erysipelas – Failure to respond to appropriate

therapy should prompt consideration that the initial diagnosis of cellulitis is incorrect.
Cellulitis is often confused with other infectious and noninfectious illnesses, and
misdiagnosis is perhaps the most common cause of lack of response to therapy
[47,48]. The differential diagnosis of cellulitis and erysipelas is broad and is discussed
in detail elsewhere. (See "Cellulitis and skin abscess: Epidemiology, microbiology,
clinical manifestations, and diagnosis", section on 'Cellulitis and erysipelas'.)

● Resistant pathogen – Re-evaluating for the possibility of resistant microorganisms

and reviewing past culture data can help guide antibiotic change. Methicillin-resistant
S. aureus (MRSA) or other organisms associated with certain conditions or
environmental exposures should be considered. (See 'Considerations prior to
selecting antibiotics' above.)

In immunocompromised individuals, cellulitis can be due to a multitude of organisms

including atypical bacteria, fungi, viruses, and parasites. If these individuals fail to
respond to broad-spectrum antibiotic therapy, a dermatologic evaluation and skin
biopsy can be beneficial. Nodular or ulcerative lesions should be biopsied early
during the clinical course in highly immunocompromised individuals, especially for
those who are septic or have rapidly progressive illness. Further discussion of skin
infection in neutropenic individuals is found elsewhere. (See "Diagnostic approach to
the adult cancer patient with neutropenic fever", section on 'Skin and mucous
membranes'.)

● Inadequate adherence – A repeat course of antimicrobial therapy and further

instruction regarding elevation and other adjunctive therapies may be appropriate
for patients with inadequate adherence to the treatment plan.

RECURRENT INFECTION

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Acute cellulitis and erysipelas in adults: Treatment

Recurrent erysipelas and cellulitis are not uncommon occurrences. Recurrences have been
reported to occur in 14 percent of cellulitis cases within one year and up to 45 percent of
cases within three years, usually in the same location [3,49,50]. In one review of over
400,000 admissions for cellulitis, the readmission rate was 10 percent and most
readmissions were due to recurrent cellulitis [51].

Management of recurrent infection — During the active stage of infection, management

of recurrent episodes is the same as the approach for initial episodes (see 'Acute cellulitis'
above). For individuals who have frequent or severe recurrences, prefilled prescriptions for
treatment doses of antibiotics can be provided so that patients can self-initiate antibiotic
therapy at the onset of symptoms while seeking immediate medical attention.

Prevention of recurrences — Potential tools for prevention of recurrent cellulitis include

alleviation of predisposing conditions (such as use of compression therapy for
management of edema), antibiotic prophylaxis, and S. aureus decolonization. These are
discussed below.

Alleviation of predisposing conditions — Predisposing conditions should be identified

and treated, if possible [3]. Examples of modifiable predisposing conditions include the
following:

● Edema. Elevation of the affected area and diuretic therapy can help to alleviate
edema. Compression therapy has been shown in studies to be highly effective for
lymphedema and venous insufficiency and is discussed in detail below. (See
'Compression therapy' below.)

● Foot infections including intertrigo in the toe webs of the feet, tinea pedis, and
onychomycosis. (See "Intertrigo" and "Dermatophyte (tinea) infections" and
"Onychomycosis: Management".)

● Lower extremity ulcers. (See "Approach to the differential diagnosis of leg ulcers".)

● Chronic skin conditions, such as eczema and psoriasis. (See "Treatment of atopic
dermatitis (eczema)" and "Treatment of psoriasis in adults".)

● Obesity. (See "Obesity in adults: Overview of management".)

● Immunosuppression.
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Acute cellulitis and erysipelas in adults: Treatment

Compression therapy — For patients with recurrent episodes of cellulitis in the setting of
chronic lower extremity venous insufficiency or lymphedema, compression therapy is an
essential component of management that has been shown to be effective in reducing
episodes of recurrent cellulitis [52].

In a randomized trial involving 84 patients with chronic lower extremity edema and ≥2
prior episodes of cellulitis, daily use of compression therapy reduced the rate of recurrent
cellulitis compared with no compression therapy (15 versus 40 percent, respectively, at a
median follow-up of six months; hazard ratio [HR] 0.23, 95% CI 0.09-0.59) [52]. The
compression therapy was provided by specialized lymphedema physiotherapists and
usually consisted of prescription knee-high stockings that included the foot and were worn
throughout the day. The compression therapy was provided only when no active cellulitis
was present, and no adverse events related to compression therapy were observed. Of
note, the trial was stopped early for benefit, which tends to overestimate treatment
efficacy.

Additional details regarding compression therapy in patients with chronic venous

insufficiency and lymphedema are provided separately. (See "Lower extremity
lymphedema" and "Clinical staging and conservative management of peripheral
lymphedema" and "Compression therapy for the treatment of chronic venous
insufficiency".)

Antibiotic prophylaxis for selected patients — For patients who optimize predisposing
conditions but still develop recurrent cellulitis in the same anatomic site, we suggest
suppressive antibiotic therapy [2]. Although infrequent, there are scenarios (eg,
complicated bacteremia in patients with a prosthetic device) when initiation of suppressive
therapy after an initial bout of cellulitis may be warranted; consultation of clinicians with
experience in these cases is suggested.

For suppressive therapy, we suggest one of the following antibiotic regimens:

● For patients with known or presumed beta-hemolytic streptococcal infection [53-55]:

• Penicillin V (250 to 500 mg orally twice daily)

• Penicillin G benzathine intramuscular (IM) injections (1.2 to 2.4 million units IM
every four weeks; shorten interval to every two weeks if longer interval is not
effective)
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Acute cellulitis and erysipelas in adults: Treatment
● For patients with known or presumed staphylococcal infection:

• Cefadroxil (500 mg orally twice daily)

• Cephalexin (500 mg orally four times daily)
• Trimethoprim-sulfamethoxazole (TMP-SMX; one double-strength tablet orally
twice daily)

Cefadroxil and cephalexin have no activity against methicillin-resistant S. aureus (MRSA)

and should only be used if recurrent methicillin-sensitive S. aureus (MSSA) infection is
suspected.

For patients with reported beta-lactam allergies, we suggest referral to an allergist. If beta-
lactam allergy is confirmed and TMP-SMX is not an option, we try doxycycline (100 mg
orally twice daily). We avoid clindamycin (150 mg orally once daily) unless there are no
other options due to risk of C. difficile infection [56].

Other than penicillin and clindamycin, minimal data exist to support the options listed
above as suppressive agents. The optimal dosing for these antibiotics when used as
prophylaxis is unknown and may be lower than the suggested doses. Titration to lower
dosages over time may allow determination of the best dose for individual patients.

Serologic testing for beta-hemolytic streptococci may be a useful diagnostic tool to help
guide the choice of suppressive antibiotic therapy. Such tests include the anti-streptolysin-
O reaction and the anti-deoxyribonuclease B test (anti-DNAse B). Further information
regarding serologic testing for beta-hemolytic streptococci is found elsewhere. (See
"Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and
diagnosis", section on 'Diagnosis'.)

Support for suppressive antibiotic therapy for prevention of recurrent cellulitis comes from
multiple trials:

● In a randomized trial that included 274 patients with two or more episodes of lower
extremity cellulitis, penicillin (250 mg orally twice daily) nearly halved the risk of
recurrence during 12 months of prophylaxis (HR 0.55, 95% CI 0.35 to 0.86), but the
protective effect diminished rapidly after the prophylaxis period ended [53]. A lower
likelihood of response was observed among patients with a body mass index ≥33
kg/m2, multiple previous episodes of cellulitis, or lower extremity edema.

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Acute cellulitis and erysipelas in adults: Treatment
● Two separate meta-analyses of five trials totalling over 500 patients with recurrent
cellulitis concluded that prophylactic antibiotics substantially reduce the risk of
subsequent cellulitis (relative risk [RR] 0.46, 95% CI 0.26-0.79, and RR 0.31, 95% CI
0.13 to 0.72, respectively) [57,58]. Findings from two of the included studies also
demonstrated that antibiotic prophylaxis is cost-effective [55,59].

In the trials and meta-analyses, no significant differences in adverse effects were found
between the groups that received antibiotics and those that did not.

Suppressive therapy may be continued for several months to years with interval
assessments for efficacy and tolerance. Patients in whom recurrent cellulitis occurs while
on suppressive therapy should undergo re-evaluation of predisposing conditions and
antimicrobial agents. (See 'Prevention of recurrences' above.)

S. aureus decolonization — For patients with suspected recurrent S. aureus infection, we

suggest an attempt at S. aureus decolonization. Detailed discussion of S. aureus
decolonization is found elsewhere. (See "Methicillin-resistant Staphylococcus aureus
(MRSA) in adults: Prevention and control", section on 'Decolonization' and "Methicillin-
resistant Staphylococcus aureus (MRSA) in children: Prevention and control".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and

regions around the world are provided separately. (See "Society guideline links: Skin and
soft tissue infections".)

SUMMARY AND RECOMMENDATIONS

● Overview – Patients with skin and soft tissue infection may present with cellulitis,
erysipelas, or abscess. This topic addresses management of cellulitis and erysipelas in
adults. The management of skin abscess is discussed separately. (See "Skin abscesses
in adults: Treatment".)

● Identify conditions treated differently than cellulitis ( algorithm 1)

• "Red-flag" conditions – These warrant immediate hospitalization and often

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Acute cellulitis and erysipelas in adults: Treatment

surgery. Examples include ( table 6):

- Toxic shock syndrome
- Necrotizing soft tissue infection (eg, necrotizing fasciitis, including Fournier's
gangrene)
- Clostridial myonecrosis
- Pyomyositis
- Deep venous thrombosis (DVT)
- Compartment syndrome

(See '"Red-flag" conditions that warrant hospitalization' above.)

• Specific exposures and anatomic sites – Some exposures or anatomic sites may
require distinct antibiotic coverage, surgical intervention, or specific radiographic
imaging:

- Involvement of the hand, periorbital space, or neck

- Location over a joint (native or prosthetic), vascular graft, or other foreign
body
- Infection of a diabetic foot ulcer, pressure ulcer, animal or human bite,
puncture wound, or surgical wound
- Infection following exposure to water, soil, or recent travel

(See 'Wounds and exposures that warrant specific coverage' above and 'Anatomic
site of infection' above.)

● Antibiotic selection for cellulitis in immunocompetent patients without severe

sepsis

• Determine risk for MRSA or adverse outcomes – Antibiotic selection depends on

the risk for methicillin-resistant S. aureus (MRSA) or adverse outcomes. Features
that increase those risks in this population include (see 'Indications for MRSA
coverage' above):

- Systemic toxicity (eg, fever, tachycardia)

- Purulent wound drainage
- Known MRSA colonization or infection
- Injection drug use

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Acute cellulitis and erysipelas in adults: Treatment

- Immunocompromise

• Antibiotic regimens

For immunocompetent patients with one of the above features, we suggest a

regimen that covers beta-hemolytic streptococci, methicillin-sensitive S. aureus
(MSSA), and MRSA ( algorithm 1) (Grade 2C) (see 'With an indication for MRSA
coverage' above):

- Oral – Trimethoprim-sulfamethoxazole, amoxicillin plus doxycycline, or

linezolid
- Intravenous (IV) – Vancomycin
- Other risk factors ( table 2) may not be as strongly associated with MRSA
infection so we individualize the decision for MRSA coverage in such cases.

For immunocompetent patients without the above features, we suggest a

narrower regimen with coverage for beta-hemolytic streptococci and MSSA
( algorithm 1) (Grade 2C). (See 'Without an indication for MRSA coverage'
above.)

- Oral – Dicloxacillin, flucloxacillin, cephalexin, or cefadroxil

- IV – Cefazolin, nafcillin, oxacillin, or flucloxacillin

Intravenous therapy is warranted for patients with systemic toxicity (eg, fever,
tachycardia), rapidly progressive or extensive erythema, or inability to absorb oral
therapy. (See 'Indications for parenteral therapy' above.)

● Antibiotic regimens for cellulitis in patients with severe sepsis or an

immunocompromising condition

• For patients with severe sepsis (eg, evidence of tissue hypoperfusion or organ
dysfunction) or high-risk neutropenia ( table 5), we suggest initial therapy with
vancomycin plus cefepime (Grade 2C). This regimen provides broad coverage
against MRSA, methicillin-sensitive S. aureus (MSSA), beta-hemolytic streptococci,
and gram-negative organisms for patients at highest risk for poor outcomes. (See
'Patients with severe sepsis' above.)

• For patients with other immunocompromising conditions (and without severe

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Acute cellulitis and erysipelas in adults: Treatment

sepsis), we often use the same regimens as for immunocompetent patients. The
decision to cover additional pathogens associated with specific conditions should
be individualized ( table 1). (See 'Immunocompromised patients without severe
sepsis' above.)

● Antibiotic regimens for erysipelas – For patients with unambiguous erysipelas (eg,
bright red erythema with distinct raised borders), we suggest antibiotics that
primarily target streptococci (Grade 2C).

Oral options include penicillin V potassium, amoxicillin, cephalexin, and cefadroxil.

Parenteral options include cefazolin, nafcillin, and flucloxacillin. (See 'Treatment of
erysipelas' above.)

● Duration of antibiotic therapy – We suggest five to six days of therapy rather than
longer durations (Grade 2C). However, extended regimens (ie, up to 14 days) may be
appropriate for severe or slowly responding cellulitis. Parenteral antibiotics should be
switched to an oral option once clinical improvement has occurred. (See 'Duration of
antibiotic therapy' above.)

● Adjunctive therapy – We instruct patients with cellulitis of the limb to elevate it to

allow drainage of edema and hasten improvement.

Areas of skin breakdown are potential points of entry that should be identified and
managed. Common points of entry include intertrigo in the toe webs, tinea pedis,
onychomycosis, lower extremity ulcers, atopic dermatitis, and psoriasis. (See
'Adjunctive treatments' above.)

● Expected response – Symptomatic improvement typically occurs within 24 to 48

hours, although visible improvement of skin manifestations can take 72 hours or
longer. (See 'Monitoring response to therapy' above.)

● Refractory infection – Significant progression of erythema or continued systemic

symptoms should prompt a search for possible reasons for treatment failure.
Considerations include deeper infection, inadequate antibiotic penetration (eg, due to
edema), or incorrect diagnosis. (See 'Refractory infection' above.)

● Recurrent infection – During the active stage of infection, management of recurrent

episodes is the same as the approach for initial episodes.
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Acute cellulitis and erysipelas in adults: Treatment

There are multiple tools to prevent recurrences (see 'Recurrent infection' above):

• Treating points of entry (eg, intertrigo, chronic skin conditions). (See 'Alleviation
of predisposing conditions' above.)

• Managing predisposing conditions – For patients with lymphedema or venous

insufficiency, we suggest compression therapy (Grade 2B). (See 'Compression
therapy' above.)

• Antibiotic prophylaxis for select patients – For patients who optimize

predisposing conditions but still have recurrent cellulitis in the same anatomic
site, we suggest prophylactic antibiotics (Grade 2B). For most patients, our
preferred regimen is penicillin V (250 to 500 mg orally twice daily). (See 'Antibiotic
prophylaxis for selected patients' above.)

• S. aureus decolonization – For patients with suspected recurrent S. aureus

infection, some experts attempt decolonization. (See "Methicillin-resistant
Staphylococcus aureus (MRSA) in adults: Prevention and control", section on
'Decolonization' and "Methicillin-resistant Staphylococcus aureus (MRSA) in
children: Prevention and control".)

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