Nonpurulent Cellulitis With Weeping
Nonpurulent cellulitis should be treated with systemic antibiotics targeted at beta-hemolytic streptococci and with elevation plus management of predisposing factors such as edema or underlying cutaneous disorders. [1]
Weeping is not an indication for incision and drainage unless a purulent collection or abscess is present. [1]
Medication Selection Algorithm
Antibiotic selection should be based on cellulitis type and severity.
- Mild nonpurulent cellulitis (no SIRS, no altered mental status, no hemodynamic instability): oral beta-lactam therapy targeting streptococci. [1]
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Examples: penicillin, cephalexin, amoxicillin, dicloxacillin (per Table 2 antimicrobial options). [1]
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Moderate nonpurulent cellulitis (systemic signs of infection): systemic antibiotics. [1]
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Coverage typically includes streptococci. [1]
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Severe nonpurulent cellulitis or specific MRSA-associated features (penetrating trauma, MRSA elsewhere, nasal MRSA colonization, injection drug use, or SIRS): vancomycin (or another antimicrobial effective against both MRSA and streptococci). [1]
- Severe infection needing broad empiric coverage: vancomycin plus piperacillin-tazobactam or imipenem/meropenem. [1]
Initiation Thresholds and Need for Admission
Outpatient therapy is recommended when none of the following are present: SIRS, altered mental status, or hemodynamic instability. [1]
Hospitalization is recommended when concern exists for deeper or necrotizing infection, when adherence to therapy is poor, when immunocompromise is severe, or when outpatient treatment is failing. [1]
Expected Duration of Therapy
A 5-day course of antimicrobial therapy is recommended. [1]
Therapy should be extended if the infection has not improved within the initial 5 days. [1]
Supportive and Local Care for Weeping
Elevation of the affected area is recommended. [1]
Treatment of predisposing factors such as edema or underlying cutaneous disorders is recommended. [1]
For lower-extremity disease, examination of toe-web spaces is recommended because treatment of fissuring, scaling, or maceration may reduce recurrent infection. [1]
Antimicrobial Adjuncts
Systemic corticosteroids (for example, prednisone 40 mg daily for 7 days) could be considered in nondiabetic adults with cellulitis. [1]
Common Pitfalls to Avoid
Treating cellulitis associated with a purulent focus as nonpurulent cellulitis is a major error because drainage is the major component of management for purulent collections such as skin abscesses. [1]
Targets of Therapy
Clinical improvement should occur within the initial 5 days of antimicrobial therapy, with extension of therapy when improvement does not occur within that timeframe. [1]