Cellulitis, lower or upper limb, including ambulatory care

Preferred: flucloxacillin 500mg to 1g po qds

Alternatives:

doxycycline 100mg po bd

OR

cefalexin 1g po tds 

In pregnant patients: cefalexin 1g po tds or erythromycin 500mg po qds

For MRSA positive patients or patients that have failed to respond to other agents: co-trimoxazole 960mg po bd  

Preferred: flucloxacillin 1g iv qds (increase to 2g iv qds for severe infection or in obese patients)

Alternative (for penicillin allergy non-severe): cefazolin 1g iv tds (increase to 2g iv tds for severe infections)

For penicillin allergy (severe) or for MRSA positive patients: co-trimoxazole 960mg po bd (iv if NBM)

For cases with sepsis: Consider adding gentamicin 5mg/kg iv single dose. If creatinine clearance less than 30 ml/min reduce dose to 3mg/kg.

Oral options (for ambulatory care)

For oral options for ambulatory care patients see above, mild cellulitis

Intravenous options (for ambulatory care)

Preferred:

cefazolin 2g iv od AND probenecid 1g po od (including for penicillin allergy non-severe)

Or, If PICC or midline in place:

elastomeric flucloxacillin 8g iv daily 

Alternative:

For penicillin allergy severe or MRSA positive: teicoplanin 6mg/kg iv every 12 hours for 3 doses, then 6 mg/kg once daily

For cases where other treatments cannot be given AND following the advice of Micro/ID:

dalbavancin 1500mg single dose iv [OR dalbavancin 1000mg iv dose on day 1 and 500mg iv dose on day 8]

Principles are based upon NICE NG141

1. To ensure that cellulitis and erysipelas are treated appropriately, exclude other causes of skin redness such as:

• • an inflammatory reaction to an immunisation or an insect bite, or
  • a non-infectious cause such as chronic venous insufficiency.

2. Consider taking a swab for microbiological testing from people with cellulitis or erysipelas to guide treatment, but only if the skin is broken and:

• • there is a penetrating injury, or
  • there has been exposure to water-borne organisms, or
  • the infection was acquired outside the UK.

3. Before treating cellulitis or erysipelas, consider drawing around the extent of the infection with a single-use surgical marker pen to monitor progress. Be aware that redness may be less visible on darker skin tones.

4. When choosing an antibiotic take account of:

1. • the severity of symptoms (less severe cases can be treated with oral)
   • the site of infection (for example, near eyes or ENT focus)
   • the risk of uncommon pathogens (for example, from a penetrating injury, after exposure to water-borne organisms, or an infection acquired outside the UK) ALWAYS discuss these cases with Micro/ID
   • previous microbiological results from a swab
   • the person’s MRSA status if known.

5. Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

6. If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.

7. Manage any underlying condition that may predispose to cellulitis or erysipelas, for example:

• • diabetes
  • venous insufficiency
  • eczema
  • oedema, which may be an adverse effect of medicines such as calcium channel blockers.

8. When prescribing antibiotics for cellulitis or erysipelas, give advice about:

• • possible adverse effects of antibiotics
  • the skin taking some time to return to normal after the course of antibiotics has finished
  • seeking medical help if symptoms worsen rapidly or significantly at any time, or do not start to improve within 2 to 3 days.

9. Reassess people with cellulitis or erysipelas if symptoms worsen rapidly or significantly at any time, do not start to improve within 2 to 3 days, or the person:

• • becomes systemically very unwell, or
  • has severe pain out of proportion to the infection, or
  • has redness or swelling spreading beyond the initial presentation (taking into account that some initial spreading may occur, and that redness may be less visible on darker skin tones).

10. When reassessing people with cellulitis or erysipelas, take account of

• • other possible diagnoses, such as an inflammatory reaction to an immunisation or an insect bite, gout, superficial thrombophlebitis, eczema, allergic dermatitis or deep vein thrombosis
  • any underlying condition that may predispose to cellulitis or erysipelas, such as oedema, diabetes, venous insufficiency or eczema
  • any symptoms or signs suggesting a more serious illness or condition, such as lymphangitis, orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis
  • any results from microbiological testing
  • any previous antibiotic use, which may have led to resistant bacteria.

11. Consider taking a swab for microbiological testing from people with cellulitis or erysipelas if the skin is broken and this has not been done already.

12. If a swab has been sent for microbiological testing:

• • review the choice of antibiotic(s) when results are available, and,
  • change the antibiotic(s) according to results if symptoms or signs of the infection are not improving, using a narrow-spectrum antibiotic if possible.