Cellulitis and erysipelas

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

suspected sepsis

1st line – follow local sepsis protocol

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1st line –

follow local sepsis protocol

Think 'Could this be sepsis?' based on acute deterioration in a patient in whom there is clinical evidence or strong suspicion of infection.[27][28][29] See our topic Sepsis in adults.

The patient may present with non-specific or non-localised symptoms (e.g., acutely unwell with a normal temperature) or there may be severe signs with evidence of multi-organ dysfunction and shock.[27][28][29]
Remember that sepsis represents the severe, life-threatening end of infection.[35]

Use a systematic approach (e.g., National Early Warning Score 2 [NEWS2]), alongside your clinical judgement, to assess the risk of deterioration due to sepsis.[28][29][36][37] Consult local guidelines for the recommended approach at your institution.

Arrange urgent review by a senior clinical decision-maker (e.g., ST4 level doctor in the UK) if you suspect sepsis:[30]

Within 30 minutes for a patient who is critically ill (e.g., NEWS2 score of 7 or more, evidence of septic shock, or other significant clinical concerns).
Within 1 hour for a patient who is severely ill (e.g., NEWS2 score of 5 or 6).

Follow your local protocol for investigation and treatment of all patients with suspected sepsis, or those at risk. Start treatment promptly. Determine urgency of treatment according to likelihood of infection and severity of illness, or according to your local protocol.[30][37]

ACUTE

severe: any site (excluding near the eyes or nose)

1st line – empirical antibiotic therapy

Back

1st line –

empirical antibiotic therapy

For patients with severe infection, give intravenous flucloxacillin in the first instance.[21] If flucloxacillin is unsuitable (e.g., patient has a penicillin allergy), give intravenous clarithromycin.[21]

Alternative antibiotics for patients with severe cellulitis or erysipelas include:[21]

Amoxicillin/clavulanate, or
Cefuroxime, or
Clindamycin, or
Ceftriaxone (only for ambulatory care).

Aim to start antibiotics immediately after taking samples for microbiological testing if this is indicated.[32][33][34]

There is little high-quality evidence to indicate the most appropriate antibiotics, routes of administration, or duration of treatment for cellulitis and erysipelas.[58] [ ]

Consult your local antibiotic protocol to determine the most appropriate choice of empirical antibiotic based on local pathogen prevalence and antibiotic resistance patterns, and consider individual patient factors.[20][21][23]

Seek specialist advice for patients with immunocompromising factors.

If microbiology cultures have been requested, narrow your treatment to pathogen-targeted antibiotics in line with sensitivity results when they become available.[59]

Route of administration

Give oral antibiotics first line if the person can take oral medications, and the severity of their symptoms does not require intravenous antibiotics.[21]

For patients with severe systemic symptoms or significant comorbidities (Eron classes II-IV), give antibiotics intravenously.[21][23] See Severity assessment under Diagnosis recommendations for information on the Eron severity classification.

If a patient has a severe infection, but can be managed in the community, prescribe intravenous ceftriaxone.[21]

Intravenous antibiotics can be administered in the community if the patient has the necessary support and this resource is available in your area.[21][23]

Switching to oral antibiotics

Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics.[21] This may be possible when:[23]

The patient’s temperature is settling
Redness is reducing
Comorbidities are stable
Inflammatory markers are falling.

In practice, switch to oral antibiotics that:

Have the same spectrum of activity as the intravenous antibiotics that achieved clinical response
Are in line with microbiology culture and sensitivity results.

Total treatment duration

Prescribe antibiotics for a total of 5 to 7 days and for 10 days in patients with risk factors.[21] See the Risk factors section under Epidemiology.

Clinically assess whether the patient needs a longer course (up to 14 days) of antibiotics, but remember that skin takes time to return to normal, and full symptom resolution is not expected at 5 to 7 days.[21]

Primary options

flucloxacillin: 1-2 g intravenously every 6 hours

clarithromycin: 500 mg intravenously every 12 hours

Secondary options

amoxicillin/clavulanate: 500/125 mg orally three times daily; 1.2 g intravenously every 8 hours

cefuroxime: 0.75 to 1.5 g intravenously every 6-8 hours

clindamycin: 150-450 mg orally four times daily; 600-2700 mg/day intravenously given in 2-4 divided doses, may increase to 1200 mg every 6 hours in life-threatening infections

ceftriaxone: 2 g intravenously every 24 hours

Plus – consider hospital admission

Back

Plus –

consider hospital admission

Treatment recommended for ALL patients in selected patient group

Decide whether your patient needs admission based on the Eron severity classification.[23][42] See Severity assessment under Diagnosis recommendations for information on the Eron severity classification.

For patients with Eron class II severity, admit to hospital for up to 48 hours and discharge on outpatient parenteral antimicrobial therapy, if available.
For patients with Eron class III severity, admit until clinical improvement is evident and comorbidities are stabilised.

Other indications for admission include:

Signs of systemic illness, such as:[23]
- Confusion[20][23]
- Tachycardia[20][23]
- Tachypnoea[23]
- Hypotension[20][23]
Suspected sepsis[23]
Spreading cellulitis or erysipelas not responding to oral medication[20]
Severe immunocompromising factors[20]
Limb-threatening infection due to vascular compromise[23]
Necrotising fasciitis[20][23]
Orbital cellulitis. The National Institute for Health and Care Excellence in the UK suggests considering patients with orbital cellulitis for admission, or referring them for specialist advice.[21] However, in practice, all patients with orbital cellulitis would be admitted.

Be aware that some of these presentations require urgent referral. See Physical examination under Diagnostic recommendations for more information.

Consider admitting, or referring for specialist advice, patients with:

Rapid progression of symptoms
Lymphangitis[21]
Facial cellulitis (unless mild)
Infection near the eyes or nose, including peri-orbital cellulitis[21]
Suspected unusual pathogens[21]
Symptoms and signs of osteomyelitis[21]
Symptoms and signs of septic arthritis[21]
A comorbidity that may complicate or delay recovery, or that is unstable[23]
Poor adherence to therapy[20]
Inability to take oral antibiotics.[21]

If a patient has a severe infection, but can be managed in the community, prescribe intravenous ceftriaxone.[21]

Intravenous antibiotics can be administered in the community if the patient has the necessary support and this resource is available in your area.[21][23]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Fluids

Consider whether your patient needs intravenous or oral hydration.[23]

Thromboprophylaxis

Consider thromboprophylaxis based on risk stratification as for all admitted patients in your hospital. Follow your local protocol.

Wound management

Proactively aspirate and/or deroof any blisters using aseptic technique.[23] Send aspirate for microbiological processing. If in doubt, seek specialist advice.[23]

Manage wound exudate if the skin ulcerates.[23] In practice, use absorbent but non-adhesive dressings according to your local wound management protocols.

Practical tip

Do not prescribe compression bandages in the acute phase of cellulitis.[23]

Monitoring

Before treating, consider drawing around the edge of the infection with a single-use surgical marker pen to monitor progress. Note that the extent of the infection may be less clear on darker skin tones.[21]

Monitor inflammatory markers to assess response to treatment.[23] In practice, take blood for processing every 24 to 48 hours.

Predisposing factors

Manage any underlying conditions that may predispose to cellulitis, such as:[20][21][57]

Diabetes
Venous insufficiency
Eczema
Oedema and lymphoedema
Obesity
Tinea infection.

Refer patients with chronic lymphoedema to lymphoedema services.[23]

Consider – analgesia

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Consider –

analgesia

Additional treatment recommended for SOME patients in selected patient group

Prescribe adequate pain relief.[23] Paracetamol or a non-steroidal anti-inflammatory drug (NSAID; e.g., ibuprofen, diclofenac) are usually appropriate. In view of their habit-forming risk, opioids (e.g., morphine) are reserved as a last resort in practice.

Practical tip

Be cautious and monitor renal function closely when prescribing NSAIDs to older people and people with comorbidities such as hypertension and heart disease. Be aware that NSAIDs may increase the risk of acute kidney injury in people with sepsis.

Monitor and manage fever with an antipyretic, such as paracetamol, if clinically indicated.[23] In practice, this means treating the fever if it is making the patient feel more unwell. Do not treat the fever merely to maintain euthermia.

Elevate an affected lower leg to reduce pain, swelling, and damage to the venous system.[23] Consider using a bed cradle.[23]

Primary options

paracetamol: oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

ibuprofen: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

diclofenac potassium: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

Secondary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – MRSA antibiotic cover

Consider – Aeromonas hydrophila antibiotic cover (fresh-water exposure)

Back

Consider –

Aeromonas hydrophila antibiotic cover (fresh-water exposure)

Additional treatment recommended for SOME patients in selected patient group

For patients with fresh-water exposure, add in one of the antibiotics below to the first-line antibiotic regimen. In practice, considering the safety issues with fluoroquinolones, doxycycline or trimethoprim/sulfamethoxazole may provide alternative cover. Consult with a microbiologist about whether a fluoroquinolone is an appropriate option for your patient.

Ciprofloxacin[23]
Doxycycline
Trimethoprim/sulfamethoxazole.

Prescribe antibiotics for at least 7 days.

EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

Consider safety issues with fluoroquinolones such as ciprofloxacin. In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects. As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, it recommends that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided.[63] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[64]

Primary options

ciprofloxacin: 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

Secondary options

doxycycline: 200 mg orally (immediate-release) as a loading dose on day 1, followed by 100 mg once daily thereafter

Tertiary options

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily; 160/800 mg intravenously every 12 hours, may increase to 240/1200 mg every 12 hours in severe infections

Consider – Vibrio vulnificus antibiotic cover (salt-water exposure)

Consider – antibiotic cover for specific organisms from bites

Consider – reassessment

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Consider –

reassessment

Additional treatment recommended for SOME patients in selected patient group

Reassess the patient if:[21]

Symptoms worsen, for example:
- Significant redness and swelling spreading beyond 48 hours after initial presentation
- Pain becomes severe
You suspect systemic involvement
There is no improvement within 2 to 3 days.

Practical tip

In practice, check for signs of re-emerging infection 24 to 48 hours after starting oral antibiotic treatment and before discharging the patient home.

Practical tip

Some increase in redness may occur in the first 24 to 48 hours after starting treatment.[21] This may be due to toxin release.[23]

Even after an effective course of antibiotics, complete resolution at 5 to 7 days is unlikely. The skin may take several weeks to return to normal.[21]

If the patient’s condition is not improving, consider whether:[21]

The diagnosis is correct; consider other possible diagnoses
You have managed any underlying conditions optimally
There are symptoms or signs that suggest more serious illness; these may need onward referral
Results from microbiological testing support your empirical treatment; change the antibiotic if necessary
Bacterial resistance may have developed due to previous antibiotics; if so, a change in treatment may be required
A swab for microbiological testing might be helpful if this has not been done already (if skin is broken).

If there is no improvement in symptoms and signs after 48 hours, or the diagnosis is in doubt, seek advice from a microbiologist, a dermatologist, or a surgeon.[23]

any severity: site near eyes or nose

1st line – empirical antibiotic therapy

Back

1st line –

empirical antibiotic therapy

Give patients with cellulitis or erysipelas in the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes, and including peri-orbital cellulitis, amoxicillin/clavulanate and consider seeking specialist advice.[21]

If the patient is allergic to penicillin or if amoxicillin/clavulanate is unsuitable, give a macrolide antibiotic (e.g., clarithromycin) plus anaerobic cover (e.g., metronidazole) and consider seeking specialist advice.[21]

Aim to start antibiotics immediately after taking samples for microbiological testing if this is indicated.[32][33][34]

There is little high-quality evidence to indicate the most appropriate antibiotics, routes of administration, or duration of treatment for cellulitis and erysipelas.[58] [ ]

Seek specialist advice for patients with immunocompromising factors.

If microbiology cultures have been requested, narrow your treatment to pathogen-targeted antibiotics in line with sensitivity results when they become available.[59]

Route of administration

Give oral antibiotics first line if the person can take oral medications, and the severity of their symptoms does not require intravenous antibiotics.[21]

Switching to oral antibiotics

Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics.[21] This may be possible when:[23]

The patient’s temperature is settling
Redness is reducing
Comorbidities are stable
Inflammatory markers are falling.

In practice, switch to oral antibiotics that:

Have the same spectrum of activity as the intravenous antibiotics that achieved clinical response
Are in line with microbiology culture and sensitivity results.

Total duration of treatment

Prescribe antibiotics for a total of 7 days and for 10 days in patients with risk factors.[21] See the Risk factors section under Epidemiology.

Primary options

amoxicillin/clavulanate: 500/125 mg orally three times daily; 1.2 g intravenously every 8 hours

Secondary options

clarithromycin: 500 mg orally (immediate-release)/intravenously twice daily

and

metronidazole: 400 mg orally three times daily; 500 mg intravenously every 8 hours

Plus – consider hospital admission

Back

Plus –

consider hospital admission

Treatment recommended for ALL patients in selected patient group

The National Institute for Health and Care Excellence in the UK suggests considering patients with orbital cellulitis for admission, or referring them for specialist advice.[21]

Seek advice from a senior clinical decision-maker or ophthalmology about whether a patient with orbital or peri-orbital cellulitis requires admission.[21]
Be aware that patients with orbital cellulitis require urgent (in practice, within 30 minutes of initial clinical assessment) referral for senior review. These patients are usually admitted under ophthalmology services.

Other indications for admission include:

Signs of systemic illness, such as:[23]
- Confusion[20][23]
- Tachycardia[20][23]
- Tachypnoea[23]
- Hypotension[20][23]
Suspected sepsis[23]
Spreading cellulitis or erysipelas not responding to oral medication[20]
Severe immunocompromising factors[20]
Necrotising fasciitis.[20][23]

Consider admitting, or referring for specialist advice, patients with:

Rapid progression of symptoms
Lymphangitis[21]
Facial cellulitis (unless mild)
Suspected unusual pathogens[21]
Symptoms and signs of osteomyelitis[21]
Symptoms and signs of septic arthritis[21]
A comorbidity that may complicate or delay recovery, or that is unstable[23]
Poor adherence to therapy[20]
Inability to take oral antibiotics.[21]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Fluids

Consider whether your patient needs intravenous or oral hydration.[23]

Thromboprophylaxis

Consider thromboprophylaxis based on risk stratification as for all admitted patients in your hospital. Follow your local protocol.

Wound management

Proactively aspirate and/or deroof any blisters using aseptic technique.[23] Send aspirate for microbiological processing. If in doubt, seek specialist advice.[23]

Manage wound exudate if the skin ulcerates.[23] In practice, use absorbent but non-adhesive dressings according to your local wound management protocols.

Practical tip

Do not prescribe compression bandages in the acute phase of cellulitis.[23]

Monitoring

Monitor inflammatory markers to assess response to treatment.[23] In practice, take blood for processing every 24 to 48 hours.

Predisposing factors

Manage any underlying conditions that may predispose to cellulitis, such as:[20][21][57]

Diabetes
Venous insufficiency
Eczema
Oedema and lymphoedema
Obesity
Tinea infection.

Refer patients with chronic lymphoedema to lymphoedema services.[23]

Consider – analgesia

Back

Consider –

analgesia

Additional treatment recommended for SOME patients in selected patient group

Practical tip

Elevate an affected lower leg to reduce pain, swelling, and damage to the venous system.[23] Consider using a bed cradle.[23]

Primary options

ibuprofen: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

diclofenac potassium: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

Secondary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – MRSA antibiotic cover

Consider – Aeromonas hydrophila antibiotic cover (fresh-water exposure)

Back

Consider –

Aeromonas hydrophila antibiotic cover (fresh-water exposure)

Additional treatment recommended for SOME patients in selected patient group

For patients with fresh-water exposure, add in one of the antibiotics below to the first-line antibiotic regimen. In practice, considering the safety issues with fluoroquinolones, doxycycline or trimethoprim/sulfamethoxazole may provide alternative cover. Consult with a microbiologist about whether a fluoroquinolone is an appropriate option for your patient.

Ciprofloxacin[23]
Doxycycline
Trimethoprim/sulfamethoxazole.

Prescribe antibiotics for at least 7 days.

EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

Primary options

ciprofloxacin: 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

Secondary options

doxycycline: 200 mg orally (immediate-release) as a loading dose on day 1, followed by 100 mg once daily thereafter

Tertiary options

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily; 160/800 mg intravenously every 12 hours, may increase to 240/1200 mg every 12 hours in severe infections

Consider – Vibrio vulnificus antibiotic cover (salt-water exposure)

Consider – antibiotic cover for specific organisms from bites

Consider – reassessment

Back

Consider –

reassessment

Additional treatment recommended for SOME patients in selected patient group

Reassess the patient if:[21]

Symptoms worsen, for example:
- Significant redness and swelling spreading beyond 48 hours after initial presentation
- Pain becomes severe
You suspect systemic involvement
There is no improvement within 2 to 3 days.

Practical tip

In practice, check for signs of re-emerging infection 24 to 48 hours after starting oral antibiotic treatment and before discharging the patient home.

Practical tip

Some increase in redness may occur in the first 24 to 48 hours after starting treatment.[21] This may be due to toxin release.[23]

Even after an effective course of antibiotics, complete resolution at 5 to 7 days is unlikely. The skin may take several weeks to return to normal.[21]

If the patient’s condition is not improving, consider whether:[21]

The diagnosis is correct; consider other possible diagnoses
You have managed any underlying conditions optimally
There are symptoms or signs that suggest more serious illness; these may need onward referral
Results from microbiological testing support your empirical treatment; change the antibiotic if necessary
Bacterial resistance may have developed due to previous antibiotics; if so, a change in treatment may be required
A swab for microbiological testing might be helpful if this has not been done already (if skin is broken).

If there is no improvement in symptoms and signs after 48 hours, or the diagnosis is in doubt, seek advice from a microbiologist, a dermatologist, or a surgeon.[23]

non-severe: any site (excluding near eyes or nose)

1st line – empirical antibiotic therapy

Back

1st line –

empirical antibiotic therapy

Give flucloxacillin first line to patients with non-severe upper- or lower-extremity cellulitis or erysipelas. If the patient is allergic to penicillin or if flucloxacillin is unsuitable, give clarithromycin or doxycycline.

Aim to start antibiotics immediately after taking samples for microbiological testing if this is indicated.[32][33][34]

There is little high-quality evidence to indicate the most appropriate antibiotics, routes of administration, or duration of treatment for cellulitis and erysipelas.[58] [ ]

If microbiology cultures have been requested, narrow your treatment to pathogen-targeted antibiotics in line with sensitivity results when they become available.[59]

Route of administration

Give oral antibiotics first line if the person can take oral medications, and the severity of their symptoms does not require intravenous antibiotics.[21]

Switching to oral antibiotics

Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics.[21] This may be possible when:[23]

The patient’s temperature is settling
Redness is reducing
Comorbidities are stable
Inflammatory markers are falling.

In practice, when switching from intravenous to oral antibiotics, start oral antibiotics that:

Have the same spectrum of activity as the intravenous antibiotics that achieved clinical response
Are in line with microbiology culture and sensitivity results.

Total duration of treatment

Prescribe antibiotics for a total of 5 to 7 days and for 10 days in patients with risk factors.[21] See the Risk factors section under Epidemiology.

Primary options

flucloxacillin: 0.5 to 1 g orally four times daily; 1-2 g intravenously every 6 hours

Secondary options

clarithromycin: 500 mg orally (immediate-release)/intravenously twice daily

doxycycline: 200 mg orally on the first day, followed by 100 mg once daily thereafter

Plus – consider hospital admission

Back

Plus –

consider hospital admission

Treatment recommended for ALL patients in selected patient group

For patients with Eron class II severity, admit to hospital for up to 48 hours and discharge on outpatient parenteral antimicrobial therapy, if available.
For patients with Eron class III severity, admit until clinical improvement is evident and comorbidities are stabilised.

Other indications for admission include:

Spreading cellulitis or erysipelas not responding to oral medication[20]
Severe immunocompromising factors.[20]

Consider admitting, or referring for specialist advice, patients with:

Rapid progression of symptoms
Lymphangitis[21]
Facial cellulitis (unless mild)
Suspected unusual pathogens[21]
Symptoms and signs of osteomyelitis[21]
Symptoms and signs of septic arthritis[21]
A comorbidity that may complicate or delay recovery, or that is unstable[23]
Poor adherence to therapy[20]
Inability to take oral antibiotics.[21]

Plus – supportive care

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Fluids

Consider whether your patient needs intravenous or oral hydration.[23]

Thromboprophylaxis

Consider thromboprophylaxis based on risk stratification as for all admitted patients in your hospital. Follow your local protocol.

Wound management

Proactively aspirate and/or deroof any blisters using aseptic technique.[23] Send aspirate for microbiological processing. If in doubt, seek specialist advice.[23]

Manage wound exudate if the skin ulcerates.[23] In practice, use absorbent but non-adhesive dressings according to your local wound management protocols.

Practical tip

Do not prescribe compression bandages in the acute phase of cellulitis.[23]

Monitoring

Monitor inflammatory markers to assess response to treatment.[23] In practice, take blood for processing every 24 to 48 hours.

Predisposing factors

Manage any underlying conditions that may predispose to cellulitis, such as:[20][21][57]

Diabetes
Venous insufficiency
Eczema
Oedema and lymphoedema
Obesity
Tinea infection.

Refer patients with chronic lymphoedema to lymphoedema services.[23]

Consider – analgesia

Back

Consider –

analgesia

Additional treatment recommended for SOME patients in selected patient group

Practical tip

Elevate an affected lower leg to reduce pain, swelling, and damage to the venous system.[23] Consider using a bed cradle.[23]

Primary options

ibuprofen: 300-600 mg orally (immediate-release) every 6-8 hours when required, maximum 2400 mg/day

diclofenac potassium: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

Secondary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

Consider – MRSA antibiotic cover

Consider – Aeromonas hydrophila antibiotic cover (fresh-water exposure)

Back

Consider –

Aeromonas hydrophila antibiotic cover (fresh-water exposure)

Additional treatment recommended for SOME patients in selected patient group

Ciprofloxacin[23]
Doxycycline (if patient is not already on doxycycline for first-line empirical treatment)
Trimethoprim/sulfamethoxazole.

If the patient is already on doxycycline for first-line empirical treatment, use a combination of doxycycline plus ciprofloxacin.

Prescribe antibiotics for at least 7 days.

EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

Primary options

ciprofloxacin: 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

Secondary options

doxycycline: 200 mg orally (immediate-release) as a loading dose on day 1, followed by 100 mg once daily thereafter

Tertiary options

trimethoprim/sulfamethoxazole: 160/800 mg orally twice daily; 160/800 mg intravenously every 12 hours, may increase to 240/1200 mg every 12 hours in severe infections

Consider – Vibrio vulnificus antibiotic cover (salt-water exposure)

Back

Consider –

Vibrio vulnificus antibiotic cover (salt-water exposure)

Additional treatment recommended for SOME patients in selected patient group

For patients with salt-water exposure, add in the following antibiotic to the first-line antibiotic regimen:[25]

Doxycycline.

If the patient is already on doxycycline for first-line empirical treatment, add ciprofloxacin to doxycycline.

Prescribe antibiotics for at least 7 days.

Primary options

doxycycline: 200 mg orally (immediate-release) as a loading dose on day 1, followed by 100 mg once daily thereafter

Secondary options

ciprofloxacin: 500-750 mg orally twice daily; 400 mg intravenously every 8-12 hours

Consider – antibiotic cover for specific organisms from bites

Consider – reassessment

Back

Consider –

reassessment

Additional treatment recommended for SOME patients in selected patient group

If the patient is managed in the community, advise them to access healthcare advice for reassessment and consideration of admission if:[21]

Symptoms worsen, for example:
- Significant redness and swelling spreading beyond 48 hours after initial presentation
- Pain becomes severe
Symptoms develop suggesting systemic involvement
There is no improvement within 2 to 3 days.

If managed in hospital, reassess the patient if:[21]

Symptoms worsen, for example:
- Significant redness and swelling spreading beyond 48 hours after initial presentation
- Pain becomes severe
You suspect systemic involvement
There is no improvement within 2 to 3 days.

Practical tip

In practice, check for signs of re-emerging infection 24 to 48 hours after starting oral antibiotic treatment and/or before discharging the patient home.

Practical tip

Some increase in redness may occur in the first 24 to 48 hours after starting treatment.[21] This may be due to toxin release.[23]

Even after an effective course of antibiotics, complete resolution at 5 to 7 days is unlikely. The skin may take several weeks to return to normal.[21]

If the patient’s condition is not improving, consider whether:[21]

The diagnosis is correct; consider other possible diagnoses
You have managed any underlying conditions optimally
There are symptoms or signs that suggest more serious illness; these may need onward referral
Results from microbiological testing support your empirical treatment; change the antibiotic if necessary
Bacterial resistance may have developed due to previous antibiotics; if so, a change in treatment may be required
A swab for microbiological testing might be helpful if this has not been done already (if skin is broken).

If there is no improvement in symptoms and signs after 48 hours, or the diagnosis is in doubt, seek advice from a microbiologist, a dermatologist, or a surgeon.[23]

ONGOING

frequent relapses

1st line – manage predisposing factors

Consider – antibiotic prophylaxis

Back

Consider –

antibiotic prophylaxis

Additional treatment recommended for SOME patients in selected patient group

Do not routinely offer antibiotic prophylaxis.[21]

Patients with an episode of cellulitis have annual recurrence rates of 8% to 20%, with the risk being higher if the legs were involved.[20]

Consult with a dermatologist or an infectious diseases consultant about whether to prescribe a 6-month trial of low-dose phenoxymethylpenicillin prophylaxis in adults treated at least twice in hospital for cellulitis or erysipelas in the previous 12 months.[21][23] [ ] [Evidence B] Low-dose erythromycin can be used in patients with penicillin allergy.[21][23]

Tell patients that their prophylaxis should be reviewed at least every 6 months.[21]

Practical tip

Based on expert opinion and resistance data, the UK National Institute for Health and Care Excellence suggests avoiding the same antibiotic for treatment and prophylaxis.[21]

Primary options

phenoxymethylpenicillin: 250 mg orally twice daily

Secondary options

erythromycin: 250 mg orally twice daily

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Cellulitis and erysipelas

Treatment algorithm

suspected sepsis

follow local sepsis protocol

severe: any site (excluding near the eyes or nose)

empirical antibiotic therapy

Route of administration

Switching to oral antibiotics

Total treatment duration

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

consider hospital admission

supportive care

Fluids

Thromboprophylaxis

Wound management

Practical tip

Monitoring

Predisposing factors

analgesia

Practical tip

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

MRSA antibiotic cover

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

Aeromonas hydrophila antibiotic cover (fresh-water exposure)

EMA and MHRA restrictions on the use of fluoroquinolone antibiotics

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

Vibrio vulnificus antibiotic cover (salt-water exposure)

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

antibiotic cover for specific organisms from bites

reassessment

Practical tip

Practical tip

any severity: site near eyes or nose

empirical antibiotic therapy

Route of administration

Switching to oral antibiotics

Total duration of treatment

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options