Definition: Cellulitis with purulent drainage or exudates but without a drainable abscess. Usually caused by S. aureus (MSSA and MRSA).
Severity: *Mild / Moderate to Severe
H&P performed.
Labs:
Imaging/Studies:
Treatment:
-Parenteral (Moderate to Severe): Vancomycin
-Duration: 5-7 days
-“Always elevate affected extremity. Treatment failure is more commonly due to failure to elevate than a failure of antibiotics. Improvement of erythema can take days, especially in patients with lymphedema, because dead bacteria in the skin continue to induce inflammation.”
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Tx: Oral (Mild): B, C, D – Bactrim, or Clindamycin, or Doxycycline.
-Bactrim (TMP / SMX) DS, 1-2 tabs po BID.
-Clindamycin 300 po Q8H or clindamycin 600mg IV (when parenteral treatment is needed).
-Doxycycline 100mg po BID or Minocycline 100mg po BID
In training Example Question
A 65-year-old male presents to an urgent care center with a foot ulcer. His past medical history is significant for hypertension, COPD, and diabetes mellitus. He has been hospitalized several times in the past year for COPD exacerbations and a hip fracture. He does not have any other current problems.
On examination, he has a temperature of 37.3°C (99.1°F), a pulse rate of 105 beats/min, a respiratory rate of 16/min, and a blood pressure of 142/83 mm Hg. His examination is unremarkable except for a 2-cm ulcer on the ball of his left foot that has 3 cm of surrounding erythema and some purulent drainage. His CBC is normal except for a WBC count of 14,300/mm3 (N 4300–10,800).
Which one of the following would be the most appropriate choice for initial treatment?
A) Amoxicillin/clavulanate (Augmentin)
B) Linezolid (Zyvox)
C) Ciprofloxacin (Cipro)
D) Ceftriaxone (Rocephin) and levofloxacin (Levaquin)
E) Piperacillin/tazobactam (Zosyn) and vancomycin (Vancocin)
ANSWER: E
This patient has a severe diabetic foot ulcer. It appears to be infected and there are signs of a systemic inflammatory response. This is an indication for intravenous antibiotics. Piperacillin/tazobactam and vancomycin would be the most appropriate choice of antibiotics because together they cover the most common pathogens in diabetic foot ulcers, as well as MRSA, which is present in 10%–32% of diabetic foot ulcers. This patient has recently been hospitalized and would thus be at high risk for a MRSA infection. Moderate to severe diabetic foot ulcers are often polymicrobial and can include gram-positive cocci, gram-negative bacilli, and anaerobic pathogens.
Ref: Gemechu FW, Seemant F, Curley CA: Diabetic foot infections. Am Fam Physician 2013;88(3):177-184.
https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540106/all/Cellulitis