Treatment of Toe Cellulitis

Antibiotic Selection

The American College of Physicians and the Infectious Diseases Society of America recommend a 5-day course of antibiotics active against streptococci, such as penicillin, amoxicillin, dicloxacillin, cephalexin, or clindamycin, with extension if the infection has not improved within this time period 1, 2
For typical cases without systemic signs of infection, antimicrobial agents active against streptococci are recommended 3
First-line options include penicillin 1, amoxicillin 1, dicloxacillin 1, cephalexin (500 mg four times daily) 2, and clindamycin (300-450 mg three times daily) 1

Consider MRSA coverage if cellulitis is associated with penetrating trauma 3, evidence of MRSA infection elsewhere 1, purulent drainage 2, concurrent evidence of MRSA infection elsewhere 2, or illicit drug use 2
MRSA treatment options include trimethoprim-sulfamethoxazole 1, clindamycin 1, and doxycycline (with a β-lactam for streptococcal coverage) 2

For patients with systemic signs of infection, intravenous antibiotics are recommended 1
Options include vancomycin 1, daptomycin 1, linezolid 1, and telavancin 2, 1

The recommended initial duration is 5 days 3, 1, 4
Treatment should be extended if the infection has not improved within the initial 5-day period 3, 4

Elevation of the affected area to promote drainage of edema and inflammatory substances is recommended 2, 1
Careful examination and treatment of interdigital toe spaces to eradicate colonization with pathogens is recommended 3, 4
Treatment of predisposing conditions such as trauma 3, edema 1, and obesity 2, 3 is recommended

Severe infections with systemic inflammatory response syndrome (SIRS) require hospitalization 1
Altered mental status or hemodynamic instability require hospitalization 3
Concern for deeper or necrotizing infection requires hospitalization 1
Poor adherence to therapy requires hospitalization 3
Infection in a severely immunocompromised patient requires hospitalization 3
Outpatient treatment failure requires hospitalization 3

For patients with 3-4 episodes of cellulitis per year despite treatment of predisposing factors, consider prophylactic antibiotics 2, 1
Options include oral penicillin or erythromycin twice daily for 4-52 weeks 5, and intramuscular benzathine penicillin every 2-4 weeks 2, 1

For diabetic patients with toe cellulitis, broader coverage including both streptococci and S. aureus is recommended 5
Appropriate options include amoxicillin-clavulanate 1, trimethoprim-sulfamethoxazole 1, and clindamycin 5

MRSA is an unusual cause of typical cellulitis - treatment for MRSA is usually unnecessary unless specific risk factors are present 2
Failure to recognize treatment failure within the initial 5-day period may lead to complications 4
Not addressing underlying predisposing factors can lead to recurrent infections despite appropriate antibiotic therapy 4