Inpatient Management of Cellulitis

Classification and Initial Assessment

The Infectious Diseases Society of America recommends that cellulitis requiring hospitalization can be categorized based on severity, including moderate nonpurulent cellulitis and severe nonpurulent cellulitis, which is associated with systemic signs of infection, SIRS, altered mental status, or hemodynamic instability 1, 2, 3
Hospitalization is recommended for patients with concern for deeper or necrotizing infection, poor adherence to therapy, or severe immunocompromise 1, 2, 3

The Infectious Diseases Society of America recommends vancomycin plus either piperacillin-tazobactam or imipenem/meropenem as a reasonable empiric regimen for severe infections (strong, moderate) 1
For complicated skin and soft tissue infections, empiric therapy for MRSA should be considered pending culture data, with options including intravenous vancomycin, oral or intravenous linezolid, daptomycin, telavancin, or clindamycin 4, 5
For nonpurulent cellulitis in hospitalized patients, a β-lactam antibiotic may be considered initially, with modification to MRSA-active therapy if there is no clinical response (A-II) 4, 5

For streptococcal skin infections, penicillin is recommended, with alternatives including clindamycin, vancomycin, linezolid, daptomycin, or telavancin 6
For recurrent abscesses, nafcillin is recommended, with treatment extended to a 5-10 day course of an antibiotic active against the pathogen after obtaining cultures 6
For pediatric patients, vancomycin is recommended for hospitalized children with complicated skin and soft tissue infections (A-II), with alternatives including clindamycin or linezolid 2, 4, 5

The Infectious Diseases Society of America recommends 7-14 days of therapy for complicated skin and soft tissue infections, with treatment individualized based on clinical response 4, 5
Treatment should be extended if the infection has not improved within the initial treatment period (strong, high) 1

Blood cultures are recommended in hospitalized patients with cellulitis (strong, moderate), with cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, or animal bites 1, 3

Elevation of the affected area is recommended (strong, moderate), with treatment of predisposing factors such as edema or underlying cutaneous disorders, and examination of interdigital toe spaces for lower-extremity cellulitis 1, 2
Systemic corticosteroids could be considered in nondiabetic adult patients (weak, moderate) 1