b'Medical Management of Cellulitis: Use of Antibiotics trimethoprim 160 mg) twice daily and metronidazole Cephalexin 1 gram taken twice daily by mouth (Note 400 mg three times daily in combination shouldin the UK and Australia, the equivalent used is oralbe used.flucloxacillin 500 mg1g 6-hourly is recommended) If these treatments are unsuccessful, advice from as the treatment of choice (NICE 2019). (NB Currentan infectious disease specialist or lymphedema microbiology guidance favors the use of the upperservice should be sought.dose (EUCAST 2022), but gastrointestinal side effectsComplications from Antibiotic Treatment:may be more pronounced with this dose, and 1gClostridium difficile 6-hourly is an off-label dosing schedule).Clostridium difficile (C. diff) infection is a rare but Although the likely causative organisms of cellulitis serious complication of treatment with a variety of in lymphedema are beta-hemolytic streptococci,antibiotics. If your patient presents with diarrhea microbiologists suggest the use of single-agentfollowing a course of antibiotic(s), consider the flucloxacillin for all cellulitis, as this covers bothpossibility of C. diff If positive for C. diff, then the streptococcal and staphylococcal infections. However,antibiotics should be stopped immediately, and from clinical experience, amoxicillin (500 mg 8-hourly)treatment for C. diff be initiated immediately. Further, can be an effective alternative, e.g., in those whoconsultation with an infectious disease specialist is develop side effects with flucloxacillin. warranted to guide treatment for both the C. diff treatment and continued treatment for the cellulitis. In unusual circumstances, e.g., an animal bite or lick preceding an attack, should be discussedDuration of Antibiotic Treatment in thewith a local infectious disease specialist. Management of CellulitisAntibiotics should be given for 14 days. ExperienceAlternatives to Penicillin in lymphedema clinics suggests a significant rate of Patients who are allergic to penicillin should beearly recurrence of cellulitis with shorter courses,prescribed clarithromycin 500 mg twice daily. implying incomplete resolution of the infection.Erythromycin 500 mg four times daily is Local community/hospital or NICE guidance may recommend 57 days of treatment but these maypreferred if a macrolide is needed in pregnancy, not be specifically aimed at treating cellulitis in for example, if there is a true penicillin allergy andlymphedema.the benefits of antibiotic treatment outweigh the harms (NICE 2019). If recurrence/deterioration occurs soon after For those allergic to penicillin and unable to takecompletion of a 14-day course, advice shouldmacrolides, e.g., because they are taking statins,be sought from an infectious disease specialistdoxycycline 100 mg 12-hourly is recommended. and/or lymphedema service. Longer courses are occasionally needed.No Response After 48 hours of Treatment with Skin changes e.g. discolouration/staining mayFirst Line or Second Line Antibioticspersist for months or longer following severe cellulitis If there is no response or a poor response and do not require ongoing antibiotics.(unresolving systemic symptoms or worsening inflammation) to oral cephalexin (or amoxicillin /Conservative and Symptomaticclarithromycin) after 48 hours, then clindamycin Management of Cellulitis 300mg four times daily should be substituted asPatients report that rest and elevation are importantsecond line oral treatment. If signs or symptomsto help resolve the symptoms of cellulitis. deteriorate despite oral flucloxacillin (at any time)If wearing the usual compression garment causesconsider hospital admission/IV antibiotics. pain, then it should be removed but replaced as Anogenital Cellulitissoon as the affected area is comfortable enough to For those with cellulitis associated with lympho- tolerate it. This should reduce the risk of worsening the swelling if the garment is left off for a prolonged edema of the the anogenital region, flucloxacillin, period, e.g., one week. The fit of the compression or amoxicillin should be used as first-line treatmentgarment may need to be checked as the area may as the causative organism may be streptococcal. become more swollen after an episode of cellulitis.If penicillin-allergic, clarithromycin should be used.The recommended analgesia is acetaminophen If not responding to this regimen, then the causative (taken as directed and not to exceed 4 grams inorganism may not be streptococcal, and Amoxicllin/ 24 hours). Clavulinic Acid (Augmentin) 500/125 mg threeIbuprofen is an alternative (Note: It has been times daily is recommended. For those allergic to penicillin, Bactrim DS (sulfamethoxazole 800 mg/ suggested previously that non-steroidal anti-| Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|28'