Cellulitis and Skin Abscess in Adults: Treatment

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Cellulitis and skin abscess in adults: Treatment

Authors: Denis Spelman, MBBS, FRACP, FRCPA, MPH, Larry M Baddour, MD, FIDSA, FAHA
Section Editor: Franklin D Lowy, MD
Deputy Editor: Keri K Hall, MD, MS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2022. | This topic last updated: Oct 29, 2021.
INTRODUCTION
Patients with skin and soft tissue infection may present with cellulitis, abscess, or both [1-3].
Treatment of cellulitis and skin abscess are reviewed here.

(Related Pathway(s): Cellulitis and skin abscesses: Empiric antibiotic selection for adults.)
Issues related to clinical manifestations and diagnosis of cellulitis and abscess are discussed
separately. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations,
and diagnosis".)
Issues related to skin and soft tissue infections associated with specific epidemiologic factors
(such as diabetes, animal bites, and water exposure) are discussed separately. (See "Clinical
manifestations, diagnosis, and management of diabetic infections of the lower extremities" and
"Soft tissue infections following water exposure" and "Animal bites (dogs, cats, and other
animals): Evaluation and management" and "Human bites: Evaluation and management".)
Issues related to infection involving the gluteal area and perineum are discussed separately.
(See "Perianal and perirectal abscess" and "Pilonidal disease".)
GENERAL PRINCIPLES
Overview — The approach to management of skin and soft tissue infection depends on the
clinical presentation:
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● Patients with nonpurulent infection (ie, cellulitis or erysipelas in the absence of abscess or
purulent drainage) should be managed with empiric antibiotic therapy ( algorithm 1).
(See 'Nonpurulent infection' below.)
● Patients with drainable abscess should undergo incision and drainage; the technique is
discussed separately (see "Techniques for skin abscess drainage"). In addition, antibiotic
therapy is warranted if clinical criteria are met, as discussed below ( algorithm 2). (See
'Drainable abscess present' below.)
● Patients with purulent cellulitis (ie, cellulitis associated with purulent drainage in the
absence of drainable abscess) should be managed with antibiotic therapy ( algorithm 2).
(See 'Purulent cellulitis (no drainable abscess)' below.)
Issues related to choosing between oral and parenteral therapy are discussed below. (See 'Oral
versus parenteral therapy' below.)
Attention to antibiotic dosing is important, particularly in obese individuals; underdosing

(particularly in those with obesity and lymphedema) may result in higher rates of treatment
failure [4].
The approach to empiric antimicrobial therapy should be modified as indicated in the setting of
known pathogens, underlying conditions (such as diabetes), and special circumstances (such as
animal bites and water exposure). Management of patients in these settings is discussed in
detail separately. (See "Clinical manifestations, diagnosis, and management of diabetic
infections of the lower extremities" and "Animal bites (dogs, cats, and other animals): Evaluation
and management" and "Soft tissue infections following water exposure" and "Human bites:
Evaluation and management".)
Other components of management include elevation of the affected area and treatment of
underlying conditions (such as edema or underlying cutaneous disorders) if present [2].
Elevation facilitates gravity drainage of edema and inflammatory substances. The skin should
be sufficiently hydrated to avoid dryness and cracking without interdigital maceration.
We do not favor use of nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids in the

setting of cellulitis; these drugs can mask signs and symptoms of inflammation in patients with
necrotizing soft tissue infection and their use may be associated with delay in diagnosis. While
some data suggest that use of NSAIDs may shorten time to regression of inflammation among
patients with cellulitis [5,6], and some data suggest that use of corticosteroids may be
associated with a shorter median healing time among patients with erysipelas [7], these results
are limited by small sample size. (See "Necrotizing soft tissue infections".)
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Oral versus parenteral therapy — Patients with mild infection may be treated with oral
antibiotics. Treatment with parenteral antibiotics is warranted in the following circumstances:
● Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

● Rapid progression of erythema
● Progression of clinical findings after 48 hours of oral antibiotic therapy
● Inability to tolerate oral therapy
● Proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular
graft)
The decision to initiate parenteral therapy should be based on individual clinical circumstances
such as severity of clinical presentation and patient comorbidities. As an example, the presence
of an immunocompromising condition (such as neutropenia, recent organ transplant, advanced
HIV infection, B cell or T cell deficiency, or use of immunosuppressive agents) should lower the
threshold for parenteral therapy.
CLINICAL APPROACH
Nonpurulent infection — Forms of nonpurulent skin and soft tissue infection include cellulitis
and erysipelas. (See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical
manifestations, and diagnosis", section on 'Cellulitis and erysipelas'.)
Management of cellulitis and erysipelas should include elevation of the affected area and
treatment of underlying conditions. (See 'Overview' above.)
Many patients with cellulitis have underlying conditions that predispose them to developing
recurrent cellulitis (these include tinea pedis, lymphedema, and chronic venous insufficiency). In
such patients, treatment should be directed at both the infection and the predisposing
condition if modifiable. As an example, patients with edema may benefit from treatment with
compressive stockings and diuretic therapy.
Cellulitis — Patients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or

exudate and no associated abscess) should be managed with empiric therapy for infection due
to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) [1-3].
Common options are cefazolin for intravenous therapy and cephalexin for oral therapy; options
and doses are summarized in the algorithm ( algorithm 1). Issues related to choosing
between oral and parenteral therapy are discussed above. (See 'Oral versus parenteral therapy'
above.) (Related Pathway(s): Cellulitis and skin abscesses: Empiric antibiotic selection for adults.)
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This approach is supported by the following studies:
● A randomized trial including 496 patients with nonpurulent cellulitis (in the modified
intention-to-treat analysis) noted similar clinical cure rates among those treated with
cephalexin plus placebo (for empiric treatment of beta-hemolytic streptococci and MSSA;
69 percent) and those treated with cephalexin plus trimethoprim-sulfamethoxazole (TMP-
SMX; for empiric treatment of beta-hemolytic streptococci and methicillin-resistant S.
aureus [MRSA]; 76 percent; difference 7.3 percent; 95% CI -1.0 to 15.5 percent; p=0.09) [8].
While these findings raise the possibility that addition of TMP-SMX may be somewhat
superior to cephalexin alone, the results were likely skewed by a relatively large number of
patients who did not complete the full course of therapy.
● A randomized trial including 153 patients with cellulitis without abscess noted comparable
cure rates among those treated with cephalexin (for empiric treatment of beta-hemolytic
streptococci and MSSA; 82 percent) and those treated with cephalexin and TMP-SMX (for
empiric MRSA coverage; 85 percent) [9].
Additional empiric coverage for MRSA is warranted in the following circumstances [2,10]:

● Prior episode of MRSA infection or known MRSA colonization
● Lack of clinical response to antibiotic regimen that does not include activity against MRSA
● Presence of risk factor(s) for MRSA infection (including recent hospitalization, residence in
a long-term care facility, recent surgery, hemodialysis, and HIV infection)
● Proximity of the lesion to an indwelling medical device (eg, prosthetic joint or vascular
graft)
Issues related to treatment of MRSA infection are also discussed below. (See 'Approach to
antibiotic therapy' below.)
Deepening of erythema may be observed following initiation of antimicrobial therapy. This may
be due to destruction of pathogens that release particles that enhance local inflammation and
should not be mistaken for therapeutic failure.
Patients with cellulitis typically have symptomatic improvement within 24 to 48 hours of

beginning antimicrobial therapy, although visible improvement of clinical manifestations in
more severe cases may take up to 72 hours. Persistence of erythema and/or systemic
symptoms after this period of time should prompt consideration of resistant pathogens or
alternative diagnoses. In such cases, culture data should be reviewed carefully, pursuit of
radiographic evaluation for deeper infection is appropriate, and broadening antibiotic therapy
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to include coverage for gram-negative bacilli pending further diagnostic data is reasonable.
(See "Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and
diagnosis", section on 'Diagnosis'.)
The duration of therapy should be individualized depending on clinical response. In general,

five to six days of therapy is appropriate for patients with uncomplicated cellulitis whose
infection has improved within this time period [2,11,12]. Extension of antibiotic therapy (up to
14 days) may be warranted in the setting of severe infection, slow response to therapy, or
immunosuppression.
The above approach is supported by a trial including 151 patients hospitalized with nonpurulent
cellulitis randomly assigned to treatment with a 6-day or 12-day course with a penicillin
(flucloxacillin), cure rates were similar between the groups (74 versus 67 percent); however,
relapse rates after 90 days were higher in the 6-day group (6 versus 24 percent) [13]. In an
earlier study including 216 patients hospitalized with nonpurulent cellulitis, 90 percent of
patients had improvement in clinical findings and serum C-reactive protein concentration 3
days after initiation of antimicrobial therapy [14,15]. More than half of patients had residual
inflammation at the end of therapy (median 11 to 15 days), but relapse occurred in only 16
percent of them.
Erysipelas — Patients with erysipelas should be managed with empiric therapy for infection
due to beta-hemolytic streptococci.
Patients with systemic manifestations (such as fever and chills) should be treated with
parenteral therapy. Appropriate choices include cefazolin, ceftriaxone, or flucloxacillin (
algorithm 1). Cefazolin has activity against streptococci as well as MSSA, which is useful in
settings where erysipelas cannot be reliably distinguished from cellulitis. Ceftriaxone has
activity against streptococci (and may be used for activity against MSSA in some circumstances),
and its once-daily dosing allows for convenient outpatient administration.
We do not favor use of parenteral penicillin for initial empiric treatment of suspected erysipelas,
given the challenges associated with distinguishing erysipelas from cellulitis on clinical
grounds. If a microbiologic diagnosis of beta-hemolytic streptococcus is subsequently
established, then a switch to intravenous aqueous crystalline penicillin G (4 million units
intravenously every 4 hours) may be made.
Patients with mild infection or those who have improved following initial treatment with
parenteral antibiotic therapy may be treated with oral penicillin or amoxicillin ( algorithm 1).
In the setting of beta-lactam allergy, cephalexin (if the patient can tolerate cephalosporins),
clindamycin, trimethoprim-sulfamethoxazole, or linezolid may be used; data regarding use of
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trimethoprim-sulfamethoxazole are limited [2,16]. Macrolides (such as erythromycin) may not

be adequate in areas with relatively high resistance rates among beta-hemolytic streptococci
[2,17]. (Related Pathway(s): Cellulitis and skin abscesses: Empiric antibiotic selection for adults.)
The duration of therapy should be individualized depending on clinical response; 5 to 14 days is

usually appropriate.
Recurrent infection — Recurrent cellulitis is common; 22 to 49 percent of patients with

cellulitis report at least one prior episode [3]. Recurrences occur in approximately 14 percent of
cellulitis cases within one year and 45 percent of cases within three years, usually in the same
location [3]. In one review of more than 447,000 index admissions for cellulitis, the readmission
rates was 9.8 percent; most readmissions are due to skin and soft tissue infections [18].
Management — The approach to antibiotic therapy for management of a recurrent

episode is the same as the approach for an initial episode.
Prevention — Potential tools for prevention of recurrent cellulitis include alleviation of

predisposing conditions (such as use of compression therapy for management of edema),
antibiotic suppression, and S. aureus decolonization. These are discussed below.
Predisposing condition(s) should be identified and alleviated if possible [3]. Underlying

conditions that predispose to recurrent cellulitis include (see "Cellulitis and skin abscess:
Epidemiology, microbiology, clinical manifestations, and diagnosis", section on 'Epidemiology'):
● Edema (See "Clinical manifestations and evaluation of edema in adults" and "General
principles of the treatment of edema in adults".)
● Venous insufficiency (See "Medical management of lower extremity chronic venous
disease".)
● Fissuring or maceration of the interdigital toe spaces (See "Intertrigo".)
● Tinea pedis (See "Dermatophyte (tinea) infections".)
● Obesity (See "Obesity in adults: Overview of management".)
● Immunosuppression
Compression therapy — For patients with recurrent episodes of cellulitis in the setting

of chronic lower extremity venous insufficiency and edema, compression therapy is an essential
component of management that has been shown to be effective in reducing episodes of
recurrent cellulitis in addition to other benefits [19]. Compression therapy should be used only
after complete resolution of cellulitis; it should not be used at the time of active infection.
Additional details regarding compression therapy in patients with chronic venous insufficiency
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are provided separately. (See "Medical management of lower extremity chronic venous disease"
and "Compression therapy for the treatment of chronic venous insufficiency".)
In a randomized trial involving 84 patients with chronic lower extremity edema and ≥2 prior
episodes of cellulitis, daily use of compression therapy (consisting in most cases of knee-high
stockings that were worn throughout the day) reduced the rate of recurrent cellulitis episodes
compared with no compression therapy (15 versus 40 percent, respectively, at a median follow-
up of six months; hazard ratio 0.23, 95% CI 0.09-0.59) [19]. Of note, the trial was stopped early
for benefit, which tends to overestimate treatment efficacy. No adverse events related to
compression therapy were observed.
Role of antibiotic suppression — For patients with three to four episodes of cellulitis

per year in the setting of predisposing factors that cannot be alleviated, suppressive antibiotic
therapy may be warranted (for as long as the predisposing factors persist) [2]. Suppressive
therapy is less likely to be effective in some patients; these include those with chronic edema,
multiple (≥3) cellulitis episodes, and/or high body mass index (≥33 kg/m2) [20].
Serologic testing for beta-hemolytic streptococci may be a useful diagnostic tool to help guide
the choice of suppressive antibiotic therapy. (See "Cellulitis and skin abscess: Epidemiology,
microbiology, clinical manifestations, and diagnosis", section on 'Diagnosis'.)
Antibiotic options for suppressive therapy include:
● For patients with known or presumed beta-hemolytic streptococcal infection [20,21]:
• Penicillin V (250 to 500 mg orally twice daily)

• Penicillin G benzathine intramuscular (IM) injections (1.2 to 2.4 million units IM every 4
weeks; shorten interval to every 2 weeks if longer interval is not effective)
● For patients with known or presumed staphylococcal infection [22]:
• Cefadroxil (500 mg orally twice daily; for suppression of MSSA infection)

• Clindamycin (150 mg orally once daily)
• Trimethoprim-sulfamethoxazole (one double-strength tablet orally twice daily)
Suppressive therapy may be continued for several months with interval assessments for
efficacy and tolerance. If recurrent cellulitis occurs, the patient should be reevaluated promptly;
patients may be given instructions to self-initiate antibiotic therapy at onset of symptoms prior
to seeking immediate medical attention.
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Support for suppressive antibiotic therapy in prevention of recurrent cellulitis comes from the
following studies:
● In a study of 209 cases of cellulitis, recurrences were observed in 17 percent of patients;

among 143 patients with erysipelas, 29 percent had recurrent infection [23,24]. Early
episodes of cellulitis cause lymphatic inflammation, and repeated infection can lead to
lymphedema. Supportive care with elevation of the affected area and treatment of
underlying predisposing conditions are paramount. (See "Clinical staging and conservative
management of peripheral lymphedema".)
● In a systematic review and meta-analysis of five trials with a total of over 500 patients with
at least one prior episode of cellulitis, prophylactic antibiotic use reduced the risk of
subsequent cellulitis (relative risk [RR] 0.46, 95% CI 0.26-0.79) [25]. Findings from two of
the included studies also demonstrated that antibiotic prophylaxis is cost-effective [26].
● In a subsequent randomized trial that included 274 patients with two or more episodes of
lower extremity cellulitis, penicillin (250 mg orally twice daily) nearly halved the risk of
recurrence during 12 months of prophylaxis (hazard ratio 0.55; 95% CI 0.35 to 0.86), but
the protective effect diminished rapidly after the prophylaxis period ended [20]. A lower
likelihood of response was observed among patients with a body mass index ≥33 kg/m2,
multiple previous episodes of cellulitis, or lower extremity edema. These findings warrant
further investigation since patients in these categories are most likely to receive long-term
prophylaxis.
S. aureus decolonization — For patients with recurrent MRSA infection despite

hygiene optimization and/or if ongoing transmission is occurring among household members
or other close contacts, we suggest S. aureus decolonization; this is discussed further
separately. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Prevention and
control", section on 'Decolonization' and "Methicillin-resistant Staphylococcus aureus (MRSA) in
children: Prevention and control".)
Purulent infection — Purulent infection refers to presence of a drainable abscess or cellulitis

associated with purulent drainage (in the absence of drainable abscess) ( algorithm 2). An
infection involving purulence (whether the process began as an abscess [with secondary
cellulitis] or as a cellulitis [with secondary purulence]) is potentially attributable to S. aureus,
which should be reflected in the choice of empiric antimicrobial therapy.
Drainable abscess present — Patients with drainable abscess should undergo incision and
drainage ( algorithm 2) [27,28]. The technique for incision and drainage and the role of
culture are discussed separately. (See "Techniques for skin abscess drainage".)
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Individuals at risk for endocarditis warrant empiric antibiotic therapy prior to incision and
drainage; an oral antibiotic with activity against MRSA and beta-hemolytic Streptococcus should
be administered one hour prior to procedure ( algorithm 2) [29,30]. (See "Antimicrobial
prophylaxis for the prevention of bacterial endocarditis".)
Role of antibiotic therapy — For patients undergoing incision and drainage of a skin

abscess, we suggest antibiotic treatment. In particular, we favor antibiotic treatment for
patients with any of the following:
● Single abscess ≥2 cm [31-33]

● Multiple lesions
● Extensive surrounding cellulitis
● Associated immunosuppression or other comorbidities
● Inadequate clinical response to incision and drainage alone
● Presence of an indwelling medical device (such as prosthetic joint, vascular graft, or
pacemaker)
● High risk for adverse outcomes with endocarditis (these include a history of infective
endocarditis, presence of prosthetic valve or prosthetic perivalvular material, unrepaired
congenital heart defect, or valvular dysfunction in a transplanted heart)
● High risk for transmission of S. aureus to others (such as in athletes or military personnel)
However, because many abscesses can be treated successfully with incision and drainage alone,
expert opinion varies, and it is reasonable to forgo antibiotic therapy in otherwise healthy
patients who have small abscesses (eg, <2 cm in diameter) and none of the above factors [34-
36]. An antibiotic-sparing approach may be particularly compelling in patients who have
multiple antibiotic allergies or intolerances.
The 2014 Infectious Diseases Society of America (IDSA) guidelines on the management of skin
and soft tissue infections did not recommend routine antibiotic therapy for patients with mild
skin abscesses in the absence of systemic infection, immunocompromising conditions,
extremes of age, or multiple abscess, based on earlier data that suggested similar cure rates
with incision and drainage alone [2]. However, subsequent large trials have indicated a benefit
to antibiotic therapy, even in patients with small abscesses:
● In a randomized trial including 1220 patients >12 years of age (median 35 years) with
abscess 2 to 5 cm in diameter who underwent incision and drainage, treatment with TMP-
SMX (320 mg/1600 mg twice daily) resulted in higher cure rates 7 to 14 days after
treatment than placebo (80.5 versus 73.6 percent) [31]. Wound cultures were positive for
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MRSA in 45 percent of cases. A subsequent subgroup analysis of this cohort also

demonstrated improved outcomes among the TMP-SMX recipients [33].
● In another randomized trial including more than 780 patients with skin abscess ≤5 cm (45
percent were ≤2 cm) who underwent incision and drainage, treatment with TMP-SMX or
clindamycin each resulted in higher cure rates at 10 days than placebo (82 or 83 percent
versus 69 percent) [32]. MRSA was isolated in 49 percent of cases.
The above randomized trials were included in a systematic review and meta-analysis of more
than 2400 patients with drained abscess treated with antibiotics or placebo [37]. The rate of
treatment failure was lower among patients who received antibiotics (7 versus 16 percent); the
odds ratio for clinical cure was 2.3 (95% CI 1.7-3.1). A separate systematic review and meta-
analysis including more than 400 patients concluded treatment with TMP-SMX or clindamycin
reduced the risk of treatment failure compared with placebo, albeit with some risk of drug-
adverse (primarily gastrointestinal) events; cephalosporins failed to reduce treatment failure
rates [38].
Antimicrobial therapy may also decrease the risk of recurrent skin abscess. In one randomized
trial, new infections at one month of follow-up were less common among those who received
clindamycin than those who received TMP-SMX or placebo [32]. In another randomized trial, the
likelihood of recurrent abscess formation was lower in patients who received TMP-SMX than in
patients who received placebo [36].
The approach to empiric antibiotic selection and duration of therapy is as described below. (See
'Approach to antibiotic therapy' below.)
Purulent cellulitis (no drainable abscess) — Patients with cellulitis associated with purulent
drainage (in the absence of drainable abscess) should be managed with antibiotic therapy (
algorithm 2). The approach to empiric antibiotic selection and duration of therapy is as
described below. (See 'Approach to antibiotic therapy' below.)
Approach to antibiotic therapy — The approach to empiric antibiotic selection is the

same for all patients with purulent infection, including:
● Patients with drainable abscess and relevant clinical criteria (see 'Role of antibiotic
therapy' above)
● Patients with cellulitis and associated purulent drainage, in the absence of a drainable
abscess (see 'Purulent cellulitis (no drainable abscess)' above)
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It is useful to document the baseline appearance of the physical findings at the start of
antibiotic therapy. A baseline digital image should be taken to monitor progress.
Pathogens to cover — Patients with purulent infection (as defined in the preceding

section) should be managed with empiric therapy for infection due to MRSA, pending culture
results ( algorithm 2) [1,2]. Empiric therapy for infection due to beta-hemolytic streptococci is
usually not necessary. Empiric therapy selection should be tailored to culture and susceptibility
results when available.
This approach is supported by findings of a study including 422 patients with purulent soft
tissue infection in which MRSA was the dominant organism (isolated from 59 percent of
patients), followed by MSSA (isolated from 17 percent of patients); beta-hemolytic streptococci
accounted for a much smaller proportion of these infections (2.6 percent) [39].
Initial management of patients with purulent infection in association with a pressure ulcer, a
perioral or peri-rectal site of infection, or prominent skin necrosis consists of antimicrobial
therapy that includes empiric coverage for MRSA as well as gram-negative and anaerobic
organisms (pending culture and susceptibility results) ( algorithm 2).
Choosing an antibiotic agent — Issues related to choosing between oral and

parenteral therapy are discussed above. (See 'Oral versus parenteral therapy' above.)
Options for empiric oral therapy of purulent infection (ie, with activity against MRSA) include
clindamycin, TMP-SMX, or tetracyclines (doxycycline or minocycline) ( table 1 and
algorithm 2). The efficacy of clindamycin and TMP-SMX for treatment of uncomplicated skin
infection may be considered comparable; this was illustrated in a randomized trial that included
524 patients with uncomplicated skin infections, including both cellulitis and abscesses (cure
rates for clindamycin and TMP-SMX were 80 and 78 percent, respectively) [40]. For oral anti-
MRSA coverage, however, we generally favor TMP-SMX, doxycycline, or minocycline;
clindamycin is less frequently chosen due to its greater risk of Clostridioides difficile infection
[41]. In addition, in vitro susceptibility of MRSA to clindamycin must be confirmed [42,43].
Oxazolidinones (linezolid or tedizolid), delafloxacin, and omadacycline are additional agents

with activity against MRSA; they should be reserved for circumstances in which none of the
other regimens listed can be used. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in
adults: Treatment of skin and soft tissue infections".)
For patients who are at high risk of an adverse outcome if infective endocarditis occurs (eg,
individuals with prior infective endocarditis, prosthetic heart material, unrepaired congenital
heart defect, and valvular dysfunction in a transplanted heart), we favor covering beta-
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hemolytic streptococci in addition to MRSA pending culture data because of the possibility
(albeit small) of streptococcal involvement. In such patients who are undergoing incision and
drainage, antibiotics should be administered 60 minutes prior to the incision.
Antimicrobial therapy with activity against MRSA and beta-hemolytic streptococci may be
achieved with clindamycin or TMP-SMX monotherapy; there may be regional differences in
MRSA susceptibility to these agents [16,44]. In one systematic review that included 10
randomized trials evaluating the utility of TMP-SMX for treatment of skin and soft tissue
infection due to beta-hemolytic streptococci or S. aureus, eight studies demonstrated efficacy of
TMP-SMX for these conditions, although the number of nonpurulent cellulitis cases in these
trials due to beta-hemolytic streptococci was limited [16]. In vitro susceptibility data support the
notion that TMP-SMX is active against Streptococcus pyogenes [44]. Because of uncertain
streptococcal coverage with doxycycline or minocycline, we add amoxicillin to each of these
agents to ensure adequate antistreptococcal activity.
Options for empiric parenteral therapy of MRSA include vancomycin and daptomycin (
algorithm 2); alternative parenteral agents with activity against MRSA are summarized in the
table ( table 2) and are discussed in detail separately. These agents also have activity against
beta-hemolytic Streptococcus. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults:
Treatment of skin and soft tissue infections", section on 'Parenteral antibiotic therapy'.)
Duration of therapy — The appropriate duration of therapy for treatment of skin and

soft tissue infection depends on the nature of the clinical presentation, and the clinical response
should guide duration of therapy.
Patients with mild infection who warrant outpatient management with oral antibiotic therapy
should have repeat evaluation after 24 to 48 hours to verify clinical response [2]. Patients with
MRSA responsive to oral therapy are typically treated for 5 days; extension of the duration (up
to 14 days) may be warranted in the setting of severe infection, slow response to therapy, or
immunosuppression. Lack of response may be due to infection with resistant organism(s),
inadequate adherence, or presence of a deeper, more serious infection than previously realized.
Patients with infection warranting parenteral therapy (in the absence of bacteremia or
involvement beyond soft tissue) are typically treated for a total duration of 5 to 14 days. Once
there are signs of clinical improvement with no evidence of systemic toxicity, antibiotics may be
transitioned from parenteral to oral therapy.
For patients with abscess that was detected radiographically, follow-up imaging may be useful
for assessing response to therapy. (See "Cellulitis and skin abscess: Epidemiology, microbiology,
clinical manifestations, and diagnosis", section on 'Diagnosis'.)
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Recurrent infection — The approach to management of recurrent purulent cellulitis is the

same as the approach to management of the initial episode.
A recurrent abscess at a site of previous infection should prompt consideration of additional

causes such as pilonidal cyst, hidradenitis suppurativa, or presence of foreign material [2].
Surgical exploration and debridement may be warranted, and suppressive antibiotics may be
reasonable if no drainable collection or treatable underlying condition is found. In patients with
recurrent abscess beginning in early childhood, evaluation for a neutrophil disorder is
warranted. (See "Primary disorders of phagocyte number and/or function: An overview".)
For patients with recurrent infection due to S. aureus, attempting decolonization is reasonable;
this is discussed separately. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults:
Prevention and control", section on 'Targeted decolonization' and "Methicillin-resistant
Staphylococcus aureus (MRSA) in children: Prevention and control".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Skin and soft tissue
infections".)
SUMMARY AND RECOMMENDATIONS
● Patients with skin and soft tissue infection may present with cellulitis, abscess, or both.
The approach to management depends on the nature of the clinical presentation. (See
'General principles' above.)
● In general, patients with mild infection may be treated with an oral antibiotic regimen. The
decision to initiate parenteral antibiotic therapy should be based on individual clinical
circumstances such as severity of clinical presentation and patient comorbidities. We
recommend that patients with signs of systemic toxicity or rapid progression of erythema
be treated initially with parenteral antibiotics (Grade 1B). Parenteral therapy is also
appropriate for patients with persistence or progression of symptoms despite 48 hours of
oral antibiotic therapy, inability to tolerate oral therapy, or proximity of the lesion to an
indwelling medical device (eg, prosthetic joint or vascular graft). (See 'Oral versus
parenteral therapy' above.)
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● The management of patients with nonpurulent infection (ie, cellulitis or erysipelas in the
absence of abscess or purulent drainage) consists of antibiotic therapy ( algorithm 1).
(See 'Nonpurulent infection' above.)
• Patients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or exudate
and no associated abscess) should be managed with empiric therapy for infection due
to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus
(MSSA); additional empiric coverage for methicillin-resistant S. aureus (MRSA) is
warranted in the circumstances summarized above ( algorithm 1). (See 'Cellulitis'
above.)
• Patients with erysipelas should be managed with empiric therapy for infection due to
beta-hemolytic streptococci. (See 'Erysipelas' above.)
• The duration of antibiotic therapy for treatment of nonpurulent infection should be

individualized depending on clinical response. In general, 5 days of therapy is
appropriate for patients with uncomplicated infection who have improved within this
time period. Extension of the duration (up to 14 days) may be warranted in the setting
of severe infection and/or slow response to therapy.
● Potential tools for prevention of recurrent nonpurulent cellulitis include alleviation of

predisposing conditions, antibiotic suppression, and S. aureus decolonization (See
'Prevention' above.)
• For patients with recurrent episodes of cellulitis in the setting of chronic lower
extremity venous insufficiency and edema, compression therapy is an essential
component of management as discussed separately. (See "Medical management of
lower extremity chronic venous disease" and "Compression therapy for the treatment
of chronic venous insufficiency".)
• For patients with three to four episodes of cellulitis per year in the setting of
predisposing factors that cannot be alleviated, we suggest use of suppressive antibiotic
therapy (for as long as the predisposing factors persist) (Grade 2B).
• For patients with recurrent MRSA infection despite hygiene optimization and/or if
ongoing transmission is occurring among household members or other close contacts,
we suggest S. aureus decolonization (Grade 2C).
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● The management of patients with purulent infection depends on whether a drainable

abscess is present (see 'Purulent infection' above):
• Patients with drainable abscess should undergo incision and drainage ( algorithm 2).
(See 'Drainable abscess present' above and "Techniques for skin abscess drainage".)
• The role of antimicrobial therapy in the setting of drainable abscess depends on

individual clinical circumstances.
- In general, we recommend antibiotic therapy for patients with multiple lesions,

extensive surrounding cellulitis, associated comorbidities or immunosuppression,
signs of systemic infection, or inadequate clinical response to incision and
drainage alone (Grade 1B), and we suggest antibiotic therapy for patients with skin
abscess ≥2 cm (Grade 2A), an indwelling device, or high risk for transmission of S.
aureus to others (Grade 2B). (See 'Role of antibiotic therapy' above.)
- For otherwise healthy patients with no risk factors, we suggest administering

antimicrobial therapy (Grade 2C). However, because many abscesses can be
treated successfully with incision and drainage alone, expert opinion varies, and it
is reasonable to forgo antibiotic therapy in otherwise healthy patients who have
small (eg, <2 cm) abscesses and no other comorbidities. (See 'Role of antibiotic
therapy' above.)
• Patients with purulent cellulitis (ie, cellulitis associated with purulent drainage in the
absence of drainable abscess) should be managed with antibiotic therapy (
algorithm 2). (See 'Purulent cellulitis (no drainable abscess)' above.)
● Initial treatment for patients with purulent infection who warrant antibiotic therapy should
consist of treatment for MRSA (pending culture and susceptibility results) ( algorithm 2).
In addition, initial treatment of patients with purulent infection in association with a
pressure ulcer, a perioral or peri-rectal site of infection, or prominent skin necrosis should
consist of antimicrobial therapy that includes empiric coverage for gram-negative and
anaerobic organisms (pending culture and susceptibility results). The duration of therapy
should be individualized depending on clinical response. (See 'Approach to antibiotic
therapy' above.)
● The duration of antibiotic therapy for treatment of purulent infection should be

individualized depending on clinical response. Patients with MRSA responsive to oral
therapy are typically treated for 5 days; extension of the duration (up to 14 days) may be
warranted in the setting of severe infection, slow response to therapy, or
6/20/22, 2:01 AM 110530
immunosuppression. Patients with infection warranting parenteral therapy (in the

absence of bacteremia or involvement beyond soft tissue) are typically treated for a total
duration of 5 to 14 days. Once there are signs of clinical improvement with no evidence of
systemic toxicity, antibiotics may be transitioned from parenteral to oral therapy. (See
'Duration of therapy' above.)
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society of america for the treatment of methicillin-resistant Staphylococcus aureus
infections in adults and children. Clin Infect Dis 2011; 52:e18.
2. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and
management of skin and soft tissue infections: 2014 update by the infectious diseases
society of America. Clin Infect Dis 2014; 59:147.
3. Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA 2016; 316:325.
4. Halilovic J, Heintz BH, Brown J. Risk factors for clinical failure in patients hospitalized with
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8. Moran GJ, Krishnadasan A, Mower WR, et al. Effect of Cephalexin Plus Trimethoprim-
Sulfamethoxazole vs Cephalexin Alone on Clinical Cure of Uncomplicated Cellulitis: A
Randomized Clinical Trial. JAMA 2017; 317:2088.
9. Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness of cephalexin
plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of
uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis 2013; 56:1754.
10. The Medical Letter. Drugs for MRSA Skin and Soft-Tissue Infections, May 12, 2014. https://s
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n%20and%20Soft-Tissue%20Infections&cannotaccesstitle=1 (Accessed on May 22, 2018).
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11. Hepburn MJ, Dooley DP, Skidmore PJ, et al. Comparison of short-course (5 days) and
standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med 2004; 164:1669.
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13. Cranendonk DR, Opmeer BC, van Agtmael MA, et al. Antibiotic treatment for 6 days versus
12 days in patients with severe cellulitis: a multicentre randomized, double-blind, placebo-
controlled, non-inferiority trial. Clin Microbiol Infect 2020; 26:606.
14. Bruun T, Oppegaard O, Kittang BR, et al. Etiology of Cellulitis and Clinical Prediction of
Streptococcal Disease: A Prospective Study. Open Forum Infect Dis 2016; 3:ofv181.
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Study of Dynamics and Predictors. Clin Infect Dis 2016; 63:1034.
16. Bowen AC, Carapetis JR, Currie BJ, et al. Sulfamethoxazole-Trimethoprim (Cotrimoxazole)
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18. Fisher JM, Feng JY, Tan SY, Mostaghimi A. Analysis of Readmissions Following
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of the Leg. N Engl J Med 2020; 383:630.
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cellulitis: a critical appraisal. Br J Dermatol 2014; 171:1300.
22. Klempner MS, Styrt B. Prevention of recurrent staphylococcal skin infections with low-dose
oral clindamycin therapy. JAMA 1988; 260:2682.
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cellulitis in a population-based cohort. Arch Intern Med 2007; 167:709.
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prophylaxis. Infection 1987; 15:105.
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systematic review and meta-analysis. J Infect 2014; 69:26.
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26. Mason JM, Thomas KS, Crook AM, et al. Prophylactic antibiotics to prevent cellulitis of the
leg: economic analysis of the PATCH I & II trials. PLoS One 2014; 9:e82694.
27. Fitch MT, Manthey DE, McGinnis HD, et al. Videos in clinical medicine. Abscess incision and
drainage. N Engl J Med 2007; 357:e20.
28. Miller LG, Quan C, Shay A, et al. A prospective investigation of outcomes after hospital
discharge for endemic, community-acquired methicillin-resistant and -susceptible
Staphylococcus aureus skin infection. Clin Infect Dis 2007; 44:483.
29. Bobrow BJ, Pollack CV Jr, Gamble S, Seligson RA. Incision and drainage of cutaneous
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30. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from
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Interdisciplinary Working Group. Circulation 2007; 116:1736.
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Placebo for Uncomplicated Skin Abscess. N Engl J Med 2016; 374:823.
32. Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for
Smaller Skin Abscesses. N Engl J Med 2017; 376:2545.
33. Talan DA, Moran GJ, Krishnadasan A, et al. Subgroup Analysis of Antibiotic Treatment for
Skin Abscesses. Ann Emerg Med 2018; 71:21.
34. Rajendran PM, Young D, Maurer T, et al. Randomized, double-blind, placebo-controlled trial
of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for
community-acquired methicillin-resistant Staphylococcus aureus infection. Antimicrob
Agents Chemother 2007; 51:4044.
35. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in
the management of community-acquired skin abscesses in the pediatric patient. Ann
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36. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-
sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-
associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010;
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37. Gottlieb M, DeMott JM, Hallock M, Peksa GD. Systemic Antibiotics for the Treatment
of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-Analysis. Ann Emerg Med
2019; 73:8.
38. Wang W, Chen W, Liu Y, et al. Antibiotics for uncomplicated skin abscesses: systematic
review and network meta-analysis. BMJ Open 2018; 8:e020991.
39. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among
patients in the emergency department. N Engl J Med 2006; 355:666.
40. Miller LG, Daum RS, Creech CB, et al. Clindamycin versus trimethoprim-sulfamethoxazole
for uncomplicated skin infections. N Engl J Med 2015; 372:1093.
41. Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for
uncomplicated skin abscesses: a clinical practice guideline. BMJ 2018; 360:k243.
42. Harrington AT, Black JA, Clarridge JE 3rd. In Vitro Activity of Retapamulin and Antimicrobial
Susceptibility Patterns in a Longitudinal Collection of Methicillin-Resistant Staphylococcus
aureus Isolates from a Veterans Affairs Medical Center. Antimicrob Agents Chemother
2015; 60:1298.
43. Al-Rawahi GN, Reynolds S, Porter SD, et al. Community-associated CMRSA-10 (USA-300) is
the predominant strain among methicillin-resistant Staphylococcus aureus strains causing
skin and soft tissue infections in patients presenting to the emergency department of a
Canadian tertiary care hospital. J Emerg Med 2010; 38:6.
44. Bowen AC, Lilliebridge RA, Tong SY, et al. Is Streptococcus pyogenes resistant or
susceptible to trimethoprim-sulfamethoxazole? J Clin Microbiol 2012; 50:4067.
Topic 110530 Version 33.0
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GRAPHICS
Clinical approach to management of nonpurulent cellulitis in adults
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This algorithm outlines our approach to initial empiric antibiotic therapy of patients with cellulitis or erysipe
patient presentation. The choice among them further depends on factors such as patient allergies or medic
expected local rates of resistance, cost, and convenience of administration.
MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible S. aureus; IV: intravenously; A
* The decision to administer antimicrobial therapy parenterally should be individualized based on clinical pr
or any of these features is present. Comorbidities that increase the risk of severe or complicated infection, s
infection, B cell or T cell deficiency, or use of immunosuppressive agents), should lower the threshold for pa
¶ Five days of antibiotic therapy is generally sufficient; extension up to 14 days may be warranted for slow re
Δ Intravenous antibiotic dosing as follows (if 2 doses are listed for a given agent, the higher one is for patien
Cefazolin 1 to 2 g IV every 8 hours.
Ceftriaxone 1 to 2 g IV every 24 hours.
Ciprofloxacin 400 mg IV every 12 hours.
Clindamycin 600 to 900 mg IV every 8 hours.
Daptomycin 4 to 6 mg/kg IV every 24 hours.
Flucloxacillin 2 g IV every 6 hours.
Nafcillin 1 to 2 g IV every 4 hours.
Oxacillin 1 to 2 g IV every 4 hours.
Vancomycin: For severely ill patients, a loading dose (20 to 35 mg/kg) is appropriate; the loading dose
range, we use a higher dose for critically ill patients. The initial maintenance dose and interval are det
Subsequent dose and interval adjustments are based on AUC-guided or trough-guided serum concen
AUC-guided and trough-guided vancomycin dosing.
◊ Oral antibiotic dosing as follows (if 2 doses are listed for a given agent, the higher one is for patients with
Amoxicillin 875 mg orally twice daily.
Cefadroxil 500 mg twice daily OR 1 g orally daily.
Cephalexin 500 mg orally 4 times daily.
Clindamycin 450 mg orally 3 times daily.
Dicloxacillin 500 mg orally 4 times daily.
Doxycycline 100 mg orally twice daily.
Flucloxacillin 500 mg orally 4 times daily.
Minocycline 200 mg orally once, then 100 mg orally every 12 hours.
Penicillin V potassium 500 mg orally every 6 hours.
Trimethoprim-sulfamethoxazole 1 to 2 double-strength tablets orally every 12 hours.
§ Penicillin and amoxicillin are preferred for erysipelas. For patients with a penicillin allergy, cephalexin (dep
alternative but should be reserved for circumstances in which the other options cannot be used.
¥ Risk factors for MRSA include:

Recent (eg, within the prior 1 to 2 months) hospitalization or surgery.
Residence in a long-term care facility.
Hemodialysis.
HIV infection.
‡ For oral treatment of beta-hemolytic Streptococcus and MRSA, we generally favor trimethoprim-sulfametho
difficile infection with clindamycin. However, doxycycline and minocycline do not have good antistreptococca
but these should be reserved for circumstances in which the other options cannot be used.
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† Vancomycin is the preferred parenteral anti-MRSA option. Daptomycin is an acceptable alternative agent f
≥2, do not respond to vancomycin, have prior treatment failure with vancomycin, or do not tolerate vancom
telavancin, dalbavancin, and oritavancin; use of these agents is limited by high cost and, in some cases, avai
discussion of the approach to antibiotic selection.
** For patients who require oral treatment with activity against beta-hemolytic Streptococcus and MRSA, mo
streptococcal coverage with doxycycline or minocycline, we add amoxicillin to each of these agents to ensur
Graphic 111732 Version 11.0
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Approach to management of drainable abscess or skin infection with purulent
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This algorithm outlines our approach to initial empiric antibiotic therapy and abscess management of patien
options depending on the patient presentation. The choice among them further depends on factors such as
with the different antibiotics, expected local rates of resistance, cost, and convenience of administration.
MRSA: methicillin-resistant S. aureus; IV: intravenously; AUC: area under the 24-hour time-concentration curv
* This includes a history of infective endocarditis, prosthetic valve or perivalvular material, and unrepaired c
¶ We suggest antibiotic therapy for all patients with skin abscesses. However, because many abscesses can
otherwise healthy patients who have small (eg, <2 cm) abscesses without the features listed in the first box.
allergies or intolerances.
Δ The decision to administer antimicrobial therapy parenterally should be individualized based on clinical pr
of these features are present. Comorbidities that increase the risk of severe or complicated infection, such a
advanced HIV infection, B cell or T cell deficiency, or use of immunosuppressive agents), should lower the th
◊ Wound cultures are not necessary in healthy patients who do not receive antibiotics. For patients receivin
any of the following are present:
Severe local infection (eg, extensive cellulitis).
Systemic signs of infection (eg, fever).
History of recurrent or multiple abscesses.
Failure of initial antibiotic therapy.
Extremes of age (young infants or older adults).
Immunocompromising condition.
Indications for prophylaxis against infective endocarditis.
The community patterns of S. aureus susceptibility are unknown or rapidly changing.
§ Five days of antibiotic therapy is generally sufficient; extension up to 14 days may be warranted for slow re
determine whether the chosen antimicrobial regimen is appropriate or warrants revision.
¥ Oral antibiotic dosing as follows (if 2 doses are listed for a given agent, the higher one is for patients with
Amoxicillin 875 mg orally twice daily.
Amoxicillin-clavulanate 875 mg orally twice daily.
Clindamycin 450 mg orally 3 times daily.
Ciprofloxacin 500 mg orally twice daily.
Doxycycline 100 mg orally twice daily.
Levofloxacin 750 mg orally once daily.
Metronidazole 500 mg orally 3 times daily.
Minocycline 200 mg orally once, then 100 mg orally twice daily.
Trimethoprim-sulfamethoxazole 1 to 2 double-strength tablets orally twice daily.
‡ For oral anti-MRSA coverage, we generally favor trimethoprim-sulfamethoxazole, doxycycline, or minocycl
clindamycin. Other active options include linezolid, tedizolid, delafloxacin, and omadacycline, but these shou
† Intravenous antibiotic dosing as follows (if 2 doses are listed for a given agent, the higher one is for patien
Ampicillin-sulbactam 3 g IV every 6 hours.
Ceftriaxone 1 to 2 g IV every 24 hours.
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Ciprofloxacin 400 mg IV every 12 hours.

Daptomycin 4 to 6 mg/kg IV every 24 hours.
Levofloxacin 750 mg IV once daily.
Metronidazole 500 mg IV every 8 hours.
Piperacillin-tazobactam 3.375 or 4.5 g IV every 6 hours.
Ticarcillin-clavulanate 3.1 g IV every 4 hours.
Vancomycin: For severely ill patients, a loading dose (20 to 35 mg/kg) is appropriate; the loading dose
Within this range, we use a higher dose for critically ill patients. The initial maintenance dose and inte
normal renal function). Subsequent dose and interval adjustments are based on AUC-guided or troug
nomogram and discussion of AUC-guided and trough-guided vancomycin dosing.
** Vancomycin is the preferred parenteral anti-MRSA option. Daptomycin is an acceptable alternative agent
vancomycin, have prior treatment failure with vancomycin, or do not tolerate vancomycin. Additional altern
dalbavancin, and oritavancin; use of these agents is limited by high cost and, in some cases, availability. Ref
discussion of the approach to antibiotic selection.
¶¶ Because of uncertain streptococcal coverage with doxycycline or minocycline, we add amoxicillin to each
can be discontinued if cultures do not grow Streptococcus species.
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Oral antimicrobial therapy for treatment of skin and soft tissue infections
due to methicillin-resistant Staphylococcus aureus (MRSA) in adults
Treatment Adult dose
Preferred agents*
Trimethoprim-sulfamethoxazole 1 or 2 DS tablets twice daily

(cotrimoxazole)
Clindamycin 450 mg orally 3 times daily
Doxycycline 100 mg orally twice daily
Minocycline 200 mg orally once, then 100 mg orally twice

daily
Alternative agents¶
Linezolid 600 mg orally twice daily
Tedizolid 200 mg orally once daily
Delafloxacin 450 mg orally twice daily
Omadacycline 300 mg orally once daily
The doses recommended above are intended for patients with normal renal function; the doses of
some of these agents must be adjusted in patients with renal insufficiency.
DS: double strength (ie, 160 mg trimethoprim with 800 mg sulfamethoxazole per tablet).
* In general, the choice between the preferred oral antibiotic agents is guided by individual clinical
circumstances including local antibiotic resistance patterns, allergy history, and concomitant
medications.
¶ Use of alternative oral antibiotic agents is limited by cost, clinical experience, and adverse drug
effects. They should be reserved for patients who do not respond to or cannot tolerate the preferred
agents.
Data from:
1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft
tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59:e10.
2. Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011;
52:e18 (note: for TMP-SMX dose in osteomyelitis, refer to p e38).
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Parenteral antimicrobial therapy for treatment of skin and soft tissue

infections due to methicillin-resistant Staphylococcus aureus (MRSA) in
adults
Drug Adult dose
Antibiotics of choice*
Vancomycin¶ 15 to 20 mg/kg/dose every 8 to 12 hours
DaptomycinΔ 4 to 6 mg/kg IV once daily
Alternative agents
Short-acting agents with parenteral or oral dosing
Linezolid 600 mg IV (or orally) twice daily
Tedizolid 200 mg IV (or orally) once daily
Delafloxacin 300 mg IV twice daily (or 450 mg orally twice daily)
Omadacycline◊ 100 mg IV once daily (or 300 mg orally once daily)
Short-acting agent with parenteral dosing§
Ceftaroline 600 mg IV every 12 hours
Long-acting agents with parenteral dosing
Dalbavancin Single-dose regimen: 1500 mg once
Two-dose regimen: Initial dose 1000 mg, followed by 500 mg dose one week
later
Oritavancin 1200 mg IV as a single dose
Telavancin 10 mg/kg once daily
IV: intravenously; AUC: area under the 24-hour time-concentration curve.
* In areas outside the United States where teicoplanin is available, some use it as the drug of choice
for initial therapy of gram-positive pathogens, while others favor its use for patients with intolerance
to vancomycin.
¶ For severely ill patients, a vancomycin loading dose (20 to 35 mg/kg) is appropriate[1] ; within this
range, we use a higher dose for critically ill patients. The loading dose is based on actual body
weight, rounded to the nearest 250 mg increment and not exceeding 3000 mg. The initial
maintenance dose and interval are determined by nomogram (typically 15 to 20 mg/kg every 8 to 12
hours for most patients with normal renal function). Subsequent dose and interval adjustments are
based on AUC-guided or trough-guided serum concentration monitoring. Refer to the UpToDate
topic on vancomycin dosing for sample nomogram and discussion of vancomycin monitoring.
Δ Dosing of daptomycin for treatment of skin and soft tissue infection is 4 to 6 mg/kg IV once daily;
dosing for treatment of bacteremia is at least 6 mg/kg IV once daily. (Refer to the UpToDate topic on
6/20/22, 2:01 AM 110530
treatment of MRSA bacteremia for further discussion.)
◊ A loading dose may be used: 200 mg IV over 60 minutes OR 100 mg IV over 30 minutes twice.
§ Ceftobiprole has broad-spectrum activity against gram-positive and gram-negative organisms and
is available in some countries outside the United States.
Data from: Lui C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the
treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011; 52:285.
Reference:
1. Rybak MJ, Le J, Lodise TP, et al. Therapeutic Monitoring of Vancomycin for Serious Methicillin-Resistant Staphylococcus
Aureus Infections: A Revised Consensus Guideline and Review by the American Society of Health-System Pharmacists,
the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious
Diseases Pharmacists. Am J Health Syst Pharm 2020; 77:835.
6/20/22, 2:01 AM 110530
Contributor Disclosures
Denis Spelman, MBBS, FRACP, FRCPA, MPH No relevant financial relationship(s) with ineligible
companies to disclose. Larry M Baddour, MD, FIDSA, FAHA Consultant/Advisory Boards: Boston Scientific
[Cardiovascular device infection];Roivant Sciences [Phage therapy for Staphylococcus aureus bacteremia
and endocarditis].
Other Financial Interest: Botanix Pharmaceuticals[Antibiotic therapy].
All of the relevant
financial relationships listed have been mitigated. Franklin D Lowy, MD Consultant/Advisory Boards:
GlaxoSmithKline [Staphylococcal vaccines and skin infections].
All of the relevant financial relationships
listed have been mitigated. Keri K Hall, MD, MS No relevant financial relationship(s) with ineligible
companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Cellulitis and Skin Abscess in Adults: Treatment

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Cellulitis and skin abscess in adults: Treatment

Treatment of cellulitis and skin abscess are reviewed here.

Attention to antibiotic dosing is important, particularly in obese individuals; underdosing

We do not favor use of nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids in the

● Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

Cellulitis — Patients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or

This approach is supported by the following studies:

● Systemic signs of toxicity (eg, fever >100.5°F/38°C, hypotension, or sustained tachycardia)

Patients with cellulitis typically have symptomatic improvement within 24 to 48 hours of

The duration of therapy should be individualized depending on clinical response. In general,

trimethoprim-sulfamethoxazole are limited [2,16]. Macrolides (such as erythromycin) may not

The duration of therapy should be individualized depending on clinical response; 5 to 14 days is

Recurrent infection — Recurrent cellulitis is common; 22 to 49 percent of patients with

Management — The approach to antibiotic therapy for management of a recurrent

Prevention — Potential tools for prevention of recurrent cellulitis include alleviation of

Predisposing condition(s) should be identified and alleviated if possible [3]. Underlying

Compression therapy — For patients with recurrent episodes of cellulitis in the setting

Role of antibiotic suppression — For patients with three to four episodes of cellulitis

Antibiotic options for suppressive therapy include:

● For patients with known or presumed beta-hemolytic streptococcal infection [20,21]:

• Penicillin V (250 to 500 mg orally twice daily)

● For patients with known or presumed staphylococcal infection [22]:

• Cefadroxil (500 mg orally twice daily; for suppression of MSSA infection)

● In a study of 209 cases of cellulitis, recurrences were observed in 17 percent of patients;

S. aureus decolonization — For patients with recurrent MRSA infection despite

Purulent infection — Purulent infection refers to presence of a drainable abscess or cellulitis

Role of antibiotic therapy — For patients undergoing incision and drainage of a skin

● Single abscess ≥2 cm [31-33]

MRSA in 45 percent of cases. A subsequent subgroup analysis of this cohort also

Approach to antibiotic therapy — The approach to empiric antibiotic selection is the

Pathogens to cover — Patients with purulent infection (as defined in the preceding

Choosing an antibiotic agent — Issues related to choosing between oral and

Oxazolidinones (linezolid or tedizolid), delafloxacin, and omadacycline are additional agents

Duration of therapy — The appropriate duration of therapy for treatment of skin and

Recurrent infection — The approach to management of recurrent purulent cellulitis is the

A recurrent abscess at a site of previous infection should prompt consideration of additional

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

• The duration of antibiotic therapy for treatment of nonpurulent infection should be

● Potential tools for prevention of recurrent nonpurulent cellulitis include alleviation of

● The management of patients with purulent infection depends on whether a drainable

• The role of antimicrobial therapy in the setting of drainable abscess depends on

- In general, we recommend antibiotic therapy for patients with multiple lesions,

- For otherwise healthy patients with no risk factors, we suggest administering

● The duration of antibiotic therapy for treatment of purulent infection should be

immunosuppression. Patients with infection warranting parenteral therapy (in the

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7. Bergkvist PI, Sjöbeck K. Antibiotic and prednisolone therapy of erysipelas: a randomized,

31. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-Sulfamethoxazole versus

Clinical approach to management of nonpurulent cellulitis in adults

MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible S. aureus; IV: intravenously; A

¥ Risk factors for MRSA include:

Graphic 111732 Version 11.0

Approach to management of drainable abscess or skin infection with purulent

Ciprofloxacin 400 mg IV every 12 hours.

Graphic 114919 Version 10.0

Treatment Adult dose

Trimethoprim-sulfamethoxazole 1 or 2 DS tablets twice daily

Clindamycin 450 mg orally 3 times daily

Doxycycline 100 mg orally twice daily

Minocycline 200 mg orally once, then 100 mg orally twice