Sandbox/Alejandro

Empiric TherapyAdapted from Clinical Practice Guidelines CID 2011 and Guidelines for Skin and Soft-Tissue Infections CID 2005

▸ Click on the following categories to expand treatment regimens.

Cellulitis Non-Purulent Cellulitis   ▸  Adults   ▸  Children age >28 days Purulent Cellulitis   ▸  Adults   ▸  Children age >28 days Complicated Cellulitis†   ▸  Adults   ▸  Children age >28 days

Non-Purulent Cellulitis Parental Regimen Preferred Regimen ▸ Oxacillin 2g IV q4h OR ▸ Nafcillin 2g IV q4h Alternative Regimen (penicillin-allergic patients) ▸ Cefazolin 1-2 g IV q8h (without immediate hypersensitivity reactions) OR ▸ Clindamycin 600 mg IV q8h (with immediate hypersensitivity reactions) Oral Regimen Preferred Regimen ▸ Dicloxacillin 500 mg orally q6h Alternative Regimen (penicillin-allergic patients) ▸ Cephalexin 500 mg orally q6h (without immediate hypersensitivity reactions) OR ▸ Doxycycline 100 mg orally q12h OR ▸ Minocycline 100 mg orally q12h OR ▸ Trimethoprim-sulfamethoxazole 1 or 2 double-strength tablets orally q12h OR ▸ Clindamycin 300–450 mg orally q8h

Non-Purulent Cellulitis Parental Regimen Preferred Regimen ▸ Oxacillin 100-150 mg/kg per day IV in 4 doses OR ▸ Nafcillin 100-150 mg/kg per day IV in 4 doses Alternative Regimen (penicillin-allergic patients) ▸ Cefazolin 50 mg/kg per day IV in 3 doses (without immediate hypersensitivity reactions) OR ▸ Clindamycin 25-40 mg/kg per day IV in 3 doses(with immediate hypersensitivity reactions) OR ▸ Trimethoprim-sulfamethoxazole 8–12 mg/kg IV in 4 doses Oral Regimen Preferred Regimen ▸ Dicloxacillin 25 mg/kg per day orally in 4 doses Alternative Regimen (penicillin-allergic patients) ▸ Cephalexin 25 mg/kg per day orally in 4 doses(without immediate hypersensitivity reactions) OR ▸ Clindamycin 10-20 mg/kg per day orally in 4 doses OR ▸ Trimethoprim-sulfamethoxazole 8–12 mg/kg orally in 2 doses Purulent Cellulitis Parental Regimen Preferred Regimen ▸ Vancomycin 30 mg/kg/dose IV q12h Alternative Regimen ▸ Linezolid 600 mg IV q12h OR ▸ Clindamycin 600 mg IV q8h OR ▸ Daptomycin 4 mg/kg IV q24h Oral Regimen Preferred Regimen ▸ Linezolid 600 mg orally q12h Alternative Regimen ▸ Clindamycin 300 to 450 mg q8h OR ▸ Linezolid 600 mg orally q12h OR ▸ Minocycline 100 mg orally q12h OR ▸ Doxycycline 100 mg orally q12h OR ▸ Trimethoprim-sulfamethoxazole 1 or 2 double-strength tablets orally q12h Purulent Cellulitis Parental Regimen Preferred Regimen ▸ Vancomycin 40 mg/kg/day IV in 4 divided doses Alternative Regimen ▸ Linezolid 10 mg/kg IV q12h OR ▸ Clindamycin 25–40 mg/kg/day IV in 3 divided dose OR ▸ Trimethoprim-sulfamethoxazole 8–12 mg/kg/day (based on the trimethoprim component) IV in 4 divided doses Oral Regimen Preferred Regimen ▸ Linezolid 10 mg/kg orally q12h Alternative Regimen ▸ Clindamycin 10-20 mg/kg per day orally divided in 3 doses OR ▸ Trimethoprim-sulfamethoxazole 8-12 mg trimethoprim component/kg per day orally divided in 2 doses Complicated Cellulitis Parental Regimen Preferred Regimen ▸ Vancomycin 15-20 mg/kg IV q8-12h OR ▸ Linezolid 600 mg IV q12h OR ▸ Daptomycin 4mg/kg IV q24h OR ▸ Telavancin 10mg/kg IV q24h Alternative Regimen ▸ Clindamycin 600 mg IV q8h Oral Regimen Preferred Regimen ▸ Linezolid 600 mg PO q12h Alternative Regimen ▸ Clindamycin 600 mg PO q8h † Complicated cellulitis refers to a deeper soft-tissue infections and the association with necrotizing fasciitis, septic arthritis, or osteomyelitis Complicated Cellulitis Parental Regimen Preferred Regimen ▸ Vancomycin 15 mg/kg IV q6h OR ▸ Linezolid 10 mg/kg IV q8h (max: 600mg/dose) Alternative Regimen ▸ Clindamycin 10-13 mg/kg IV q6-8h (max:40 mg/kg/day) Oral Regimen Preferred Regimen ▸ Linezolid 10 mg/kg PO q8h (max: 600mg/dose) OR ▸ Clindamycin 10-13 mg/kg PO q6-8h (max:40 mg/kg/day) † Complicated cellulitis refers to a deeper soft-tissue infections and the association with necrotizing fasciitis, septic arthritis, or osteomyelitis

Note:

• Treatment of cellulitis in neonates usually requires hospitalization and parenteral therapy. Oral therapy is given for completion of the treatment when the patogen is unknown.
• Optimal dose should be based on determination of serum concentrations.
• The above antibiotic regimen is NOT for initial empirical treatment of infections involving the face.
• Dose alteration for renal insufficiency may be needed in case of cephalosporins.
• Clindamycin is an alternate therapy for patients at risk of severe hypersensitivity reaction to penicillins and cephalosporins.
• Doxycycline is NOT recommended for children <8 years of age.
• Studies have shown an increase in treatment failure with TMP-SMX compared to other agents for cellulitis in children, reflecting TMP-SMX less action against Group A streptococcus.