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Cellulitis and erysipelas are types of skin and soft tissue infections (SSTIs) that occur when bacteria, commonly group A beta-hemolytic
A 2010 Cochrane Review [
Macrolides and streptogramins proved superior to penicillin antibiotics in eliminating or reducing cellulitis symptoms (N=2488). Trials comparing oral macrolides against intravenous penicillin found the former to be superior (n=419). No significant differences were found in studies comparing penicillin to cephalosporins (n=88) or among cephalosporin generations (n=538). These comparisons are summarized in
Notably, the review [
Notably, the review [
Current Infectious Diseases Society of America guidelines for the management of nonpurulent cellulitis and erysipelas.a
Disease entity and antibiotic | Dosage, adults | Dosage, children | Comment | |
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Nafcillin or oxacillin | 1-2 g every 4 h IVd | 100-150 mg/kg/d in 4 divided doses | Inactive against MRSAe |
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Cefazolin | 1 g every 8 h IV | 50 mg/kg/d in 3 divided doses | For penicillin-allergic patients, except those with immediate hypersensitivity reactions; more convenient than nafcillin with less bone marrow suppression |
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Clindamycin | 600 mg every 8 h IV or 300-450 mg 4 times daily by mouth | 25-40 mg/kg/d in 3 divided doses IV or 25-30 mg/kg/d in 3 divided doses by mouth | Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA |
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Dicloxacillin | 500 mg 4 times daily by mouth | 25–50 mg/kg/d in 4 divided doses by mouth | Oral agent of choice for methicillin-susceptible strains in adults; rarely used in pediatrics |
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Cephalexin | 500 mg 4 times daily by mouth | 25-50 mg/kg/d 4 divided doses by mouth | For penicillin-allergic patients except those with immediate hypersensitivity reactions; the availability of a suspension and requirement for less frequent dosing |
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Doxycycline, minocycline | 100 mg twice daily by mouth | Not recommended for age <8 y | Bacteriostatic; limited recent clinical experience |
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Trimethoprim-sulfamethoxazole | 1-2 double-strength tablets twice daily by mouth | 8-12 mg/kg (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses by mouth | Bactericidal; efficacy poorly documented |
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Vancomycin | 30 mg/kg/d in 2 divided doses IV | 40 mg/kg/d in 4 divided doses IV | For penicillin-allergic patients; parenteral drug of choice for treatment of infections caused by MRSA |
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Linezolid | 600 mg every 12 h IV or 600 mg twice daily by mouth | 10 mg/kg every 12 h IV or by mouth for children <12 y | Bacteriostatic; limited clinical experience; no cross-resistance with other antibiotic classes; costly |
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Clindamycin | 600 mg every 8 h IV or 300-450 mg 4 times daily by mouth | 25-40 mg/kg/d in 3 divided doses IV or 30-40 mg/kg/d in 3 divided doses by mouth | Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA; important option for pediatrics |
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Daptomycin | 4 mg/kg every 24 h IV | N/Af | Bactericidal; possible myopathy |
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Ceftaroline | 600 mg twice daily IV | N/A | Bactericidal |
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Doxycycline, minocycline | 100 mg twice daily by mouth | Not recommended for age <8 y | Bacteriostatic; limited recent clinical experience |
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Trimethoprim-sulfamethoxazole | 1-2 double-strength tablets twice daily by mouth | 8–12 mg/kg/d (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses by mouth | Bactericidal; limited published efficacy data |
Streptococcal skin infections | Penicillin: 2-4 million units every 4-6 h IV; Clindamycin: 600-900 mg every 8 h IV; Nafcillin: 1-2 g every 4-6 h IV; Cefazolin: 1 g every 8 h IV; Penicillin: VK 250-500 mg every 6 h by mouth; Cephalexin 500 mg every 6 h by mouth | Penicillin: 60,000-100,000 units/kg/dose every 6 h; 10-13 mg/kg dose every 8 h IV; 50 mg/kg/dose every 6 h; 33 mg/kg/dose every 8 h IV | N/A |
aRecommendation according to the Infectious Diseases Society of America. Doses listed are not appropriate for neonates. Infection due to
bMSSA: methicillin-susceptible
cSSTI: skin and soft tissue infection.
dIV: intravenous.
eMRSA: methicillin-resistant
fN/A: not applicable.
Treatment comparison with respective results, risk ratio, and CI.a
Comparison | Measurement | Results | RRb (95% CI) | Studies, n | Patients, n |
Macrolides/streptogramins vs penicillin antibiotics | Symptoms rated by participant or medical practitioner | Macrolides/streptogramins were superior | 0.84 (0.73-0.97) | 25 | 2488 |
Oral macrolide vs IVc penicillin | Symptoms rated by participant or medical practitioner | Oral therapy was superior | 0.85 (0.73-0.98) | 3 | 419 |
Penicillin vs cephalosporin | Symptoms rated by participant or medical practitioner | No difference in treatment effect | 0.99 (0.68-1.43) | 3 | 88 |
Cephalosporin vs cephalosporind | Symptoms rated by participant or medical practitioner | No difference in treatment effect | 1.00 (0.94-1.06) | 6 | 538 |
aPrimary outcomes included symptoms rated by participant or medical practitioner (eg, duration and intensity of fever, pain, redness of the affected area, swelling of the skin surface and subcutaneous tissue, blister formation), proportion symptom‐free (
bRR: relative risk.
cIV: intravenous.
dAggregate data from studies evaluating the following cephalosporins: ceftriaxone, cefdinir, cefonicid, cefditoren, cefadroxil, and cefuroxime.
The review reported insufficient data to determine the ideal duration of therapy. International recommendations for treatment duration in SSTIs are inconsistent (5-14 days) [
skin and soft tissue infection
RD is a Joint Coordinating Editor for
The views expressed in this paper are those of the author(s) and in no way represent the Cochrane Library or Wiley.
This article is based on a Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2010, Issue 6, DOI: 10.1002/14651858.CD004299 (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review.