Standard cellulitis management changes significantly when high-risk features are present. This protocol applies to erysipelas and cellulitis cases where MRSA is a central concern — either through confirmed infection at another site, nasal colonization, or clinical circumstances that substantially raise the risk.
This protocol covers erysipelas or cellulitis occurring in the setting of one or more of the following: penetrating trauma, evidence of MRSA infection elsewhere, nasal MRSA colonization, injection drug use, purulent drainage, systemic inflammatory response syndrome (SIRS), failure of oral antibiotic treatment, or severe immunocompromise.
These presentations require intravenous antimicrobial therapy providing dual coverage against both MRSA and streptococci, combined with elevation of the affected area. In severely immunocompromised patients, broader empiric coverage is warranted. The complete agent selection, escalation criteria, and duration guidance are in the full protocol.
DOI: 10.1093/cid/ciu296
For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, purulent drainage, or SIRS (severe nonpurulent), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (strong, moderate).
In severely compromised patients (as defined in question 13), broad-spectrum antimicrobial coverage may be considered (weak, moderate).
Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended (strong, moderate).
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