Recommendations

1.1 Managing cellulitis and erysipelas

Treatment

1.1.1 To ensure that cellulitis and erysipelas are treated appropriately, exclude other causes of skin redness such as:

  • an inflammatory reaction to an immunisation or an insect bite or

  • a non-infectious cause such as chronic venous insufficiency.

1.1.2 Consider taking a swab for microbiological testing from people with cellulitis or erysipelas to guide treatment, but only if the skin is broken and:

  • there is a penetrating injury or

  • there has been exposure to water-borne organisms or

  • the infection was acquired outside the UK.

1.1.3 Before treating cellulitis or erysipelas, consider drawing around the extent of the infection with a single-use surgical marker pen to monitor progress. Be aware that redness may be less visible on darker skin tones.

1.1.4 Offer an antibiotic for people with cellulitis or erysipelas. When choosing an antibiotic (see the recommendations on choice of antibiotic), take account of:

  • the severity of symptoms

  • the site of infection (for example, near the eyes or nose)

  • the risk of uncommon pathogens (for example, from a penetrating injury, after exposure to water-borne organisms, or an infection acquired outside the UK)

  • previous microbiological results from a swab

  • the person's meticillin-resistant Staphylococcus aureus (MRSA) status if known.

1.1.5 Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

1.1.6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.

1.1.7 Manage any underlying condition that may predispose to cellulitis or erysipelas, for example:

  • diabetes

  • venous insufficiency

  • eczema

  • oedema, which may be an adverse effect of medicines such as calcium channel blockers.

Advice

1.1.8 When prescribing antibiotics for cellulitis or erysipelas, give advice about:

  • possible adverse effects of antibiotics

  • the skin taking some time to return to normal after the course of antibiotics has finished

  • seeking medical help if symptoms worsen rapidly or significantly at any time, or do not start to improve within 2 to 3 days.

Reassessment

1.1.9 Reassess people with cellulitis or erysipelas if symptoms worsen rapidly or significantly at any time, do not start to improve within 2 to 3 days, or the person:

  • becomes systemically very unwell or

  • has severe pain out of proportion to the infection or

  • has redness or swelling spreading beyond the initial presentation (taking into account that some initial spreading may occur, and that redness may be less visible on darker skin tones), see recommendation 1.1.3.

1.1.10 When reassessing people with cellulitis or erysipelas, take account of:

  • other possible diagnoses, such as an inflammatory reaction to an immunisation or an insect bite, gout, superficial thrombophlebitis, eczema, allergic dermatitis or deep vein thrombosis

  • any underlying condition that may predispose to cellulitis or erysipelas, such as oedema, diabetes, venous insufficiency or eczema

  • any symptoms or signs suggesting a more serious illness or condition, such as lymphangitis, orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis

  • any results from microbiological testing

  • any previous antibiotic use, which may have led to resistant bacteria.

1.1.11 Consider taking a swab for microbiological testing from people with cellulitis or erysipelas if the skin is broken and this has not been done already.

1.1.12 If a swab has been sent for microbiological testing:

  • review the choice of antibiotic(s) when results are available and

  • change the antibiotic(s) according to results if symptoms or signs of the infection are not improving, using a narrow-spectrum antibiotic if possible.

Referral and seeking specialist advice

1.1.13 Refer people to hospital if they have any symptoms or signs suggesting a more serious illness or condition, such as orbital cellulitis, osteomyelitis, septic arthritis, necrotising fasciitis or sepsis.

1.1.14 Consider referring people with cellulitis or erysipelas to hospital, or seek specialist advice, if they:

  • are severely unwell or

  • have infection near the eyes or nose (including periorbital cellulitis) or

  • could have uncommon pathogens, for example, after a penetrating injury, exposure to water-borne organisms, or an infection acquired outside the UK or

  • have spreading infection that is not responding to oral antibiotics or

  • lymphangitis or

  • cannot take oral antibiotics (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, where appropriate).

See the committee discussion on managing cellulitis and erysipelas.

1.2 Choice of antibiotic

1.2.1 When prescribing an antibiotic for cellulitis or erysipelas, follow:

  • table 1 for adults aged 18 years and over

  • table 2 for children and young people under 18 years.

Table 1 Antibiotics for adults aged 18 years and over

Antibiotic 1

Dosage and course length 2

First-choice antibiotic (give oral unless person unable to take oral or severely unwell) 3

Flucloxacillin

500 mg to 1 g four times a day orally4 for 5 to 7 days5

or 1 to 2 g four times a day IV6

Alternative first-choice antibiotics for penicillin allergy or if flucloxacillin unsuitable (give oral unless person unable to take oral or severely unwell) 3

Clarithromycin

500 mg twice a day orally for 5 to 7 days5

or 500 mg twice a day IV6

Erythromycin (in pregnancy)

500 mg four times a day orally for 5 to 7 days5

Doxycycline

200 mg on first day, then 100 mg once a day orally for 5 to 7 days in total5

First-choice antibiotic if infection near the eyes or nose 7 (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell) 3

Co-amoxiclav

500/125 mg three times a day orally for 7 days5

or 1.2 g three times a day IV6

Alternative first-choice antibiotics if infection near the eyes or nose 7 for penicillin allergy or if co‑amoxiclav unsuitable (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell) 3

Clarithromycin

500 mg twice a day orally for 7 days5

or 500 mg twice a day IV6

with metronidazole

400 mg three times a day orally for 7 days5

or 500 mg three times a day IV6

Alternative choice antibiotics for severe infection

Co-amoxiclav

500/125 mg three times a day orally for 7 days5

or 1.2 g three times a day IV6

Cefuroxime

750 mg to 1.5 g three or four times a day IV6

Clindamycin

150 to 300 mg four times a day (can be increased to 450 mg four times a day) orally for 7 days5

or 600 mg to 2.7 g daily IV in two to four divided doses, increased if necessary in life-threatening infection to 4.8 g daily (maximum per dose 1.2 g)6

Ceftriaxone (only for ambulatory care8)

2 g once a day IV6

Antibiotics to be added if MRSA infection is suspected or confirmed (combination therapy with an antibiotic listed above) 8

Vancomycin9,10

15 to 20 mg/kg two or three times a day IV (maximum 2 g per dose), adjusted according to serum vancomycin concentration6

Teicoplanin9,10

Initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV6

Linezolid (if vancomycin or teicoplanin cannot be used; specialist use only)10

600 mg twice a day orally

or 600 mg twice a day IV6

1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.

2 Oral doses are for immediate-release medicines.

3 Give oral antibiotics first line if the person can take oral medicines, and the severity of their symptoms does not require intravenous antibiotics.

4 The upper dose of 1 g four times a day would be off‑label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

5 A longer course (up to 14 days in total) may be needed based on clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 5 to 7 days is not expected.

6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible for the appropriate course length.

7 Infection around the eyes or the nose (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes including periorbital cellulitis) is of more concern because of risk of a serious intracranial complication.

8 Other antibiotics may be appropriate based on microbiological results and specialist advice.

9 See BNF for information on therapeutic drug monitoring.

10 See BNF for information on monitoring of patient parameters.

Abbreviations: BNF, British national formulary; IV, intravenous; MRSA, meticillin-resistant Staphylococcus aureus.

Table 2 Antibiotics for children and young people under 18 years

Antibiotic 1

Dosage and course length 2

Children under 1 month

Antibiotic choice based on specialist advice

Children aged 1 month and over

First-choice antibiotic (give oral unless person unable to take oral or severely unwell) 3

Flucloxacillin4

1 month to 1 year, 62.5 mg to 125 mg four times a day orally for 5 to 7 days5

2 to 9 years, 125 mg to 250 mg four times a day orally for 5 to 7 days5

10 to 17 years, 250 mg to 500 mg four times a day orally for 5 to 7 days5

or 1 month to 17 years, 12.5 mg to 25 mg/kg four times a day IV (maximum 1 g four times a day)6

Alternative first-choice antibiotics for penicillin allergy or if flucloxacillin unsuitable (give oral unless person unable to take oral or severely unwell) 3

Co-amoxiclav (not in penicillin allergy)7

1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day orally for 5 to 7 days5 (dose doubled in severe infection)

1 to 5 years, 0.25 ml/kg or 5 ml of 125/31 suspension three times a day orally for 5 to 7 days5 (dose doubled in severe infection)

6 to 11 years, 0.15 ml/kg or 5 ml of 250/62 suspension three times a day orally for 5 to 7 days5 (dose doubled in severe infection)

12 to 17 years, 250/125 mg or 500/125 mg three times a day orally for 5 to 7 days5

or 1 to 2 months, 30 mg/kg twice a day IV6

3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6

Clarithromycin

1 month to 11 years:

Under 8 kg, 7.5 mg/kg twice a day orally for 5 to 7 days5

8 to 11 kg, 62.5 mg twice a day orally for 5 to 7 days5

12 to 19 kg, 125 mg twice a day orally for 5 to 7 days5

20 to 29 kg, 187.5 mg twice a day orally for 5 to 7 days5

30 to 40 kg, 250 mg twice a day orally for 5 to 7 days5

12 to 17 years:

250 to 500 mg twice a day orally for 5 to 7 days5

or 1 month to 11 years, 7.5 mg/kg twice a day IV (maximum 500 mg per dose)6

12 to 17 years, 500 mg twice a day IV6

Erythromycin (in pregnancy)

8 to 17 years, 250 to 500 mg four times a day orally for 5 to 7 days5

First-choice antibiotic if infection near the eyes or nose 8 (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell) 3

Co-amoxiclav7

1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled in severe infection)

1 to 5 years, 0.25 ml/kg or 5 ml of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled in severe infection)

6 to 11 years, 0.15 ml/kg or 5 ml of 250/62 suspension three times a day orally for 7 days5 (dose can be doubled in severe infection)

12 to 17 years, 250/125 mg or 500/125 mg three times a day orally for 7 days5

or 1 to 2 months, 30 mg/kg twice a day IV6

3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6

Alternative first-choice antibiotics if infection near the eyes or nose 8 for penicillin allergy or if co‑amoxiclav unsuitable (consider seeking specialist advice; give oral unless person unable to take oral or severely unwell) 3

Clarithromycin

1 month to 11 years:

Under 8 kg, 7.5 mg/kg twice a day orally for 7 days5

8 to 11 kg, 62.5 mg twice a day orally for 7 days5

12 to 19 kg, 125 mg twice a day orally for 7 days5

20 to 29 kg, 187.5 mg twice a day orally for 7 days5

30 to 40 kg, 250 mg twice a day orally for 7 days5

12 to 17 years:

250 to 500 mg twice a day orally for 7 days5

or 1 month to 11 years, 7.5 mg/kg twice a day IV (maximum 500 mg per dose)6

12 to 17 years, 500 mg twice a day IV6

with (if anaerobes suspected):

Metronidazole

1 month, 7.5 mg/kg twice a day orally for 7 days5

2 months to 11 years, 7.5 mg/kg three times a day orally (maximum per dose 400 mg) for 7 days5

12 to 17 years, 400 mg three times a day for 7 days5

or 1 month, loading dose 15 mg/kg, then (after 8 hours) 7.5 mg/kg three times a day IV6

2 months to 17 years, 7.5 mg/kg three times a day IV (maximum per dose 500 mg)6

Alternative choice antibiotics for severe infection 9

Co-amoxiclav7

1 to 11 months, 0.25 ml/kg of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled)

1 to 5 years, 0.25 ml/kg or 5 ml of 125/31 suspension three times a day orally for 7 days5 (dose can be doubled)

6 to 11 years, 0.15 ml/kg or 5 ml of 250/62 suspension three times a day orally for 7 days5 (dose can be doubled)

12 to 17 years, 250/125 mg or 500/125 mg three times a day orally for 7 days5

or 1 to 2 months, 30 mg/kg twice a day IV6

3 months to 17 years, 30 mg/kg three times a day IV (maximum 1.2 g three times a day)6

Cefuroxime

1 month to 17 years, 20 mg/kg three times a day IV (maximum 750 mg per dose), can be increased to 50 to 60 mg/kg three or four times a day IV (maximum 1.5 g per dose)6

Clindamycin

1 month to 17 years, 3 to 6 mg/kg four times a day orally (maximum per dose 450 mg) for 7 days5

or 1 month to 17 years, 3.75 to 6.25 mg/kg four times a day IV, increased if necessary, in life-threatening infection to 10 mg/kg four times a day IV (maximum per dose 1.2 g); total daily dose may alternatively be given in three divided doses (maximum per dose 1.2 g)6

Antibiotics to be added if suspected or confirmed MRSA infection (combination therapy with an antibiotic listed above) 9

Vancomycin10,11

1 month to 11 years, 10 to 15 mg/kg four times a day IV, adjusted according to serum vancomycin concentration6

12 to 17 years, 15 to 20 mg/kg two or three times a day IV (maximum 2 g per dose), adjusted according to serum vancomycin concentration6

Teicoplanin10,11

1 month, initially 16 mg/kg for one dose, then (after 24 hours) 8 mg/kg once a day IV6

2 months to 11 years, initially 10 mg/kg every 12 hours for 3 doses, then 6 to 10 mg/kg once a day IV6

12 to 17 years, initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg once a day IV6

Linezolid (if vancomycin or teicoplanin cannot be used; specialist use only)11,12

1 month to 11 years, 10 mg/kg three times a day orally (maximum 600 mg per dose)

12 to 17 years, 600 mg twice a day orally

or 1 month to 11 years, 10 mg/kg three times a day IV (maximum 600 mg per dose)6

12 to 17 years, 600 mg twice a day IV6

1 See BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.

2 The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition and the child's size in relation to the average size of children of the same age. Oral doses are for immediate-release medicines.

3 Give oral antibiotics first line if the child or young person can take oral medicines, and the severity of their symptoms does not require intravenous antibiotics.

4 If flucloxacillin oral solution is not tolerated because of poor palatability, consider capsules (see Medicines for Children leaflet on helping your child to swallow tablets).

5 A longer course (up to 14 days in total) may be needed based on clinical assessment. However, skin does take some time to return to normal, and full resolution of symptoms at 5 to 7 days is not expected.

6 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible for the appropriate course length.

7 Co-amoxiclav 400/57 suspension may also be considered to allow twice daily dosing (see BNF for children for dosing information).

8 Infection around the eyes or the nose (the triangle from the bridge of the nose to the corners of the mouth, or immediately around the eyes including periorbital cellulitis) is of more concern because of risk of a serious intracranial infection.

9 Other antibiotics may be appropriate based on microbiological results and specialist advice.

10 See BNF for children for information on therapeutic drug monitoring.

11 See BNF for children for information on monitoring of patient parameters.

12 Not licensed in children and young people under 18 years, so use would be off‑label. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

Abbreviations: BNF for children, British national formulary for children; IV, intravenous; MRSA, meticillin-resistant Staphylococcus aureus.

See the evidence and committee discussions on choice of antibiotics, antibiotic dose frequency, antibiotic course length and antibiotic route of administration.

1.3 Preventing recurrent cellulitis or erysipelas

1.3.1 Do not routinely offer antibiotic prophylaxis to prevent recurrent cellulitis or erysipelas. Give advice about seeking medical help if symptoms of cellulitis or erysipelas develop.

1.3.2 For adults who have had treatment in hospital, or under specialist advice, for at least 2 separate episodes of cellulitis or erysipelas in the previous 12 months, specialists may consider a trial of antibiotic prophylaxis. Involve the person in a shared decision by discussing and taking account of:

  • the severity and frequency of previous symptoms

  • the risk of developing complications

  • underlying conditions (such as oedema, diabetes or venous insufficiency) and their management

  • the risk of resistance with long-term antibiotic use

  • the person's preference for antibiotic use.

1.3.3 When choosing an antibiotic for prophylaxis (see the recommendations on choice of antibiotic prophylaxis), take account of any previous microbiological results and previous antibiotic use.

1.3.4 When antibiotic prophylaxis is given, give advice about:

  • possible adverse effects of long-term antibiotics

  • returning for review within 6 months

  • seeking medical help if symptoms of cellulitis or erysipelas recur.

1.3.5 Review antibiotic prophylaxis for recurrent cellulitis or erysipelas at least every 6 months. The review should include:

  • assessing the success of prophylaxis

  • discussing continuing, stopping or changing prophylaxis (taking into account the person's preferences for antibiotic use and the risk of antimicrobial resistance).

    Stop or change the prophylactic antibiotic to an alternative if cellulitis or erysipelas recurs (see recommendation 1.1.4 for treatment of acute infection).

See the evidence and committee discussion on antibiotic prophylaxis for the prevention of recurrent cellulitis and erysipelas.

1.4 Choice of antibiotic prophylaxis

1.4.1 When prescribing an antibiotic to prevent recurrent cellulitis or erysipelas in adults, specialists should follow table 3.

Table 3 Antibiotic prophylaxis for adults 18 years and over

Antibiotic prophylaxis 1,2

Dosage 3

First choice

Phenoxymethylpenicillin

250 mg twice a day

Alternative first choice for penicillin allergy

Erythromycin

250 mg twice a day

Consult local microbiologist for alternative antibiotics

1 See BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding.

2 Choose antibiotics according to recent microbiological results where possible. Avoid using the same antibiotic for treatment and prophylaxis.

3 Doses given are by mouth using immediate-release medicines, unless otherwise stated.

Abbreviation: BNF, British national formulary.

See the evidence and committee discussion on antibiotic prophylaxis for the prevention of recurrent cellulitis and erysipelas.

  • Public Health England
  • National Institute for Health and Care Excellence (NICE)