Long term oral antibiotic treatment for patients with recurrent lower leg cellulitis
Edema of the lower leg frequently contributes to a superficial infection of the skin called cellulitis. Cellulitis can often be treated, but if swelling persists, cellulitis will become chronic. It’s important to recognize that the root cause of cellulitis is not infectious but rather due to poor management of chronic swelling and the effect that the swelling has on the skin of the lower extremity. Many of the factors that contribute to lower extremity edema are difficult to modify. These contributing factors may include venous insufficiency, lymphedema, obesity, and May-Thurner Syndrome.
Chronic cellulitis that has failed treatment with compression therapy alone, may be treated with long term low dose oral antibiotics. Although a number of oral agents have been tried, most studies find success with the use of oral Penicillin. The most common dose is 250m of PCN VK twice daily. (1,2,3,4,5)
Lower extremity cellulitis – case study
This case study describes a 68 y/o obese female (BMI 48) who presented with chronic lower extremity edema and concurrent cellulitis. Initial treatment included use of four-layer compression wraps from the knee to the toes along with concurrent use of diuretics. Wounds of the lower leg showed significant weeping and serous drainage. Wound cultures show coag-negative staph aureus. There were no open or deep ulcerations but localized areas of maceration and drainage were found in multiple locations. Global erythema was found from the knee, distal to the toes. No lymphangitis or regional lymphadenopathy was found. The sides of the heel and plantar aspect of the foot showed no erythema. CBC was normal and sed rate and CRP mildly elevated. PCN 250mg, four times daily, was initiated.
Several weeks of four-layer compression, antibiotics and diuretics allowed for transition to Tubi-Grip compression. Although swelling subsided by 50%, each attempt to withdraw oral antibiotics resulted in recurrence of erythema due to cellulitis. After 4 months of treatment, the patient was placed on long term PCN 500mg twice daily.
Although not completely resolved, the patient’s symptoms are much more manageable. Our goal is to increase activity and focus on weight loss.
In cases of chronic lower extremity edema with cellulitis, additional treatment recommendations include –
- Management of albumin and pre-albumin
- Compression therapy 24 x 7
- Elevation of legs when possible
- Dietary consult for weight loss, increased protein consumption and decrease in sodium use
- Medicine consult for fluid management
Long term oral antibiotic use for chronic cellulitis can have a significant impact on long term care. Our goal is always to focus on using oral antibiotics as a bridge to enable an opportunity for patients to work to improve co-morbidities such as obesity and smoking.
1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373–1406.
2. Babb RR, Spittel JA Jr, Martin WJ, et al. Prophylaxis of recurrent lymphangitis complicating lymphedema. JAMA. 1966;195:871–873.
3. Sjoblom AC, Eriksson B, Jorup-Ronstrom C, et al. Antibiotic prophylaxis in recurrent erysipelas. Infection. 1993;21:390–393.
4. Wang HJ, Liu YC, Cheng DL, et al. Role of benzathine penicillin G in prophylaxis for recurrent streptococcal cellulitis of the the lower legs. Clin Infect Dis. 1997;25:685–689.
5. Kremer M, Zuckerman R, Avraham Z, et al. Long-term antimicrobial therapy in the prevention of recurrent soft-tissue infections. J Infect. 1991;22:37–40.