CREST Guidelines on the management of cellulitis in adults. Clinical Resource Efficiency Support Team. 2005. http://www.acutemed.co.uk/docs/Cellulitis%20guidelines,%20CREST,%2005.pdf Accessed 23.09.14. RATIONALE: Expert consensus is that people who have no signs of systemic toxicity and no uncontrolled co-morbidities can usually be managed on an outpatient basis with oral antibiotics. Flucloxacillin 500mg QDS (or clarithromycin 500mg BD for those with penicillin allergy) are suitable oral antibiotics because they cover staphylococci and streptococci, the most commonly implicated pathogens. Clindamycin 300mg QDS is also recommended as a further alternative for people with penicillin allergy. Most cases of uncomplicated cellulitis can be treated successfully with 1-2 weeks of treatment.

Jones, G.R. Principles and practice of antibiotic therapy for cellulitis. CPD Journal Acute Medicine. 2002;1(2):44-49.RATIONALE: Oral agents will be as effective as intravenous agents for cellulitis if they can maintain the free antibiotic level above the MIC of the pathogen for more than 40% of the dose interval. Flucloxacillin 500 mg, clarithromycin 500 mg and clindamycin 300 mg are suitable oral doses.

Morris AD. Cellulitis and erysipelas. Clinical Evidence. 2007. London. BMJ Publishing Group.RATIONALE: This systematic review found no RCTs of antibiotics compared with placebo of sufficient quality for inclusion. Although 11 RCTs were identified that compared antibiotic treatments, these studies were small and only powered to demonstrate equivalence, not superiority, between antibiotics. Two RCTs using intravenous flucloxacillin were found, but none using oral flucloxacillin. Oral azithromycin was compared with erythromycin, flucloxacillin, and cefalexin in three RCTs. Oral co-amoxiclav was compared with fleroxacin (available in Germany) in one sub-group analysis.
Fischer RG and Benjamin DK Jr. Facial cellulitis in childhood: a changing spectrum. Southern Medical Journal. 2002;95: 672-674. RATIONALE: Buccal cellulitis is commonly due to Haemophilus influenzae infection, although rates are decreasing following the Hib immunization programme. Public Health England and the British Infection Association recommends co-amoxiclav for empirical treatment of facial cellulitis because it is broader spectrum than flucloxacillin and also covers anaerobes and other less common causes of facial cellulitis.
Kilburn SA, Featherstone P, Higgins B, Brindle R. Interventions for cellulitis and erysipelas. Cochrane Database of Systematic Reviews. 2010. Issue 6. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004299.pub2/pdf Accessed 23.09.14. RATIONALE: This review included 25 studies with a total of 2488 participants. The primary outcome ‘symptoms were rated by participant or medical practitioner or proportion symptom-free’ was commonly reported. No two trials examined the same drugs, therefore the review grouped similar types of drugs together. Three studies with a total of 88 people comparing a penicillin with a cephalosporin showed no difference in treatment effect (RR 0.99,95% CI 0.68 to 1.43). Macrolides/streptogramins were found to be more effective than penicillin antibiotics (Risk ratio (RR) 0.84, 95% CI 0.73 to 0.97). In 3 trials involving 419 people, 2 of these studies used oral macrolide against intravenous (iv) penicillin demonstrating that oral therapies can be more effective than iv therapies (RR 0.85, 95% CI 0.73 to 0.98).

The POCAST project is funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London and by the Imperial College Healthcare Charity (Grant Ref No:7006/P36U).