Management

Always elevate the affected extremity. Treatment failure is commonly associated with failure to elevate versus failure of antimicrobials.

Improvement of erythema can take days, especially in patients with venous stasis or lymphedema, due to inflammation caused by the presence of bacterial debris in the skin.

The microbiology laboratory routinely assesses S. aureus isolates for inducible clindamycin resistance. If culture data to guide therapy is unavailable and there is high risk or suspicion of CA-MRSA or failure to improve on clindamycin, consider a change to an alternate antimicrobial such as TMP/SMX or doxycycline.

S. aureus resistance to fluoroquinolones is common and develops quickly. The vast majority of MRSA isolates are resistant to fluoroquinolones and therapy with this
antimicrobial class is not recommended.

Rifampin should NEVER be used as monotherapy because resistance develops rapidly.

There is NO EVIDENCE that linezolid or daptomycin are superior to TMP/SMX, doxycycline, or clindamycin for the management of skin and soft tissue infections. Linezolid or daptomycin should only be considered when the S. aureus isolate is resistant to other agents or the patient is intolerant of these agents.

Elimination or prevention of interdigital tinea is important for cases of relapsing lower extremity cellulitis.

Specialty referral should be considered in cases of lymphedema, refractory tinea pedis,chronic dermopathies, venous insufficiency, or post-surgical cellulitis.