High-dose versus standard-dose cephalosporins in the treatment of cellulitis
Date First Published:
February 14, 2024
Last Updated:
January 15, 2025
Report by:
Avneesh Bhangu, Emergency Medicine Resident (Queen's University)
Search checked by:
Hamza Shogan, Queen's University
Three-Part Question:
Amongst [patients with cellulitis], does [treatment with high dose cephalosporins compared to standard dose cephalosporins] lead to [improved patient cure and fewer treatment failures]?
Clinical Scenario:
A 46-year-old female patient presents to the emergency department with a warm to touch, painful, and erythematous rash on their right leg. No previous methicillin-resistant staphylococcus aureus colonization documented in the past. You are considering which outpatient oral antibiotic strategy would be most appropriate for this patient for suspected cellulitis.
Search Strategy:
Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations and Daily 1946 to January 25, 2024
Search Details:
([exp cellulitis OR cellulitis.mp] AND [cephalosporin.mp OR exp cephalosporins OR cephalexin.mp OR exp cephalexin OR cefuroxime.mp. OR exp cefuroxime OR cefaclor.mp. OR exp cefaclor OR cefadrine.mp. OR exp cefaclor OR cefadrine.mp OR exp cefadroxil OR cefixime.mp OR exp cefixime OR cefalexin] AND [dose.mp])
Inclusion criteria: Primary studies (including grey literature) which explored the relationship between cephalosporin dosing strategies and clinical cure or treatment failure rates, amongst patients who were clinically suspected to have cellulitis.
Exclusion criteria: 1) Review papers; 2) studies which did not perform a head-to-head comparison between cephalosporin dosing strategies and treatment outcome amongst patients with cellulitis; 3) studies with antibiotic strategies that did not include cephalosporins.
Inclusion criteria: Primary studies (including grey literature) which explored the relationship between cephalosporin dosing strategies and clinical cure or treatment failure rates, amongst patients who were clinically suspected to have cellulitis.
Exclusion criteria: 1) Review papers; 2) studies which did not perform a head-to-head comparison between cephalosporin dosing strategies and treatment outcome amongst patients with cellulitis; 3) studies with antibiotic strategies that did not include cephalosporins.
Outcome:
A total of 60 papers were initially identified of which one paper was directly relevant to the three-part research question. Three papers did evaluate high-dose cephalosporins in the treatment of cellulitis; however, these papers did not perform a direct comparison between high-dose and standard-dose cephalosporins and were thus excluded. Otherwise, the search strategy had two review papers and 54 papers which did not answer our question and, thus, were additionally excluded.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| High-dose cephalexin for cellulitis: a pilot randomized controlled trial Yadav K, Eagles D, Perry JJ, Taljaard M, Sandino-Gold G, Nemnom MJ, Corrales-Medina V, Suh KN, Stiell IG 2023 Canada | 66 adult participants presenting to the emergency department with non-purulent cellulitis as determined by the treating emergency physician were eligible for outpatient management with oral antibiotics. 4 participants were lost to follow up. 31 participants received high-dose cephalexin (1000 mg oral four times daily) for 7 days. 31 participants received standard-dose cephalexin (500 mg oral four times daily) for 7 days. |
Parallel arm double-blind randomized controlled pilot trial | Due to the nature of this study being a pilot trial, the study was underpowered and had large confidence intervals secondary to the small sample sizes. The study was limited due to the short follow-up duration, thereby does not report infection recurrence. The study only included patients with access to mobile technology to allow for appropriate follow-up, thereby limiting generalizability. |
Author Commentary:
The pilot randomized controlled trial suggests that completing a full-scale trial to investigate high-dose cephalexin (1000 mg PO QID x 7 days) compared to low dose cephalexin (500 mg PO QID x 7 days) in the treatment of adult patients with cellulitis is possible.
Bottom Line:
Amongst patients with cellulitis, there is insufficient evidence to date exploring the relationship between cephalosporin dose and clinical cure or treatment failure rates.
References:
- Yadav K, Eagles D, Perry JJ, Taljaard M, Sandino-Gold G, Nemnom MJ, Corrales-Medina V, Suh KN, Stiell IG. High-dose cephalexin for cellulitis: a pilot randomized controlled trial