Anti-Inflammatory Treatment with Antibiotics for Cellulitis

From Primary Care RAP:

  • Should anti-inflammatory agents be used to complement antibiotic treatment of cellulitis?  Though it may seem counterintuitive, several studies have suggested that combining antibiotic therapy with either a nonsteroidal anti-inflammatory agent or steroids leads to more rapid improvement of cellulitis compared with antimicrobial therapy alone.  The 2014 Infectious Disease Society Guidelines for the management of skin infections state that systemic corticosteroids (e.g. prednisone 40 mg daily for 7 days) could be considered in nondiabetic adults with cellulitis.

  • Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis. 2014 Jul 15;59(2):147-59. PMID: 24947530

  • One study showed more rapid improvement in patients with erysipelas who received steroids versus those who did not.  A RCT of 112 patients who were treated with either 8 days of steroids plus antibiotics or antibiotics alone, showed a faster resolution of cellulitis with steroids.  Those in the prednisolone group had about a 4 ½ day faster time to cure than those who only received antibiotics.  The benefit was greatest for those with leg cellulitis.  Also, the steroid treated patients had a median length of hospital stay of 5 days versus 6 days for the antibiotic only group.  There was no difference in relapse or recurrence between the two groups at 3 weeks, however there was a trend (not significant) towards an increase in cellulitis recurrence after 1 year in those who received only antibiotics (13 in the placebo group versus 6 in the steroid group).

  • Bergkvist PI, et al. Antibiotic and prednisolone therapy of erysipelas: a randomized, double blind, placebo-controlled study. Scand J Infect Dis. 1997;29(4):377-82. PubMed PMID: 9360253

  • Another study showed a benefit of nonsteroidal anti-inflammatory agents in the management of cellulitis.  60 patients were randomized to receive antibiotics plus 400 mg of ibuprofen every 6 hours or antibiotics alone.  They found complete regression in 100% of the patients who received adjuvant NSAIDs compared with only 75% randomized to only antibiotics.  This equates to a number needed to treat of 4.

  • Dall L, Peterson S, Simmons T, Dall A. Rapid resolution of cellulitis in
    patients managed with combination antibiotic and anti-inflammatory therapy.
    Cutis. 2005 Mar;75(3):177-80. PubMed PMID: 15839362

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