Reducing Vancomycin Prescribing in Non-Purulent Cellulitis

Posted on Nov 1, 2019 in Announcements | 0 comments

Reducing Vancomycin Prescribing in Non-Purulent Cellulitis

The Infectious Diseases Society of America (IDSA) guidelines recommend that MRSA coverage is not routinely needed in non-purulent cellulitis because Streptococcus species constitute the most common causative organisms.  The distinction between purulent and non-purulent skin and soft tissue (SSTIs) is based on the presence of drainage, abscess, and systemic signs of infection.   A prospective study from 2010 of hospitalized adults with non-purulent cellulitis found that 73% had serologic evidence for streptococcal infection, and overall 95.8% responded to cefazolin monotherapy. A separate study of emergency room patients with non-purulent cellulitis randomized to cephalexin alone or cephalexin plus Bactrim found no difference in response rates and concluded that the addition of anti‐MRSA therapy for uncomplicated cellulitis was unnecessary.

IDSA recommends cefazolin for mild to moderate non-purulent cellulitis in the absence of penetrating trauma, history of MRSA cellulitis, failed oral antibiotics, failed incision & drainage (I&D), immunosuppression, hypotension, or end-organ dysfunction. IDSA currently does not recommend routine treatment for MRSA in the absence of these patient characteristics and risk factors.  Avoiding MRSA-active antibiotics (i.e. vancomycin) offers an opportunity to improve antimicrobial stewardship efforts and reduce unwanted complications such as acute kidney injury and infusion reactions.

For hemodynamically-stable patients without altered mental status, oral options are as follows:

  • For MSSA and streptococcus coverage: cephalexin, clindamycin, amoxicillin-clavulanate.
  • For MRSA coverage: doxycycline, trimethoprim-sulfamethoxazole, clindamycin.


  • Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 59, Issue 2, 15 July 2014, Pages e10–e52,
  • Jeng A, Beheshti M, Li J, Nathan R. The role of beta‐hemolytic streptococci in causing diffuse, nonculturable cellulitis: a prospective investigation. Medicine (Baltimore).2010;89(4):217–226.
  • Pallin DJ, Binder WD, Allen MB, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim‐sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clin Infect Dis.2013;56(12):1754–1762.
  • Raff AB, Kroshinsky D. Cellulitis: A Review. JAMA. 2016;316(3):325–337. doi:10.1001/jama.2016.8825


Justin J. Roth, Pharm.D., BCPS
Clinical Pharmacy Manager
Alta Bates Summit Medical Center (Summit Campus)

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