New cellulitis treatment guidance published

A 5-day course of flucloxacillin may be sufficient to treat some cases of cellulitis, according to newly published NICE antimicrobial prescribing guidance.

New cellulitis treatment guidance aims to optimise antibiotic use and reduce antibiotic resistance. | DR P. MARAZZI/SCIENCE PHOTO LIBRARY

A concise summary of the new NICE treatment recommendations for cellulitis and erysipelas in adults can be found in the MIMS table of antibiotic regimens.

The new advice is the first NICE antimicrobial prescribing guidance to be finalised for skin infections. Guidance for antibiotic treatment of impetigo was recently issued in draft form

NICE says the first-choice oral antibiotic for cellulitis and erysipelas in children and adults should be flucloxacillin, a relatively narrow-spectrum penicillin which has activity against Staphylococcus aureus and Streptococcus pyogenes. In adults the recommended dose is 500mg to 1g four times daily (flucloxacillin has poor oral bioavailability so people with impaired circulation may require the higher 1g dose, which is off-label). A 5- to 7-day course is sufficient in most cases, but up to 14 days' treatment may be needed for some people based on their symptoms and history.

Clarithromycin (or in pregnancy, erythromycin) is recommended as an alternative to flucloxacillin in people who have penicillin allergy or where flucloxacillin is otherwise unsuitable. Oral macrolides were at least as effective as an oral penicillin in studies and have a similar spectrum of activity.

Doxycycline can be considered for adults who have penicillin allergy or if flucloxacillin is unsuitable.

Facial infection

For infection near the eyes or nose, the first-choice oral antibiotic should be co-amoxiclav, a broader-spectrum antibiotic. This is because of the risk of a serious intracranial complication in the event of treatment failure, and because co-amoxiclav provides cover for Haemophilus and anaerobic bacteria.

Although routine dual therapy was not recommended, clarithromycin with metronidazole is a suitable alternative to co-amoxiclav in adults with infection near the eyes or nose, if co-amoxiclav is not suitable or the patient has penicillin allergy.


In children, co-amoxiclav can be used as an alternative first-choice antibiotic if flucloxacillin is unsuitable. However, if flucloxacillin is only not suitable because of poor palatability of the oral solution, flucloxacillin capsules should be considered because children can often take tablets or capsules if they are supported to do this.

The guidance also provides recommendations on suitable intravenous antibiotics for adults and children who are unable to take oral antibiotics or who are severely unwell. 

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