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Chapter 150: Face and Jaw Emergencies

Jeffrey G. Norvell

FACIAL INFECTIONS

Facial Cellulitis

Cellulitis is a soft tissue infection that involves the skin and subcutaneous tissues. Facial cellulitis is most commonly caused by Streptococcus pyogenes and Staphylococcus aureus, with an increasing predominance of methicillin-resistant Staphylococcus aureus (MRSA). Less commonly, cellulitis may represent an extension from a deeper facial infection. Cellulitis is characterized by erythema, edema, warmth, pain, and loss of function. Clinical features of a well-defined, palpable border are absent.

The diagnosis of cellulitis is clinical. Ultrasound and computed tomography (CT) may be used to evaluate for abscess or more extensive infection. In most cases, treatment involves oral antibiotics for 7 to 14 days. Antibiotic recommendations for conditions discussed in this chapter are listed in Tables 150-1 and 150-2. Consider hospitalization and parenteral antibiotics for patients with signs of systemic illness, failed outpatient therapy, or significant comorbidities.

Table 150-1

Antibiotic Therapy for Facial Infections

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Table 150-1

Antibiotic Therapy for Facial Infections
Cellulitis

  • Oral therapy: clindamycin, dicloxacillin, or cephalosporins

  • Suspected MRSA: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, or minocycline

  • Parenteral therapy: vancomycin, clindamycin

  • Total duration 7–10 days
Erysipelas

  • Oral therapy: penicillin

  • Methicillin-sensitive Staphylococcus aureus suspected: amoxicillin/clavulanate, cephalexin, dicloxacillin

  • Bullous erysipelas: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, or minocycline

  • Parenteral therapy: vancomycin, nafcillin, clindamycin

  • Total duration 7–10 days
Impetigo

  • Topical: mupirocin or retapamulin ointment alone or with oral therapy

  • Oral therapy: dicloxacillin, amoxicillin/clavulanate, cephalexin

  • MRSA suspected: clindamycin or trimethoprim-sulfamethoxazole

  • Total duration 7 days
Suppurative parotitis

  • Oral therapy: amoxicillin-clavulanate, clindamycin, or cephalexin and metronidazole

  • Parenteral therapy: nafcillin, ampicillin-sulbactam, or vancomycin with metronidazole

  • Hospital acquired or nursing home patients: include vancomycin

  • Total duration: 10–14 days
Masticator space infection

  • Parenteral therapy: IV clindamycin is recommended; alternatives include ampicillin-sulbactam, cefoxitin, or the combination of penicillin with metronidazole

  • Oral therapy: clindamycin or amoxicillin-clavulanate

  • Total duration: 10–14 days

Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.

Table 150-2

Antibiotic Doses for Facial Infections

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Table 150-2

Antibiotic Doses for Facial Infections
Antibiotic Dosage
Topical Antibiotics
Mupirocin ointment 2%, apply to lesions three times per day
Retapamulin ointment 1%, apply to lesions two times per day
Oral Antibiotics
Amoxicillin/clavulanate 875/125 mg two times per day
Cephalexin 500 mg four times per day
Clindamycin 300–450mg four times per day
Dicloxacillin 500 mg four times per day
Doxycycline 100 mg two times per day
Metronidazole 500 mg every 8 hours
Minocycline 100 mg two times per day
Penicillin V 500 mg four times per day
Trimethoprim-sulfamethoxazole 1–2 double-strength tablets two times per day
Parenteral Antibiotics
Ampicillin-sulbactam 1.5–3.0 g every 6 hours
Clindamycin 600 mg every 8 hours
Cefazolin 1 g every 8 hours
Metronidazole 1 g loading dose, then 500 mg every 8 hours
Nafcillin 1–2 g every 4 hours
Penicillin G 2–3 million units every 6 hours
Vancomycin 1 g every 12 hours

Erysipelas

Erysipelas is a superficial ...

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