4.10 - Skin and Soft Tissue Infection

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Cellulitis

 
Group A Streptococcus
Staph aureus
 
Cloxacillin 1 - 2 gm IV q6H
± Benzylpenicillin 1 - 2 MU IV q4 - 6H


Cefazolin 1 gm IV q8H
OR Cephalexin PO 500 mg q8H
 
Duration: 5 - 10 days

Abscess / Carbuncle
Group A Streptococcus 
Staph aureus
Anaerobes
Gram negative

 
Co-amoxiclav 1.2 gm IV q8H
 
Cefazolin 1 - 2 gm IV q8H
+ Metronidazole 500 mg IV q8H
 
Duration: 7 - 14 days
(subjected to clinical assessment)

Irrigate and debridement of the abscess if present.

Diabetic Foot Infection

 
Limited, mild infection, no osteomyelitis
Staph aureus
Streps
Anaerobes

 
Ampicillin / Sulbactam 1.5 gm IV q8H
 
Cephalexin 500 mg PO q8H + Metronidazole 400 mg PO q8H
 
Duration: 5 - 7 days
 
Severe sepsis with septic shock, limb threatening

Piperacillin / Tazobactam 4.5 gm IV q8H
+ Clindamycin 600 mg - 900 mg IV q8H
 
Imipenem 500 mg IV q6H
+ Clindamycin 600 mg - 900 mg IV q8H
 
Duration: 7 - 14 days
(subjected to clinical assessment)
With toxin production: Clindamycin 7 days

Surgical debridement URGENT.
Based on intraoperative culture and sensitivity, antibiotic should be streamlined.

 
Chronic, recurrent diabetic foot ulcer, no evidence of infection

 
No antibiotic, daily dressing
   

Necrotising Fasciitis

 
Monomicrobial
S pyogenes
S aureus
Clostridium spp


Polymicrobial
In diabetes / perianal abscess, post op wound infection (esp. abdominal wound)

 
Piperacillin / Tazobactam 4.5 gm IV q8H
+ Clindamycin 600 mg - 900 mg IV q8H

 
If allergic to penicillin, consult ID.

 

B) Paediatrics

Disease / Etiology

Preferred

Alternative

Comments

Cellulitis

 
Furuncle / Carbuncle/ Abscess formation
Staph aureus
 
Mild:
Cloxacillin 15 mg/kg PO q6H

Moderate to severe :
Cloxacillin 15 - 50 mg/kg IV q6H
± Benzylpenicillin 50,000 units/kg IV q6H

 
Co-amoxiclav 15 - 25 mg/kg (as Amoxicillin) PO q12H
OR
Cephalexin 12.5 mg/kg q6H (Non MRSA and Strep)
 
Source control is important (whenever possible).

If patient receives adequate source control, antibiotic may not be needed.
Avoid topical antibiotics.

Impetigo

 
Non-Bullous Impetigo:
Streptococcus
GAS


Topical Mupirocin 2% q8H or Fucidin for 10 - 12 days
   
Consider Mupirocin to eliminate nasal carriage.
 
Bullous impetigo:
Staph aureus (MSSA/MRSA): non-exfoliative toxin producers

 
Cloxacillin 15 mg/kg PO q6H
OR
Cephalexin 12.5 mg/kg q6H
 
MSSA: Mupirocin / Fucidin ointment
 
Increasing reports of resistance to topical Fucidin.
 
Erysipelas:
Streptococcus sp (Groups A,B,C,G)
MSSA
MRSA (rare)
 
Co-amoxiclav 15 - 25 mg/kg (Amoxicillin component) PO q12H

Azithromycin 15 mg/kg PO q24H for 3 days

Mild cases:
Penicillin V 10 - 15 mg/kg PO q6H

 
Benzylpenicillin 25,000 units/kg/dose IV q6H
OR
Vancomycin 15 mg/kg q8H (allergic to penicillin)
OR
Linezolid (MRSA) 10 mg/kg (max 600 mg) q8H
 
Duration of treatment: 10 days

Necrotising Fasciitis

 
S pyogenes
MRSA
Pseudomonas




Polymicrobial:
Clostridium perfringens
Bacteroides fragilis
 
Piperacillin / Tazobactam 100 mg/kg (Piperacillin component) IV q6 - 8H
+
Clindamycin 6 - 10 mg/kg (max 1.2 gm) IV q6H

Benzylpenicillin 50,000 units/kg IV q4 - 6H
+
Clindamycin 10 mg/kg (max 1.2 gm) IV q6H

 
If allergic to penicillin, call ID team.

Vancomycin or Linezolid in cases where MRSA is highly likely or isolated from wound.
 
NF in children often without a precipitating cause; can follow blunt trauma. Can present with streptococcal toxic shock syndrome.

Pseudomonas infection often follows burn or trauma. When a precipitating cause is identified, Varicella infection can precede NF by 3 - 4 days.

Consider urgent surgical debridement.