3.10 - Skin and Soft Tissue Infection

Ref: Stevens et al. Clin Infect Dis 2014; 59 (2): e10

Mild: Localized infection. Incision and drainage indicated. Oral antibiotic can be used if size of abscess is >5cm or surrounding erythema is >5cm.
Moderate: Evidence of systemic signs of infection, or extensive lesions. Incision and drainage indicated. Oral or systemic (IV) antibiotics can be used.
Severe: Evidence of severe sepsis or septic shock OR immunocompromised. Incision and drainage indicated. IV antibiotics should be used.

Non-purulent SSTI 

Mild: Localised infection with no evidence of purulence. Oral antibiotics can be used.

Moderate: Evidence of systemic signs of infection, or extensive lesions. Oral or IV antibiotics can be used

Severe: Evidence of severe sepsis or septic shock, clinical signs of deeper infection, organ dysfunction OR immunocompromised. IV antibiotics should be used.


Consider IV antibiotic if there are multiple abscesses or extremes of age or lack of response to incision and drainage alone.
Antibiotic allergy refers to a true hypersensitivity reaction (immediate or delayed). Gastrointestinal symptoms are usually side effects and NOT a true allergy.

A) Adults

Disease / Etiology

Preferred

Alternative

Comments

Purulent SSTI

Impetigo

 
Staphylococcus aereus

Streptococcus pyogens

Localized/mild




 


Topical Mupirocin 2% *q12H 5 - 7 days
               
                     OR

Cloxacillin 500mg PO q6H, 5-7 days (if topical options are not available)





Topical Fusidic Acid 2% *q8 - 12H 5 - 7 days 

Cephalexin 500 mg PO q6H, 5-7 days (if topical options are not available)





Incision and drainage indicated.
Send pus / exudate for C&S.
De-escalate/
streamline once C&S result is available.

If penicillin allergic:
Erythromycin Ethylsuccinate 400 mg PO q6H

OR

Clindamycin 300 mg PO q6H

OR

Co-trimoxazole 480 mg 2 - 4 tablets PO q12H

If MRSA suspected, 
Clindamycin 300 mg PO q6H

OR
Co-trimoxazole 480 mg 2 - 4 tablets q12H

*

Topical Mupirocin 2% and Topical Fusidic Acid 2% are not available in UMMC formulary

 

**Note: Co-trimoxazole may not cover streptococci
Generalized/moderate   Cloxacillin 500mg PO q6H, 5-7 days  Cephalexin 500 mg PO q6H, 5-7 days (if topical options are not available)
OR
Co-amoxiclav 625 mg PO q8H
Duration 5 - 7 days
 

Abscess, Carbuncles & Furuncles

 
Staphylococcus aureus
Streptococcus pyogens

Polymicrobial (regional skin flora)

Mild

 





Cloxacillin 500 mg PO q6H, 5 days



 



Cephalexin 500 mg PO q6H, 5 days
 
Incision and drainage indicated.

Send pus / exudate for C&S.

De-escalate/streamline once C&S result is available.

IV antibiotics should be de-escalated to oral once clinical improvement occurs


Total duration 5 - 7 days
Duration is suggested and can be adjusted depending on clinical progress.

** Consider in diabetes mellitus or immunocompromised/ in shock / not responding to Co-amoxiclav or Ampicillin/Sulbactam


*** Risk for ESBL or failed Piperacillin/Tazobactam
or penicillin allergy

If penicillin allergic:

Clindamycin 300 mg PO /IV q6H

OR

Co-trimoxazole 480 mg PO 3 - 4 tablets q12H

 

If MRSA suspected:

Clindamycin 300 mg PO q6H

OR

Co-trimoxazole 480 mg PO 3 - 4 tablets q12H

OR

Vancomycin 25 - 30 mg/kg (max. 2gm) IV loading dose, followed by 15 - 20 mg/kg IV q8 - 12H.

 

Optimise Vancomycin dose by doing therapeutic drug monitoring.

Note: Co-trimoxazole may not cover streptococci

 
Moderate

Cloxacillin 2g IV q6H

Cefazolin 2 gm IV q8H


 
Severe
 

Co-amoxiclav 1.2g IV q8H

 

OR


Ampicillin/Sulbactam 1.5g IV q8H


Piperacillin / Tazobactam 4.5 gm IV q6H **


OR


Meropenem 1 gm IV q8H*** 

Non Purulent SSTI

Erysipelas

 
Streptococcus pyogenes
Staphylococcus aureus

Localized/
mild









 


Cloxacillin 500mg PO q6H, 5 days
OR
Phenoxymethylpenicillin 500 mg PO q6H,
5 days
OR
Amoxicillin 500 mg PO q
6H, 5 days*





Cephalexin 500 mg PO q6H, 5 days










Total duration

Duration is suggested and can be adjusted depending on clinical progress.

IV antibiotics should be de-escalated to oral once clinical improvement occurs

 Systemic  Cloxacillin 2 gm IV q6H  Cefazolin 1 gm IV q8H If Penicillin allergy:

Erythromycin Ethylsuccinate 400 mg PO q6H

Clindamycin 300 mg PO q6H

OR

Clindamycin 600mg IV q8H (for severe infection)

OR

Co-trimoxazole 480 mg 3 - 4 tablets PO q12H

OR

Co-trimoxazole 15mg/kg/day IV (trimethoprim component) divided into BD (for severe infection)

*If only S. pyogenes is strongly suspected or cultured

Note: Co-trimoxazole may not cover streptococci

Cellulitis

 
Streptococcus pyogenes
Staph
ylococcus aureus
Mild








 

Cloxacillin 500mg PO q6H, 5-7 day

OR

Phenoxymethylpenicillin 500mg PO q6H, 5-7 days*
OR
Amoxicillin 500 mg PO q
6H, 5-7 days*








Cephalexin 500 mg PO q6H, 5-7 days




 

Total duration: 5 - 7 days 

Duration is suggested and can be adjusted depending on clinical progress.

Blood C&S if moderate to severe infection.
De-escalate/
streamline once C&S result is available.
IV antibiotics should be de-escalated to oral once clinical improvement occurs

Elevation of the leg is important to aid healing


*If only S. pyogenes is strongly suspected or 

** if not responded to Cefazolin or Cloxacillin


***Consider if diabetes mellitus or immunocompromised/ in shock / not responding to Co-amoxiclav or Ampicillin/Sulbactam.


****Risk for ESBL

 

^To cover for MRSA if:

  • Had previous MRSA infection / colonization
  • History of recent hospitalization
  • Recent surgical procedure (especially surgical implant related surgery)
  • Illicit drug user
  • Athlete
  • MSM (consider)
  • Penetration injury (consider)
  • Severe sepsis / shock
  • Failed initial antibiotic 
  • Impaired host defences

Optimise Vancomycin dose by doing therapeutic drug monitoring.

Refer to ID if allergy to vancomycin

Note: Co-trimoxazole does not cover streptococci.

Penicillin allergy:

Clindamycin 300 mg POq6H

OR

Clindamycin 600mg IV q8H (for severe infection)

OR

Co-trimoxazole 480 mg 2 - 4 tablets PO q12H

OR

Vancomycin 25 - 30 mg/kg  (max 2gm) IV loading dose, followed by 15 - 20 mg/kg IV q8 - 12H




 Moderate



 Cloxacillin 2 gm IV q6H


 Cefazolin 2 gm IV q8H
 Severe






 





^If MRSA suspected in severe infection


If community acquired MRSA suspected or MRSA suspected in mild infection



 Cloxacillin 2 gm IV q6H





 





 

Vancomycin 25 - 30 mg/kg  (max 2gm) IV loading dose, followed by 15 - 20 mg/kg IV q8 - 12H


Clind
amycin 300 mg PO q6H, 5-7 days

 Cefazolin 2 gm IV q8H

OR

Co-amoxiclav 1.2g IV

q8H**

OR

Ampicillin/ Sulbactam 1.5g IV q8H**

OR

Piperacillin / Tazobactam 4.5 gm IV q6H***


OR
Meropenem 1 gm IV q8H
****

Co-trimoxazole 480 mg 2 - 4 tablets PO q12H,
5-7 days



Diabetic Foot Infection

 

Staphylococcus aureus
Strep
tococcus spp

Gram negatives
Anaerobes


Mild


 

Co-amoxiclav 625 mg PO q8H 

OR
Ampicillin / Sulbactam 375 mg PO q12H 


 

Cephalexin 500 mg PO q6 H

+
  
Metronidazole 400 mg PO q8H

 

Send tissue/deep swabs for C&S


Total duration: 5 - 7 days

Duration is suggested and can be adjusted depending on clinical progress.

IV antibiotics should be de-escalated to oral once clinical improvement occurs

De-escalate/streamline once C&S result is available.

If penicillin immediate hypersensitivity, call ID

 
Moderate infection

Co-amoxiclav 1.2 gm IV q8H


OR

Ampicillin / Sulbactam 1.5 gm IV q8H
 

Cefazolin 2g IV q8H

+

Metronidazole 500mg IV q12H
 
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.

 
S
evere infection

 
Piperacillin / Tazobactam 4.5 gm IV q6H
  
+

 * ADD Clindamycin 900 mg IV q8H if necrotizing fasciitis suspected/ confirmed

Meropenem 1g IV q8H
+

* Clindamycin 900 mg IV q8H
URGENT Surgical debridement. 

Antibiotics should be streamlined based on intraoperative culture results


Total duration: 7 - 10 days 
Duration is suggested and can be adjusted depending on clinical progress

IV antibiotics should be de-escalated to oral once clinical improvement occurs

*Clindamycin is used to stop toxin production in  infections due to Staphylococcus aureus, Streptococcus pyogenes and some anaerobic gram positive organisms

Clindamycin should be stopped once clinical improvement occurs

If penicillin allergy:

Meropenem 1g IV q8H
+
*Clindamycin - 900 mg IV q8H



Chronic, recurrent diabetic foot ulcer, no evidence of infection


 No antibiotics, daily dressing, wound care    

Necrotising Fasciitis

 

Monomicrobial
S
treptococcus pyogenes

Streptococcus spp
S
taphylococcus aureus 
Clostridium spp 

Vibrio spp

Aeromonas hydrophila



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

Mixed aerobes-anaerobes

 


Piperacillin / Tazobactam 4.5 gm IV q6H
  
+
  
*Clindamycin 900 mg IV q8H
 


Meropenem 1g IV q8H
+

* Clindamycin 900 mg IV q8H

 

URGENT Surgical debridement. 

Antibiotics should be streamlined based on intraoperative culture results
Total duration: 7 -10 days Duration is suggested and can be adjusted depending on clinical progress.

IV antibiotics should be de-escalated to oral once clinical improvement occurs

*Clindamycin is used to stop toxin production in  infections due to Staphylococcus aureus, Streptococcus pyogenes and some anaerobic gram positive organisms

 

Clindamycin should be stopped once clinical improvement occurs (max duration 7 days)


Add Vancomycin if MRSA suspected.


If penicillin allergy:

Meropenem 1gm IV q8H

+

*Clindamycin 900mg IV q8H

Animal / Human Bites

 
Purulent:
Polymicrobial, mixed aerobes and anaerobes

Non Purulent Wounds:
Staphylococci spp
Streptococci
spp



Mild























Moderate























Severe Sepsis
 







Co-amoxiclav 625 mg PO q8H, 5 days

OR
Ampicillin / Sulbactam 375 mg PO q12H,
5 days





















Co-amoxiclav 1.2g IV q8H

 

OR


Ampicillin/ Sulbactam 3g IV q8H















Piperacillin / Tazobactam 4.5 gm IV q6H





 




Cefuroxime 500 mg PO q12H, 5 days

+

or Metronidazole 400 mg PO q8H,
5 days

OR

Clindamycin 300 mg PO q
6 H, 5 days

+

Ciprofloxacin 500mg PO q12H, 5 days


OR

Metronidazole 400mg PO q8H, 5 days

+

Co-trimoxazole (480 mg) 2 tablets PO q12H






Cefuroxime 750 mg IV q8H
+
Metronidazole 500 mg IV q8H

 

OR

 

Co-trimoxazole (Trimethoprim component) 5 - 10 mg/kg/day in divided dose

+
Metronidazole 500 mg IV q8H



Meropenem 1g IV q8H

 

Surgical debridement usually required.

Antibiotics should be streamlined based on intraoperative culture results.

Total duration for mild infection: 5 days

Duration is suggested and can be adjusted depending on clinical progress.

Total duration for moderate to severe infection: 10-14 days. Duration is suggested and can be adjusted depending on clinical progress.

For wounds that do not have established infection, antibiotics may be considered if:

*delayed presentation (>8 hours)

*wound cannot be debrided adequately

*involving deeper tissues

*immunocompromised

Use Co-amoxiclav 625 mg PO q8H 3-5 days

 

If penicillin allergy:

Use one of the established infection regimens.


For cat bites, Clindamycin has no Pasturella multocida cover.


Consider adding rabies
post exposure prophylaxis if fulfil criteria.

Tetanus vaccination should be considered for high risk bites eg. Contaminated with soil

 
















Valacyclovir is not available in UMMC


For monkey bite (only macaque family) Herpes simiae
Herpes B
virus
Monkey B virus
Herpesvirus B 


 
As above

+

Post-exposure prophylaxis Valacyclovir** 1 gm PO q8H or Acyclovir 800 mg PO 5x/day should be given for 14
days


 


Surgical Site Infections

 
No systemic symptoms:

WBC not raised
Erythema < 5 cm around incision


 


Systemic symptoms:
WBC raised
Erythema > 5 cm around incision
Induration / necrosis



Mild






Moderate

 
No antibiotics
Change dressing








Clean wound, wound on trunk, head, neck, extremities:
Cephalexin 500 mg PO q6H,
5 days



Wound of perineum, GIT, female genital tract:
Co-amoxiclav 625 mg PO q8H,
5 days

Clean wound

Wound on trunk, head, neck, extremities:

IV Cloxacillin 2gm IV q6H



Wound of perineum, GIT, female genital tract:

Co-amoxiclav 1.2gm IV q8H

 










Clindamycin 300mg PO q6H, 5 days

OR

Co-trimoxazole 2-3 tablets PO q12H, 5 days



Cefuroxime 500mg PO q12H, 5 days

+

Metronidazole 400mg PO q8H, 5 days

Cefazolin 2 gm IV q8H



Cefuroxime 1.5 gm IV q8H

+
Metronidazole 500 mg IV q8H

 

 Collect deep samples for C&S

 

Antibiotics should be streamlined based on intraoperative culture results

 


Total duration for mild infection: 5 days

Duration is suggested and can be adjusted depending on clinical progress.

 

 







Total duration for moderate to severe infection:5-7 days, depending on response
 

If MRSA is suspected,
in mild infection:

Clindamycin 300mg PO q6H

OR

Co-trimoxazole 2-3 tablets  PO q12H

 

If MRSA is suspected in moderate to severe infection: add Vancomycin 25 - 30 mg/kg (max 2 gm) IV loading dose, then 15 - 20 mg/kg q8 - 12H.

 

Optimise vancomycin dosing by doing drug monitoring

 
Severe

 
Piperacillin / Tazobactam 4.5 gm IV q6H

 
Meropenem 1g IV q8H


Non Diabetic Ulcers

Not infected

Infected

wound care, no antibiotics required

Treat as diabetes food ulcer

 

 

Herpes zoster

Immunocompetent patients

 

 

 

 

Immunocompromised patients with disseminated disease

Acyclovir 800mg PO five times daily, 7 days

 

 

 

 

Acyclovir 10mg/kg IV q8H

After clinical improvement, change to oral.

Total duration: 7 days

 

Antiviral treatment indicated for immunocompetent patients who present within 72 hours of onset of rash, and for all immunocompromised patients regardless of duration of rash

 

Herpes simplex (oral lesions, mouth, lips)

Acyclovir 400mg PO 5x/day

 

Acyclovir cream 5%

 

Leprosy

Mycobacterium leprae,

Mycobacterium lepromatosis

Paucibacillary (PB)

 

 

 

 

 

 

Multibacillary (MB)

 

 

 

 

 

 

 

 

 

Rifampicin Resistance leprosy**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rifampicin and Ofloxacin resistance**

 

 

Rifampicin 600mg PO monthly

+

Dapsone 100mg PO q24H*,

for 6 months

 

 

 

Rifampicin 600mg PO monthly

+

Clofazimine 300mg PO monthly

+

Clofazimine 50mg PO q24H

+

Dapsone 100mg PO q24H*,

for 12 months

 

Ofloxacin 400mg*** PO q24H

+

Minocycline 100mg PO q24H

+

Clofazimine 50mg PO q24H

, for first 6 months

 

Ofloxacin 400mg*** PO q24H

 OR

minocycline 100mg PO q24H

 +

Clofazimine 50mg PO q24H,

 for next  18 months

 

 

 

 

 

Clarithromycin PO 500mg q24H

+

Minocycline PO 100 mg q24H

+

Clofazimine PO  50 mg q24H

, for first 6 months

 

Clarithromycin  PO 500mg q24H

OR

Minocycline PO 100mg q24H

+

Clofazimine PO 50mg q24H for next  18  months

 

 

Rifampicin 600mg monthly

+

Clofazimine 300mg monthly

+

Clofazimine 50mg q24H

+Dapsone 100mg q24H

 

Same regime for both PB (6 months duration) and MB (12 months duration) **

 

 

Ofloxacin 400mg*** PO q24H

+

Clarithromycin 500mg PO q24H

+

Clofazimine 50mg PO q24H,

for first 6 months

 

Ofloxacin*** 400mg PO q24H

+

Clofazimine 50mg PO q24H, for next 18 months

*to check G6PD status

Paucibacillary (PB) case: a case of leprosy with 1 to 5 skin lesions, without demonstrated presence of bacilli in a skin smear

Multibacillary (MB) case: a case of leprosy with more than five skin lesions; or with nerve involvement (pure neuritis, or any number of skin lesions and neuritis); or with the demonstrated presence of bacilli in a slit-skin smear, irrespective of the number of skin lesions

 

**WHO guideline 2018

 

*** Ofloxacin 400mg is not available in UMMC, can be replace by Levofloxacin 500mg

Acne Vulgaris

Oral antibiotic should be used for the shortest possible duration to minimize risk of adverse effects and development of bacterial resistance

 

Options for oral antibiotic

Oral Tetracycline

1g daily in divided doses. Reduce gradually to 125-500mg/day once improvement is noted

 

Oral Doxycycline

100mg bd

 

Oral Erythromycin

400-800mg q12H, followed by 400-800mg q24H

 

Oral Azithromycin

500mg q24H for 4 consecutive days per month for 3 consecutive months

Or

500mg q24H for 3 days, followed by 500mg once a week for 10 weeks

Or

500mg q24H for 3 consecutive days each week in month 1, followed by 500mg q24H for 2 consecutive days each week in month 2, then 500mg q24H for 1 days each week in month 3

 

Rosacea

Choice of oral antibiotic

Doxycycline 50-100mg q12-24H

 

Nail infection

Onychomycosis

Dermatophytes (Trichophyton rubrum and T.mentagrophytes)

Candida, molds (rare)

 

Adult:

Itraconazole 200mg q24H, 2-3 months

Or

Itraconazole 400mg q24H x1 week/month for 2-3 months

Or Fluconazole 150-300mg/week for 3-12 months

 

Children:

Itraconazole 1 week/month For 2-3 months

Weight <20kg- 5mg/kg/day

Weight 20-40kg- 100mg/day

Weight 40-50kg- 200mg/day

Weight>50mg 200mg q12H

Or

Fluconazole 3-6mg/kg/week 3-6 months

 

 

 

Skin fungal infection^

Tinea corporis/ cruris

Trichophyton rubrum

T. mentagrophytes

Epidermphyton floccosum

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tinea capitis

(requires systemic treatment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tinea barbae (required systemic treatment)

 

 

 

 

 

 

 

 

Tinea Pedis/ Manuum

 

Topical:

Terbinafine 1% cream * apply q12H for 1 week

OR

Ketoconazole 2% cream

 

Adult

Oral Options

Itraconazole 100-200mg/day x 1 week

OR

Fluconazole 150-300mg /day x 4-6 weeks

OR

Griseofulvin (micronized) 500mg/day 2-4 weeks

 

Children

Itraconazole 5mg/kg/day x 1 week

Griseofulvin 10-20mg/kg/day

 

Adults:

Griseofulvin 20-25mg/kg/day for 6-8 weeks

OR

Itraconazole 5mg/kg/day (or 100-200mg/day) for  2-4 weeks

OR

Fluconazole 6mg/kg/day for 3-6 weeks

Children

Griseofulvin, Daily for 6-8 weeks

Age 1month to 2 years: 10mg/kg/day

Age≥ 2 Years: 20-25mg/kg/day (micronized)

OR

Itraconazole

3-5mg/kg/day for 2-4 weeks

OR

Itraconazole

5mg/kg/day for 1 week/month, 2-3 months

 

 

Adult

Griseofulvin 1g/day for 6 weeks

OR

Itraconazole 200mg/day for 2-4 weeks

OR

Fluconazole 200mg/day for 4-6 weeks

 

 

Adults

Itraconazole 200mg PO q12H  for 1 week

OR

Itraconazole 200mg PO q24H for 2 weeks

OR

Fluconazole  150mg/week  for 3-4 weeks

Children

Itraconazole 5mg/kg/day  for 2 weeks

 

 

*Not available in UMMC formulary

 

Intertrigo

Candida sp

 

Topical Miconazole/ketoconazole/ powder clotrimazole/

Fluconazole 100mg PO q24H for refractory cases

General management: weight loss, control of diabetes, drying agents

 

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.