4.10 - Skin and Soft Tissue Infection - UMMC Pharmacy Portal v2

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4.10 - Skin and Soft Tissue Infection

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

Mild: Localized infection.

Moderate: Extensive generalized disease / infection / lesions OR evidence of systemic infection.

Severe: Evidence of severe sepsis or septic shock OR immunocompromised.

Oral antibiotics can be used for mild and moderate infection.

Systemic (IV) antibiotics are indicated for severe infection, outbreaks of poststreptococcal glomerulonephritis.

Consider IV antibiotic if there is multiple abscesses or extremes of age or lack of response to incision and drainage alone.

A) Adults

Disease / Etiology	Preferred	Alternative	Comments
Purulent SSTI
Impetigo
Staphylococcus & Streptococcus pyogens Localized Generalized Impetigo or Ecthyma	Topical Mupirocin q12H 5 - 7 days Cloxacillin 500 mg PO q6H	Topical Fusidic Acid 2% q8 - 12H 5 - 7 days Cephalexin 500 mg PO q6H OR Co-amoxiclav 625 mg PO q8H Duration 5 - 7 days	Incision and drainage indicated. Send pus / exudate for C&S. De-escalate once C&S result is available. If penicillin allergic: Erythromycin Ethylsuccinate 400 mg PO q6H * if MRSA suspected, Clindamycin 300 mg PO q6H Co-trimoxazole 480 mg 2 - 4 tablets q12H
Abscess, Carbuncles & Furuncles Monomicrobial
Staphylococcus aureus Streptococcus pyogens Polymicrobial (regional skin flora) Mild	Cloxacillin 500 mg PO q6H	Cephalexin 500 mg PO q6H	Incision and drainage indicated. De-escalate once C&S result is available. Duration 5 - 10 days depending on clinical improvement. * Risk for ESBL or failed Piperacillin / Tazobactam If MRSA is suspected, Vancomycin 15 - 20 mg/kg IV q8 - 12H
Moderate	Co-amoxiclav 1.2 gm IV q8H	Cefazolin 1 gm IV q8H ± Metronidazole 500 mg IV q8H
Severe	Piperacillin / Tazobactam 4.5 gm IV q6H	Imipenem 500 mg IV q6H* OR Meropenem 1 gm IV q8H*
Non Purulent SSTI
Erysipelas
Group A Streptococcus Localized Systemic	Phenoxymethylpenicillin 500 mg PO q6H OR Amoxicillin 500 mg PO q8H Cloxacillin 2 gm IV q6H	Cephalexin 500 mg PO q6H Cefazolin 1 gm IV q8H	Duration: Continue for 5 days upon improvement If documented past history of IgE medicated allergic reaction to beta lactam, Erythromycin Ethylsuccinate 400 mg PO q6H Clindamycin 600 mg PO q8H
Cellulitis
Group A Streptococcus Staph aureus Mild Moderate Severe If MRSA SSTI suspected in severe infection *If CA MRSA suspected	Amoxicillin 500 mg PO q8H Cloxacillin 2 gm IV q4 - 6H Piperacillin / Tazobactam 4.5 gm IV q6H Vancomycin 25 - 30 mg/kg (max 2gm) IV loading dose, followed by 15 - 20 mg/kg IV q8 - 12H Clindamycin 300 mg PO q6 - 8H	Cephalexin 500 mg PO q6H Cefazolin 1 gm IV q8H Imipenem 500 mg IV q6H* OR Meropenem 1 gm IV q8H* Refer to ID if allergy to vancomycin Doxycycline 100 mg PO q12H OR Co-trimoxazole 480 mg 2 - 4 tablets PO q12H	Duration: 5 - 10 days (depending on clinical response) Blood C&S if moderate to severe infection. De-escalate once C&S result is available. To cover for MRSA if: Had previous MRSA infection / colonization Illicit drug user Athlete MSM Penetration injury Severe sepsis / shock Failed initial antibiotic / impaired host defences Optimise Vancomycin dose by doing therapeutic drug monitoring. Note: Doxycycline and Bactrim do not cover streptococci.
Diabetic Foot Infection
Limited, mild to moderate infection, no osteomyelitis Staph aureus Streps Anaerobes	Co-amoxiclav 625 mg PO q8H or Co-amoxiclav 1.2 gm IV q8H OR Ampicillin / Sulbactam 375 mg PO q12H or 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 q6H + 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 q6H + 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. Add Vancomycin if MRSA suspected.
Animal / Human Bites
Purulent: Polymicrobial, mixed aerobes and anaerobes Non Purulent Wounds: Staphylococci Streptococci Severe Sepsis	Co-amoxiclav 625 mg PO q8H or Co-amoxiclav 1.2 gm IV q8H OR Ampicillin / Sulbactam 375 mg PO q12H or Ampicillin / Sulbactam 3 gm IV q8H Piperacillin / Tazobactam 4.5 gm IV q6H	Cefuroxime 500 mg PO q12H or Cefuroxime 750 mg IV q8H + Metronidazole 500 mg IV q8H or Metronidazole 400 mg PO q8H OR Clindamycin 300 mg PO q8H or Clindamycin 600 mg IV q6 - 8H + Doxycyline 100 mg PO q12H OR Co-trimoxazole (Trimethoprim component) 5 - 10 mg/kg/day in divided dose or Co-trimoxazole (480 mg) 2 tablets PO q12H + Metronidazole 500 mg IV q8H or Metronidazole 400 mg PO q8H or Clindamycin 300 mg PO q8H or Clindamycin 600 mg IV q6 - 8H Imipenem 500 mg IV q6H	Post exposure prophylaxis antibiotics may be given for a 3- to 5-day course. If the wound is infected on presentation, a course of 10 days or longer is recommended. For cat / dogs bites, Clindamycin has no Pasturella multocida cover. Consider adding rabies vaccine if fulfill criteria.
For monkey bites, commonly Herpes simiae Herpes B 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 Induration / necrosis Systemic symptoms: WBC raised Erythema > 5 cm around incision Induration / necrosis Mild to Moderate	No antibiotics Change dressing Clean wound, trunk, head, neck, extremities: Cephalexin 500 mg PO q6H Wound of perineum, GIT, female genital tract: Co-amoxiclav 625 mg PO q8H	Cefazolin 1 gm IV q8H Cefuroxime 1.5 gm IV q8H + Metronidazole 500 mg IV q8H	If MRSA is suspected, add Vancomycin 25 - 30 mg/kg (max 2 gm) IV loading dose, then 15 - 20 mg/kg q8 - 12H.
Severe	Piperacillin / Tazobactam 4.5 gm IV q6H	Imipenem 500 mg IV q6H

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.

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