3.10 - Skin and Soft Tissue Infection [updated]

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3.10 - Skin and Soft Tissue Infection [updated]

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 q6H, 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 Staphylococcus aureus Mild	Cloxacillin 500mg PO q6H, 5-7 day OR Phenoxymethylpenicillin 500mg PO q6H, 5-7 days* OR Amoxicillin 500 mg PO q6H, 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 Clindamycin 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 Streptococcus 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.
Severe 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 Streptococcus pyogenes Streptococcus spp Staphylococcus 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 q6 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.

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3.10 - Skin and Soft Tissue Infection [updated]

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