Skin and Soft Tissue Infections (SSTI

Skin and Soft Tissue Infections (SSTI) Skinand Soft Tissue Infections (SSTI) Skin and Soft Tissue Infections (SSTI)

NONPURULENT NONPURULENT Necrotizing Infection/Cellulitis/Erysipelas Necrotizing Infection/Cellulitis/Erysipelas[Usually Streptococcus pyogenes (Group A Strep)] [Usually Streptococcus pyogenes (Group A Strep)]

Mild: Mild: Nosystemic signs No systemic signs of infection* of infection*

Oral Oral Antibiotic Therapy Antibiotic Therapy

Select ONE: Select ONE:Penicillin VK

Penicillin VK250-500 mg PO Q6H 250-500 mg PO Q6HCephalexin Cephalexin 500 mg PO Q6H 500 mg PO Q6H Dicloxacillin Dicloxacillin 250 mg PO Q6H 250 mg PO Q6H Clindamycin Clindamycin 300-450 mg PO Q6H 300-450 mg PO Q6H

Moderate: Moderate: Systemic signsof Systemic signs of infection* infection*

Intravenous Intravenous Antibiotic Therapy Antibiotic Therapy

Select ONE: Select ONE:Penicillin

Penicillin 2-4 million units IV 2-4 million units IV Q4-6H Q4-6H Ceftriaxone Ceftriaxone 1 gm IV Q24H 1 gm IV Q24HCefazolin Cefazolin 1 gm IV Q8H 1 gm IV Q8H Clindamycin Clindamycin 600-900 mg IV Q6H 600-900 mg IV Q6H

Severe: Severe: (any ofthe following):

(any of the following): Systemicsigns of infection*, Systemic signs of infection*, failed antibiotic treatment, failed antibiotic treatment, immunocompromise, immunocompromise, hemodynamicinstability, or hemodynamic instability, or deep infection deep infection

Intravenous Antibiotic Therapy Intravenous Antibiotic Therapy

Emergent Surgical Emergent Surgical Inspection/Debridement

Inspection/Debridement • Ruleout necrotizing • Rule out necrotizing process process Culture &Sensitivity

Culture & Sensitivity Empiric Treatment

Empiric Treatment • Vancomycin 15 mg/kg • Vancomycin IV** PLUS 15 mg/kg • IV** PLUS Piperacillin/tazobactam • Piperacillin/tazobactam3.375 gm IV Q6H 3.375 gm+/- IV Q6H • +/Clindamycin 900 mg IV • Clindamycin 900 mg IV Q8H***

Q8H***

DefinedTreatment (NecrotizingInfections) Defined Treatment (Necrotizing Infections) Monomicrobial

Monomicrobial Streptococcus pyogenes Streptococcus pyogenes • Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H • Penicillin 2-4 million units IV Q4-6H Vibriovulnificus PLUS Clindamycin 600-900 mg IV Q8H Vibrio vulnificus • Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H • Doxycycline 100 mg IV Q12H Aeromonashydrophila PLUS Ceftazidime 2 gm IV Q8H Aeromonashydrophila • Doxycycline100 mg IV Q12H PLUS Ciprofloxacin400 mg IV Q12H • Doxycycline 100 mg IV Q12H Polymicrobial PLUS Ciprofloxacin 400 mg IV Q12H Polymicrobial • Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H • Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H H= hours; IV=intravenous;PO=oral;Q= every H= hours; IV= intravenous; PO= oral; Q= every *Systemic signs ofinfection include,but are not limited to, temperature >38°C,tachycardia(heartrate >90beatsper minute), *Systemic signs of infection include, but are not limited to, temperature >38°C, tachycardia (heart rate >90 beats per minute),tachypnea(respiratory rate >24breaths perminute) orabnormal white bloodcell count (>12 000 or<4000 cells/µL). tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count **Referto sectionon Vancomycin Dosing and Monitoringin Adult Patients. (>12 000 or <4000 cells/µL). **Refer to section on Vancomycin Dosing and Monitoring in Adult Patients. ***Consider this addition for necrotizing fasciitis. ***Consider this addition for necrotizing fasciitis. Note: Referto Table of Contents for section onAntimicrobialDosing forAdult Patients BasedonRenal Functionfor dosing in Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in patients with renalimpairment. patients with renal impairment.

References:

References: 1. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, et al. Practice guidelines for the diagnosis and management of skin 1. Stevens DL, Bisno AL,Chambers HF,Dellinger EP,Goldstein EJ, Gorbach SL, et al.Practiceguidelinesforthe diagnosis and management ofskin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52. 2. and soft tissueinfections:2014 updateby theInfectiousDiseasesSocietyofAmerica. Clin Infect Dis. 2014;59(2): e10-52.Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin 2. Duong M, MarkwellS, PeterJ, Barenkamp S. Randomized, controlled trial abscesses in the pediatric patient. Ann Emerg Med 2010; 55:401–7. of antibioticsin the managementof community-acquired skin 3. abscesses in the pediatricpatient. Ann Emerg Med 2010; 55:401–7.Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6. 3. Macfie J, HarveyJ.The treatmentof acute superficialabscesses: a prospective clinical trial.4.Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Br J Surg 1977; 64:264–6.Med 1985; 14:15–9. 4.Llera JL, Levy RC.Treatmentofcutaneous abscess:a double-blind clinical study. Ann Emerg Med 1985; 14:15–9.5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:1077–80. 5. 6. Rutherford WH,HartD, Calderwood JW, Merrett JD.Antibiotics in surgical treatment of septiclesions. Lancet 1970; 1:1077–80. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in 6. SchmitzGR, BrunerD, Pitotti R, etal. Randomized controlled trial of trimethoprim-sulfamethoxazolepatients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann for uncomplicated skin abscesses Emerg Med 2010; 56:283–7. in patients at risk forcommunity-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7. PAGE 25

Skin and Soft Tissue Infections (SSTI) Skin and Soft Tissue Infections (SSTI)

PURULENT Furuncle/Carbuncle/Abscess (Usually Staphylococcus aureus)

Mild: No systemic signs of infection*

No Antibiotic Therapy

Incision and Drainage

Moderate: Systemic signs of infection*

Incision and Drainage and C&S

Oral Antibiotic Therapy Severe: (any of the following):

Failed I&D and oral antibiotics, systemic signs of infection*, immunocompromise, hemodynamic instability, or deep infection

Incision and Drainage and C&S

Empiric Therapy (select ONE): • TMP/SMX 1-2 DS tablets PO Q12H • Doxycycline 100 mg PO Q12H

Defined Therapy

MRSA • TMP/SMX (see empiric dose) MSSA (select ONE): • Dicloxacillin 500 mg PO Q6H • Cephalexin 500 mg PO Q6H

Intravenous Antibiotic Therapy

Empiric Therapy (select ONE): • Vancomycin 15 mg/kg IV** • Daptomycin 6 mg/kg IV Q24H • Linezolid 600 mg IV Q12H • Ceftaroline 600 mg IV Q12H

Defined Therapy

MRSA • See empiric therapy above MSSA (select ONE): • Nafcillin 1-2 gm IV Q4H • Cefazolin 1 gm IV Q8H • Clindamycin 600 mg IV Q8H

C&S= culture and sensitivity; DS= double-strength; H= Hours; I&D= incision and drainage; IV= intravenous; MRSA= methicillinresistant Staphylococcus aureus; MSSA= methicillin-susceptible Staphylococcus aureus; PO= by mouth; Q= every; Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole

*Systemic signs of infection, but are not limited to, include temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL). **Refer to section on Vancomycin Dosing and Monitoring in Adult Patients.

References:

1. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52. 2. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med 2010; 55:401–7. 3. Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6. 4.Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9. 5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:1077–80. 6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.