Skin and Soft Tissue Infections (SSTI) Clinical Guideline

Warmth, erythema, edema,tenderness

• Fluctuant/Purulent • Acutely tender, warm, inflamed mass NO• Purulent drainage

UNSUREYES

• Consider antibiotic YES Ultrasound NOprophylaxis (Table 1) positive• Incision and drainage for abscess• Break loculations• Culture, closure >2 cm• Toxic or immunosupp: MSSA: cephalexin or dicloxacillin MRSA: clindamycin, doxycycline, bactrim, vancomycin

LRINEC score < 6

Consider other causes • Infectious (vasculitis, herpes zoster, erythema migrans) • Allergic/Immune (lupus, rash, hives, dermatitis) • Venous/Lymphatic (DVT, Lymphedema) • Joint (septic arthritis, gout) LRINEC score > 5

NO

Clinical picture consistent with necrotizing infection • Broad spectrum antibiotics covering strep, MRSA,

anaerobes, and gram negative or vibrio if suspected(Table 4).• Surgical debridement needed, early TRANSFER

Cellulitis

• Mark borders of erythema with surgical marker, date, elevate• Resolve contributing: tinea pedis, lymphedema, hyperglycemia• Consult surgeon if debridement needed• Consult surgeon if suspicion for osteomyelitis:

• visible bone or ability to probe bone, large ulcer, ESR>70

• ID consult for periorbital cellulitis, or failure to improve• Criteria for admission

Failed outpatient therapyTreatment delay > 12 hrs after human/animal biteUnderlying immunosuppressionSepsis

• Assess tetanus status • Rabies prophylaxis as needed • Consider HIV/Hep B human bite • Consider X-ray for hand injury • Clean and irrigate

Bite wound? YES • See Table 2 for antibiotics

NO • Cephalexin 500 mg PO QID or • Cephalexin 1 GM IV Q8H or • Clindamycin 300 mg PO TID or • Clindamycin 600 mg IV Q8H

Water exposure? YES PLUS (if indicated) • Levaquin 750mg PO/IV (freshwater)

• Flagyl 500mg IV/PO QID (sewage) • Doxycycline 100mg PO/IV BID or

NO • Cipro 750mg PO BID (saltwater)

Inpatient admissionObservationOutpatient treatment

See Table 3 for antibiotic choices

Table 1

Indications for antimicrobial prophylaxis before surgery or drainage for bacterial endocarditis

• prosthetic heart valves, including bioprosthetic and homograft valves• prosthetic material used for cardiac valve repair• A prior history of IE• Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits• completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure• repaired congenital heart disease with residual defects at the site or adjacent the site of the prosthetic device• cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as documentation of substantial leaflet pathology and regurgitation

Table 2 Bite Wounds

Table 3

Strep Pyogenes and MSSA Treatment (most cellulitis and erypsipelas)

Outpatient Inpatient• Cepalexin 500 mg PO QID • Cefazolin 1 GM IV q8hrs• Clindamycin 300 mg PO TID • Azithromycin 500 mg IV daily• Azithromycin 250-500 mg PO daily • Clindamycin 600 mg IV daily• PCN VK 125-250 mg q6-8hrs • PCN GK 5-20 mill U per day divided or continu IV• Dicloxacillin 125-250 mg q6hrs PO• Augmentin 500-875 mg q12hrs PO

MRSAIf the patient has MRSA risk factors, purulent discharge, or is septic, consider CA-MRSA coverage

• Vancomycin 15-20 mg/kg IV for 7-10 days for INPATIENTS, pharm may dose, alsoClindamycin 600 mg IV daily and Daptomycin 4mg/kg daily IV for community acquired• Doxycycline 100 mg PO BID and/or Bactrim DS 1-2 tabs BID for 7-10 days or Clindamycin for community acquired 300 mg PO TID OUTPATIENT (poor strep coverage, except for

Clindamycin)

Diabetic foot ulcers (add coverage for gram negatives and anaerobes to above)• Levofloxacin 400-750 mg PO or IV daily (poor gram +)• Ciprofloxacin 400 mg IV q12hrs or 500 mg PO q12hrs (poor strep)• Ceftriaxone 1-2 gms IV daily or divided (poor gram +)• Zosyn IV 3.375 mg IV q6hrs (covers it all, single agent)• Ertapenum (no pseudomonas) 1 GM IV daily• Imipenem-cilastatin 250-500 mg q6hr IV or 500-750 IM q12hrs (also ESBL)• Daptomycin 4mg/kg IV daily

TABLE 4: Necrotizing infection suspected

Strep coverage: PCN G, ampicillin, Piperacillin, ClindamycinClostridium: PCN G, Ampicillin, PiperacillinMRSA: Clindamycin, VancomycinGram negative: Carbapenums, Aminoglycosides, Fluoroquinolones, and 3rd, 4th gen cephalosporins, ZosynAnaerobes: Clindamycin and metronidazole• Full coverage, fewest antibiotics: Zosyn and Clindamycin

Vibrio: carbapenums, fluoroquinolones, 3rd gen cephalosporin PLUS tetracycline or minoxycline