Treatment Guidelines on Common Primary Cutaneous Bacterial Infections (2007) Philippine Dermatological Society Rm. 1015 South Tower, Cathedral Heights Building St. Luke’s Medical Center, E. Rodriguez Sr. Ave., Quezon City Email: [email protected] Website: http://www.pds.org.ph Telephone No: 727-7309; 723-0101 loc. 2015 2009-2010 PDS Officers and Board of Directors President Vice President Secretary Treasurer Georgina C. Pastorfide, MD Ma. Teresita G. Gabriel, MD Rosalina E. Nadela, MD Lonabel A. Encarnacion, MD Directors Daisy K. Ismael, MD Marcellano S. Cruz, MD Evelyn R. Gonzaga, MD Ma. Juliet E. Macarayo, MD Cecilia R. Rosete, MD Eleanor L. Letran, MD Bernadette B. Arcilla, MD Immediate Past President Arnelfa C. Paliza, MD Cutaneous Bacterial Infections Treatment Guidelines on Common Primary Cutaneous Bacterial Infections Impetigo Impetigo contagiosa is a common superficial bacterial infection caused by Streptococcus and Staphylococcus sp. or a combination of both bacteria. While it is more common in children, it may occur at any age. Bullous and non-bullous impetigo represent two clinical forms. It presents clinically as thin-roofed bullae or more commonly ruptured vesicles/bullae which expose a red, moist base covered by honey-colored crusts with a “stuck-on appearance”, usually on the face and other exposed areas. Prevention • Antibacterial cleansers • Screen and treat family members with impetigo Treatment For limited local infections: • Mupirocin 2% or fusidic acid ointment or cream is to be applied 2- 3x a day for 7-10 days. • May soak the lesions TID in warm water or saline solution to remove the crusts Organism Drug of Choice Alternative Group A Strep Penicillin Benzathine PCN ≤6 years old 600,000 units, IM >7 years old 1.2M units Erythromycin Cefalexin Staphylo- coccus aureus (children) Cloxacillin/ Dicloxacillin 250 mg QID Cefalexin 40-50 mg/kg Grp A Strep & S. aureus Erythromycin 40 mg/kg/day (children) Clarithromycin Azithromycin Clindamycin 15 mg/kg/day (children) MRSA (Methicillin- Resistant Staphylococ- cus aureus) Minocycline Cotrimoxazole Sodium fusidate Ciprofloxacin 250-500 mg/tab, BID or TID for 7-14 days For widespread infections: • Recurrent disease maybe secondary to the colonization of Staphylococcus aureus in the nares. Mupirocin cream or ointment maybe applied BID to the anterior nares • A penicillinase resistant systemic antibiotic such as cloxacillin 250 mg, cefalexin 250 mg 4x a day or sodium fusidate 250-500 mg BID may be prescribed. See table for other drugs. Ecthyma Ecthyma is a deeper bacterial infection characterized by an ulcerative staphylococcal or streptococcal pyoderma, nearly always of the shins or dorsal feet. Ecthyma is characterized by a saucer-shaped ulcer with a raw base and elevated edges. Lesions usually heal with scarring. Treatment • Cleansing with soap and water, followed by application of mupirocin, bacitracin, or fusidic acid cream or ointment, 2-3x a day. • Cloxacillin or a first-generation cephalosporin must be given systemically Folliculitis The common folliculitis is a staphylococcal infection involving the superficial portion of the follicular duct and presents with perifollicular red papules or pustules eventually with crust formation. Tenderness may be present. Distribution is variable; often the scalp, arms, legs, axillae and trunk are involved. Treatment • Heat, friction and occlusion should be avoided or minimized. • Antibacterial soap and topical antibiotics like mupirocin or fusidic acid are effective in limited areas of involvement. • Oral antistaphylococcal antibiotics (oxacillin, cloxacillin, cefuroxime, sodium fusidate are indicated for extensive cases.) Furuncles & Carbuncles A furuncle (boil) is a walled-off, deep, painful, fluctuant mass enclosing a collection of pus, often evolving from staphylococcal folliculitis. A carbuncle is an extremely painful, deep, interconnec ted aggregate of infected follicles (coalescing furuncles). Treatment • Warm, moist compresses are applied 15 to 30 minutes several times a day. • Oral anti-staphylococcal antibiotics for at least 7 days should be given • Drainage is the primary management for fluctuant lesions. • Nasal carriage of Staphylococcus aureus is eradicated by mupirocin 2% cream or fusidic acid cream applied www.TheFilipinoDoctor.com l Sign up and open your clinic to the world. 35 Cutaneous Bacterial Infections to the anterior nares BID for 5 days. For persistent colo nization, rifampicin 600 mg once a day and cloxacillin 500 mg four times a day, for 7 to 10 days is prescribed. Cellulitis Cellulitis is an infection of the dermis and subcutaneous tissue characterized by red, hot, tender and painful plaque with an ill defined border. In adults and children this is most often caused by Group A ß-hemolytic Streptococcus and Staphylococcus aureus. Facial, periorbital, head and neck involvement in children less than 2 years old is most commonly caused by H. influenza. Treatment • Warm compresses and analgesics to relieve pain. • Elevation of an involved extremity hastens recovery. • Empiric treatment with antibiotics aimed at Staphy lococcal and Streptococcal organisms is appropriate. • Ampicillin for children because it has coverage for H. influenza. • Hib immunization in children has dramatically reduced the incidence of cellulitis in children less than 2 years old. • Hib serves as chemoprophylaxis of household mem bers in patients less than 4 years old who are un immunized. Erysipelas Erysipelas is an acute inflammatory form of cellulitis with prominent lymphatic involvement More superficial involvement with margins that are more clearly demarcated from normal skin. Prodromal symptoms consist of malaise, chills, fever and occasionally, anorexia and vomiting. Treatment • Penicillin V orally (20 to 50 mg 4x a day) is the drug of choice. Erythromycin can also be used. • Azithromycin 500 mg on day 1 and 250 mg on days 2 to 5, or clarithromycin 250 to 500 mg every 12 hours for 7 to 14 days are alternatives for patients who cannot take penicillin. Paronychia Paronychia is an inflammatory reaction involving the folds of the skin surrounding the nail. Paronychia is characterized by acute or chronic purulent, tender, and painful swellings of the tissues around the nail usually of the fingers. Causative bacteria are usually Staphylococcus aureus, Streptococcus pyogenes, Pseudomonas, Proteus sp or anaerobes. 36 Treatment • Protection against trauma. Cover with a bandage or dressing. • Incision and drainage should be done on acutely inflamed abscesses. • For acute suppurative paronychia due to S. aureus, a semisynthetic penicillin or a first-generation cephalos porin maybe given orally. Sodium fusidate tablet 250500 mg BID or TID is also effective. Erythrasma Erythrasma is a chronic, bacterial infection caused by Corynebacterium minutissimum. It affects the intertriginous areas like the groin, axillae and occasionally the toes. Present as sharply marginated, brownish-red, scaling patches on affected areas. Predisposing factors include diabetes, warm, humid climate and prolonged occlusion of the skin. Treatment • Antibacterial cleanser • Benzoyl peroxide (2.5%) gel daily for 7 days or topical erythromycin solution BID for 7 days. Topical azoles are also effective. • Systemic antibiotic therapy using erythromycin or tetracycline 250 mg QID for 7 days is prescribed in resistant cases. Characteristics of an ideal antibacterial agent for common skin infections: 1. Should have activity against Staph. aureus (including methicillin-resistant strains) and Streptococcus. 2. Low resistance rates 3. Low sensitizing potential 3. No cross sensitivity with other antibiotics 4. Excellent pharmacokinetics Protective device for wound healing Protect the wound from further damage, such as contact with dirt, soil or insects, by applying protective gauze or dressing. Dressings may also help reduce odor and help absorption of moisture especially in highly exudative lesions. Wound dressings are also beneficial in improving the appearance of wound site and may even help promote the functional use of the affected part. As a further precaution, dressings must be changed frequently and disposed immediately. Cutaneous Bacterial Infections Recommended Therapeutics The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's reference, available drugs are listed under each therapeutic class. For drug information, please refer to the Philippine Drug Directory System (PPD, PPDr, PPD Text, PPD Tabs). Cephalosporins First Generation Cefadroxil Drugmaker's Biotech Cefadroxyl Lexipad Cefalexin Airex Bloflex Cefalin Capsule Cefalin Drops/Suspension Ceporex CFA Drugmaker's Biotech Cefalexin Forexine Keflex Lewimycin Lyceplix Madexin Medilexin Medoxine Oneflex Pharex Cefalexin Ritemed Cefalexin Vamsler Cefalexin Xinflex Zeporin Cefazolin Fonvicol Ilozef Stancef Cefradine Altozef Drugmaker's Biotech Cefradine Tolzep Zepdril Second Generation Cefaclor Ceclobid Ceclor/Ceclor CD Cfc Clorcef Drugmaker's Biotech Cefaclor Pharex Cefaclor Ritemed Cefaclor Surecef Verzat/Verzat-ER Xelent Xeztron Zunecar Cefotiam Ceradolan Cefoxitin Monowel Panafox Cefuroxime Aeruginox Injection Aeruginox Altacef C-Tri T Drugmaker's Biotech Cefuroxime Furovex Ifurax Infekor Kefsyn Panaxim Powder For Inj (IM/IV) Panaxim Tab Ritemed Cefuroxime Rovix Roxicef Roxym Xorimax Zefur Zegen Capsule Zegen Zinacef Zinnat Penicillins Amoxicillin Amoxil/Amoxil Forte Clearamox Daisamox Drugmaker's Biotech Amoxicillin Eleomox Globamox Globapen Himox Lewixin Medimoxil Medvox Megamox Moxillin Pediamox Pharex Amoxicillin Ritemed Amoxicillin Sumoxil Teramoxyl Trexil Valzimox Zymoxyl Ampicillin Ampicin Bactimed Cilisod Drugmaker's Biotech Ampicillin Eurocin Excillin Panacta Pentrexyl Picaplin Polypen Benzathine benzylpenicillin Zalpen Benzylpenicillin potassium Rhea Benzylpenicillin Potassium Benzylpenicillin sodium Yss Benzylpenicillin Sodium Cloxacillin Avastoph Drugmaker's Biotech Cloxacillin Encloxil Lewinex Medix Oxaclen Pannox Pharex Cloxacillin Prostaphlin-A Ritemed Cloxacillin Secloxin Co-Amoxiclav Amoclav Amoclav Suspension Augmentin Augmex Bactoclav Bioclavid Cax Clavace Clavmex Clavoxel Clovimax Drugmaker's Biotech Amoxicillin + Clavulanic Acid Enhamox Exten Natravox Sullivan Flucloxacillin Drugmaker's Biotech Flucloxacillin Fluclox Stafloxin Oxacillin Prostaphlin Wydox Phenoxymethylpenicillin K Sumapen Sulbactam/Ampicillin Unasyn IM/IV Sulbactam/Amoxicillin Ultramox Sultamicillin Unasyn Oral Zunamyn Tazobactam/Piperacillin Piptaz Tazocin Ticarcillin sodium/Clavulanate potassium Timentin Lincosamines Clindamycin Anerocin Clindal Cliz Dalacin C HCl/Dalacin C Palmitate/ Dalacin C Phosphate Klindex Pharex Clindamycin Lincomycin Lincocin Macrolides Azithromycin Azyth Zithromax Zmax One Dose Clarithromycin Claranta Clariget Claristad Galemin Klargen Klaricid/Klaricid OD Klarmyn Klaz Larizin Maclar Maxulid Onexid Pharex Clarithromycin Ritromax Erythromycin Drugmaker's Biotech Erythromycin Erasymin Erythrocin/Erythrocin DS Ilosone/Ilosone DS Pharex Erythromycin Ritemed Erythromycin Sansacne Stiemycin Upperzin Roxithromycin Guamil Macrol/Macrol Kiddie Learn to access drug info on your cellphone. Send PPD to 2600 for Globe/Smart/Sun users. 37 Cutaneous Bacterial Infections Pharex Roxithromycin Roxid Rulid Thromyn Quinolones Ciprofloxacin Cifloxin Ciloxan Ciprobay/Ciprobay XR Cipromax Cipromet Cirok Drugmaker's Biotech Ciprofloxacin Floxacef Hyprocel Iprolan Ipromax Pharex Ciprofloxacin Proxivex Quiprime Rapiqure Ritemed Ciprofloxacin Xipro Zunexan Zyflox Gatifloxacin Tequin Levofloxacin Floxel Glevo Levocin Levox Wilovex Moxifloxacin Avelox Norfloxacin Drugmaker's Biotech Norfloxacin Ellatracid Euroflox NRX Pharex Norfloxacin Septinor Uritracin Reformulated Urobacid Winaflox Ofloxacin Baciflox Drugmaker's Biotech Ofloxacin Floxastad Gyros Inoflox Iquinol Keftil Pharex Ofloxacin Qiflon Qinolon Pefloxacin Floxin Rufloxacin HCl Uroclar Sulfonamide Combinations Cotrimoxazole Bacidal Bactille-TS Bactrim Bacxal Chromo-Z Costazole Drugmaker's Biotech Cotrimoxazole Globaxol Kathrex Lagatrim Forte Macromed Moxzole Onetrim Pharex Cotrimoxazole Rimezone/Rimezone Forte Ritemed Cotrimoxazole 38 Septrin Trim-S Trizole Suspension Tetracyclines Doxycycline Biocolyn Doryx Doxin Dyna-Doxycycline Vibramycin Lymecycline Tetralysal Oxytetracycline Terramycin Tetracycline RiteMed Tetracycline Other Anti-infectives Cefoperazone/ Sulbactam Sulperazone Rifampin (Rifampicin) Crisarfam Drugmaker's Biotech Rifampicin Natricin Forte Pharex Rifampicin Refam Rimactane Rimaped Sodium fusidate Fucidin Dermatologicals Anti-acne Benzoyl peroxide Benzac AC Gel/Wash Brevoxyl Panoxyl Anti-infectives (Topical) Erythromycin Sansacne Stiemycin Gentamicin sulfate Garamycin 0.1% Cream/Ointment Mupirocin Bactifree Bactroban Cream Foskina Nitrofurazone Drugmaker's Biotech Nitrofurazone Furacin Polymyxin B Sulfate/Bacitracin zinc/Neomycin sulfate Terramycin Plus Skin Ointment Trimycin Topical Ointment Silver sulfadiazine Flammazine Innoxiderm Silver sulfadiazine/Cerium nitrate Flammacerium Sodium fusidate/Fusidic acid Fucidin Ointment/Cream Fucithalmic Antiseptics Betadine Cream 5% Betadine Ointment 10% Betadine Skin Cleanser Betadine Wound Solution Drapolene Fixed-Dose Combinations Antibacterial, Antifungal & Anti-inflammatory Candibec Dermovate NN Kenacomb Lidex NGN Nerisona Combi Quadriderm Triderm Trimycin-H Ointment Antibiotic & Anti-Inflammatory Aplosyn 10-N Baycuten N Betnovate-N Clotrasone Diprogenta Foskina-B Fucicort Fucidin H Hoebedic Neo-Synalar 10/Neo-Synalar 25 Vaccines HiB Act-HiB Hiberix Tetract-HiB Vaxem HiB Medicated Dressings, Plasters and Bandages Leukoplast Adhesive Plaster Mediplast Assorted Strips Mediplast Checker Adhesive Strips Mediplast Hypoallergenic Paper Tape Mediplast Plastic Strip w/ Acrinol Mediplast Sheer Strips (Skintone) Mediplast Transparent Strips
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