Skin and Soft Tissue Infections (SSTI)
Skin
and
Infections
(SSTI)
Skin and
SoftSoft
TissueTissue
Infections
(SSTI)
NONPURULENT
Necrotizing Infection/Cellulitis/Erysipelas
NONPURULENT
[Usually
Streptococcus
pyogenes (Group A Strep)]
Necrotizing
Infection/Cellulitis/Erysipelas
[Usually Streptococcus pyogenes (Group A Strep)]
Mild:
No systemic
Mild: signs
infection*
Noofsystemic
signs
Moderate:
Systemic
signs of
Moderate:
infection*
Systemic
signs of
Oral
Antibiotic
OralTherapy
Antibiotic Therapy
Intravenous
Antibiotic
Therapy
Intravenous
Select ONE:
Penicillin VK
Select ONE:
250-500 mg PO Q6H
Penicillin VK
Cephalexin
250-500 mg PO Q6H
500 mg PO Q6H
Cephalexin
Dicloxacillin
500 mg PO Q6H
250 mg PO Q6H
Dicloxacillin
Clindamycin
250 mg PO Q6H
300-450 mg PO Q6H
Clindamycin
300-450 mg PO Q6H
Select ONE:
Penicillin
Select ONE:
2-4 million units IV
Penicillin
Q4-6H
2-4 million units IV
Ceftriaxone
Q4-6H
1 gm IV Q24H
Ceftriaxone
Cefazolin
1 gm IV Q24H
1 gm IV Q8H
Cefazolin
Clindamycin
1 gm IV Q8H
600-900 mg IV Q6H
Clindamycin
600-900 mg IV Q6H
of infection*
infection*
Antibiotic Therapy
Severe:
(any of Severe:
the following):
Systemic signs of infection*,
(any of the following):
failed antibiotic treatment,
Systemic signs of infection*,
immunocompromise,
failed antibiotic treatment,
hemodynamic instability, or
immunocompromise,
deep infection
hemodynamic instability, or
deep infection
Intravenous Antibiotic Therapy
Intravenous Antibiotic Therapy
Emergent Surgical
Inspection/Debridement
Emergent Surgical
• Rule out necrotizing
Inspection/Debridement
process
• Rule out necrotizing
Culture & Sensitivity
process
Empiric Treatment
Culture & Sensitivity
• Vancomycin 15 mg/kg
Empiric Treatment
IV** PLUS
• Vancomycin 15 mg/kg
• Piperacillin/tazobactam
IV** PLUS
3.375 gm IV Q6H
• Piperacillin/tazobactam
+/3.375 gm IV Q6H
• Clindamycin 900 mg IV
+/Q8H***
• Clindamycin 900 mg IV
Q8H***
Defined Treatment (Necrotizing Infections)
Monomicrobial
Defined Treatment (Necrotizing Infections)
Streptococcus pyogenes
Monomicrobial
• Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H
Streptococcus pyogenes
Vibrio vulnificus
• Penicillin 2-4 million units IV Q4-6H PLUS Clindamycin 600-900 mg IV Q8H
• Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H
Vibrio vulnificus
Aeromonas hydrophila
• Doxycycline 100 mg IV Q12H PLUS Ceftazidime 2 gm IV Q8H
• Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H
Aeromonas hydrophila
Polymicrobial
• Doxycycline 100 mg IV Q12H PLUS Ciprofloxacin 400 mg IV Q12H
• Vancomycin 15 mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H
Polymicrobial
• Vancomycin
15every
mg/kg IV** PLUS Piperacillin/tazobactam 3.375 gm IV Q4H
H= hours; IV= intravenous;
PO= oral; Q=
*Systemic
of infection include,
not limited to, temperature >38°C, tachycardia (heart rate >90 beats per minute),
H= hours;signs
IV= intravenous;
PO= oral;but
Q=are
every
tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL).
*Systemic
of on
infection
include,
but are
limited to,intemperature
>38°C, tachycardia (heart rate >90 beats per minute),
**Refer
to signs
section
Vancomycin
Dosing
andnot
Monitoring
Adult Patients.
tachypnea (respiratory
rate
breaths per
minute) or abnormal white blood cell count (>12 000 or <4000 cells/µL).
***Consider
this addition
for>24
necrotizing
fasciitis.
**Refer
to
section
on
Vancomycin
Dosing
and
Monitoring
in
Adult
Patients.
Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in
***Consider
addition
for necrotizing fasciitis.
patients
withthis
renal
impairment.
Note: Refer to Table of Contents for section on Antimicrobial Dosing for Adult Patients Based on Renal Function for dosing in
patients with renal impairment.
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
and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
References:
2.
Markwell
S, Chambers
Peter J, Barenkamp
S. Randomized,
trialSL,ofetantibiotics
in guidelines
the management
community-acquired
skinof skin
1. Duong
StevensM,DL,
Bisno AL,
HF, Dellinger
EP, Goldsteincontrolled
EJ, Gorbach
al. Practice
for the of
diagnosis
and management
abscesses
in theinfections:
pediatric patient.
Ann Emerg
2010; Diseases
55:401–7.Society of America. Clin Infect Dis. 2014; 59(2): e10-52.
and soft tissue
2014 update
by the Med
Infectious
3.
J, Harvey
J. The
treatment
of acute superficial
abscesses:
a prospective
clinical trial.
Br Jmanagement
Surg 1977; 64:264–6.
2. Macfie
Duong M,
Markwell
S, Peter
J, Barenkamp
S. Randomized,
controlled
trial of antibiotics
in the
of community-acquired skin
4. Llera
JL, Levy
RC. pediatric
Treatment
of cutaneous
abscess:
double-blind
clinical study. Ann Emerg Med 1985; 14:15–9.
abscesses
in the
patient.
Ann Emerg
Meda2010;
55:401–7.
5.
WH, Hart
D,treatment
Calderwood
Merrett
JD. Antibiotics
treatment
septic
Lancet
1970; 1:1077–80.
3. Rutherford
Macfie J, Harvey
J. The
of JW,
acute
superficial
abscesses:ina surgical
prospective
clinicaloftrial.
Br Jlesions.
Surg 1977;
64:264–6.
6.
D, Pitotti of
R, cutaneous
et al. Randomized
trial of
trimethoprim-sulfamethoxazole
for14:15–9.
uncomplicated skin abscesses in
4. Schmitz
Llera JL, GR,
LevyBruner
RC. Treatment
abscess:controlled
a double-blind
clinical
study. Ann Emerg Med 1985;
patients
at
risk
for
community-associated
methicillin-resistant
Staphylococcus
aureus
infection.
Ann
Emerg
Med
2010;
56:283–7.
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.
PAGE 22
Skin
and
Infections
(SSTI)
Skin and
SoftSoft
TissueTissue
Infections
(SSTI)
PURULENT
Skin and Soft Tissue Infections
(SSTI)
Furuncle/Carbuncle/Abscess
(Usually Staphylococcus
aureus)
PURULENT
Furuncle/Carbuncle/Abscess
Moderate: aureus)
(Usually Staphylococcus
Mild:
No systemic signs
Mild:
of infection*
Systemic signs of
Moderate:
infection*
Systemic signs of
infection*
No systemic signs
of infection*
No
Antibiotic
No
Therapy
Incision and Drainage
and C&S
Antibiotic
Therapy
Incision and Drainage
Incision and Drainage
Incision and Drainage
and C&S
Oral
Antibiotic
Oral
Therapy
Antibiotic
instability, or deep
infection
Incision and Drainage
andDrainage
C&S
Incision and
and C&S
Therapy
Empiric Therapy (select ONE):
Severe:
(any of the following):
Severe:
Failed
I&D and oral
(anyantibiotics,
of the following):
systemic
Failed
I&D
oral
signs
ofand
infection*,
antibiotics,
systemic
immunocompromise,
signs hemodynamic
of infection*,
immunocompromise,
instability, or deep
hemodynamic
infection
• TMP/SMX
1-2
DS tablets
Empiric
Therapy
(select
ONE): PO Q12H
Doxycycline
mg POPO
Q12H
•• TMP/SMX
1-2100
DS tablets
Q12H
Therapy
•Defined
Doxycycline
100 mg PO Q12H
MRSA Therapy
Defined
MRSA
• TMP/SMX (see empiric dose)
•MSSA
TMP/SMX
empiric dose)
(select(see
ONE):
MSSA
(select ONE):
• Dicloxacillin
500 mg PO Q6H
•• Dicloxacillin
Cephalexin 500
500mg
mgPO
POQ6H
Q6H
• Cephalexin 500 mg PO Q6H
Intravenous
Antibiotic
Intravenous
Therapy
Antibiotic
Therapy
Empiric Therapy (select ONE):
Empiric Therapy (select ONE):
• Vancomycin 15 mg/kg IV**
• Vancomycin 15 mg/kg IV**
• Daptomycin 6 mg/kg IV Q24H
• Daptomycin 6 mg/kg IV Q24H
• Linezolid 600 mg IV Q12H
• Linezolid 600 mg IV Q12H
Ceftaroline
mgQ12H
IV Q12H
• •Ceftaroline
600600
mg IV
Defined
Therapy
Defined
Therapy
MRSA
MRSA
empiric
therapy
above
• •SeeSee
empiric
therapy
above
MSSA
(select
ONE):
MSSA
(select
ONE):
Nafcillin
IV Q4H
• •Nafcillin
1-2 1-2
gm gm
IV Q4H
• •Cefazolin
1 gm
IV Q8H
Cefazolin
1 gm
IV Q8H
• •Clindamycin
600600
mg IV
Clindamycin
mgQ8H
IV Q8H
C&S=
cultureand
andsensitivity;
sensitivity; DS=
DS= double-strength;
double-strength; H=
incision
andand
drainage;
IV= intravenous;
MRSA=
methicillinC&S=
culture
H=Hours;
Hours;I&D=
I&D=
incision
drainage;
IV= intravenous;
MRSA=
methicillinresistantStaphylococcus
Staphylococcusaureus;
aureus; MSSA=
MSSA= methicillin-susceptible
Staphylococcus
aureus;
PO=PO=
by mouth;
Q= every;
resistant
methicillin-susceptible
Staphylococcus
aureus;
by mouth;
Q= every;
Rx= treatment; TMP/SMX= trimethoprim-sulfamethoxazole
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),
*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).
tachypnea
rate >24 breaths
or abnormal
white blood
cell count (>12 000 or <4000 cells/µL).
**Refer to(respiratory
section on Vancomycin
Dosingper
andminute)
Monitoring
in Adult Patients
.
**Refer to section on Vancomycin Dosing and Monitoring in Adult Patients.
References:
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 DL,
Infectious
Diseases
Society
ofet
America.
Clin Infect
Dis. 2014;
59(2):
e10-52. and management of skin and soft tissue infections: 2014 update
1. Stevens
Bisno AL,
Chambers
HF,
al. Practice
guidelines
for the
diagnosis
2.byDuong
M, Markwell
S, Peter
J, Barenkamp
S. Randomized,
controlled
of e10-52.
antibiotics in the management of community-acquired skin
the Infectious
Diseases
Society
of America.
Clin Infect Dis.
2014; trial
59(2):
abscesses
in the pediatric
Ann Emerg
Med 2010; 55:401–7.
2. Duong
M, Markwell
S, Peterpatient.
J, Barenkamp
S. Randomized,
controlled trial of antibiotics in the management of community-acquired skin
3.abscesses
Macfie J,inHarvey
J. The treatment
acute
superficial
abscesses:
a prospective clinical trial. Br J Surg 1977; 64:264–6.
the pediatric
patient. of
Ann
Emerg
Med 2010;
55:401–7.
Llera JL,
Levy RC.J. Treatment
of cutaneous
a double-blind
study. Ann
Emergtrial.
MedBr1985;
14:15–9.
3. 4.Macfie
J, Harvey
The treatment
of acuteabscess:
superficial
abscesses:clinical
a prospective
clinical
J Surg
1977; 64:264–6.
Rutherford
Hart D, Calderwood
JW, Merrett
JD.aAntibiotics
in surgical
of Emerg
septic lesions.
Lancet
1970; 1:1077–80.
4. 5.Llera
JL, Levy WH,
RC. Treatment
of cutaneous
abscess:
double-blind
clinicaltreatment
study. Ann
Med 1985;
14:15–9.
6. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in
5. Rutherford WH, Hart D, Calderwood JW, Merrett JD. Antibiotics in surgical treatment of septic lesions. Lancet 1970; 1:1077–80.
patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med 2010; 56:283–7.
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.
PAGE 23
Skin
Skinand
andSoft
SoftTissue:
Tissue:
Diabetic
Foot
Infections
Diabetic
Foot
Infections
SEVERITY OF INFECTION
Mild
• Only skin and
subcutaneous tissue
involvement
AND
• Erythema > 0.5 cm and
≤ 2 cm around ulcer
• Perform incision and
drainage as necessary
Moderate**
• Deeper tissue
involvement
OR
• Erythema > 2.0 cm
around ulcer
AND
• No systemic signs of
infection
• Perform incision and
drainage as necessary
SUSPECTED ORGANISMS
RECOMMENDED EMPIRICAL
TREATMENT
DURATION
MSSA
Streptococcus spp.
Oral
Amoxicillin/clavulanate 875 mg
PO Q12H
OR
Cephalexin 500 mg PO Q6H
OR
Dicloxacillin 250 – 500 mg PO
Q6H
MRSA
Doxycycline 100 mg PO Q12H
OR
SMX/TMP 2 DS tablets PO Q12H
(Does not cover Group A Strep)
Oral OR Initially Parenteral
1–3 weeks
Ampicillin-sulbactam 1.5–3 gm IV
Q6H
OR
Ceftriaxone 1 gm IV Q24H
MSSA
Streptococcus spp.
Enterobacteriaceae
Obligate anaerobes
1–2 weeks
Penicillin Allergy:
MRSA
Pseudomonas
aeruginosa
Ciprofloxacin 500 mg PO Q12H
AND
Clindamycin 300 mg PO Q6H
OR
Ceftriaxone 1 gm IV Q24H
Linezolid 600 mg IV/PO Q12H†
(Requires ID Consult)
OR
Daptomycin 6 mg/kg IV Q24H†
(Requires ID Consult)
OR
Vancomycin 15 mg/kg IV*
Piperacillin-tazobactam
3.375 gm IV Q4H
DS= Double Strength; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus;
PO= by mouth; Q= every; SMX-TMP= sulfamethoxazole/trimethoprim; spp= species
† Restricted Antibiotic – refer to Table of Contents for Guidelines for Restricted Antimicrobials
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
PAGE 24
Skin and Soft Tissue: Diabetic Foot Infections
Skin
Skinand
andSoft
SoftTissue:
Tissue:
Diabetic
Foot
Infections
Diabetic
Foot
Infections
R
E
SEVERITY OF INFECTION
SUSPECTED ORGANISMS
ECOMMENDED MPIRICAL
DURATION
TREATMENT
RECOMMENDED EMPIRICAL
SUSPECTED ORGANISMS Initially Parenteral
DURATION
MSSA/MRSA
TREATMENT
P. aeruginosa
Vancomycin
15
mg/kg
IV*
MSSA/MRSA
Initially Parenteral
Streptococcus spp.
AND**
P.
aeruginosa
2–4 weeks
Enterobacteriaceae
Vancomycin
15 IV
mg/kg
Cefepime 2 gm
Q8HIV*
+
Streptococcus
spp.
Obligate anaerobes
AND**
metronidazole 500 mg IV Q6H 2–4 weeks
Enterobacteriaceae
Cefepime
2 gm IV Q8H +
OR
Obligate anaerobes
metronidazole
500 mg IV Q6H
Piperacillin-tazobactam
OR
3.375 gm IV Q4H
Piperacillin-tazobactam
3.375 gm IV Q4H
Bone OR Joint Involvement‡
SevereS**EVERITY OF INFECTION
• Same
as moderate
**
Severe
AND
•• Same
as moderate
Systemic
signs of infection
AND
present
•
Systemic
signs
of infection
Systemic Inflammatory
presentSyndrome (SIRS)
Response
Systemic
Criteria ≥2Inflammatory
of the following:
Response Syndrome (SIRS)
• Temperature
Criteria
≥2 of the <96.8°F
following:
OR >100.4°F
•• Temperature
P > 90 BPM <96.8°F
SourceOR
removed:
2-5 days ‡
Joint Involvement
Bone
• OR
RR >>100.4°F
20 BPM
•• PPaCO
> 90 BPM
<
32
mmHg
Source
removed
but
2
removed: 2-5 residual
days tissue infection:
•• RR
> 20
BPM cells/mm³
WBC
< 4000
1-3 weeks
• PaCO
Source removed but residual tissue infection:
2 < 32 mmHg
OR >12,000
cells/mm³
Source
removed but residual bone infection:
•• WBC
4000 cells/mm³
1-3
weeks
≥ 10%< immature
(band)
4-6 weeks
>12,000 cells/mm³
OR
forms
Source removed but residual bone infection:
•• ≥Perform
10% immature
(band)
incision and
Source
not removed: ≥3 months
4-6
weeks
forms
drainage as necessary
• Perform incision and
Source not removed: ≥3 months
BPM= beats or breaths per minute; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin
drainage as necessary
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
Inflammatory
Syndrome;
spp=
species;
white blood
cellmethicillin resistant S. aureus; MSSA= methicillin
BPM=
beats orResponse
breaths per
minute; H=
hour(s);
IV=WBC=
intravenous;
MRSA=
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
†
Restricted
Antibiotic
–
refer
to
Table
of
Contents
for
Guidelines
for
Restricted Antimicrobials
Inflammatory Response Syndrome; spp= species; WBC= white blood cell
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
Consult Infectious
and
Podiatry
†**Restricted
AntibioticDiseases
– refer to
Table
of Contents for Guidelines for Restricted Antimicrobials
Discuss
Infectious
Podiatry,
and Vascular
*‡ Refer
toplan
Tablewith
of Contents
forDiseases,
section on
Vancomycin
Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE:
Dosing
based
on
normal
renal
function.
Refer
to
Table of Contents for section on Antimicrobial Dosing for Adult
‡ Discuss plan with Infectious Diseases, Podiatry, and Vascular
Patients Based on Renal Function
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
References:
1. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
References:
2.
insert].
York,
2015.EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
1. Flagyl
Lipsky[package
BA, Berendt
AR, New
Cornia
PB, NY:
Pile Pfizer;
JC, Peters
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
2. Flagyl [package insert]. New York, NY: Pfizer; 2015.
PAGE 25