Download I and D alone is sufficient for most small simple

ED: Initial Empiric Antimicrobials for Management of Skin and Soft-Tissue Infections
Condition
Preferred treatment options
Comments
Simple small abscess
I and D alone is sufficient for most
small simple abscesses
MRSA is commonly isolated from
purulent infections in ED patients
(e.g., carbuncles and furuncles).
Complicated skin abscess
Clindamycin 300-450 mg orally
every 6 hours
Consider antibiotics:
Skin abscess
Cover MRSA
OR
Trimethoprim/Sulfamethoxazole 12 double-strength (DS) tablets
(160mg/800mg) orally every 12
hours
OR
Doxycycline or minocycline 100 mg
orally every 12 hours
 Abscess located in a critical
anatomic location
 Surrounding cellulitis
 Large abscess
 Signs and symptoms of systemic
infection (e.g., fever)
 Comorbid conditions
Clindamycin has excellent antistaphylococcal activity, but there is
the potential for emergence of
inducible resistance to clindamycin if
erythromycin resistance is present.
Cellulitis – being discharged from ED
-hemolytic Streptococcus
Group A Streptococcus (S.
pyogenes)
Cephalexin 500 mg orally every 6
hours
Methicillin-sensitive
Staphylococcus aureus
(MSSA)
If severe β-lactam allergy:
Methicillin-resistant
Staphylococcus aureus
(MRSA)
Clindamycin 300-450 mg orally
every 6 hours
Most cases of MRSA
associated skin and soft
tissue infections require
incision and drainage of
furuncles, carbuncles, and
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Clindamycin 300-450 mg orally
every 6 hours
OR
Trimethoprim/Sulfamethoxazole 12 double-strength (DS) tablets
(160mg/800mg) orally every 12
hours
Most cases of cellulitis are caused by
Group A Streptococcus unless there is
a portal of entry such as furuncles,
carbuncles, abscesses or penetrating
trauma in which case S. aureus is more
common.
Clindamycin has excellent antistaphylococcal activity, but there is
the potential for emergence of
inducible resistance to clindamycin if
erythromycin resistance is present.
abscesses.
OR
Doxycycline or minocycline 100 mg
orally every 12 hours
Cellulitis – requiring IV therapy
-hemolytic Streptococcus
Cefazolin 1-2 g IV every 8 hours
Group A Streptococcus
OR
Methicillin-sensitive
Staphylococcus aureus
(MSSA)
Nafcillin 500 mg – 1 g IV every 4
hours
The current incidence of MRSA in
cellulitis is not known
Consider coverage for MRSA
If severe β-lactam allergy:
Consider drawing blood
cultures
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)

If there is purulence

With systemic toxicity

Critical anatomic location

Comorbidities or
immunocompromised host
OR
Clindamycin 600 – 900 mg IV every
8 hours
Methicillin-resistant
Staphylococcus aureus
(MRSA)
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)
Consider drawing blood
cultures
Necrotizing Skin and Soft Tissue Infections (e.g., Necrotizing fasciitis)
Community-acquired
Infections
Group A Streptococcus
(Streptococcus pyogenes)
remains the most common
organism
Gas gangrene can also be
associated with Clostridium
spp. especially in the
setting of penetrating
trauma
Please draw 2 sets of blood
cultures.
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Ampicillin-sulbactam 3 g IV every 6
hours
AND
Clindamycin 600 – 900 mg IV every
8 hours
If severe β-lactam allergy:
Levofloxacin 750 mg IV every 24
hours
AND
Clindamycin 600 – 900 mg IV every
8 hours
Surgical consultation recommended
for necrotizing skin and soft tissue
infections.
In patients with a history of alcoholism
and/or liver disease consider covering
Vibrio vulnificus infections especially in
the setting of recent water exposure
or shellfish consumption. Please call
infectious diseases consultation in
these cases.
MRSA is a rare cause of necrotizing
skin and soft tissue infections. In the
case of suspected MRSA infection
addition of Vancomycin is appropriate.
Mixed polymicrobial
infections
Risk factors:
immunocompromised,
recent surgical procedures,
diabetes, peripheral
vascular disease, and
spontaneous mucosal tears
of the gastrointestinal or
genitourinary tract (i.e.,
Fournier’s gangrene)
Please draw 2 sets of blood
cultures
Piperacillin-tazobactam 3.375 g IV
every 6 hours
Surgical consultation recommended.
OR
Imipenem-cilastatin 500 mg IV
every 6 hours
AND
Clindamycin 600 - 900 mg IV every
8 hours
AND
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)
If severe β-lactam allergy :
Levofloxacin 750 mg IV every 24
hours
AND
Clindamycin 600 - 900 mg IV every
8 hours
AND
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)
Animal and Human Bites
Outpatient - (being
discharged from ED)
Amoxicillin-clavulanate 875/125 mg
orally every 12 hours
Pasteurella species are isolated from
50% of dog bite wounds and 75% of
cat bite wounds.
If severe β-lactam allergy:
Doxycycline 100 mg every 12 hours
OR
Levofloxacin 500 mg orally every 24
hours or Ciprofloxacin 500 mg
orally every 12 hours
AND
Clindamycin 300-450 mg orally
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Human bites reflect oral flora of the
biter and tend to be more serious:
Streptococcus viridans, Eikenella
corrodens, Fusobacterium species,
Peptostreptococcus, and Prevotella.
For bites involving hand and wrist
please call covering hand surgical
service for assessment.
Please offer tetanus vaccination.
every 6 hours
Being admitted and
requiring IV therapy
Ampicillin-sulbactam 3 g IV every 6
hours
Consider drawing blood
cultures
If severe β-lactam allergy:
Please offer tetanus vaccination.
Levofloxacin 750 mg IV every 24
hours
AND
Clindamycin 600 - 900 mg IV every
8 hours
Diabetic Foot Infections
Uninfected Ulcerations
Avoid prescribing antibiotics
Wound lacking purulence
or any manifestations of
inflammation
Cellulitis without
ulceration
Please see above
recommendations for cellulitis
Ulceration with
surrounding skin and soft
tissue infection not
requiring admission
Cephalexin 500 mg orally every 6
hours for 7-14 days
Evidence does not support the use of
antibiotics for the management of
clinically uninfected ulcerations, either
to enhance wound healing or as
prophylaxis against infection.
OR
Amoxicillin-clavulanate 875/125 mg
orally every 12 hours for 7-14 days
If β-lactam allergy:
Trimethoprim/Sulfamethoxazole 2
double-strength (DS) tablets
(160mg/800mg) orally every 12
hours for 7-14 days
OR
Levofloxacin 750 mg orally every
24 hours for 7-14 days
Being admitted for
intravenous therapy
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Ampicillin-sulbactam 3 g IV every 6
hours
Low threshold to provide coverage for
MRSA
OR
Please draw 2 sets of blood
cultures
Piperacillin-tazobactam 3.375 g IV
every 6 hours
Use previous culture data to choose
empiric antibiotics (e.g., if patient has
a history of ESBL E. coli or K.
pneumoniae infections, consider
Ertapenem 1 g every 24 hours)
If severe β-lactam allergy:
Severe: Necrotizing
infection or gangrenous
Please draw 2 sets of blood
cultures
Levofloxacin 750 mg IV every 24
hours
AND
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)
Piperacillin-tazobactam 3.375 g IV
every 6 hours
OR
Imipenem-cilastatin 500 mg IV
every 6 hours
Seek surgical consultation.
AND
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)
If severe β-lactam allergy:
1.
2.
3.
4.
5.
6.
7.
8.
Levofloxacin 750 mg IV every 24
hours
AND
Metronidazole 500 mg IV every 8
hours
AND
Vancomycin 15 mg/kg IV every 12
hours (rounded to nearest 250 mg)
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Clin Infect Dis. 2004; 39: 885-910
N Engl J Med. 2007; 357: 380-390
Am Fam Physician. 2008; 78:71-82
NEJM 2006; 355: 666-674
www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_expmtgstrategies.pdf
Inf Dis Clinics NA. 2008; 1:89-116
Emerg Med Clinics NA. 2008; 26:431-455
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