Download Skin and Soft Tissue Infections (SSTI) in the Emergency Department

Care Process Model
FE B RUA RY
2014
ASSESSMENT A ND TR E ATMENT OF
Skin and Soft Tissue Infections (SSTI) in
the Emergency Department
This CPM was created by the ED Development Team within the Intensive Medicine Clinical Program at Intermountain Healthcare.
It guides treatment of adult patients with abscess or cellulitis presenting to emergency departments. See pages 2–3 for algorithm notes
on treatment of specific conditions. See page 4 for common pathogens, antibiograms, and antibiotic adjustments.
Signs/Symptoms of Abscess and/or Cellulitis
EVALUATE for complicating factors
infection: WBC >12,000 or <4,000
cells/mm3; temp >38.3°C or <36°C;
heart rate >90 bpm; respiratory rate >20 bpm
……Systemic
……Immunosuppression
……End-stage
……Diabetes
……Elderly
organ failure
(>65 years old)
surrounding cellulitis
SIMPLE CELLULITIS
lesions
……Water
exposure
……History
of trauma, purulent cellulitis, recurrent
MRSA infection, MRSA in the family
response to treatment after 48 hours
2 or more factors
yes
SIMPLE ABSCESS
(Painful, tender, fluctuant
red nodules)
Extending cellulitis?
no
Treat simple
cellulitis (a) as per
order sheet*
……Multiple
COMPLICATED cutaneous abscess
and/or cellulitis (b,c)
Purulent lesion or
concern for abscess?
(No evidence of abscess,
bites, water exposure,
diabetic foot ulcer, or
recent surgery)
>5 cm in diameter
……No
0–1 factors
no
difficult to drain (face, genitals)
……Abscess
……Bites
(excluding foot infections/abscess)
……Extensive
……Abscess
Treat abscess as
per order sheet*
yes
Treat abscess +
cellulitis (a) as
per order sheet*
Observation or follow-up
•• If 1 complicating factor listed above, close observation for
clinical decline (inpatient or outpatient)
•• If NO complicating factors, 48-hour follow-up with ED or PCP
If no improvement, start antibiotics based on risk (a) or treat based
on gram-negative pathogen risk if antibiotic therapy has failed (d)
* The ED Skin and Soft Tissue Order Sheet covers simple
cellulitis, simple abscess, abscess + cellulitis, and complicated
cellulitis. Special circumstances: For facial cellulitis,
see CPM page 3, note (g). For bites, see note (h).
EVALUATE need for hospitalization
Severe SSTI with one or more of the following:
……Failed outpatient therapy (>48 hours) and patient requires
hospital support (d)
……Severe SSTI in immunocompromised patients (transplant patients,
diabetes, chemotherapy, end-stage organ dysfunction, etc.) (e)
……Concerns for necrotizing fascitis (consider CT, surgical consult) (f)
……Sepsis not responding to fluids (See Sepsis Bundle)
……Septic shock (See Sepsis Bundle)
ANY of
the above
Hospital admission
•• Consider blood culture
at admission
•• Consider abscess culture
before antibiotics
•• Treat based on condition:
see notes (b), (d), (e), (f),
or Sepsis Bundle
NONE of
the above
ED or infusion center
Daily PO/IV antibiotics in ED
or infusion center based on
condition as per order sheet* (c)
SKIN & SOFT TISSUE INFEC TIONS IN THE ED
FEB RUA RY 2 014
ALGORITHM NOTES: SKIN & SOFT TISSUE INFECTIONS (SSTI)
(a) Antibiotics for simple cellulitis (See order sheet for other treatment details)
CELLULITIS WITH MRSA RISK FACTORS
CELLULITIS, NO MRSA RISK
Oral antibiotics:
•• Cephalexin: 500 mg, 4 times a day* plus
TMP/SMX DS: 2 tabs, twice a day*
•• Cephalexin: 500 mg, 4 times a day* plus
Doxycycline: 100 mg, twice a day
•• Clindamycin: 300–450 mg, 4 times a day
Oral antibiotics:
•• Cephalexin: 500 mg, 4 times a day*
•• Dicloxacillin: 250 mg, 4 times a day
ABSCESS + CELLULITIS
Oral antibiotics:
•• TMP/SMX DS: 2 tabs, twice a day*
•• Doxycycline: 100 mg, twice a day
•• Clindamycin: 300–450 mg, 4 times a day
For added strep coverage for patients on
TMP/SMX or doxycycline:
•• Cephalexin: 500 mg, 4 times a day*
* See page 4 for dose adjustments based on renal function.
(b) Hospital admission: complicated cellulitis
and/or abscess
•• If NON-sepsis or ICU admit:
–– Vancomycin: 15–20 mg/kg IV, one dose†,‡
–– Clindamycin: 600 mg IV, one dose†
–– Plus, if gram-negative coverage needed,
Ceftriaxone: 1–2 g IV, once a day
•• If sepsis or ICU admit:
–– Vancomycin: 25 mg/kg IV, one dose†,‡
plus piperacillin-tazobactam: 3.375 g IV, one dose†
or meropenem: 1 g IV, one dose†
† One ED dose; additional inpatient doses determined by hospitalist.
‡ Consult clinical pharmacist if patient is renally compromised.
(c) ED or infusion center treatment: complicated
cellulitis and/or abscess
•• If patient can be treated with oral antibiotics only, one of
the following (7–10 days):
–– Cephalexin: 500 mg, 4 times a day*
plus TMP/SMX DS: 2 tabs, twice a day*
–– Cephalexin: 500 mg, 4 times a day*
plus Doxycycline: 100 mg, twice a day
–– Clindamycin: 300–450 mg, 4 times a day
•• If IV therapy is necessary:
–– Social work consult for infusion therapy x 48 hours
–– Vancomycin: 15 mg/kg, one dose (additional doses based on CrCl)‡
–– Ceftriaxone: 1–2 g IV, once a day
plus TMP/SMX DS: 2 tabs oral, twice a day*
or Doxycycline: 100 mg oral, twice a day
–– Cefazolin: 1 g IV, once a day
plus Probenecid: 1 g oral, once a day (for GFR>60)
plus TMP/SMX DS: 2 tabs oral, twice a day*
or Doxycycline: 100 mg oral, twice a day
–– Consider skin and soft tissue ultrasound
* See page 4 for dose adjustments based on renal function.
‡ Consult clinical pharmacist if patient is renally compromised.
RENAL DYSFUNCTION AND ANTIBIOTICS
Before antibiotic administration for patients with renal
failure or GFR <60, always consult a clinical pharmacist
for renal adjustment.
2 (d) Failed therapy or severely ill patient (May require
drainage, IV, or agent with better penetration)
RISK
TREATMENT
NO gram-negative
pathogen risk:
Patient has NO gramnegative pathogen risk
factors (see list of risk
factors below)
•• Treat MSSA/Strep with IV antibiotics:
–– Cefazolin: 1–2 g IV every 8 hours‡
–– Nafcillin: 1–2 g IV every 4 hours
–– Ceftriaxone: 1–2 g IV, every 24 hours
–– Clindamycin: 600 mg IV, every 8 hours
•• Treat MRSA with IV antibiotics:
–– Vancomycin (preferred): 15–20 mg/kg IV every
8 to 48 hours, based on renal function‡
–– Daptomycin: 4–8 mg/kg IV daily (nonformulary)‡
–– Linezolid: 600 mg IV, every 12 hours
Gram-negative
•• Add IV ceftriaxone to MSSA/strep or MRSA
treatment described above:
pathogen risk:
•• Neutropenia
–– Ceftriaxone: 2 g IV every 24 hrs to
gram-negative coverage
•• HIV or severe
immunocompromise
•• Burns
•• Infection after trauma in
aquatic environment
•• Infection after skin graft
‡ Consult clinical pharmacist if patient is renally compromised.
(e) Immunocompromised patient
•• CONSIDER CONSULT w/ infectious disease, transplant, or oncology
•• TREAT with one of the following, in order of preference:
–– Vancomycin (strongly preferred): 15–20 mg/kg IV, one dose†
–– Daptomycin: 4–8 mg/kg IV (nonformulary), one dose†
–– Linezolid: 600 mg IV, one dose†
PLUS one of the following:
–– Piperacillin-tazobactam: 4.5 g IV,† or extended interval infusion protocol
–– Meropenem: 1 g IV, one dose†
–– Imipenem: 500–1000 mg IV, one dose†
–– Cefepime: 2 g IV, one dose†
•• CONSIDER COVERAGE for MRSA and resistant gram-negative bacteria
such as Pseudomonas aeruginosa; patients may also require antifungal or
antiviral medications. Immunocompromised patients can be infected with
common or unusual pathogens.
† One ED dose; additional doses for inpatients based on creatinine clearance
for all meds (except linezolid, which is given every 12 hours).
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
FEB RUA RY 2 014
SKIN & SOFT TISSUE INFEC TIONS IN THE ED
ALGORITHM NOTES, CONTINUED
(f) Necrotizing fasciitis
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
•• Severe, constant pain
•• Evaluate for clinical features at left
•• Bullae, related to occlusion of deep
blood vessels that traverse the fascia
or muscle compartments
•• Also consider anaerobic streptococcal
myositis, pyomyositis, Fournier's gangrene,
clostridial myonecrosis
•• Surgical intervention plus antibiotic therapy
•• Consult surgery and infectious disease
•• Skin necrosis
•• Perform CT/MRI if feasible
•• Gas in the soft tissue
•• Most common pathogens:
S. pyogenes, S. aureus, V. vulnificus,
A. hydrophila, Peptostreptococcus spp.
•• Edema that extends beyond the margin
of erythema
•• Systemic toxicity
•• Rapid spread while on antibiotic therapy
•• Cutaneous anesthesia
•• Wooden-hard feel of subcutaneous tissue
•• Obtain blood culture before starting IV antibiotics:
One of these:
–– Vancomycin (preferred): 15–20 mg/kg IV, one dose†,‡
–– Daptomycin: 4–8 mg/kg IV, one dose†,‡
–– Linezolid: 600 mg IV, one dose†
PLUS one of these:
–– Piperacillin-tazobactam: 3.375 g IV, one dose†
–– Imipenem-cilastatin: 1 g IV, one dose†
–– Meropenem: 1 g IV, one dose†
–– Ertapenem: 1 g IV, one dose†
PLUS Clindamycin: 600–900 mg IV, one dose†
† One dose in the ED; additional inpatient doses determined by hospitalist.
‡ Consult clinical pharmacist if patient is renally compromised.
(g) Facial cellulitis
LOCATION
PATHOGENS
TREATMENT
Preseptal
Infection of the anterior part
of the eyelid
Common: S. aureus, S. pneumoniae,
Streptococcus spp., anaerobes
•• Oral antibiotics (7–10 days) — one of these, in preferred order:
–– TMP-SMX: 160 mg/800 mg, twice a day,* PLUS Cephalexin: 500 mg, 4 times a day*
–– Clindamycin: 300 mg, 3 times a day
Common: S. aureus, S. pyogenes,
Postseptal
Infection of the contents of the S. pneumoniae, S. intermedius
orbit (fat and ocular muscle)
Uncommon: H. influenza, A.
hydrophila, E. corrodens, anaerobes,
Mucorales, Aspergillus spp.
•• Consult ENT and ophthalmology
•• IV antibiotics:
One of these, in preferred order:
–– Vancomycin (strongly preferred): 15–20 mg/kg IV, one dose †
–– Daptomycin: 4–8 mg/kg IV, one dose †
–– Linezolid: 600 mg IV, one dose†
PLUS one of these:
–– Ceftriaxone: 2 g IV, one dose†
–– Cefotaxime: 2 g IV, one dose†
–– Ampicillin-sulbactam: 3 g IV, one dose†
–– Piperacillin-tazobactam: 4.5 g IV, one dose†, or extended interval infusion
protocol (7–10 days)
* See page 4 for oral antibiotic dose adjustments based on renal function.
† One ED dose; additional inpatient doses determined by hospitalist. For vancomycin and daptomycin, consult clinical pharmacist if patient is renally compromised.
(h) Bite infections
WHEN TO TREAT
Animal bites — Antibiotics indicated for:
•• Deep punctures/wounds needing
surgical repair
•• Moderate or severe wounds associated with
crushing injury
•• Wounds in areas of underlying venous and/or
lymphatic compromise
•• Infected wounds
•• Immunocompromised patients
ANTIBIOTIC AGENTS
OTHER
•• ORAL antibiotics (5–10 days), in order of preference:
–– Amoxicillin/clavulanate: 500–875 mg, twice a day
–– Doxycycline: 100 mg, twice a day
–– TMP-SMX: 160–800 mg, twice a day* +/metronidazole: 250–500 mg, 4 times a day
–– Ciprofloxacin: 500–750 mg, twice a day
Animal bites:
•• IV antibiotics, in order of preference:
–– Ampicillin-sulbactam: 1.5–3 g IV, every 6–8 hours
–– Cefoxitin (animal bites only): 1 g IV, every 6–8 hours
–– Piperacillin-tazobactam: 3.375 g IV, every 6–8 hours
or extended interval infusion protocol
–– Carbapenem: ertapenem, imipenem, meropenem
Human bites — Antibiotics for ALL bites
requiring irrigation or topical wound cleansing
•• Consider rabies series if animal cannot
be located
•• Give Tdap if tetanus is not up to date
Human bites: Evaluate for HIV,
Hepatitis B, Hepatitis C risk
* See page 4 for oral antibiotic dose adjustments based on renal function.
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED.
3
SKIN & SOFT TISSUE INFEC TIONS IN THE ED
REFERENCES
The following references informed this CPM
and the accompanying order sheet.
GUIDELINES:
• Liu C, Bayer A, Cosgrove SE, Daum RS, et
al; Infectious Diseases Society of America.
Clinical practice guidelines by the Infectious
Diseases Society of America for the treatment
of methicillin-resistant Staphylococcus aureus
infections in adults and children. Clin Infect
Dis. 2011;52(3):e18-55.
• Stevens DL, Bisno AL, Chambers HF,
et al; Infectious Diseases Society of
America. Practice guidelines for the
diagnosis and management of skin and
soft-tissue infections. Clin Infect Dis.
2005;41(10):1373-1406.
OTHER REFERENCES:
• Corey GR, Wilcox MH, Talbot GH, Thye
D, Friedland D, Baculik T; CANVAS 1
investigators. CANVAS 1: the first Phase III,
randomized, double-blind study evaluating
ceftaroline fosamil for the treatment
of patients with complicated skin and
skin structure infections. J Antimicrob
Chemother. 2010;65 Suppl 4:iv41-51.
• Cox VC, Zed PJ. Once-daily cefazolin
and probenecid for skin and soft
tissue infections. Ann Pharmacother.
2004;38(3):458-463.
• Grayson ML, McDonald M, Gibson K,
Athan E, Munckhof WJ, Paull P, Chambers
F. Once-daily intravenous cefazolin plus
oral probenecid is equivalent to oncedaily intravenous ceftriaxone plus oral
placebo for the treatment of moderate-tosevere cellulitis in adults. Clin Infect Dis.
2002;34(11):1440-1448.
• Intermountain Healthcare Biogram Tool
available on Intermountain’s GermWatch
site at https://physician.intermountain.
net/gw. Accessed November 6, 2013.
• Micromedex 2.0 database (multiple
medication pages). Accessed November
6, 2013.
• Wilcox MH, Corey GR, Talbot GH, Thye
D, Friedland D, Baculik T; CANVAS 2
investigators. CANVAS 2: the second
Phase III, randomized, double-blind study
evaluating ceftaroline fosamil for the
treatment of patients with complicated skin
and skin structure infections. J Antimicrob
Chemother. 2010;65 Suppl 4:iv53-iv65.
4
FEB RUA RY 2 014
PATHOGENS AND ANTIBIOTICS
Common pathogens
• Erysipelas: Most commonly caused by Group A ß-hemolytic streptococci, but
can be caused by Group C and G. Rarely caused by Group B streptococci or
Staphylococcus aureus.
• Cellulitis: Most commonly caused by Group A streptococci and other
ß-hemolytic Streptococci. Staphylococcus aureus is most common with previous
penetrating trauma or IV drug abuse. Other pathogens can be found in animal
bites and immunocompromised patients. For specific pathogens associated with
facial cellulitis, see note (g) on the previous page.
Antibiograms
Antibiograms for each Intermountain region are
available on the Antibiograms page within the
GermWatch site. Antibiograms for 2011 and 2012
are available for each region.
If you’re logged in and within the Intermountain firewall, you can also access an
antibiogram tool with up-to-date information via the link on the page — or by
simply typing antibiogram in the address bar of your browser. The tool provides
custom antibiogram reports for pathogen, patient type, infection type, facility,
and/or service for any given time period.
For example, the antibiogram tool shows the following susceptibilities for
methicillin-resistant Staphylococcus aureus (MRSA) in adult patients with
abscess at IMED from Jan–Oct, 2013 (a few example meds):
• Daptomycin, TMP/SMX, vancomycin, or linezolid: 100%
• Tetracycline: 96%
• Clindamycin: 89%
• Ceftriaxone: 63%
• Erythromycin: 39%
Antibiotic adjustments for renal function
• Cephalexin: CrCl 10–50 mL/min, usual dose every 12 hours
• Clindamycin: No adjustments necessary
• Daptomycin: CrCl <30 mL/min, 4 mg/kg IV every 48 hours
• Dicloxacillin: No adjustments necessary
• Doxycycline: No adjustments necessary
• Linezolid: No adjustments necessary
• Minocycline: No adjustments necessary
• TMP/SMX: CrCl 15-30 mL/min, 50% of recommended dose, 2 times a day
• Vancomycin: Adjust IV interval; consult clinical pharmacist
This CPM presents a model of best care based on the best available scientific evidence at the time
of publication. It is not a prescription for every physician or every patient, nor does it replace clinical
judgment. All statements, protocols, and recommendations herein are viewed as transitory and
iterative. Although physicians are encouraged to follow the CPM to help focus on and measure quality,
deviations are a means for discovering improvements in patient care and expanding the knowledge
base. Send feedback to Joseph Bledsoe, MD, Director of Research, Department of Emergency
Medicine, Intermountain Medical Center ([email protected]).
©2014 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. Patient and Provider Publications 801-442-2963 CPM072 - 02/14