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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