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Skin and
Soft-Tissue
Infections

Consultant:
Oenms L. Stevens. MD, PhD
VA Med. Center
Boise, ID

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­+ Recently there has been a dramatic increase in the frequency and
severity of skin and soft­tissue infections (SSTls) accompanied by
the emergence of resistance to many of the antimicrobial agents
commonly used to treat skin and soft­tissue infections in the past.
• There was a 29% increase in the total hospital admissions for these infections
between 2000 and 2004.
• 6.3 million physician's office visits per year are attributable to $$Tis.
• Between 1993 and 2005, annual emergency department visits for SSTls increased
from 1.2 million to 3.4 million patients.
.,. Some of this increased frequency is relared to the cmcr:gencc of communiry
associated merhicillin-rcsistanr S. aureus {lv!RSA).
­+ Clinical evaluation of patients with SSTI aims to establish the cause
and severity of infection and must take into account pathogen­specific
and local antibiotic resistance patterns.
­+ When developing an adequate differential diagnosis and an
appropriate index of suspicion for specific etiological agents it is
essential to obtain a careful history that includes information about
the patient's immune status, geographical locale, travel history, recent
trauma or surgery, previous antimicrobial therapy, lifestyle, hobbies,
and animal exposure or bites.
­+ Recognition of the physical examination findings and understanding
the anatomical relationships of skin and soft tissue are crucial for
establishing the correct diagnosis.
Impetigo and Ecthyma
­+ Gram stain and culture of the pus or exudates from skin lesions of
impetigo and ecthyma are recommended to help identify whether
Staphylococcus aureus and/or a �­hemolytic streptococcus is the
cause (SR·M), but treatment without these studies is reasonable in
typical cases (SR­M).
­+ Bullous and nonbullous impetigo can be treated with oral or topical
antimicrobials, but oral therapy is recommended for patients with
numerous lesions or in outbreaks affecting several people to help
decrease transmission of infection. Treatment for ecthyma should be
an oral antimicrobial.
• Treatment ofbullous and nonbullous impetigo should be with tither mupirocin or
rerapamulin hid for 5 days (SR-I I).
• Oral therapy for ecthyma or impetigo should be a 7-day regimen with an
agent active against S. aureus unless cuhures yield streptococci alone (when
oral penicillin is the recommended agent) (SR-H). Because S, aureus isolates
from impetigo and ecrhyma are usually merhicillin-susceprible, dicloxacillln or
cephalexin is recommended. \'(!hen MRSA is suspected or confirmed, doxycycline,
clindamycin, or sulfamethoxazole-rrlmethoprim {Sl\1X-TMP) is recommended
(SR-,\().
• Systemic anrlmicrobials should be used for infections during outbreaks of
post-streptococcal glomerulonephritis to help eliminate nephritogenic strains
of Streptococcus pyogenes from the community {SR-l\·1)

­+ When information from history and physical are insufficient, biopsy or

aspiration of tissue may be necessary, and radiographic procedures
may be critical to determine the level of infection and the presence of
gas, abscess or a necrotizing process.
­+ Surgicalexploration or debridement is an important diagnostic as well
as therapeutic procedure in patients with necrotizing infections or
myonecrosis.

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Figure 1. Management of SSTI Infections Purulent SS Tis (cutaneous abscesses, furuncles, carbuncles, and
inflamed cpidermoid cysts) (Figure 1)
NONPURULENT ­+ Gram stain and culture of
pus from carbuncles and abscesses are
Ncc,otizing Infection/
Cellu liris/Erysipelas recommended, but treatment without these studies is reasonable in
typical cases (SR­M).
­+ Gram stain and culture of pus from inflamed epidermoid cysts are NOT
MODERATE
recommended (SR­M).
­+ Incision and drainage is the recommended treatment for inflamed
epidermoid cysts, carbuncles, abscesses and large furuncles
• Emergent Surgical Intravenous Rx Oral Rx
(See Fig. 1/Purulent/MILD) (SR­H).
Iuspeceion/Debridemenr • Penicillin or • Penicillin VK or
,. Rule out necrotizing
process
• Ceferiaxone or • Cephalosporin or ­+ The decision to administer antibiotics directed against S. aureus as an
• Ccfazolin or • Dicloxacillin 01·
adjunct to incision and drainage should be made based on the presence
• Empiric Rx • Clindamycm • Clindamycin
• Vancomycin PLUS or absence of systemic inflammatory response syndrome (SIRS) such as
Piperacillin/Tazobacram temperature >38°C or <36°C, tachypnea >24 breaths/min, tachycardia
>90 beats/min or white blood cell count (WBC) >12,000 or <400
PURULENT cells/mm' (See Fig. 1/Purulent/MODERATE) (SR­L). An antibiotic
Furuncle/Carbuncle/Abscess active against MRSA is recommended for patients with carbuncles or
abscesses who have failed initial antibiotic treatment, have markedly
impaired host defenses, or in patients with SIRS and hypotension (See
Defined Rx
MODERATE Fig. 1/Purulent/SEVERE and Table 1) (SR­L). Tedizolid and dalbavancin
(Necrorizing Infections)
are also effective treatments of SSTI including those caused by MRSA
Monomicroblal"
• Streptococcus pJ•oge11es l&D l&D and were approved by the FDA after publication of the 2014 guideline.
l&D
• Penicillin PLUS C&S C&S
Ctindamycin Recurrent Skin Abscesses
• Clostridial sp.
• Penicillin PLUS ­+ A recurrent abscess at a site ofprevious infection should prompt
Clindamycin .. Rx"
E mp11·1c _ a search for local causes such as a pilonidal cyst, hidradenitis
• Vibrio vulnifltus .. Vancomycin o,· Empiric Rx suppurativa or foreign material (SR­M).
• Doxycycline PLUS • Daptomycin or
• SMX/Tlv(P or
Ccfrazidimc .- Linczolid or • Doxycycline ­+ Recurrent abscesses should be drained and cultured early in the
Aeromo11as lrydrophilia '"" Telavancin or course of infection (SR­M).
• Doxycycline PLUS • Cefearoline
Ciprofloxacin ­+ After obtaining cultures of recurrent abscess, treat with a 5­ to 10­day
Polymicrobial' course of an antibiotic active against the pathogen isolated (WR­L).
Defined Rx Defined Rx
• Vancomycin PLUS
Piperacillin/ MRSA MRSA ­+ Consider a 5­day decolonization regimen of intranasal mupirocin bid,
Tazobacrarn • Sec Empiric • SMX/Ti\<IP daily chlorhexidine washes, and daily decontamination of personal
l\'ISSA MSSA items such as towels, sheets, and clothes for recurrent S. aureus
• Nafcillin or • Dicloxacillin or infection (WR­l).
• Cefazolin or • Cephalcxin
• Clindamycin ­+ Adult patients should be evaluated for neutrophil disorders if recurrent
abscesses began in early childhood (SR­M).
me
'Tedi:wlid and dalbavancin (approved after publication of 2014 guideline:) are also effecrive
treatments ofSSTI including ehose caused by MRSA.
bSincc dapcomycin and telavancin are not approved for use in children_, vancomydn is
recommended. Clindamycin may be used ifclindamycin mis-ranee is< 10%� 15% at the insnrueion,

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Erysipelas and Cellulitis Anti­inflammatory Agents for Cellulitis

­+ Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT ­+ Systemic corticosteroids (eg, prednisone 40 mg daily for 7 days) could
routinely recommended (SR·M). be considered in nondiabetic adult patients with cellulitis (WR­M).
­+ Cultures of blood are recommended (SR­M), and cultures and Recurrent Cellulitis
microscopic examination of cutaneous aspirates, biopsies, or swabs
should be considered in patients with malignancy on chemotherapy, ­+ Identify and treat predisposing conditions such as edema, obesity,
neutropenia, severe cell­mediated immunodeficiency, immersion eczema, venous insufficiency, and toe web abnormalities (SR·M).
injuries, and animal bites (WR·M). These practices should be performed as part of routine patient care
and certainly during the acute stage of cellulitis (SR·M).
­+ Typical cases of cellulitis without systemic signs of infection should
receive an antimicrobial agent that is active against streptococci ­+ Administration of prophylactic antibiotics, such as oral penicillin
(See Fig. 1/Nonpurulent/MILD) (SR­M). For cellulitis with systemic or erythromycin bid for 4­52 weeks, or intramuscular benzathine
signs of infection (See Fig. 1/Nonpurulent/MODERATE) systemic penicillin every 2­4 weeks should be considered in patients who have
antibiotics are indicated. Many clinicians could include coverage 3­4 episodes of cellulitis per year despite attempts to treat or control
against methicillin­susceptible S. aureus (MSSA) (WR­L). For patients predisposing factors (WR·M). This program should be continued so
whose cellulitis is associated with penetrating trauma, evidence of long as the predisposing factors persist (SR­M).
MRSA infection elsewhere, nasal colonization with MRSA, injection
drug use, or SIRS (See Fig. 1/Nonpurulent/SEVERE), vancomycin or
another antimicrobial effective against both MRSA and streptococci
is recommended (SR­M). In severely compromised patients as
defined above (See Fig. 1/Nonpurulent/SEVERE) broad­spectrum
antimicrobial coverage may be considered (WR­M). Vancomycin
plus either piperacillin­tazobactam or imipenem/meropenem is
recommended as a reasonable empiric regimen for severe infections
(SR­M).
­+ The recommended duration of antimicrobial therapy is 5 days, but
treatment should be extended if the infection has not improved within
this time period (SR­H).
­+ Elevation of the affected area and treatment of predisposing factors,
such as edema or underlying cutaneous disorders, are recommended
(SR·M).
­+ In lower extremity cellulitis, clinicians should carefully examine
the interdigital toe spaces because treating fissuring, scaling, or
maceration may eradicate colonization with pathogens and reduce the
incidence of recurrent infection (SR·M).
­+ Outpatient therapy is recommended for patients who do not have
SIRS, altered mental status, or hemodynamic instability (See Fig. 1/
Nonpurulent/MILD) (SR·M). Hospitalization is recommended if there
is concern for a deeper or necrotizing infection, for patients with poor
adherence to therapy, for infection in a severely immunocompromised
patient or if outpatient treatment is failing (See Fig. 1/Nonpurulent/
MODERATE or SEVERE) (SR·M).

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Figure 2. Wound Infection Algorithm Surgical Site Infections

T , -+ Suture removal plus incision and drainage should be performed for
1L
I\
Operation I surgical site infections (SR·L).
I ::i
-+ Adjunctive systemic antimicrobial therapy is NOT routinely indicated
Fever in ftrsc 48 hours Fever >4 days after but in conjunction with incision and drainage may be beneficial for
(and up to 4 days) operation surgical site infections associated with a significant systemic response
(See Figure 2) such as erythema and induration extending >5 cm from
E ::i

Unlikely to represent
wound infection
Erythema
and/or
induration
..-'':i
"'
\Vound
normal ro
exan,
the wound edge, temperature >38.5°C, heart rate >110/min, or WBC
count >12,000/mm3 (WR­L).
-+ A brief course of systemic antimicrobial therapy is indicated in
patients with surgical site infections after clean operations on the

,
II
E ::i :II I , E
trunk, head and neck, or extremities that also have systemic signs of
infection (SR­L).
No systemic Systemic Open wound
Seek ocher -+ A first­generation cephalosporin or an anti­staphylococcal penicillin
illness illness sources of fc\•cr for MSSA or vancomycin, linezolid, daptomycin, telavancin or
II ceftaroline where risk factors for MRSA are high (nasal colonization,
�1:i .11:i
No wound
• ::i �
prior MRSA infection, recent hospitalization, recent antibiotics) is
recommended (SR­L).
\Vound drainage or • Temp >38°C
infecnon • Temp <38°C
,...., marked local signs
• \VBC < 12,000
• \VBC > 12,000 -+ Agents active against Gram­negative bacteria and anaerobes, such as
of inflammation • Eryrhema > 5 cm a cephalosporin or fluoroquinolone in combination with metronidazole,
• Eryrhema < 5 cm
Observe I from incision
are recommended for infections after operations on the axilla,
.
with induration

"
gastrointestinal (GI) tract, perineum or female genital tract (SR­L).
. •... IC'':ll
or any necrosis
0
Dressing
Necrotizing F'asciitis, Including F'ournier's Gangrene
Gram stain to rule Seek other Begin antibiotics
our streptococci and resources of changes, no and dressing -+ Prompt surgical consultation is recommended for patients with
closrridia fever antibiotics
changes aggressive infections associated with signs of systemic toxicity
II
.. .JI or suspicion of necrotizing fasciitis or gas gangrene (See Fig. 1/
Nonpurulent/SEVERE) (SR­L) .
� � t) i\ -+ Empiric antibiotic treatment should be broad (eg, vancomycin or
Seek ocher Open wound, Clean. wound,
Wound of perineum linezolid plus piperacillin­tazobactam or plus a carbapenem; or plus
sources of debride, scare or operation on GI
trunk, head, ceftriaxone and metronidazole), since the etiology can be polymicrobial
fever penicillin and neck, extremity
tract or female genital
dindamycin tract (mixed aerobic­anaerobic microbes) or monomicrobial (Group A
(''!I t''l streptococcus, community­acquired MRSA [CA­MRSA)) (SR·L).

Scarr cefazolin or Scare -+ Penicillin plus clindamycin is recommended for treatment of

vancornycin' until cephalosporin+merronidazole documented Group A streptococcal necrotizing fasciitis (SR­L).
l'vfRSA ruled out or
lcvofloxacin+mcrronidazolc
or carbapenem­
'For patients with type I (anaphyl:uis or hives) allergy to �­lactam amibiotics. lfGram stain
not available, open and de bride if purulent drainage present. \Y/herc the rate of infection with
MRSA 1$ . high.
. consider
. . . . or linezoltd.
. dapromyctn,
vancomycm,
. . . pending .
. results of culture '
and .
suscepcibiliry tests,
Ada red and modified with ermission from Dellin er EP.

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Pyomyositis
­+ Magnetic resonance imaging (MRI) is the recommended imaging
modality for establishing the diagnosis of pyomyositis. Computed
tomography (CT) scan and ultrasound studies are also useful (SR·M).
­+ Cultures of blood and abscess material should be obtained (SR·M).
­+ Vancomycin is recommended for initial empiric therapy. An agent
active against enteric Gram­negative bacilli should be added for
infection in immunocompromised patients or after open trauma
to the muscles (SR­M).
­+ Cefazolin or antistaphylococcal penicillin (eg, nafcillin or oxacillin) is
recommended for treatment of pyomyositis caused by MSSA (SR­M).
­+ Early drainage of purulent material should be performed (SR·H).
­+ Repeat imaging studies should be performed in patients with
persistent bacteremia to identify undrained foci of infection (SR­L).
­+ Antibiotics should be administered intravenously initially, but once
the patient is clinically improved oral antibiotics are appropriate
for patients in whom bacteremia cleared promptly and there is no
evidence of endocarditis or metastatic abscess. Two to three weeks of
therapy is recommended (SR­L).
Clostridial Gas Gangrene or Myonecrosis
­+ Urgent surgical exploration of the suspected gas gangrene site and
surgical debridement of involved tissue should be performed
(See Fig. 1/Nonpurulent/SEVERE) (SR­M).
­+ In the absence of a definitive etiologic diagnosis, broad­spectrum
treatment with vancomycin plus either piperacillin/tazobactam,
ampicillin/sulbactam or a carbapenem antimicrobial is recommended
(SR­L). Definitive antimicrobial therapy with penicillin and clindamycin
is recommended for treatment of clostridial myonecrosis (SR­L).
­+ Hyperbaric oxygen (HBO) therapy is NOT recommended because it has
not been proven as a benefit to patients and may delay resuscitation
and surgical debridement (SR·L).
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Preemptive Antimicrobial Therapy to Prevent Infection
for Dog or Cat Bites
­+ Preemptive early antimicrobial therapy for 3­5 days is recommended
for patients who:
a} are immunocompromised,
b) are asplenic;
c) have advanced liver disease;
d) have preexisting or resultant edema of the affected area;
e} have moderate to severe injuries, especially ro rhe hand or face; or
f) have injuries that may have penetrated the periosceum or joint capsule (SR-L}.
­+ Postexposure prophylaxis for rabies may be indicated. Consultation
with local health officials is recommended to determine if vaccination
should be initiated (SR·L).
Infected Animal Bite­related Wounds
­+ An antimicrobial agent or agents active against both aerobic and
anaerobic bacteria such as amoxicillin­clavulanate should be used
(SR·M).
­+ Tetanus toxoid should be administered to patients without toxoid
vaccination within 10 years. Tdap is preferred over Td if the former
has not been previously given (SR·L).
Primary Wound Closure for Animal Bite Wounds
­+ Primary wound closure is NOT recommended for wounds, with the
exception of those to the face, which should be managed with copious
irrigation, cautious debridement and preemptive antibiotics (SR­L).
Other wounds may be approximated (WR­L).
Cutaneous Anthrax
­+ Oralpenicillin V 500 mg qid tor 7­10 days is the recommended
treatment for naturally acquired cutaneous anthrax (SR­H).
­+ Ciprofloxacin 500 mg PO bid or levofloxacin 500 mg IV/PO q24h
for 60 days is recommended for bioterrorism cases because of
presumed aerosol exposure (SR­L).
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Cat Scratch Disease and Bacillary Angiomatosis
­+ Azithromycin is recommended for cat scratch disease (SR­M)
according to the following dosing protocol:
• Patients >45 kg, 500 mg on day I followed by 250 mg for 4 additional. days
(SR-1' l}.
• Parienrs <45 kg, 10 mg/kg on day l and 5 mg/kg for 4 more days (SR-1'1).
­+ Erythromycin 500 mg qid or doxycycline 100 mg bid for 2 weeks to 2
months is recommended for treatment of bacillary angiomatosis (SR­M).
Erysipeloid
­+ Penicillin 500 mg qid or amoxicillin 500 mg tid for 7­10 days is
recommended for treatment of erysipeloid (SR­H).
Glanders
­+ Ceftazidime, gentamicin, imipenem, doxycycline or ciprofloxacin is
recommended based on in vitro susceptibility (SR­L).
Bubonic Plague
­+ Bubonic plague should be diagnosed by Gram stain and culture
of aspirated material from a suppurative lymph node (SR­M).
Streptomycin 15 mg/kg IM q12h or doxycycline 100 mg bid PO is
recommended for treatment of bubonic plague (SR­L). Gentamicin
could be substituted for streptomycin (WR­L).
Tularemia
­+ Sero logic tests are the preferred method of diagnosing tularemia (WR­L).
­+ Streptomycin 15 mg/kg q12h IM or gentamicin 1.5 mg/kg qBh IV is
recommended for treatment of severe cases of tularemia (SR·L).
­+ Tetracycline 500 mg qid or doxycycline 100 mg bid PO is
recommended for treatment of mild cases of tularemia (SR­L).
­+ Notify the microbiology laboratory if tularemia is suspected (SR­H).
lmmunocompromised Patients
­+ In addition to infection, differential diagnosis of skin lesions should
include drug eruption, cutaneous infiltration with the underlying
malignancy, chemotherapy­ or radiation­induced reactions, Sweet's
syndrome, erythema multiforme, leukocytoclastic vasculitis and graft­
versus­host disease among allogeneic transplant recipients (SR­H).
­+ Differential diagnosis for infection of skin lesions should include
bacterial, fungal, viral and parasitic agents (SR­H).
10
­+ Biopsy or aspiration of the lesion to obtain material for histologic and
microbiologic evaluation should always be implemented as an early
diagnostic step (SR­H).
Fever and Neutropenia
­+ Determine whether the current presentation of fever and neutropenia
is the patient's initial episode of fever and neutropenia or a persistent
unexplained fever from their initial episode (after 4-7 days), or a
subsequent episode of fever and neutropenia (recurrent) (SR­L).
­+ Aggressively determine the etiology of the SSTI by aspiration and/or
biopsy of skin and soft tissue lesions and submit these for thorough
cytologic/histologic assessments, microbial staining and cultures
(SR­L).
­+ Risk­stratify patients with fever and neutropenia according to
susceptibility to infection: high­risk patients are those with
anticipated prolonged (>7 days) and profound neutropenia
(ANC <100 cells/pt) or with a Multinational Association for
Supportive Care (MASCC) score of <21; low­risk patients are
those with anticipated brief (<7 days) periods of neutropenia and
few comorbidities (SR­L) or with a MASCC of �21 (SR­M).
­+ Determine the extent of infection through a thorough physical
examination, blood cultures, chest radiograph and additional imaging
(including chest CT) as indicated by clinical signs and symptoms (SR­L).
Initial Antibiotic Therapy
­+ Hospitalization and empiric antibacterial therapy with vancomycin
plus antipseudomonal antibiotics such as cefepime, a carbapenem
(imipenem­cilastatin or meropenem or doripenem) or piperacillin­
tazobactam are recommended (SR­H).
­+ Documented clinical and microbiologic SSTls should be treated based
on antimicrobial susceptibilities of isolated organisms (SR­H).
­+ The treatment duration for most bacterial SSTls should be 7-14 days
(SR­M).
­+ Surgical intervention is recommended for drainage of soft­tissue
abscess after marrow recovery or for a progressive polymicrobial
necrotizing fasciitis or myonecrosis (SR­L).
­+ Adjunct colony­stimulating factor therapy (G­CSF, GM­CSF) or
granulocyte transfusions are NOT routinely recommended (WR­M).
­+ Acyclovir should be administered to patients suspected or confirmed
to have cutaneous or disseminated herpes simplex (HSV) or varicella
zoster virus (VZV) infection (SR­M).
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Persistent or Recurrent Episodes

Cellular Immunodeficiency
-+ Yeasts and molds remain the primary cause of infection­associated
fever and neutropenia. Therefore, empiric antifungal therapy (Table 5) -+ Consider immediate consultation with a dermatologist familiar with
should be added to the antibacterial regimen (SR,H). cutaneous manifestations of infection in patients with cellular immune
defects (eg, those with lymphoma, lymphocytic leukemia, recipients
• Empiric administration of vancomycin or other agents with Gram ..positive activity
of organ transplants, or those receiving immunosuppressive drugs
(linczolld, daptomycin or cefcaroline} should be added if not already being
such as anti­tumor necrosis factors or certain monoclonal antibodies)
administered (SR-11)
(WR­L).
• Candida spp. SSTls should be treated with an cchinocandin or, if C. parapsilosis
has been isolated, lipid formulation amphotcricin-B (SR-I 1) with fluconazolc as an -+ Consider biopsy and surgical debridement early in the management of
acceptable alternative (SR-II!). Treatment should be for 2 weeks after clearance of these patients (WR­L).
blood stream infection or resolution of skin lesions (SR-II!).
• Aspergillus $$Tis should be treated with voriconazole {SR-H) or, alternatively,
-+ Empiric antibiotics, antifungals and/or antivirals should be considered
in life­threatening situations (WR­M). The use of specific agents
lipid formulations of amphorericin B, posaconazole or echinocandin for 6­12
should be decided with the input of the primary team, dermatology,
weeks {SR-L). Mucor/Rbizopus infections should be treated with lipid formulation
infectious disease and other consulting teams (SR­M).
amphorericin B (SR-i\1) or posaconazole (SR-L) (T.1ble 5). The addition of
an echinocandin could be considered based on synergy in murine models of
muconnycosis and observational clinical data (W'R-L).
• Fusarium spp. infections should be treated with high-dose IV voriconazole or
posaconazole (SR-L).
• Begin treatment for anribiodc-resisranr bacterial organisms (T.1ble 6) in patients
currently on antibiotics (SR-.\1).
• Intravenous acyclovir should be added to the patient's antimicrobial regimen
for suspected or confirmed cutaneous or disseminated HSV or VZV infections
(SR-i\f).
-+ Blood cultures should be obtained, and skin lesions in this population
of patients should be aggressively evaluated by culture aspiration,
biopsy or surgical excision since they may be caused by resistant
microbes, yeast or molds (SR­M).
-+ The sensitivity of a single serum fungal antigen test (1­3 �­D­glucan
or galactomannan tests] is low particularly in patients receiving
antifungal agents, and benefits from laboratory tests for fungal
antigen or DNA detection remain inconsistent (SR­M).
-+ Polymerase chain reaction (PCR) in peripheral blood for HSV and VZV
might be helpful in establishing a diagnosis of disseminated infection
in patients with unexplained skin lesions (WR­M).

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Table 1. Antimicrobial therapy for Staphylococcal and

Streptococcal SSTls•
Disease Entity Antibiotic
l.mperigo' Dicloxacillln (generic)
(Staphylococcus and
St>·eptococcus) Cephalexin
Kefle�, (generic)
Erythromycin (generic)
Clindamycin
Cleocin®, (generic)
Amox ic il Iin Icl av ulana re
Augmtmtin®, (generic)
Rccapamulin ointment Altaba:>!' Apply to lesions bid
Mupirocin ointment Bactroban® Apply ro lesions tid
MSSA Nafcillin or oxacillin (generic)
Cefazolin® (generic)
Clindamycin
Ckocin®, (generic)
Dicloxacillin (generic)
Cephalexin
Kefle:!J, (generic)
Doxycycline Vibramycin®, (generic) JOO mgbic/ PO
Minocyclinc ,,1inocin®, (generic)
Adult Dosage Pediatric Dosage• Comment I
250mgqidPO NIA NIA
250 mgqid PO 25-50 mg/kg/day in 3 or 4 divided NIA
doses PO
250 mg qid PO• 40 mg/kg/day in 3-4 divided doses PO; Some strains of S. nureus and S. pyogenes
may be resistant.
300-400 mg qid PO 20 mg/kg/day in 3 divided doses PO NIA
875/ 125 mg bid PO 25 mg/kg/day of the amoxicillin NIA
component in 2 divided doses PO
Apply to lesions bid for patients with limited number of lesions.
Apply to lesions tid for patients with limited number oflesions.
l-2gq4h IV I 00-150 mg/kg/day in 4 divided doses Parental drug of choice.
lnacrive against MRSA.
1gq8h rv 50 mg/kg/day in 3 divided doses • For penicillin-allergic patients except those
with immediate hypersensitivity reactions.
• More convenient than nafcillin with less
bone marrow suppression.
600 mgq8h IV or 25-40 mg/kg/day in 3 divided doses IV • Bacrenosraric.
300-450 mgq;.d PO or • Potential for cross-resistance and emerge.nee
25-30 mg/kg/day in 3 divided doses PO of resistance in eryrhrornycin-resisranr strains.
• Inducible resistance in MRSA.
500mgqidPO 25-50 mg/kg/day in 4 divided doses PO • Oral agent of choice for rnerhicillin-
susceptible strains in adults.
• Not used much in pediatrics
500 mg qid PO 25-50 mg/kg/day in 4 divided doses PO • For penicillin-allergic patients except those
with immediate hypersensitivity reactions.
• A primary option in pcdiacrics because of its
availability as a suspension.
1VOT recommended for age c 8 years' • Bacreriostaric.
• Limited recent clinical experience.

SlvlX-TMP Bactrim®, Septra®, One or two double-strength 8-12 mg/kg (based on rrimerhoprim • Bactericidal.
(generic) rablets bid PO component) in either 4 divided doses • Efficacy poorly documented.
IV or 2 divided doses PO

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Table 1. Antimicrobial therapy for Staphylococcal and

Streptococcal SST1s• (continued)

Disease Entity Antibiotic Adult Dosage Pediatric Dosage" Comment

MRSA Vancomycin 30 mg/kg/din 2 divided 40 mg/kg/day in 4 divided doses IV • For penicillin allergic patients
Vancodn®, (generic) doses IV • Parenteral drug of choice for treatment of
infections caused by MRSA
Linezolid 600 mgq12h IV or 10 mg/kg every 12h IV • Bacteriostatic
Zyvo.,� 600 mg bid PO or • Limited clinical experience
PO for ch ildrcn < 12 years • No cross-resistance with other antibiotic
classes
• Expensive
Clindamycin 600 mgq8h rv or 25-40 mg/kg/da)' in 3 divided doses IV • Bacreriosratic
Cleocin®, (generic) 300-450 mg qid PO or • Potential of cross-resistance and emergence
30-40 n1g/kg/da)' in 3 divided doses PO of resistance in eryrhromycin-resistanr
strains
• Inducible resistance in M RSA
• Important option for children
Oaptm�rcin 4 mg/kgq24h JV N/A • Bactericidal
Cubicin • Possible myopathy
Cefraroline 600 mg bid JV NIA • Bactericidal
Teflaro&
Doxycydine Vib1'flmyci11®, I 00 mg bid PO NOT recommended for age <8 years' • Bacreriosratic
minocycline Minocin®. • Limited recent clinical experience
{generic)
SMX·TMP One or two double-strength 8· 12 mg/kg/day (based on crimeehoprim • Bactericidal
BflClrim®, Septra®, {generic) tablets bid PO component) in either4 divided doses JV • Limited published efficacy dara
or 2 divided doses PO

Streptococcal skin Penicillin {generic) 2·4 million units q4·6h IV 60· l 00,000 u/kg/dose q6h For patients with severe peniciJlin
infections hypersensitivity, use clindamycin, vancomycin,
Penicillin VK (generic) 250-500 mgq6h PO 125-250 mgq6h PO linezolid, daprornycin, or relavancin.
Nafcillin (generic) 1·2 gq4·6h JV 50 mglkg dose q8h IV
Cefazolin {generic) I gq8h IV 33 mg/kg/dose q8h JV
Ccphalexin Kefle:�, 500 mg q6h PO 12.5-25 mg/kgq12h PO
(generic)
Clindamycin 600-900 mgq8h JV 10-13 mg/kg!doseq8h JV Clindamycin resistance is <I% but may be
Cleocin", (generic) increasing in Asia.
, Tedizobd and dnlbavancin (approved after publication of the 2014 guideline) nre also effective 'Infection due to Stapbyl«1,uu.J and Stn:pttJcQtcu.s species. Duration of therapy is 7 days, depending on
treatments ofSSTl including those caused by MRSA. the clinical response.
Orieavancin (Orbruriv} received approval by FDA fo1· this indicarion prior co the lDSA's approval d Adule dosage of cryrhromycin crhylsuccinarc is 400 mg11id PO
of this guideline. Ir will be full)' considered fur inclusion by the panel the: next time rllis guideline is c For alreruarives in children see: Pickering LK. Committee on Infectious Diseases. American
updated. Academy ofPediatrics. Antimirrubial agents and related therapy. 26th ed. Elk Grove village, 1L:
b Doses lisrcd arc nor appropriate for neonates. For neonatal doses, refer to Pickering LK, ed. Red Boole American Academy of Pediatrics; 2003.
Report t?,(the Committee 011 hfettitms Dueasa. 26th ed. Elk Grove Village, JL: American Academy of
Pediatrics: 2003.

16 17
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Table 2. Treatment of Necrotizing Infections of the Skin,

Fascia and Muscle
First-Line Antimicrobial Pediatric Dosage beyond the Antimicrobial Agent for Patients with
Agent Adult Dosage Neonatal Period• Severe Penicillin Hypersensitivity
Mixed Infections Piperacillln-razobactam 3.37 g q6-8h IV 60-75 mg/kg/dose of the piperacillin Clindamycin or merronidazole'' with an
plus component q6h IV aminoglycoside or Auoroquinolone.
vancomycin 30 mg/kgld in 2 divided 10-13 mg/kg/doseq8h IV
doses
Imipenem/cilasrarin I gq6-8h IV NIA NIA
Mero pen cm l gq8h IV 20 mg/kg/dose q8h IV NIA
Errapenem I g daily IV 15 mg/kg/dose ql2h IV for children NIA
3 months to 12 years
Cefotaxime 2 gq6h IV 50 mg/kg/dose q6h IV NIA
plus
merronidnzole 500 mgq6h IV 7.5 mg/kg/dose q6h IV
or
clindamycin 600-900 mg q8h IV 10-13 mglkg/doseq8h IV
Streptococcus Penicillin 2-4 mu q4-6h IV 60.000-100,000 u/kg/doseq6h IV Vancomycin, Iinezolid, quinupristin/
plus dalfoprisrin, daptomycin
clindamycin 600-900 mg q8h IV 10-13 mg/kg/dose q8h IV
Stnphylococcus aureus Nafcillin l-2gq4h!V 50 mg/kg/dose q6h IV Vancomycin, linezolid, quinuprisrin/
dalfopristin, daptornycin
Oxacillin 1-2 gq4h IV 50 mg/kg/dose q6h IV
Cefazolin I gq8h IV 33 mg/kg/dose q8h IV
Vancomycin (for resistant 30 mg/kgld in 2 divided 15 mg/kg/dose q6h IV NIA
strains) doses IV
Clindamycin 600-900 mg q8h IV 10-13 mg/kg/doseq8h IV Bactcriostatic. potential cross-resistance and
emergence of resistance in erythromycin-
resistant strains; inducible resistance in i\·1RSA.'
Clostridium. species Clindamycin 600-900 mgq8h IV 10-13 mg/kg/doseq8h JV NIA
plus penicillin 2-4 mu q4-6h IV 60,000-100,00 u/kg/dose q6h IV
Aerotriona.s hydrophilA. Doxycycl inc 100 mgql2h IV NOT recommended foe children, bur NIA
plus may need to use in life-threatening
ciprofloxacin 500 mgql2h IV situations.
or
cefiriaxone J-2 gq24h JV
Vibrio vulnijicus Doxycycline 100 mgq12h IV 1V01' recommended for children, but NIA
plus may need to use in lifo�chrcarcning
cefiriaxonc l gqidIV situations.
or
cefotaxime 2 gtid IV
� Not co exceed rhe maximum adule dose.
l, If $1ap/J)'fiU()«U.f prC$CnC Or Suspected, add an appropriate agent.

� lf .MRSA arc present or suspected, add vancomycin.

18 19
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Table 3. Antibiotics for Treatment of lncisional Surgical Site Table 4. Recommended Therapy for Infections after Animal
Infections or Human Bites
Surgery of Intestinal or Genitourinary Tract Antimicrobial Agent by Type of Bite
Single-drug regimens Ticarcillin-clavulanare 3.J gq6h Oral Intravenous Comments

Piperacillin-tazobacmm 3.375 gq6h or 4.5 gtf8h Animal Bite

lmipcncm-cilastarin 500 mgq6h

Amoxicillin/ 875/ l 25 mg bid ... Some Gram-negative rods
clavulanarc arc resistant; misses MRSA
Meropenem 1 g q8h Ampicillin- ... 1.5-3.0 g q6·8h Some Gram-negative rods
sulbacrarn are resistant: misses MRSA
Errapcncm 1 g q24h
Pipcracillin/ ... 3.37 gq6·8h Misses MRSA
Combinarion regimens Cefiriaxone 1 g q24h plus merronidazole 500 mg q8h razobacram
Ciprofloxacin 400 mg 1 V q J 2h or 750 mg PO q J 2h plus Carbapcnerns ... Sec individual info. Misses MRSA
mctronidazolc 500 mg q8h
Doxycycline 100 mg/,;,/ 100 mgql2h Excellent activity against
Levofloxacin 750 mgq24h plus merronidazole 500 mgq8h Pasteurell« multocida, some
Arnpicillin-sulbacrarn 3 gq6h plus gcntamicin or streptococci are resistant
robramycin 5 mg/kgq24h Penicillin plus 500 mgqitl/ ...
dicloxacillin 500 mgqid
Surgery of Trunk or Extremity away from Axilla or Perineum
St.1X/TMP 160-800 mg bid 5-10 mg/kg/day Good activity against
Oxacillin or nafcillin 2 g q6h ofTlv!P aerobes: poor activity
Cefazolin 0.5· l g q8h component against anaerobes
Merren idazole 250-500 mg tid 500 mgq8h Good activity against
Cephalexin 500 mg PO q6h anaerobes; no activity
SMX-TlvtP 160-800 mg PO q6h agai.nsr aerobcs

Vancomycin 15 mg/kg q J2h Clindamycin 300 mg tid 600 mg q6-8h Good acriviry against
staphylococci, streptococci
Surgery of Axilla or Perineum' and anaerobes: misses
P. mulrocidn
Merronidazole 500 mgq8h
plus ciprofloxacin 4-00 mg IV qi 2h or 750 mg PO ql 2h Second-generation cephalosporin Good activity against. P.
OR muliocidai misses anaerobes
levofloxacin 750 mg q24h
Ccfuroximc 500 mg bid 1 gql2b
OR
cefiriaxonc 1 g q24h Cefoxitin ... 1 gq6-8h
I
May also need to cover for �·(RSA with vanccmycin 15 mg/kg qi 21,. Third-generation cephalosporin
Cefiriaxone ... 1 gql2h
Ceforaxime ... l-2gq6-8h
Fluoroquinolones Good activity against P
mtdtocida; misses MRSA
and some anaerobes
CiproAoxacin 500-750 mg bid 400mgql2h
Levofloxacin 750 mg daily 750 mg daily
Moxlfloxacin 4-00 mg daily 400 mg daily Monorherapy, good for
anaerobes also

20 21
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Table 4. Recommended Therapy for Infections after Animal • • • ••

or Human Bites (continued)
Category/Grade Definition
Antimicrobial Agent by Type of Bite
Recommendation
Oral Intravenous Comments
SR-Strong Clear desirable or undesirable effects
Human Bite
Amoxicillin/ 8751125 mg ". Some Gram-negative rods are W'R - \'!(leak Desirable and undesirable effeces closely balanced or uncertain
clavulanarc bid resistant; misses MRSA �aliry of Evidence
Ampicillinl ... 1.5·3.0 g q6h Some Gram-negative rods are
H ­ High Consistent evidence from well-perforrned RCT1 or exceptionally
sulbacram resistant; misses MRSA
strong evidence from unbiased observational studies
Carbapenems See individual agents Misses 1'1RSA
1'1- Moderate Evidence from RCTs with important limitations or moderately
Doxycycline 100 mg bid ". Good activity against Eikenella strong evidence from unbiased observarional studies
species, staphylococci, and anaerobes;
some streptococci are resistant L­Low Evidence for � 1 critical outcome from observational studies, from
RCTs with serious flaws or from indirect evidence
Table 5. Standard Doses of Antifungal Agents VL- Very low Evidence for z I critical outcome from unsystematic clinical
observations or very indirect evidence
Antifungal
agent Oral dose IV dose Comments Grade Implicarion Comment
Fluconazole I 00·400 mg q24h 800 mg loading Candida krusei and SR-1 l
dose, then Applies to most patients in most Further research is unlikely to
C. glabrata are resistant circumstances change estimate
400 mg daily
Voriconazole" 400 mgbicl x 2 6 mg/kg IV Accumulation of SR-M Further research may change
doses, then q I 2h for 2 doses, cyclodexrrm vehicle wirh estimate
SR·L
200 mgq12h followed by IV formularion with renal
4 mg/kg IV q12h insufficiency SR·\'! Esrimarc of effect for at lease
one critical outcome is ver)'
Posaconazolc 400 mg hid NIA Covers Mucoralcs
uncertain
with meals
Lipid complex NIA 5 mg/kg/day Nor active against fusaria \VR·H The best action may differ Further research is unlikely co
arnphotcricin B depending on circumstances or change estimate
patients or societal values
Llposomal NIA 3·5 mg/kg/day Not active against fusaria
arnphorericin B \'.;'Jl.)\f Altcrnarivc approaches likely Further research may change
to be better for some patients estimate
• The use of panent-spectfic pharmacokincncs is recommended to improve clinical outcome.
under some circumstances

Table 6. Standard Doses of Antimicrobial Agents Active \'('R·L Other alternatives may be
equally reasonable
Against Multiple Drug­Resistant Organisms \X'R.\/L Anv estimate of effect, for ac
least' one critical outcome, is
Antimicrobial IV dose Comments I very uncertain
Vancomycin 30·60 mg/kg!d in Targer serum trough concentrations of
RCTs, randomized controlled trials.
2·4 divided doses 15·20 f'g/mL in severe infections.
for the complete Grading of Recommendations Assessment, Dcvdopmc.::nt and Evaluation
Dapcomycin 4-6 mg/kg/day Covers VRE. Strains nonsusceprible to (GRADE) Strength of Recommendarions and �aliry of rhc Evidence Table. visit the IDSA
vancornycin may be cross-resistant co website: hctp://www.idsociet)'.org/Guiddioes_Orhcr/.
dapcomycin.
Linezolid 600 mgq12h I 00% oral bioavailabiliry, so oral dose same as
IV dose. Covers VRE and /v!RSA.
Colistin 5 mg/kg load, then Nephroroxic, Does not cover Cram-posirives
2.5 mg/kgq/2/, or anaerobes, Proteus, Sermtia, Burkholderin.
22 23
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Abbreviations
ANC, absolute neurrophil count; bid, twice daily: CA-MRSA, community-acquired
MRSA; C & S, culture and scnsiriviry, CT, computed romography. G-CSF, granulocyrc
colony-sumulaeing factor: Gl, gascrolncesnnal, GM-CSF, granulocyre-macrophage
colony-stimulating factor: h, hour: HSY, herpes simplex virus; I & D, incision and
drainage; 11''1, intramuscular; IV, intravenous; MASCC, Multinational Association
for Supporrivc Care; lv{RI, magnetic resonance irnaging; MRSA, merhicillin-rcsisranc
Sraphylococcus aureus; MSSA, merhicillin-suscepnble Staphylococcus aureus; NIA, not
applicable; PCR, polymerase chain reaction: PO, by mouth: qid, four times daily: S.
aureus, Staphylotoaus aureus; Rx, prescription; SIRS, systemic intlarnmatory response
syndrome; Si\olX-Tl\•IP, sulfamcrhoxazolc-rriructhoprim, SST!, skin and sofi-nssuc
infection; tid, three times daily; u, units; VR.E, vancomycin-resistant enterococci: VZV,
varicella zosrer virus; \'i'BC, white blood cell

Source
Rubin LG. Levin l\1J, Ljungman P, Davies EG, Avery R, Tomblyn .NI, Bousvaros A,
Dhanircddy S, Sung L, Keyserling H, Kang I. 2013 IDSA Clinical Practice Guideline for
Vaccination of the Irnmunocompromiscd Hose. Clin lnfact Dis. 20 I 4;58(3):c44-100.

Disclaimer
This Guideline attempts to define principles ofpractice that should produce high-quafjty patient
care.Le is appikable to spedrtliJU, primary care, and p1'oviders ,11 ali levels. 'Ihis (i'uideline
should not be considered exclusive ofother methods ofcare reasonably directed at obtaining the
Jame results. The 11.ltimatcjudgme,u conccming 1he propriety ,,fany course �fc(Jndm:t must bt.
made by the clinician after consideration ofeacb individualpatient situation.
Neuber JGC, the medical associations, nor the authors endorse any product or service aJ.SOciau:d
with she distributor ofsbis clinical. reference tool.

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