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Documente Cultură
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Skin and
Soft-Tissue
Infections
Consultant:
Oenms L. Stevens. MD, PhD
VA Med. Center
Boise, ID
D GuidelineCentral.com•
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+ Recently there has been a dramatic increase in the frequency and Impetigo and Ecthyma
severity of skin and softtissue infections (SSTls) accompanied by
the emergence of resistance to many of the antimicrobial agents + Gram stain and culture of the pus or exudates from skin lesions of
commonly used to treat skin and softtissue infections in the past. impetigo and ecthyma are recommended to help identify whether
Staphylococcus aureus and/or a �hemolytic streptococcus is the
• There was a 29% increase in the total hospital admissions for these infections
cause (SR·M), but treatment without these studies is reasonable in
between 2000 and 2004.
typical cases (SRM).
• 6.3 million physician's office visits per year are attributable to $$Tis.
• Between 1993 and 2005, annual emergency department visits for SSTls increased + Bullous and nonbullous impetigo can be treated with oral or topical
from 1.2 million to 3.4 million patients. antimicrobials, but oral therapy is recommended for patients with
.,. Some of this increased frequency is relared to the cmcr:gencc of communiry numerous lesions or in outbreaks affecting several people to help
associated merhicillin-rcsistanr S. aureus {lv!RSA). decrease transmission of infection. Treatment for ecthyma should be
+ Clinical evaluation of patients with SSTI aims to establish the cause an oral antimicrobial.
and severity of infection and must take into account pathogenspecific • Treatment ofbullous and nonbullous impetigo should be with tither mupirocin or
and local antibiotic resistance patterns. rerapamulin hid for 5 days (SR-I I).
• Oral therapy for ecthyma or impetigo should be a 7-day regimen with an
+ When developing an adequate differential diagnosis and an agent active against S. aureus unless cuhures yield streptococci alone (when
appropriate index of suspicion for specific etiological agents it is
oral penicillin is the recommended agent) (SR-H). Because S, aureus isolates
essential to obtain a careful history that includes information about
from impetigo and ecrhyma are usually merhicillin-susceprible, dicloxacillln or
the patient's immune status, geographical locale, travel history, recent
cephalexin is recommended. \'(!hen MRSA is suspected or confirmed, doxycycline,
trauma or surgery, previous antimicrobial therapy, lifestyle, hobbies,
clindamycin, or sulfamethoxazole-rrlmethoprim {Sl\1X-TMP) is recommended
and animal exposure or bites.
(SR-,\().
+ Recognition of the physical examination findings and understanding • Systemic anrlmicrobials should be used for infections during outbreaks of
the anatomical relationships of skin and soft tissue are crucial for post-streptococcal glomerulonephritis to help eliminate nephritogenic strains
establishing the correct diagnosis. of Streptococcus pyogenes from the community {SR-l\·1)
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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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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
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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).
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Clostridial Gas Gangrene or Myonecrosis Primary Wound Closure for Animal Bite Wounds
+ Urgent surgical exploration of the suspected gas gangrene site and + Primary wound closure is NOT recommended for wounds, with the
surgical debridement of involved tissue should be performed exception of those to the face, which should be managed with copious
(See Fig. 1/Nonpurulent/SEVERE) (SRM). irrigation, cautious debridement and preemptive antibiotics (SRL).
Other wounds may be approximated (WRL).
+ In the absence of a definitive etiologic diagnosis, broadspectrum
treatment with vancomycin plus either piperacillin/tazobactam,
ampicillin/sulbactam or a carbapenem antimicrobial is recommended
Cutaneous Anthrax
(SRL). Definitive antimicrobial therapy with penicillin and clindamycin + Oralpenicillin V 500 mg qid tor 710 days is the recommended
is recommended for treatment of clostridial myonecrosis (SRL). treatment for naturally acquired cutaneous anthrax (SRH).
+ Hyperbaric oxygen (HBO) therapy is NOT recommended because it has + Ciprofloxacin 500 mg PO bid or levofloxacin 500 mg IV/PO q24h
not been proven as a benefit to patients and may delay resuscitation for 60 days is recommended for bioterrorism cases because of
and surgical debridement (SR·L). presumed aerosol exposure (SRL).
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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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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.
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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
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
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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.
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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.