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Outpatient Management of Skin and Soft Tissue Infections

Outpatient Management of Skin and Soft Tissue Infections - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Infection and Isolation, Related


Figure 1. Outpatient Management of Skin and Soft Tissue Infections
Local presentation (at least 3 of the following)
Edema Erythema Heat
Bullae Petechiae Pain
“Orange peel” appearance Vesicles
Bites
Oral options
Augmentin XR 2000/125 mg PO BID
Moxifloxacin 400 mg PO daily
IV and Oral Alternatives in Table 7
ASO titer may be useful in some
types of beta streptococcus
Superficial cellulitis, open
shallow ulcer/blister
Deep, ulcerative, and/or
chronic cellulitis or
penetrating trauma
Yes Consider alternative diagnosisNoDetermine type of skin, skin structure, or soft tissue infection
Non-purulent with extensive
lymphangitic spread
Streptococcus sp most likely
Cutaneous abscess (traumatic and non-traumatic)
with or without surrounding cellulitis
Impetigo/superficial or subcutaneous
cellulitis
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Incision & drainage
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≤ 5 cm
Consider abx therapy and culturing aspirate (to
guide de-escalation) if:
ü Multiple lesions
ü Cutaneous gangrene
ü Signs of systemic infection
ü Rapid progression of cellulitis
ü Areas that are difficult to drain (face, hand,
genitalia)
ü Risk factors for reduced ability to heal (diabetes or
immunosuppression
Assess for MRSA**
Majority of SSTIs (60-90%) are caused by Gram postive organisms.
OUTPATIENT TREATMENT DOES NOT USUALLY REQUIRE
COVERAGE OF GRAM NEGATIVE ORGANISMS
Amoxicillin 500mg PO TID
Alternatives in Table 1
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MRSA Risk Factors
TMP/SMX DS 1-2 tabs PO BID OR
doxy/minocycline 100mg PO BID
PLUS amoxicillin 500mg PO TID
Alternatives in Table 3
Dicloxacillin 500mg PO QID OR
Cephalexin 500mg QID
Alternatives in Table 2
*Consider x1 dose of IV/IM ceftriaxone
NO MRSA Risk Factors
Recommended non-pharmacologic options:
ü Elevate limb (wedge pillow)
ü Outline erythematous area with pen daily
(erythema may extend beyond margins within the first 24-36 hours without representing
treatment failure)
ü If edematous, apply ACE wrap from toes to thighs every 8 hours for lower extremity infections
ξ Lesion spread and fever may take 48-72 hours to abate. If no improvement after 72-96 hours or
worsening, consider IV therapy, expanding coverage, or alternative diagnosis (see inpatient
algorithm)
ξ The “quality” of erythema may also indicate improvement without regression of margins (i.e. fire
engine red to pink)
Risk factors for CA-MRSA
ü H/o MRSA infection or colonization in patient or
close contact
ü High prevalence of CA-MRSA in local community
or patient population
ü Recurrent skin disease
ü Crowded living conditions (eg homeless shelter or
military barracks)
ü H/o incarceration
ü Contact sports
ü Injection drug use
ü Native American, Pacific Islander, Alaskan Native
ü Male with h/o having sex with men
ü Shaving body hair
ü Recent/frequent antibiotic use
ü Skin or soft tissue infection with poor response to
beta-lactam antibiotics
Risk factors for HA-MRSA
ü Nasal colonization
ü Presence of indwelling devices such as
catheters, tracheostomies, and
nasogastric tubes
ü Hospital admission within past 90 days
ü Prolonged hospitalization
ü Residence in long-term care facility
ü Antibiotic therapy in past 90 days
ü Diabetes mellitus
ü Hemodialysis
ü HIV infection
ü Immunosuppression
Reference: Skin, Skin Structure, and Soft Tissue Infection Diagnosis and
Treatment – Adult – Inpatient/Ambulatory Guideline
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM @uwhealth.org Last Revised: 01/2016CCKM@uwhealth.org

** Risk Factors for Community-Acquired MRSA29
ξ H/o MRSA infection or colonization in patient or close
contact
ξ High prevalence of CA-MRSA in local community or
patient population
ξ Recurrent skin disease
ξ Crowded living conditions (e.g. homeless shelter or
military barracks)
ξ H/o incarceration
ξ Contact sports
ξ Injection drug use
ξ Native American, Pacific Islander, Alaskan Native
ξ Male with h/o having sex with men
ξ Shaving body hair
ξ Recent/frequent antibiotic use
ξ Skin or soft tissue infection with poor response to
beta-lactam antibiotics
---------------------------------------------------------------------------------------------------------------------------------------------------- --------------
Table 1. Antimicrobial agents directed at Streptococcus spp. (erythematous, non-purulent SSTI with lymphangitic
spreading)A,B
PO IV
ξ Amoxicillin 500 mg PO TIDC
ξ Cephalexin 500 mg PO QIDC
ξ Clindamycin 300-450 mg PO TID-QID
ξ Penicillin G 4 million units IV Q4hrC
ξ Cefazolin 1-2 g IV Q8hrC
ξ Clindamycin 600-900 mg IV Q6-8hr
A Treatment for 5-7 days duration is usually sufficient depending on initial response
B The activity of TMP/SMX is not sufficient to recommend monotherapy treatment of Streptococcus spp. infection
C
Requires renal dosing adjustment
Table 2. Antimicrobial agents directed at Streptococcus spp. and MSSA (abscess, fluctuance, penetrating trauma,
and/or open ulcer with surrounding erythema)A
PO IV
ξ Dicloxacillin 500 mg PO QIDB
ξ Cephalexin 500 mg PO QIDB
ξ Clindamycin 300-450 mg PO TID-QID
ξ Oxacillin 1-2 g IV Q4hr
ξ Cefazolin 1-2 g IV Q8hrB
ξ Clindamycin 600-900 mg IV Q6-8hr
A
Treatment for 5-7 days duration is usually sufficient depending on initial response
B Requires renal dosing adjustment
Table 3. Antimicrobial agents directed at Streptococcus spp., MSSA, and MRSA (abscess, fluctuance, penetrating
trauma, and/or open ulcer with surrounding erythema and patient has risk factors for, history of, or confirmed MRSA)
PO IV
ξ Trimethoprim-sulfamethoxazole 160-800
mg to 320-1600 mg PO BIDA PLUS
consideration of an antimicrobial agent
from Table 1 for Streptococcus coverage
ξ Doxycycline/minocycline 100 mg PO BID
PLUS consideration of an antimicrobial
agent Table 1 for Streptococcus coverage
ξ Clindamycin 300-450 mg PO TID-QID
ξ Linezolid 600 mg PO BID
ξ Vancomycin IVA (goal trough
concentration 10-15 mcg/mL)
ξ Clindamycin 600-900 mg IV Q6-8hr
ξ Ceftaroline 600 mg IV Q12hrA
ξ Daptomycin 4 mg/kg IV Q24hrA
ξ Linezolid 600 mg IV Q12hr
ξ Oritavancin 1200 mg IV once
A
Requires renal dosing adjustment
Table 7. Antimicrobial agents for skin infections caused by animal or human bitesA,B
PO IV
ξ Augmentin XR 2000-125 mg PO BIDC,D
ξ Moxifloxacin 400 mg PO daily
ξ (Cefuroxime 500 mg PO BIDD OR Cefpodoxime
400 mg PO BIDD OR Trimethoprim-
sulfamethoxazole 160-800 mg to 320-1600 mg
PO BIDD OR Doxycycline 100 mg PO BID OR
Ciprofloxacin 500 mg PO BIDD)
PLUS
(Clindamycin 300-450 mg PO TID-QID OR
Metronidazole 500 mg PO TID)
ξ Ampicillin-sulbactam 1.5-3 g IV Q6hrD
ξ Cefoxitin 2 g IV Q6hrD
ξ (Ceftriaxone 1-2 g IV Q24hr OR
Ciprofloxacin 400 mg IV Q12hrE) PLUS
(Metronidazole 500 mg IV Q8hr OR
Clindamycin 600-900 mg IV Q6-8hr)
ξ Ertapenem 1 g IV Q24 hr
ξ Moxifloxacin 400 mg IV Q24hr
A
Not all animal bites will cause infection
B
Assess need for tetanus vaccine and rabies vaccine and/or immune globulin
C
Augmentin XR is the preferred agent, but based on ability to pay amoxicillin-clavulanate 500-125 mg PO BID with or without addition
of amoxicillin 500-1000 mg PO QID may be considered as an alternative
D Requires renal dosing adjustment
E See Antibiotics for the Treatment of Gram-negative Infections – Adult – Inpatient Clinical Practice Guideline for dosing guidance
Reference: Skin, Skin Structure, and Soft Tissue Infection Diagnosis and Treatment – Adult – Inpatient/Ambulatory Guideline
Copyright © 201� University of Wisconsin Hospital s and Clinics Authority
Contact: Lee Vermeulen, CCKM @uwhealth.org Last Revised: 01/2016CCKM@uwhealth.org