Management of Skin and Soft Tissue Infections (SSTI)

Signs and Symptoms of Abscess and/or Cellulitis

Evaluate for Complicating Factors1,2

s/sx system infection: WBC > 12,000 or < 4000; T > Abscess difficult to drain (face, hand, perineum)
38.0 or <36oC ; HR > 90; RR > 24 Abscess > 5 cm in diameter
immunosuppressed Multiple lesions
End-stage organ failure Bites
Diabetes Water exposure
Extensive surrounding cellulitis History of trauma, purulent cellulitis, recurrent
Advanced age ( > 65 years of age) MRSA infection, MRSA exposure
Obesity (BMI > 30) No response to treatment after 48 hours

0-1 complicating factors2 2 or more complicating factors2

Purulent lesion or COMPLICATED

concern for abscess? Cutaneous abscess and/or cellulitis

no yes
Evaluate need for hospitalization1,2
Severe SSTI with one or more of the following:
SIMPLE CELLULITIS SIMPLE ABSCESS Failed outpatient therapy ( > 48 hours) and patient
(painful, tender, fluctuant requires hospital support
(No evidence of abscess, bites, red nodules)
water exposure, diabetic foot Severe SSTI in immunocompromised patients (transplant
ulcer, or recent surgery) patients, diabetes, chemotherapy, end-stage organ
Extending dysfunction, etc.)
cellulitis? Necrotizing fasciitis concerns (Consider CT, surgical
no yes consult)
Abscess of face, hand or perineum (difficult to drain areas)
Treat abscess Treat abscess + Severe sepsis not responding to fluids
Treat simple cellulitis Septic shock
( < 5 cm)
cellulitis--> (a)
--> I & D only --> I & D + (a)
ANY of NONE of
the above the above

Hospital Admission ED or Infusion Center

Observation or Follow-up • Blood cultures x2 • Blood cultures x2
If complicating factor (from list above), recommend
• ASO titer • Culture of drainage
close observation for clinical decline (inpatient or
• MRSA mol amp (nares) or exudate prior to
outpatient)
• Culture of drainage or antibiotics
If NO complicating factors, 48-hr follow-up with ED or
exudate prior to • PO or IV antibiotics
PCP
antibiotics in ED or infusion
If no improvement, start antibiotics based on • Treatment based on center
risk/presentation –> see algorithm (a) and consider adding algorithms (f) - (i) See algorithm (b)
(see pages 2-5) or • MD assessment of
gram-negative or MRSA coverage if initial therapy has response after 48-
sepsis bundle
failed (d) 72 hours
 TREATMENT ALGORITHM: SKIN & SOFT TISSUE INFECTIONS (SSTI)
(Options are listed in order of preference)

(a) UNCOMPLICATED CELLULITIS/ABSCESS: Outpatient Treatment1

CELLULITIS, NO MRSA RISK CELLULITIS with MRSA RISK ABSCESS + CELLULITIS
• Cephalexin 500mg po QID* • Cephalexin 500mg po QID* + • TMP/SMX DS 1-2 tabs BID*
• Dicloxacillin 250mg po QID TMP/SMX DS 1-2 tabs BID* • Doxycycline 100mg po BID
• Clindamycin 300-450mg po QID • Cephalexin 500mg po QID* + (for > 65 y.o. and/or decreased RF)
(use for severe PCN allergy) Doxycycline 100mg po BID • Clindamycin 300-450mg po QID
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Duration of therapy = 5 days for (for > 65 y.o .and/or decreased RF) For added Strep coverage:
uncomplicated Cellulitis or abscess, however • Clindamycin 300-450mg po QID • Consider adding cephalexin (with
1
treatment may be extended if not improved (use for severe PCN allergy) doxycycline or TMP/SMX)
3
Non-purulent Cellulitis Microbiology : MRSA Risk Factors5: Oral options for higher blood levels:
73% B-hemolytic Strep • Penetrating trauma • Linezolid **600mg po BID or
27% not identifiable • MRSA colonization • Tedizolid** 200mg po daily
• IV Drug abusers [Cost may be a consideration with these 2
4
Purulent Cellulitis Microbiology : • SIRS options, in addition to interactions with
59% MRSA 3% B-hem Strep 9% unknown • Failure to respond to serotonergic agents (linezolid) and possible
17% MSSA 4% other Strep 8% other Beta-lactam therapy myelosuppressive effects]
For simple Abscess < 5 cm: I & D only

(b) COMPLICATED CELLULITIS +/- ABSCESS: Treatment at ED or INFUSION CENTER

Oral antibiotics IV Therapy: Non-Purulent Cellulitis IV Therapy: Purulent Cellulitis
• Cephalexin 500mg po QID* + • Ceftriaxone 1-2g IV q24h • Vancomycin 20mg/kg load f/b
TMP/SMX DS 1-2 tabs BID* ADD if MRSA RISK: (see risk factors above) Pharmacy consult
• Cephalexin 500mg po QID* + -TMP/SMX DS 1-2 tabs BID* or
Doxycycline 100mg po BID -Doxycycline 100mg po BID
(for > 65 y.o .and/or decreased RF) (for > 65 y.o. and/or decreased RF)
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• Clindamycin 300-450mg po QID Duration of Therapy =: 5-10 days for
(use for severe PCN allergy) Complicated Cellulitis/Abscess, based
on response

(c) BITE INFECTIONS

Criteria for antibiotic therapy Empiric Therapy: Oral/IV options Cat Scratch Disease
Prophylactic antibiotic treatment x 3-5 days • Amoxicillin-clavulanate 875mg Azithromycin:
if: BID* or • Patients >45 kg: 500mg
• Immunocompromised or asplenic • Ampicillin/sulbactam 3g IV q6h* x 1, then 250mg/day x 4
• Advanced liver disease • Cefuroxime* + metronidazole • Patients <45kg: 10mg/kg
• Edema in affected area • Doxycycline 100mg po BID x 1, then 5mg/kg/d x 4
• Mod-severe injuries, especially to the • TMP-SMX* + metronidazole
hand or face For treatment of tenosynovitis or abscess Bacillary angiomatosis:
• Penetration of periosteum or joint development, surgical debridement and a Erythromycin 500mg qid or
capsule longer duration of therapy (7-14 days) may Doxycycline 100mg bid
Consider HIV, Hepatitis B or C risks with be required Duration: 2 weeks to 2 months
human bites Also consider addition of:
• Post-exposure prophylaxis for
rabies
• TDAP or Tetanus toxoid if not up
to date
 *requires dose adjustment for decreased renal function (See page 5) **ID/ASP review required † ID restricted antibiotic

TREATMENT ALGORITHM: SKIN & SOFT TISSUE INFECTIONS (SSTI)

(Options are listed in order of preference)

(d) FACIAL SKIN & SOFT TISSUE INFECTION

Deep Head & Neck Soft Tissue Infections
Facial Cellulitis Odontogenic source
originating from skin/sinuses
Pathogens: S.aureus, Strep sp. , Pathogens: Treatment:
anaerobes Common: S. aureus, S. pneumoniae and other • Amoxicillin-clavulanate 875mg
Strep sp., anaerobes TID*
Treatment: Uncommon: H. influenza, A. hydrophila,
• Ampicillin/sulbactam 3g IV
• Cephalexin 500mg po QID* + E.corrodens, Mucorales, Aspergillus
q6h*
TMP/SMX DS 1-2 tabs BID*
• Cephalexin 500mg po QID* + Treatment: • Cefuroxime 500mg BID* +
• Vancomycin: 20mg/kg load, f/b Clindamycin 300mg QID
Doxycycline 100mg po BID
Pharmacy consult • Cefuroxime 750-1.5g IV q8h* +
(for > 65 y.o .and/or decreased
+ Clindamycin 600-900mg IV q8h
RF)
• Clindamycin 300-450mg po QID
Ceftriaxone 1-2g IV q24h or (for severe penicillin allergy)
Amp-sulbactam 3g IV q6h
(use for severe PCN allergy)

(e) RECURRENT CELLULITIS/ABSCESS: ADJUNCTIVE THERAPIES MRSA Resistance to Vancomycin:

Non-purulent Cellulitis Recurrent Abscess
Treat pre-disposing factors: Although our antibiograms report
• Drain & culture
• Tinea pedis-> Clotrimazole 1% cream bid • 5-10 day course of appropriate 100% S.aureus vancomycin
• Edema antibiotic susceptibility, with 5% of SHC
• Venous insufficiency • Search for local causes: pilonidal isolates (n=6181) having an
• Underlying cutaneous disorders, i.e. cyst, hidradenitis suppurativa, or MIC=2.0, alternatives may be
eczema foreign material considered for infections that do
• Obesity • Consider 5-day decolonization: not respond to Vancomycin:
• Prophylactic antibiotics (penicillin or intranasal mupirocin, daily
erythromycin BID) if pre-disposing factors chlorhexidine washes, daily • Linezolid** 600mg po/IV
persist and >3-4 episodes/year decontamination of sheets, towels
BID
& clothes
• Tedizolid** 200mg po/IV
Other notes:
-Duration of Therapy for Complicated Cellulitis/Abscess: 5-10 days based on response daily
-Erysipelas may require 7-10 days of treatment • Daptomycin † 6mg/kg IV
-Pyomyositis should be treated as complicated purulent cellulitis with recommended duration of q24h*
therapy extended to 2-3 weeks.
-Minocycline may be substituted for Doxycycline, to avoid photosensitivity (same dose)
• Ceftaroline † 600mg IV
-The addition of Probiotic therapy is recommended with antimicrobial courses for prevention of q12h*
C.difficile infections associated with antimicrobial therapy

*requires dose adjustment for decreased renal function (See page 5) **ID/ASP review required † ID restricted antibiotic
 TREATMENT ALGORITHM: SKIN & SOFT TISSUE INFECTIONS (SSTI)
(Options are listed in order of preference)

(f) COMPLICATED NON-PURULENT CELLULITIS: Treatment for Hospital Admission

If NON-Sepsis or ICU NON-Sepsis w/MRSA Risk Severe Sepsis / ICU admission
• Cefazolin 1-2g IV q8h* • Cefazolin 1-2g IV q8h* + • Vancomycin per Pharmacy +
or Vancomycin 20mg/kg load f/b Clindamycin 900mg IV q8h +
• Ceftriaxone 1-2g IV q24h Pharmacy consult or Piperacillin-tazo 4.5g IV q8h*
(substitute for broader gram- • Clindamycin 600-900mg IV q8h
negative coverage - see risk factors • Vancomycin + Clindamycin IV +
below) • Substitute for broader gram- Meropenem** 1g IV q8h*
negative coverage if needed: (for severe penicillin allergy)
Ceftriaxone 1-2g IV q24h (see risk
factors below)
Please note: Gram Negative Rod Risk Factors:
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-Duration of Therapy for Complicated Cellulitis/Abscess: 5-10 days based on response • Neutropenia [see (f) page 3]
-Dosing: Higher listed doses of cefazolin, clindamycin, cefuroxime, nafcillin and ceftriaxone • HIV or severely
are recommended for patients >100kg immunocompromised
-De-escalate IV to oral therapy after 48-72 hours, or as patient responds/improves • Trauma in aquatic environment
-Diabetic Foot Infections are not covered in this treatment algorithm. Please refer to the • Burns
8
IDSA guideline for specific treatment. • Infection after skin graft

(g) COMPLICATED PURULENT CELLULITIS: Treatment for Hospital Admission

Empiric IV Therapy Options Defined IV Therapy Severe Sepsis / ICU admission
• Vancomycin 20mg/kg x1 f/b Pharmacy IF MSSA: • Vancomycin 20mg/kg load f/b
consult. • Cefazolin 1-2g IV q8h* or Pharmacy consult +
• Linezolid** 600mg po BID • Nafcillin 1-2g IV q4h Clindamycin 900mg IV q8h +
6,7

• Tedizolid** 200mg po daily IF MRSA: Piperacillin-tazo 4.5g IV q8h*

• Daptomycin† 6mg/kg IV q24h* Continue empiric therapy • Vancomycin + Clindamycin IV +
OTHER: (see page 3)
• Ceftaroline† 600mg IV q12h* Meropenem** 1g IV q8h*
(use for severe penicillin
allergy)

(h) NECROTIZING FASCIITIS or GAS GANGRENE** (i) NEUTROPENIC FEVER w/SSTI

Empiric IV Therapy Options: Defined Therapy:1 • Vancomycin + Cefepime (or
•Vancomycin 20mg/kg load f/b -Strep pyogenes or Clostridial sp.: pip/tazo or Meropenem**)
Pharmacy consult + • Penicillin 2-4milu q4-6h + Duration 7-14 days
Clindamycin 900mg IV q8h + Clindamycin 900mg IV q8h
Piperacillin-tazobactam 4.5g IV q8h* • Cefazolin + Clindamycin Also consider addition of:
• Vancomycin + Clindamycin IV + -Vibrio vulnificus: • Acyclovir IV for suspected HSV
Meropenem**1g IV q8h* • Doxycycline + ceftriaxone or VZV infection
(for severe penicillin allergy) -Aeromonas hydrophila: • Antifungal therapy in
**Prompt surgical consultation is • Doxycycline + ceftriaxone persistent or recurrent
recommended for aggressive infections • Doxycycline + ciprofloxacin infections
associated with s/sx systemic toxicity -Polymicrobial: vancomycin + pip/tazo

*requires dose adjustment for decreased renal function (See page 5) **ID/ASP review required † ID restricted antibiotic
 TREATMENT ALGORITHM: SKIN & SOFT TISSUE INFECTIONS (SSTI)
(Options are listed in order of preference)

*Antibiotic Dosing in Decreased Renal Function:

Antibiotic Clcr 30-50ml/min Clcr 10-29ml/min Clcr <10ml/min or HD
Cefazolin 1-2g q8h 1g q12h 1g q24h
Cefepime 1g q8h (neutropenic) 1g q12h (neutropenic) 1g q24h (neutropenic)
Ceftaroline †‡ 400mg q12h 300mg q12h 200mg q12h
Cefuroxime po 500mg BID 250mg BID 250-500mg daily
Cefuroxime IV 750mg-1.5g IV q8h 750mg-1.5g IV q12h 750mg-1.5g IV q24h
Cephalexin 500mg TID-QID 500mg TID 250-500mg daily
Ciprofloxacin 500mg BID 250mg BID 500mg daily
Dalbavancin † 1.5g or 1g f/b 500mg in 1wk 1.125g or 750mg f/b 375mg 1.125g or 750mg f/b 375mg
6mg/kg q24h 6mg/kg q48h 6mg/kg q48h
Daptomycin †
1g q12h (3hr infusion) 500mg q12h (3hr infusion) 500mg q24h (30min infusion)
Meropenem** 3.375g q8h (4hr infusion) <20ml/min: 3.375g q12h 4hr 2.25g q8h (HD, 30min infusion)
Piperacillin-tazobactam 1 DS tablet BID 1 DS tablet q24h Not recommended
TMP/SMX
**ID/ASP review required † ID restricted antibiotic ‡ q8h for S.aureus bacteremia
Source: Sharp Healthcare SARC-approved Renal Dosing

The above guidelines are recommendations based on available literature and are not intended to replace clinical
judgment.

These recommendations take on new importance because of a dramatic increase in the frequency and severity of infections and the
1
emergence of resistance to many of the antimicrobial agents commonly used to treat SSTIs in the past.

References:

1. Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue
Infections: 2014 Update by the Infectious Disease Society of America. Clin Infect Dis 2014;(6):1-43.
2. Intermountain Healthcare SSTI Treatment Algorithm 2014
3. Jeng A. Beheshti M, Li J, et al. The Role of Beta-hemolytic Streptococci in Causing Diffuse, Non-culturable Cellulitis: A
Prospective Investigation. Medicine 2010; 89:217-226
4. Moran, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S.Aureus Infections among Patients in the Emergency
Department. N Engl J Med 2006 Aug 17;355(7):666-74
5. Elliott D, Zaoutis T, Troxel A, et al. Empiric Antimicrobial Therapy for Pediatric Skin and Soft-Tissue Infections in the Era of
Methicillin-Resistant Staphylococcus aureus. Pediatrics 2009;123(6): e959-966
6. Wargo K, McCreary E, English T. Vancomycin Combined with Clindamycin for the Treatment of Acute Bacterial Skin and Skin-
Structure Infections. Clin Infect Dis. 2015 Oct 1;61:1148-54
7. Bland C, Bookstaver P. Double Gram-Positive Coverage for Acute Bacterial Skin and Skin Structure infections: Has the Eagle
Landed? Clin Infect Dis 2015;61:1155
8. Lipsky, B, Berendt A, Cornia P, et.al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis
and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012:45(12)132-173