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Home , Abscess, Carbuncle, Empiric therapy, Therapy

SKIN AND SOFT TISSUE

Clinical Setting Duration Comments Minor Skin Infections • Secondarily Mupirocin 2% topical ointment BID 7 days infected skin lesions such eczema, ulcers, or lacerations

INCISION AND DRAINAGE (I&D) IS RECOMMENDED AS PRIMARY MANAGEMENT, AND ARE NOT INDICATED UNLESS MEETS ONE OF THE , Furuncles, FOLLOWING CRITERIA: • Close clinical follow-up is and • Severe, extensive, rapidly recommended, especially in progressive , or abscess >2 no receiving - cm therapy collections of • Signs or symptoms of systemic illness • Cultures and susceptibility are within the • Elderly, immunosuppressed, active recommended when I&D is and deeper skin neoplasm or mellitus performed tissues • Circumstances where abscess is difficult to drain • Renal dose adjustment may be Furuncle - • Associated septic phlebitis required for and of the in • Inadequate response to I&D alone trimethoprim-sulfamethoxazole which purulent 5-7 days • resistance material extends EMPIRIC ORAL ANTIBIOTIC THERAPY FOR rates are lowest for TMP-SMX through the dermis OUTPATIENT THERAPY, OR ORAL STEP-DOWN (3%) and (4%), into the THERAPY MEETING ABOVE CRITERIA: compared to (43%). subcutaneous tissue, Preferred: where a small TMP-SMX* 1-2 DS tabs PO BID • Empiric therapy should target abscess forms MRSA until susceptibilities are Alternative: known, and then therapy should - Doxycycline 200 mg PO x1, then 100 be tailored. For patients with coalescence of mg PO BID MSSA, preferred oral step-down several furuncles therapy is cephalexin, TMP-SMX, into a single EMPIRIC IV ANTIBIOTIC THERAPY FOR or doxycycline if patient has inflammatory mass HOSPITALIZED PATIENTS: severe beta-lactam Preferred: Vancomycin* IV (see nomogram, AUC goal 400-600)

Clinical Setting Empiric Therapy Duration Comments

EMPIRIC IV ANTIBIOTIC THERAPY FOR HOSPITALIZED PATIENTS: Preferred: Cefazolin*2 g IV q8h

Alternative for patients with life- threatening penicillin allergy (in patients with or without risk for MRSA) Clindamycin 600 mg IV q8h Non-Purulent Cellulitis Alternative for patients at risk for MRSA non-purulent cellulitis: (Absence of purulent Vancomycin* IV (see nomogram, AUC drainage or exudate, goal 400-600) if MRSA coverage is • Blood cultures and cultures from ulceration, and no indicated 5 days for purulent SSTI are recommended associated abscess) patients with for patients with , rapidly Patients at risk for MRSA: rapid clinical progressive cellulitis, or signs of Empiric therapy for • Cellulitis worse on >48 hours of IV response. systemic illness β-hemolytic β-lactam therapy is • Known MRSA colonization Longer duration • Adjust therapy recommended. • Prior history of MRSA infection of therapy is based on culture results • Recent intravenous use indicated if If there is a concern • Severe or septic shock infection has • Consider initial aggressive dosing for necrotizing not improved of antibiotics if severe sepsis or fasciitis, please see EMPIRIC ORAL ANTIBIOTIC THERAPY FOR morbidly obese patient treatment OUTPATIENT THERAPY, OR ORAL STEP-DOWN recommendations THERAPY: listed under that Preferred section Cephalexin* 500 mg PO QID or 1000 mg PO TID + TMP-SMZ* 1-2 DS BID to cephalexin, if patient presents with risk factors for MRSA (listed above)

ALTERNATIVE FOR PATIENTS WITH LIFE- THREATENING PENICILLIN ALLERGY (IN PATIENTS WITH OR WITHOUT RISK FOR MRSA): Clindamycin 450 mg PO TID

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Clinical Setting Empiric Therapy Duration Comments EMPIRIC IV ANTIBIOTIC THERAPY FOR • Blood cultures and cultures from HOSPITALIZED PATIENTS: purulent SSTI are recommended Preferred: for patients with fever, rapidly Purulent Cellulitis Vancomycin* IV (see nomogram, AUC progressive cellulitis, or signs of

goal 400-600) systemic illness (Purulent drainage or exudate without Alternative for vancomycin, if 5-10 days • Staphylococcus aureus resistance a drainable abscess) documented allergy or intolerance: rates are lowest for TMP-SMX

Linezolid** 600 mg IV/PO BID Longer duration (3%) and doxycycline (4%), Empiric therapy for of therapy is compared to clindamycin (43%). CA-MRSA is EMPIRIC ORAL ANTIBIOTIC THERAPY FOR indicated if recommended OUTPATIENT THERAPY, OR ORAL STEP-DOWN infection has • Empiric therapy should target

THERAPY: not improved MRSA until susceptibilities are Therapy for β- Preferred: known, and then therapy should hemolytic TMP-SMX* 1-2 DS tabs PO BID be tailored. For patients with streptococci is likely MSSA, preferred oral step-down to be unnecessary Alternative: therapy is cephalexin, or TMP- Doxycycline 200 mg x1, then 100 mg SMX or doxycycline if patient has PO BID severe beta-lactam allergy

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Clinical Setting Empiric Therapy Duration Comments PREFERRED: Piperacillin-tazobactam* 4.5 g IV q6h + Clindamycin 900 mg IV q8h + Vancomycin* (see nomogram, AUC • Emergent surgical and infectious goal 400-600) consultation is Optimal recommended duration is ALTERNATIVE FOR PATIENTS WITH PENICILLIN Early and aggressive unknown but ALLERGY: • Clindamycin is initiated for anti- surgical exploration should be Mild Allergy- : toxin activity for Streptococcal and is continued for a Cefepime* 2 g IV q8h and Staphylococcal infections, critical minimum of 2-3 + Clindamycin 900 mg IV q8h and could be discontinued after 1- days after + Vancomycin* (see nomogram, 3 days if infection has improved Emergent surgical completion of AUC goal 400-600) and patient is stable (assuming consultation is surgical another antibiotic with anti- recommended debridement Anaphylaxis: anaerobic activity is also Aztreonam* 2 g IV q8h administered). + Clindamycin 900 mg IV q8h + Vancomycin* (see nomogram, AUC goal 400-600)

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Clinical Setting Empiric Therapy Duration Comments All systemic antimicrobial therapy should be used in combination with opening the incision and evacuation of infected material

PREFERRED EMPIRIC INPATIENT THERAPY FOR Superficial Surgical SUPERFICIAL SSI, WITHOUT RISK FOR MRSA OR • Risk factors for MRSA include: Site Infections GNR (SEE BELOW): o nasal colonization Cefazolin* 2 g IV q8h o prior MRSA infection Infections involving OR o recent hospitalization the subcutaneous Cephalexin 500 mg PO QID or 1000 mg o recent antibiotics tissue within 30 days PO TID for mild-moderate infection, or of operation oral step-down therapy • Adjunctive systemic antimicrobial therapy is not routinely For SSI involving ALTERNATIVE EMPIRIC INPATIENT THERAPY FOR recommended unless associated deep tissue or organ PATIENTS WITH HIGH RISK OF MRSA OR with significant systemic response space or PCN/CEPHALOSPORIN ALLERGY: complicated by Vancomycin* IV (see nomogram, AUC • Indications for systemic sepsis/septic shock, goal 400-600) include: 5 -7 days see below or organ and induration extending >5 cm specific guidelines EMPIRIC INPATIENT THERAPY FOR PATIENTS WITH Therapy may from wound edge, fever >38.5°C, (Intra-abdominal, HIGH RISK OF MRSA AND VANCOMYCIN ALLERGY need to be HR >110 beats/minute, WBC (NOT VANCOMYCIN INFUSION REACTION): Gynecology, extended based >12,000 Linezolid** 600 mg IV/PO q12h , on severity of OR • Antibiotics should be adjusted Endocarditis, Bone infection and TMP-SMX* 1-2 DS tabs PO BID for mild- based on , cultures and and Joint) response to moderate infection, or oral step-down sensitivities obtained from I&D treatment Suture removal plus therapy • Wound infection and systemic incision and EMPIRIC THERAPY FOR PATIENTS WITH SUPERFICIAL illness in the first 4 days drainage should be SSI FOLLOWING OPERATIONS OF THE AXILLA, (especially the first 48 hours) performed GASTROINTESTINAL TRACT, PERINEUM, OR FEMALE should prompt close wound If there is a concern GENITAL TRACT: examination for evidence of for necrotizing Cefazolin* 2 g IV q8h streptococcal or clostridial fasciitis, please refer + 500 mg PO/IV q8h necrotizing infection. See + Vancomycin* IV (see nomogram, AUC to that section necrotizing fasciitis section if goal 400-600), if risk for MRSA concern exists. OR Amoxicillin-clavulanate 875 mg PO BID • Consider initial aggressive dosing for mild-moderate infection, or oral of antibiotics in morbidly obese step-down therapy patient

CEPHALOSPORIN/PCN ANAPHYLAXIS: Aztreonam* 2 g IV q8h + Metronidazole 500 mg PO/IV q8h + Vancomycin* IV (see nomogram, AUC goal 400-600)

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Clinical Setting Empiric Therapy Duration Comments Deep tissue Surgical All systemic antimicrobial therapy should Site Infections or be used in combination with opening the any SSI complicated incision and evacuation of infected by sepsis/septic material shock

EMPIRIC INPATIENT THERAPY FOR DEEP TISSUE SSI Infections involving OR COMPLICATED BY SEPSIS/SEPTIC SHOCK: the deep fascia or Piperacillin-tazobactam* 4.5 g IV q6h muscle within 30 7-10 days + Vancomycin* IV (see nomogram, AUC days of operation goal 400-600) Therapy may

For SSI with organ need to be ALTERNATIVE WITH PCN ALLERGY WITHOUT space involvement, extended • Consider initial aggressive dosing of ANAPHYLAXIS, OR URTICARIA: see specific based on antibiotics if severe sepsis or Cefepime* 2 g IV q8h guidelines for Intra- severity of morbidly obese patient + Vancomycin* IV (see nomogram, AUC abdominal, goal 400-600) infection and Gynecologic, response to Meningitis, ALTERNATIVE WITH PCN ANAPHYLAXIS: treatment Endocarditis, and Aztreonam* 2 g IV q8h Bone and Joint for + Vancomycin* IV (see nomogram, AUC specific goal 400-600) recommendations

VANCOMYCIN ALTERNATIVE WITH NON- For necrotizing VANCOMYCIN INFUSION REACTIONS: infections, see Linezolid** 600 mg IV/PO q12h Necrotizing Fasciitis + Piperacillin-tazobactam* 4.5 g IV q6h section

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Clinical Setting Empiric Therapy Duration Comments PREFERRED INPATIENT THERAPY FOR HEMODYNAMICALLY STABLE PATIENTS WITH ACUTE INFECTION (<5 DAYS FROM INJURY), AND NO RISK FOR MRSA: -sulbactam* 3 g IV q6h

ALTERNATIVES FOR PCN ALLERGY WITHOUT ANAPHLAXIS, ANGIOEDEMA OR URTICARIA: Cefazolin* 2 g IV q8h + Metronidazole 500 mg PO/IV q8h • Risk factors for MRSA include: o nasal colonization PREFERRED INPATIENT THERAPY FOR PATIENTS WITH o prior MRSA infection HIGH RISK OF MRSA OR PCN/CEPHALOSPORIN ALLERGY: o recent hospitalization Metronidazole 500mg PO/IV q8h o recent antibiotics + Vancomycin* IV (see nomogram, AUC goal 400-600) • Traumatic wounds without Traumatic Wound evidence of local infection or Infections of ALTERNATIVE INPATIENT THERAPY FOR PATIENTS WITH systemic signs of infection Extremity HIGH RISK OF MRSA AND VANCOMYCIN ALLERGY (NOT typically do not need

VANCOMYCIN INFUSION REACTION): antimicrobial therapy beyond Usually Linezolid** 600 mg IV/PO BID appropriate surgical prophylaxis polymicrobial from + Metronidazole 500 mg PO/IV q8h 7-14 days environmental • Empiric therapy should take contamination into account site of wound, PREFERRED THERAPY IN PATIENTS WITH ANY OF THE prior cultures and colonization FOLLOWING: Therapy may need If there is a concern • Sepsis and traumatic wound infection to be extended • Debridement of devitalized for necrotizing • Development of infection >5 days after based on severity of tissues and contaminating fasciitis, please refer injury infection and debris critical to source control to that section • Significant exposure response to and successful healing

treatment Please see separate • Antibiotic therapy should be Piperacillin-tazobactam* 4.5 g IV q6h guidelines for bite tailored to results of deep tissue + Vancomycin* IV (see nomogram, AUC goal wounds or for Gram stain, culture and 400-600) wounds complicated sensitivities by or ALTERNATIVE FOR PATIENTS WITH PCN ALLERGY • Consider initial aggressive open fracture WITHOUT ANAPHYLAXIS: dosing of antibiotics if severe Cefepime *2 g IV q8h sepsis or morbidly obese + Metronidazole 500 mg PO/IV q8h patient + Vancomycin* IV (see nomogram, AUC goal • Osteomyelitis would require 6-8 400-600) weeks of therapy- please see osteomyelitis guidelines ALTERNATIVE FOR PATIENTS WITH PCN ANAPHYLAXIS: Aztreonam* 2 g IV q8h + Metronidazole 500 mg PO/IV q8h + Vancomycin* IV (see nomogram, AUC goal 400-600)

ALTERNATIVE FOR PATIENTS WITH VANCOMYCIN ALLERGY (NOT VANCOMYCIN INFUSION REACTION): Linezolid** 600 mg IV/PO BID + Piperacillin-tazobactam* 4.5 g IV q6h

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Clinical Setting Empiric Therapy Duration Comments INPATIENT TREATMENT FOR HEMODYNAMICALLY STABLE PATIENT PRESENTING WITH ACUTE DIABETIC FOOT INFECTION, WITHOUT RELAPSE OR REINFECTION: Vancomycin* IV (see nomogram, AUC goal 400-600) • Treatment should be modified to No gram-negative coverage is needed cover previously isolated for acute diabetic foot infection, unless: pathogens for patients with • wound was exposed to fresh recurrent or relapse infection of water (i.e., lake or river) the same site • patient received broad- spectrum antibiotic therapy in • Tailor therapy according to the previous 90 days 7-14 days culture data • recent hospitalization >2 days • Consider ID consult in the previous 90 days Therapy may • Surgical debridement is an Diabetic Foot IF PATIENT MEETS ANY OF THE ABOVE CRITERIA, OR need to be important component in Infections IF HEMODYNAMICALLY UNSTABLE: extended based management Piperacillin-tazobactam* 4.5 g IV q6h on severity of • Documented osteomyelitis may + Vancomycin* IV (see nomogram, AUC infection and require longer duration and a goal 400-600) response to higher antibiotic dosing regimen treatment ALTERNATIVE FOR PATIENTS WITH PENICILLIN • Consider initial aggressive dosing ALLERGY: of antibiotics if severe sepsis or Mild Allergy- Rash morbidly obese patient Cefepime* 2 g IV q8h • Osteomyelitis would require 6-8 + Metronidazole 500 mg IV/PO q8h weeks of therapy- please see + Vancomycin* IV (see nomogram, osteomyelitis guidelines AUC goal 400-600)

Life-threatening penicillin allergy Aztreonam* 2 g IV q8h + Metronidazole 500 mg IV/PO q8h + Vancomycin* IV (see nomogram, AUC goal 400-600)

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Clinical Setting Empiric Therapy Duration Comments Obtain deep tissue culture prior to • Blood cultures are recommended starting antibiotic therapy if patient is hemodynamically stable • When clinically indicated, evaluate for underlying PREFERRED EMPIRIC INPATIENT THERAPY: osteomyelitis Vancomycin* IV (see nomogram, AUC • Cultures of purulent drainage or goal 400-600) deep tissue cultures when + Piperacillin-tazobactam* 4.5 g IV q6h feasible are recommended (when gram-negative are suspected) • Tailor therapy according to culture data ALTERNATIVE ANTIMICROBIALS WHICH CAN BE Minimum of 14 • Consider ID consult SUBSTITUTED FOR PIPERACILLIN-TAZOBACTAM IN Complicated SSTI days THE SETTING OF PENICILLIN ALLERGY: • Surgical debridement is an without Mild Allergy- Rash important component in Osteomyelitis Duration may Cefepime *2 g IV q8h management be longer in the + Metronidazole 500 mg PO/IV q8h Decubitus or sacral setting of poor • Baseline CBCP and weekly CBCP + Vancomycin* IV (see nomogram, wound infection clinical are recommended with Linezolid AUC goal 400-600) response therapy due to risk of cytopenia, especially . Life-threatening penicillin allergy Alternative therapy should be Aztreonam* 2 g IV q8h considered in patients with + Metronidazole 500 mg PO/IV q8h thrombocytopenia + Vancomycin* IV (see nomogram, AUC goal 400-600) • Consider initial aggressive dosing of antibiotics if severe sepsis or ALTERNATIVES FOR VANCOMYCIN RESISTANCE, morbidly obese patient INTOLERANCE, OR ALLERGY (IN COMBINATION • Osteomyelitis would require 6-8 WITH GRAM-NEGATIVE AND ANAEROBIC weeks of therapy- please see COVERAGE, PER ABOVE): osteomyelitis guidelines Linezolid** 600 mg PO BID *Adjustment in dose is necessary with renal insufficiency **Complete information regarding drug interactions with linezolid

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References

1. Stevens DL, Bisno AL, ChamberHF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Society of America. Clinical Infectious Diseases 2014;59(2):e10-52. 2. Lipsky BA, Berendt RA, Cornia PB, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases 2012;54(12):132–173. 3. Liu C, Bayer A, Cosgrove SE, et al. 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;1-38.

Antimicrobial Subcommittee Approval: N/A Originated: Unknown P&T Approval: 06/2016 Last Revised: 09/2021 Revision History: 03/21: Adjusted vancomycin dosing & hyperlinks 09/21: Updated vancomycin infusion reaction terminology The recommendations in this guide are meant to serve as treatment guidelines for use at Michigan facilities. If you are an individual experiencing a medical emergency, call 911 immediately. These guidelines should not replace a provider’s professional medical advice based on clinical judgment, or be used in lieu of an Infectious Diseases consultation when necessary. As a result of ongoing research, practice guidelines may from time to time change. The authors of these guidelines have made all attempts to ensure the accuracy based on current information, however, due to ongoing research, users of these guidelines are strongly encouraged to confirm the information contained within them through an independent source.

If obtained from a source other than www.med.umich.edu/asp, please visit the webpage for the most up-to-date document.

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