Special Article Infection & https://doi.org/10.3947/ic.2017.49.4.301 Infect Chemother 2017;49(4):301-325 Chemotherapy ISSN 2093-2340 (Print) · ISSN 2092-6448 (Online) Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection Yee Gyung Kwak1,2*, Seong-Ho Choi3,4*, Tark Kim1,5*, Seong Yeon Park3,6*, Soo-Hong Seo7,8, Min Bom Kim9,10, Sang-Ho Choi2,11 1The Korean Society of Infectious Diseaes; 2Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang; 3The Korean Society for Chemotherapy; 4Department of Internal Medicine, Chung Ang University College of Medicine, Seoul; 5Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, Bucheon; 6Department of Internal Medicine, Dongguk University College of Medicine, Goyang; 7The Korean Dermatological Association; 8Department of Dermatology, Korea University College of Medicine, Seoul; 9The Korean Orthopaedic Association; 10Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul; 11Department of Infectious Diseases, Ulsan University College of Medicine, Seoul, Korea Skin and soft tissue infection (SSTI) is common and important infectious disease. This work represents an update to 2012 Korean guideline for SSTI. The present guideline was developed by the adaptation method. This clinical guideline provides recommen- dations for the diagnosis and management of SSTI, including impetigo/ecthyma, purulent skin and soft tissue infection, erysipe- las and cellulitis, necrotizing fasciitis, pyomyositis, clostridial myonecrosis, and human/animal bite. This guideline targets com- munity-acquired skin and soft tissue infection occurring among adult patients aged 16 years and older. Diabetic foot infection, surgery-related infection, and infections in immunocompromised patients were not included in this guideline. Key Words: Impetigo; Erysipelas; Cellulitis; Fasciitis; Pyomyositis Introduction and deciding on surgical treatments for purulent and necro- tizing infections. Proper care by the clinical physician can pro- 1. Background of guidelines mote speedy recovery in the patient, while also preventing se- Skin and soft tissue infection (SSTI) is a common infectious vere complications such as skin deformation, body defect, and disease. Clinical physicians who care for patients with SSTI death and preventing the abuse and misuse of broad-spectrum are responsible for determining the presence of an infection, antibiotics and expression of antibiotic-resistant bacteria. De- identifying the extent of infection, ascertaining the causative velopment of clinical practice guidelines that provide scientif- microorganism, administering the appropriate antibiotics, ic evidence for proper care by clinical physicians is very im- Received: September 27, 2017 Published online: December 21, 2017 Corresponding Author : Sang-Ho Choi, MD, PhD Department of Infectious Diseases, Ulsan University College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3304, Fax : +82-2-3010-6970, E-mail : [email protected] *These authors contributed equally This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and repro- duction in any medium, provided the original work is properly cited. Copyrights © 2017 by The Korean Society of Infectious Diseases | Korean Society for Chemotherapy www.icjournal.org 302 Kwak YG, et al. • Guidelines for skin and soft tissue infection www.icjournal.org portant. Up to now, various practice guidelines for SSTIs have 3. Recommended target groups for use of the been developed by numerous academic societies outside of guidelines Korea. In 2012, a practice guideline was developed by the Ko- This guideline is intended for general practitioners, resi- rean Society of Infectious Diseases (KSID) and Korean Society dents, and specialists responsible for inpatient, outpatient, for Chemotherapy (KSC). Revision of domestic guidelines for and emergency room care in medical institutions of various Korea was under consideration due to the accumulation of sizes, including primary care institutions. The guideline was new data and knowledge and epidemiological changes in the prepared so that it can be easily understood and referenced causative microorganisms. We developed the present guide- the user. line with support from the Korea Centers for Disease Control and Prevention in the effort to inhibit expression of antibiot- 4. Revision of the guidelines ic-resistant bacteria through the proper use of antibiotics. This guideline was prepared based on scientific articles pub- lished at the time of development. If new diagnostic and/or 2. Target groups and diseases excluded in the treatment methods are subsequently developed or important guidelines epidemiological changes in the causative microorganisms are This guideline targets community-acquired SSTI occurring found, revision of the guideline may be considered. Consider- among adult patients aged 16 years and older. The following ing the rate of epidemiological changes in bacteria and the infections were excluded from the guideline: infections in im- possible introduction of new antibiotics in Korea, it is expect- munosuppressed patients, such as patients who have recently ed that revision of this guideline may be needed in 4 to 5 undergone anticancer therapy, those currently taking immu- years. nosuppressants, and recipients of organ or bone marrow transplantation; surgery-related infection; and diabetic foot infection. Summary of Recommendations Recommendation Evidence Recommendations level level KQ 1. What are the appropriate diagnoses and treatments for impetigo and ecthyma? 1-1. Gram staining and bacterial culture testing are recommended for pus or exudate from Strong Moderate lesion(s). However, typical cases can be treated without testing. 1-2. Impetigo can be treated with oral antibiotics or antibiotic ointment. In cases of numerous Strong Moderate lesions or in outbreaks of poststreptococal glomerulonephritis due to specificStreptococ - cus pyogenes transmission, use of oral antibiotics is recommended. Ecthyma should be treated with oral antibiotics. 1-3. For oral antibiotic therapy, amoxicillin/clavulanate, first-generation cephalosporins, or Strong High clindamycin are recommended. For topical antibiotic therapy with ointment, mupirocin, fusidic acid, or retapamulin are recommended. 1-4. If methicillin-resistant Staphylococcus aureus (MRSA) is suspected or confirmed, doxycy- Strong Moderate cline, clindamycin, or trimethoprim/sulfamethoxazole are recommended for oral antibi- otic therapy. 1-5. Oral antibiotics should be used for 7 days and antibiotic ointment should be applied Strong High twice a day for 5 days. KQ 2. What tests are needed for purulent SSTI? 2-1. Gram staining and bacterial culture testing on pus samples from purulent SSTI are Strong Moderate recommended. However, typical cases may be treated without testing. KQ 3. What is the appropriate treatment for purulent SSTI? 3-1. Purulent SSTI can be treated by incision and drainage. Strong High www.icjournal.org https://doi.org/10.3947/ic.2017.49.4.301 • Infect Chemother 2017;49(4):301-325 303 Recommendation Evidence Recommendations level level 3-2. Use of antibiotics is recommended in cases of extensive cellulitis near the purulent Strong Low lesion, in patients with purulent SSTI presenting with systemic symptoms such as fever, or in immunosuppressed patients. KQ 4. What is the appropriate antibiotic therapy for purulent SSTI? 4-1. First-generation cephalosporins, amoxicillin/clavulanate, or clindamycin are recom- Strong Low mended as empirical antibiotics for purulent SSTI. Use of antibiotics active against MRSA may be considered in cases of previous MRSA infection, previous MRSA coloni- zation, and failed primary treatment. KQ 5. What is the appropriate treatment for recurrent skin abscess? 5-1. In cases where abscesses recur in the same area, it is necessary to look for the presence Strong Moderate of foreign materials and to identify and correct other local factors, such as hidradenitis suppurativa and pilonidal cyst. Moreover, incision and drainage, together with pus culture testing, should be performed early on. 5-2. Antibiotics should be used for 5–10 days against the isolated causative bacteria. Weak Low 5-3. For patients with recurrent skin abscess caused by S. aureus, intranasal application of Weak Low mupirocin ointment (twice a day for 5 days, every month), a chlorhexidine bath, and washing of personal items (towels, sheets, clothes, and so on) may be considered. KQ 6. What tests are needed for diagnosis of erysipelas and cellulitis? 6-1. Routine blood culture, aspiration culture, or punch biopsy culture for identification of the Strong Moderate causative bacteria of erysipelas and cellulitis is not recommended. However, blood culture, aspiration culture, or punch biopsy culture may be considered for Weak Moderate immunosuppressed patients, patients receiving anticancer therapy, patients with neutro- penia, those with immersion injury, and patients with infection from an animal bite. 6-2. Radiological examination for diagnosis of erysipelas and cellulitis is not required in most Weak Low cases. However, radiological examination may be required in cases suspected of involv- ing osteomyelitis or difficulty in differentiating from necrotizing fasciitis. KQ 7. What is the