Skin and Soft Tissue Infections

KALYANAKRISHNAN RAMAKRISHNAN, Dr.; ROBERT C. SALINAS, MD; and NELSON IVAN AGUDELO HIGUITA, MD, Academy of Oklahoma Health Sciences Middle, Oklahoma Urban center, Oklahoma

Am Fam Medico. 2015 Sep fifteen;92(vi):474-483.

Patient information: Encounter related handout on skin and soft tissue infections, written by the authors of this article.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Article Sections

  • Abstruse
  • Nomenclature
  • Risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Management
  • Special Considerations
  • References

Skin and soft tissue infections result from microbial invasion of the skin and its supporting structures. Management is determined by the severity and location of the infection and by patient comorbidities. Infections can be classified as uncomplicated (unproblematic) or complicated (necrotizing or nonnecrotizing), or every bit suppurative or nonsuppurative. Almost community-acquired infections are acquired by methicillin-resistant Staphylococcus aureus and beta-hemolytic streptococcus. Simple infections are normally monomicrobial and present with localized clinical findings. In dissimilarity, complicated infections can be mono- or polymicrobial and may present with systemic inflammatory response syndrome. The diagnosis is based on clinical evaluation. Laboratory testing may be required to confirm an uncertain diagnosis, evaluate for deep infections or sepsis, determine the need for inpatient care, and evaluate and care for comorbidities. Initial antimicrobial choice is empiric, and in uncomplicated infections should encompass Staphylococcus and Streptococcus species. Patients with complicated infections, including suspected necrotizing fasciitis and gangrene, require empiric polymicrobial antibiotic coverage, inpatient treatment, and surgical consultation for debridement. Superficial and small abscesses respond well to drainage and seldom require antibiotics. Immunocompromised patients crave early treatment and antimicrobial coverage for possible atypical organisms.

Skin and soft tissue infections (SSTIs) account for more than xiv million physician part visits each yr in the United states, likewise as emergency department visits and hospitalizations.ane The greatest incidence is amid persons 18 to 44 years of age, men, and blacks.1,2 Community-caused methicillin-resistant Staphylococcus aureus (MRSA) accounts for 59% of SSTIs presenting to the emergency department.3

SORT: KEY RECOMMENDATIONS FOR Exercise

Clinical recommendation Testify rating References

Claret cultures seldom change treatment and are not required in healthy immunocompetent patients with SSTIs.

C

xx

Simple purulent SSTIs in easily attainable areas without overlying cellulitis can be treated with incision and drainage only; antibiotic therapy does not improve outcomes.

C

29, 30

Inpatient treatment is recommended for patients with uncontrolled SSTIs despite adequate oral antibiotic therapy; those who cannot tolerate oral antibiotics; those who require surgery; those with initial severe or complicated SSTIs; and those with underlying unstable comorbid illnesses or signs of systemic sepsis.

C

3, 5

There is no testify that any pathogen-sensitive antibiotic is superior to another in the treatment of MRSA SSTIs.

B

35

Handling of necrotizing fasciitis involves early recognition and surgical debridement of necrotic tissue, combined with high-dose broad-spectrum intravenous antibiotics.

C

v

Best PRACTICES IN Infectious disease: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

Recommendation Sponsoring organization

Avoid antibiotics and wound cultures in emergency department patients with unproblematic pare and soft tissue abscesses after successful incision and drainage and with acceptable medical follow-up.

American College of Emergency Physicians

Classification

  • Abstruse
  • Classification
  • Risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Management
  • Special Considerations
  • References

SSTIs are classified as simple (uncomplicated) or complicated (necrotizing or nonnecrotizing) and tin can involve the peel, subcutaneous fat, fascial layers, and musculotendinous structures.four SSTIs can be purulent or nonpurulent (mild, moderate, or astringent).5  To help stratify clinical interventions, SSTIs tin exist classified based on their severity, presence of comorbidities, and demand for and nature of therapeutic intervention (Table 1).iii

Table i.

Classification Arrangement for Skin and Soft Tissue Infections

Class Description

1

Simple infection with no systemic signs or symptoms indicating spread* and no uncontrolled comorbidities that may complicate treatment; amenable to outpatient direction with topical or oral antimicrobials

ii

Infection with systemic signs or symptoms indicating spread* or with stable comorbidities, or infection without systemic spread but with uncontrolled comorbidities; may require inpatient management or parenteral antibiotics

3

Infection with signs or symptoms of systemic spread* or uncontrolled comorbidities; inpatient management with parenteral antibiotics required

4

Infection with signs of potentially fatal systemic sepsis† requiring parenteral antibiotics; inpatient management (possibly in critical care unit) required, surgery may be indicated

Simple infections bars to the skin and underlying superficial soft tissues generally respond well to outpatient management. Common simple SSTIs include cellulitis, erysipelas, impetigo, ecthyma, folliculitis, furuncles, carbuncles, abscesses, and trauma-related infections6 (Figures one through three). Complicated infections extending into and involving the underlying deep tissues include deep abscesses, decubitus ulcers, necrotizing fasciitis, Fournier gangrene, and infections from human being or creature bites7 (Effigy iv). These infections may present with features of systemic inflammatory response syndrome or sepsis, and, occasionally, ischemic necrosis. Perianal infections, diabetic foot infections, infections in patients with significant comorbidities, and infections from resistant pathogens also correspond complicated infections.8

Effigy ane.

Cellulitis inductive to abdominal wall.

Figure 2.

Abscess over left gluteal region.

Figure 3.

Furuncle.

Figure 4.

Pyoderma gangrenosum.

Gamble Factors

  • Abstract
  • Classification
  • Run a risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Direction
  • Special Considerations
  • References

Older age, cardiopulmonary or hepatorenal affliction, diabetes mellitus, debility, immunosenescence or immunocompromise, obesity, peripheral arteriovenous or lymphatic insufficiency, and trauma are amid the risk factors for SSTIs (Tabular array 2).9–11 Outbreaks are more common among military personnel during overseas deployment and athletes participating in shut-contact sports.12,xiii Community-acquired MRSA causes infection in a broad diversity of hosts, from healthy children and young adults to persons with comorbidities, health care professionals, and persons living in shut quarters.

Table 2.

Take chances Factors for Skin and Soft Tissue Infections

Age (children,* older adults)

Alcohol corruption†

Asplenia

Cardiopulmonary affliction

Decrepitude

Diabetes mellitus†‡

Dialysis (peritoneal, hemodialysis)‡

Wellness intendance professional*

Hepatorenal disease

Homo or animal bites

Immunocompromise (due east.g., human immunodeficiency virus infection, chemotherapy, antiretroviral therapy, disease-modifying antirheumatic drugs)

Immunosenescence

Long-term care‡

Long-term intravascular access‡

Lymphedema or lymphatic insufficiency

Military personnel*

Obesity

Peripheral arteriovenous insufficiency

Peripheral neuropathy

Poor diet†

Prolonged hospitalization‡

Sports participation†

Subcutaneous or intravenous drug use

Trauma (including surgery)†

Water exposure (e.g., ocean, hot tubs)

Predisposing factors for SSTIs include reduced tissue vascularity and oxygenation, increased peripheral fluid stasis and adventure of skin trauma, and decreased ability to gainsay infections. For example, diabetes increases the run a risk of infection-associated complications fivefold.14  Comorbidities and mechanisms of injury tin can determine the bacteriology of SSTIs (Table 3).5,15 For instance, Pseudomonas aeruginosa infections are associated with intravenous drug use and hot tub use, and patients with neutropenia more than often develop infections caused by gram-negative leaner, anaerobes, and fungi.

Table iii.

Bacteriology and Clinical Features of Pare and Soft Tissue Infections

Infection Microbiology Clinical features

Abscess

Staphylococcus aureus, Streptococcus, anaerobes (often polymicrobial)

Drove of pus with surrounding granulation; painful swelling with induration and central fluctuance; possible overlying skin necrosis; signs or symptoms of infection*; features adulterate in common cold abscess; recurrent abscesses with sinus tracts and scarring in axillae and groin occur in hidradenitis suppurativa

Bites (man, animate being)

Polymicrobial (Bacteroides, Bartonella henselae, Capnocytophaga canimorsus, Eikenella corrodens, Pasteurella multocida, Peptostreptococcus, S. aureus, Streptobacillus moniliformis)

Cat bites become infected more oftentimes than dog or man bites (30% to l%, up to 20%, and 10% to 50%, respectively); infection sets in 8 to 12 hours after animal bites; homo bites may transmit canker, hepatitis, or human immunodeficiency virus; may involve tendons, tendon sheaths, os, and joints

Clostridial myonecrosis (gas gangrene)

Clostridium (unremarkably C. perfringens, C. septicum)

Traumatic or spontaneous; severe pain at injury site followed by skin changes (e.thou., pale, bronze, purplish ruby-red), tenderness, induration, blistering, and tissue crepitus; diaphoresis, fever, hypotension, and tachycardia

Erysipelas, cellulitis

Beta-hemolytic streptococci, Haemophilus influenzae (children), S. aureus

Erysipelas: usually over face, ears, or lower legs; distinctly raised inflamed skin

Cellulitis: over areas of skin breakup

Signs or symptoms of infection,* lymphangitis or lymphadenitis, leukocytosis

Folliculitis

Candida, dermatophytes, Pseudomonas aeruginosa, Due south. aureus

Infection or inflammation of the pilus follicles; tends to occur in areas with increased sweating; associated with acne or steroid use; painful or painless pustule with underlying swelling

Fournier gangrene

Polymicrobial

Genital, groin, or perineal involvement; cellulitis, and signs or symptoms of infection* followed by suppuration and necrosis of overlying skin

Furuncle, carbuncle (deep folliculitis)

S. aureus

Walled-off collection of pus; painful, firm swelling; systemic features of infection; carbuncles are larger, deeper, and involve skin and subcutaneous tissue over thicker skin of cervix, dorsum, and lateral thighs, and drain through multiple pores

Impetigo (non-bullous, bullous)

Beta-hemolytic streptococci, South. aureus

Common in infants and children; affects skin of olfactory organ, oral fissure, or limbs; mild soreness, redness, vesicles, and crusting; may cause glomerulonephritis; vesicles may overstate (bullae); may spread to lymph nodes, os, joints, or lung

Necrotizing fasciitis

Type 1: polymicrobial

Spreading infection of subcutaneous tissue; usually affects genitalia, perineum, or lower extremities; severe, constant hurting; signs or symptoms of infection*; overlying redness and cutaneous anesthesia; edema and induration of apparently uninvolved tissues; skin crepitus; progression despite antibiotics

Type two: monomicrobial

Pathogenesis

  • Abstruse
  • Classification
  • Run a risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Management
  • Special Considerations
  • References

Most SSTIs occur de novo, or follow a breach in the protective pare barrier from trauma, surgery, or increased tissue tension secondary to fluid stasis. The infection may besides originate from an adjacent site or from embolic spread from a distant site. Southward. aureus and streptococci are responsible for most elementary community-caused SSTIs. In i prospective report, beta-hemolytic streptococcus was found to cause about 3-fourths of cases of lengthened cellulitis.16 S. aureus, P. aeruginosa, enterococcus, and Escherichia coli are the predominant organisms isolated from hospitalized patients with SSTIs.17 MRSA infections are characterized by liquefaction of infected tissue and abscess formation; the resulting increase in tissue tension causes ischemia and overlying pare necrosis. Lymphatic and hematogenous dissemination causes septicemia and spread to other organs (e.g., lung, bone, center valves). Diabetic lower limb infections, astringent hospital-caused infections, necrotizing infections, and caput and hand infections pose higher risks of mortality and functional disability.9

Clinical Presentation

  • Abstract
  • Classification
  • Risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Management
  • Special Considerations
  • References

Patients with simple SSTIs nowadays with erythema, warmth, edema, and pain over the affected site. Systemic features of infection may follow, their intensity reflecting the magnitude of infection. The lower extremities are nigh commonly involved.9 Induration is characteristic of more superficial infections such as erysipelas and cellulitis. Patients with necrotizing fasciitis may accept hurting disproportionate to the physical findings, rapid progression of infection, cutaneous anesthesia, hemorrhage or bullous changes, and crepitus indicating gas in the soft tissues.v Tense overlying edema and bullae, when present, aid distinguish necrotizing fasciitis from non-necrotizing infections.18

Diagnosis

  • Abstract
  • Classification
  • Chance Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Direction
  • Special Considerations
  • References

The diagnosis of SSTIs is predominantly clinical. A complete blood count, C-reactive protein level, and liver and kidney function tests should be ordered for patients with severe infections, and for those with comorbidities causing organ dysfunction. The Laboratory Risk Indicator for Necrotizing Fasciitis score uses laboratory parameters to stratify patients into high- and low-adventure categories for necrotizing fasciitis (Tabular array 4); a score of 6 or higher is indicative, whereas a score of 8 or college is strongly predictive (positive predictive value = 93.iv%).xix

Table 4.

Laboratory Risk Indicator for Necrotizing Fasciitis

Laboratory value Score

C-reactive protein

< 150 mg per L (< 1,430 nmol per L)

0

≥ 150 mg per Fifty

four

Creatinine

≤ 1.six mg per dL (≤ 141 μmol per L)

0

> 1.vi mg per dL

two

Glucose

≤ 180 mg per dL (≤ 10 mmol per L)

0

> 180 mg per dL

1

Hemoglobin

> 13.5 g per dL (> 135 m per L)

0

11 to 13.5 g per dL (110 to 135 one thousand per L)

1

< 11 chiliad per dL

2

Sodium

≥ 135 mEq per 50 (≥ 135 mmol per L)

0

< 135 mEq per L

2

Total white blood cells

< 15,000 per mm3 (< 15.0 × 109 per 50)

0

15,000 to 25,000 per mm3 (xv.0 × x9 to 25.0 × tenix per L)

1

> 25,000 per mmiii

2

Blood cultures are unlikely to change the management of simple localized SSTIs in otherwise salubrious, immunocompetent patients, and are typically unnecessary.xx Even so, because of the potential for deep tissue involvement, cultures are useful in patients with severe infections or signs of systemic interest, in older or immunocompromised patients, and in patients requiring surgery.5,21,22 Wound cultures are not indicated in most healthy patients, including those with suspected MRSA infection, only are useful in immunocompromised patients and those with significant cellulitis; lymphangitis; sepsis; recurrent, persistent, or large abscesses; or infections from human being or animate being bites.22,23 Tissue biopsies, which are the preferred diagnostic test for necrotizing SSTIs, are ideally taken from the advancing margin of the wound, from the depth of seize with teeth wounds, and after debridement of necrotizing infections and traumatic wounds. Sterile aspiration of infected tissue is some other recommended sampling method, preferably before commencing antibiotic therapy.22

Imaging studies are non indicated for simple SSTIs, and surgery should not exist delayed for imaging. Obviously radiography, ultrasonography, computed tomography, or magnetic resonance imaging may show soft tissue edema or fascial thickening, fluid collections, or soft tissue air. Magnetic resonance imaging is highly sensitive (100%) for necrotizing fasciitis; specificity is lower (86%).24 Extensive involvement of the deep intermuscular fascia, fascial thickening (more than 3 mm), and fractional or complete absence of indicate enhancement of the thickened fasciae on postgadolinium images suggest necrotizing fasciitis.25 Calculation ultrasonography to clinical exam in children and adolescents with clinically suspected SSTI increases the accurateness of diagnosing the extent and depth of infection (sensitivity = 77.6% vs. 43.7%; specificity = 61.three% vs. 42.0%, respectively).26

Management

  • Abstract
  • Nomenclature
  • Risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Direction
  • Special Considerations
  • References

The direction of SSTIs is determined primarily by their severity and location, and past the patient's comorbidities (Figure 5). According to guidelines from the Infectious Diseases Society of America, initial management is determined by the presence or absence of purulence, acuity, and type of infection.v

Initial Management of a Patient with Skin and Soft Tissue Infection

Figure v.

Initial management of peel and soft tissue infections. (MRSA = methicillin-resistant Staphylococcus aureus; MSSA = methicillin-sensitive Southward. aureus.)

MILD TO MODERATE INFECTIONS

Topical antibiotics (e.yard., mupirocin [Bactroban], retapamulin [Altabax]) are options in patients with impetigo and folliculitis (Table 5).v,27 Beta-lactams are constructive in children with nonpurulent SSTIs, such as uncomplicated cellulitis or impetigo.28 In adults, mild to moderate SSTIs respond well to beta-lactams in the absence of suppuration.xvi Patients who do non amend or who worsen later 48 hours of treatment should receive antibiotics to cover possible MRSA infection and imaging to detect purulence.16

Tabular array v.

Antibiotic Choices for Mild to Moderate Skin and Soft Tissue Infections in Adults and Children

Antibiotic Dosage Comments

Amoxicillin/clavulanate (Augmentin)

Adults: 500 mg orally 2 times per twenty-four hour period or 250 mg orally 3 times per mean solar day

Children younger than iii months and less than twoscore kg (89 lb): 25 to 45 mg per kg per day (amoxicillin component), divided every 12 hours

Children older than 3 months and forty kg or more: xxx mg per kg per day, divided every 12 hours

For impetigo; human being or animal bites; and MSSA, Escherichia coli, or Klebsiella infections

Common adverse effects: diaper rash, diarrhea, nausea, vaginal mycosis, vomiting

Rare agin effects: agranulocytosis, hepatorenal dysfunction, hypersensitivity reactions, pseudomembranous enterocolitis

Cefazolin*

Adults: 250 to 500 mg Four or IM every viii hours (500 to 1,500 mg Four or IM every 6 to 8 hours for moderate to astringent infections)

Children: 25 to 100 mg per kg per day Four or IM in 3 or 4 divided doses

For MSSA infections and man or creature bites

Common adverse effects: diarrhea, drug-induced eosinophilia, pruritus

Rare adverse effects: anaphylaxis, colitis, encephalopathy, renal failure, seizure, Stevens-Johnson syndrome

Cephalexin (Keflex)

Adults: 500 mg orally iv times per day

Children: 25 to fifty mg per kg per solar day in 2 divided doses

For MSSA infections, impetigo, and man or beast bites; twice-daily dosing is an pick

Common adverse result: diarrhea

Rare adverse effects: anaphylaxis, angioedema, interstitial nephritis, pseudomembranous enterocolitis, Stevens-Johnson syndrome

Clindamycin*

Adults: 150 to 450 mg orally 4 times per twenty-four hours (300 to 450 mg orally 4 times per solar day for v to x days for MRSA infection; 600 mg orally or 4 3 times per mean solar day for 7 to 14 days for complicated infections)

Children: 16 mg per kg per 24-hour interval in 3 or 4 divided doses (16 to 20 mg per kg per day for more astringent infections; 40 mg per kg per solar day in three or 4 divided doses for MRSA infection)

For impetigo; MSSA, MRSA, and clostridial infections; and human being or fauna bites

Common adverse effects: abdominal hurting, diarrhea, nausea, rash

Rare adverse effects: agranulocytosis, elevated liver enzyme levels, erythema multiforme, jaundice, pseudomembranous enterocolitis

Dicloxacillin

Adults: 125 to 500 mg orally every 6 hours (maximal dosage, 2 1000 per 24-hour interval)

Children less than forty kg: 12.5 to fifty mg per kg per day divided every half dozen hours

Children 40 kg or more than: 125 to 500 mg every 6 hours

For MSSA infections

Mutual adverse furnishings: diarrhea, impetigo, nausea, airsickness

Rare agin furnishings: anaphylaxis, hemorrhagic colitis, hepatorenal toxicity

Doxycycline or minocycline (Minocin)

Adults: 100 mg orally 2 times per twenty-four hour period

Children 8 years and older and less than 45 kg (100 lb): iv mg per kg per day in ii divided doses

Children eight years and older and 45 kg or more: 100 mg orally 2 times per twenty-four hours

For MRSA infections and homo or animal bites; not recommended for children younger than 8 years

Common adverse effects: myalgia, photosensitivity

Rare adverse effects: Clostridium difficile colitis, hepatotoxicity, pseudotumor cerebri, Stevens-Johnson syndrome

Fluoroquinolones

Adults: ciprofloxacin (Cipro), 500 to 750 mg orally 2 times per day or 400 mg Iv two times per day; gatifloxacin or moxifloxacin (Avelox), 400 mg orally or IV per day

For human or beast bites; not useful in MRSA infections; not recommended for children

Common adverse effects: diarrhea, headache, nausea, rash, airsickness

Rare adverse effects: agranulocytosis, arrhythmias, hepatorenal failure, tendon rupture

Mupirocin (Bactroban)*

2% ointment applied 3 times per day for 3 to 5 days

For MRSA impetigo and folliculitis; not recommended for children younger than 2 months

Rare adverse effects: burning over application site, pruritus

Retapamulin (Altabax)*

ane% ointment practical ii times per mean solar day for 5 days

For MSSA impetigo; not recommended for children younger than 9 months

Rare adverse effects: allergy, angioedema, application site irritation

Trimethoprim/sulfamethoxazole

Adults: i or 2 double-strength tablets two times per 24-hour interval

Children: 8 to 12 mg per kg per day (trimethoprim component) orally in 2 divided doses or IV in 4 divided doses

For MRSA infections and homo or animal bites; contraindicated in children younger than two months

Mutual agin effects: anorexia, nausea, rash, urticaria, airsickness

Rare adverse effects: agranulocytosis, C. difficile colitis, erythema multiforme, hepatic necrosis, hyponatremia, rhabdomyolysis, Stevens-Johnson syndrome

Balmy purulent SSTIs in easily accessible areas without significant overlying cellulitis tin be treated with incision and drainage alone.29,30 In children, minimally invasive techniques (e.m., stab incision, hemostat rupture of septations, in-dwelling drain placement) are effective, reduce morbidity and hospital stay, and are more economical compared with traditional drainage and wound packing.31

Antibiotic therapy is required for abscesses that are associated with all-encompassing cellulitis, rapid progression, or poor response to initial drainage; that involve specific sites (due east.g., face, hands, genitalia); and that occur in children and older adults or in those who have significant comorbid illness or immunosuppression.32 In uncomplicated cellulitis, five days of treatment is equally effective every bit 10 days.33 In a randomized controlled trial of 200 children with uncomplicated SSTIs primarily caused by MRSA, clindamycin and cephalexin (Keflex) were equally constructive.34

Severe INFECTIONS

Inpatient treatment is necessary for patients who take uncontrolled infection despite adequate outpatient antimicrobial therapy or who cannot tolerate oral antibiotics (Figure 6). Hospitalization is also indicated for patients who initially nowadays with astringent or complicated infections, unstable comorbid illnesses, or signs of systemic sepsis, or who demand surgical intervention nether anesthesia.3,v Wide-spectrum antibiotics with proven effectiveness against gram-positive and gram-negative organisms and anaerobes should be used until pathogen-specific sensitivities are available; coverage can then be narrowed. Intravenous antibiotics should be continued until the clinical moving picture improves, the patient tin tolerate oral intake, and drainage or debridement is completed. The recommended elapsing of antibody therapy for hospitalized patients is seven to fourteen days. A Cochrane review did not establish the superiority of any i pathogen-sensitive antibody over another in the treatment of MRSA SSTI.35 Intravenous antibiotics may exist continued at dwelling house under close supervision afterward initiation in the infirmary or emergency section.36  Antibiotic choices for severe infections (including MRSA SSTI) are outlined in Table 6.5,27

Inpatient Management of a Patient with Skin and Soft Tissue Infection

Figure 6.

Inpatient management of skin and soft tissue infections. (MRSA = methicillin-resistant Staphylococcus aureus.)

Table 6.

Antibody Choices for Necrotizing and Other Complicated Skin and Soft Tissue Infections in Adults and Children

Antibody Dosage Comments

Carbapenems

For polymicrobial necrotizing infections; rubber of imipenem/cilastatin in children younger than 12 years is not known

Mutual agin effects: anemia, constipation, diarrhea, headache, injection site pain and inflammation, nausea, vomiting

Rare adverse effects: astute coronary syndrome, angioedema, haemorrhage, Clostridium difficile colitis, congestive heart failure, hepatorenal failure, respiratory failure, seizures, vaginitis

Ertapenem (Invanz)

Adults: ane g IV per day

Children 3 months to 12 years: fifteen mg per kg IV every 12 hours, up to 1 g per day

Imipenem/cilastatin (Primaxin)

Adults: 1 g IV every 6 to 8 hours

Children: 25 mg per kg IV every 6 to 12 hours, up to 4 1000 per twenty-four hours

Meropenem (Merrem Iv)

Adults: i g IV every 8 hours

Children: 10 mg per kg (upwards to 500 mg) 4 every eight hours; increase to 20 mg per kg (upwards to ane k) IV every viii hours for Pseudomonas infections

Cefotaxime (Claforan)

Adults: 2 g IV every 6 hours

Children: fifty mg per kg IV every six hours

Used with metronidazole (Flagyl) or clindamycin for initial handling of polymicrobial necrotizing infections

Common adverse effects: diarrhea, hurting and thrombophlebitis at injection site, vomiting

Rare adverse effects: agranulocytosis, arrhythmias, erythema multiforme

Ceftaroline (Teflaro)

Adults: 600 mg Iv every 12 hours for 5 to 14 days

Unknown safety in children

Dose adjustment required in patients with renal harm

Rare adverse furnishings: abdominal pain, arrhythmias, C. difficile colitis, diarrhea, dizziness, fever, hepatitis, rash, renal insufficiency, seizures, thrombophlebitis, urticaria, airsickness

Ceftriaxone (Rocephin)

Adults: 1 to 2 g Four every 24 hours

Children: 50 to 75 mg per kg Four or IM one time per 24-hour interval or divided every 12 hours, up to two one thousand per day

Useful in waterborne infections; used with doxycycline for Aeromonas hydrophila and Vibrio vulnificus infections

Common agin effects: diarrhea, elevated platelet levels, eosinophilia, induration at injection site

Rare adverse furnishings: C. difficile colitis, erythema multiforme, hemolytic anemia, hyperbilirubinemia in newborns, pulmonary injury, renal failure

Dalbavancin (Dalvance)

Adults: i,000 mg 4 initial dose, followed by 500 mg Four 1 week later

Not recommended in children

For MSSA and MRSA infections

Common adverse furnishings: constipation, diarrhea, headache, nausea

Rare adverse effects: C. difficile colitis, gastrointestinal hemorrhage, hepatotoxicity, infusion reaction

Dalfopristin/quinupristin (Synercid)

Adults and children 12 years and older: 7.5 mg per kg IV every 12 hours

For complicated MSSA and MRSA infections, especially in neutropenic patients and vancomycin-resistant infections

Mutual adverse effects: arthralgia, diarrhea, edema, hyperbilirubinemia, inflammation at injection site, myalgia, nausea, hurting, rash, vomiting

Rare adverse furnishings: arrhythmias, cerebrovascular events, encephalopathy, hemolytic anemia, hepatitis, myocardial infarction, pancytopenia, syncope

Daptomycin (Cubicin)

Adults: 4 mg per kg Iv per twenty-four hour period for 7 to xiv days

Not recommended in children

For MRSA infections

Common adverse effects: diarrhea, throat pain, vomiting

Rare agin effects: gram-negative infections, pulmonary eosinophilia, renal failure, rhabdomyolysis

Doxycycline

Adults: 100 mg Iv every 12 hours

Children 8 years and older and less than 45 kg (100 lb): 4 mg per kg IV per day in 2 divided doses

Children eight years and older and 45 kg or more: 100 mg IV every 12 hours

Useful in waterborne infections; used with ciprofloxacin (Cipro), ceftriaxone, or cefotaxime in A. hydrophila and V. vulnificus infections

Common agin effects: diarrhea, photosensitivity

Rare agin effects: C. difficile colitis, erythema multiforme, liver toxicity, pseudotumor cerebri

Linezolid (Zyvox)

Adults: 600 mg Iv or orally every 12 hours for 7 to xiv days

Children 12 years and older: 600 mg 4 or orally every 12 hours for x to xiv days

Children younger than 12 years: 10 mg per kg IV or orally every eight hours for 10 to 14 days

For MRSA infections

Common adverse effects: diarrhea, headache, nausea, airsickness

Rare adverse effects: C. difficile colitis, hepatic injury, lactic acidosis, myelosuppression, optic neuritis, peripheral neuropathy, seizures

Metronidazole

Adults: 600 to 900 mg IV every 8 hours

Children: 10 to 13 mg per kg IV every eight hours

Used with cefotaxime for initial treatment of polymicrobial necrotizing infections

Common adverse effects: abdominal pain, contradistinct taste, diarrhea, dizziness, headache, nausea, vaginitis

Rare agin effects: aseptic meningitis, encephalopathy, hemolyticuremic syndrome, leukopenia, optic neuropathy, ototoxicity, peripheral neuropathy, Stevens-Johnson syndrome

Oritavancin (Orbactiv)

Adults: 1,200-mg infusion over iii hours

Not indicated in children

For MSSA, MRSA, and Enterococcus faecalis infections

Common adverse furnishings: headache, nausea, airsickness

Rare agin effects: C. difficile colitis, clotting abnormalities, hypersensitivity, infusion complications (thrombophlebitis), osteomyelitis

Oxacillin or nafcillin

Adults: one to 2 g Iv every iv hours

Children: 25 mg per kg IM 2 times per mean solar day

For necrotizing fasciitis acquired by sensitive staphylococci

Rare adverse effects: anaphylaxis, bone marrow suppression, hypokalemia, interstitial nephritis, pseudomembranous enterocolitis

Penicillin plus clindamycin

Adults: 2 to 4 million units penicillin IV every 6 hours plus 600 to 900 mg clindamycin IV every 8 hours

Children: 60,000 to 100,000 units penicillin per kg Four every 6 hours plus 10 to 13 mg clindamycin per kg Four per twenty-four hours in 3 divided doses

For MRSA infections in children: 40 mg per kg IV per day in 3 or 4 divided doses

Combined therapy for necrotizing fasciitis caused by streptococci; either drug is effective in clostridial infections

Adverse effects from penicillin are rare in nonallergic patients

Mutual adverse effects of clindamycin: intestinal pain, diarrhea, nausea, rash

Rare adverse effects of clindamycin: agranulocytosis, elevated liver enzyme levels, erythema multiforme, jaundice, pseudomembranous enterocolitis

Piperacillin/tazobactam (Zosyn)

Adults: iii.375 g 4 every half-dozen to 8 hours

Children: 60 to 75 mg per kg (piperacillin component) Iv every 6 hours

First-line antimicrobial for treating polymicrobial necrotizing infections

Mutual agin effects: constipation, diarrhea, fever, headache, insomnia, nausea, pruritus, vomiting

Rare adverse furnishings: agranulocytosis, C. difficile colitis, encephalopathy, hepatorenal failure, Stevens-Johnson syndrome

Telavancin (Vibativ)

Adults: x mg per kg IV per day for seven to fourteen days

Not recommended in children

For MSSA and MRSA infections; women of childbearing age should use two forms of birth control during handling

Common adverse effects: altered taste, nausea, vomiting

Rare adverse effects: hypersensitivity, prolonged QT interval, renal insufficiency

Tigecycline (Tygacil)

Adults: 100 mg IV followed by l mg IV every 12 hours for 5 to 14 days

Not recommended in children

For MRSA infections; increases bloodshed chance; considered medication of terminal resort

Common adverse effects: abdominal pain, diarrhea, nausea, vomiting

Rare agin effects: anaphylaxis, C. difficile colitis, liver dysfunction, pancreatitis, pseudotumor cerebri, septic shock

Vancomycin

Adults: 15 mg per kg IV every 12 hours

Children: 10 mg per kg IV every 6 hours

Parenteral drug of pick for MRSA infections in patients allergic to penicillin; 7- to 14-day course for pare and soft tissue infections; vi-week course for bacteremia; maintain trough levels at 10 to 20 mg per L

Common adverse effects: abdominal pain, diarrhea, nausea, vomiting

Rare adverse effects: agranulocytosis, anaphylaxis, C. difficile colitis, hypotension, nephrotoxicity, ototoxicity

Necrotizing Fasciitis. Treatment of necrotizing fasciitis involves early recognition and surgical consultation for debridement of necrotic tissue combined with empiric high-dose intravenous broad-spectrum antibiotics.5 The antibiotic spectrum can be narrowed one time the infecting microbes are identified and susceptibility testing results are available. Monomicrobial necrotizing fasciitis caused by streptococcal and clostridial infections is treated with penicillin G and clindamycin; S. aureus infections are treated according to susceptibilities. Antibiotic therapy should be continued until features of sepsis accept resolved and surgery is completed. Patients may require repeated surgery until debridement and drainage are complete and healing has commenced.

Special Considerations

  • Abstract
  • Classification
  • Risk Factors
  • Pathogenesis
  • Clinical Presentation
  • Diagnosis
  • Management
  • Special Considerations
  • References

Immunocompromised patients are more prone to SSTIs and may non demonstrate classic clinical features and laboratory findings considering of their attenuated inflammatory response. Diagnostic testing should exist performed early to identify the causative organism and evaluate the extent of involvement, and antibiotic therapy should be commenced to cover possible pathogens, including atypical organisms that tin cause serious infections (e.thou., resistant gram-negative leaner, anaerobes, fungi).5

Specific types of SSTIs may consequence from identifiable exposures. Dog and true cat bites in an immunocompromised host and those that involve the face or hand, periosteum, or articulation capsule are typically treated with a beta-lactam antibiotic or beta-lactamase inhibitor (east.g., amoxicillin/clavulanate [Augmentin]).5 In patients allergic to penicillin, a combination of trimethoprim/sulfamethoxazole or a quinolone with clindamycin or metronidazole (Flagyl) can exist used. A recent article in American Family unit Physician provides farther details about prophylaxis in patients with cat or dog bites (https://www.aafp.org/afp/2014/0815/p239.html).37

Simple SSTIs that result from exposure to fresh water are treated empirically with a quinolone, whereas doxycycline is used for those that occur after exposure to salt water. The choice is based on the presumptive infecting organisms (e.g., Aeromonas hydrophila, Vibrio vulnificus, Mycobacterium marinum).5

In patients with at to the lowest degree 1 prior episode of cellulitis, administering prophylactic oral penicillin, 250 mg twice daily for six months, reduces the adventure of recurrence for up to three years by 47%.38

Data Sources: A PubMed search was completed using the key term skin and soft tissue infections. The search included systematic reviews, meta-analyses, reviews of clinical trials and other main sources, and prove-based guidelines. As well searched were the Cochrane database, the National Institute for Health and Care Excellence guidelines, and Essential Show Plus. Search dates: May 7, 2014, through May 27, 2015.

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The Authors

prove all writer info

KALYANAKRISHNAN RAMAKRISHNAN, MD, is a professor of family unit and preventive medicine at the Academy of Oklahoma Health Sciences Center in Oklahoma City....

ROBERT C. SALINAS, MD, is an acquaintance professor of family unit and preventive medicine at the University of Oklahoma Health Sciences Center.

NELSON IVAN AGUDELO HIGUITA, Doctor, is an assistant professor of infectious disease in the Internal Medicine Division at the University of Oklahoma Health Sciences Center.

Address correspondence to Kalyanakrishnan Ramakrishnan, Medico, OUHSC, 900 NE 10th St., Oklahoma City, OK 73104 (eastward-mail: kramakrishnan@ouhsc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Hersh AL, et al. National trends in ambulatory visits and antibody prescribing for skin and soft-tissue infections. Arch Intern Med. 2008;168(fourteen):1585–1591. ...

ii. Pallin DJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibody choices, during the emergence of customs-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(three):291–298.

iii. Eron LJ, et al. Managing skin and soft tissue infections. J Antimicrob Chemother. 2003;52(suppl 1):i3–i17.

iv. May AK. Pare and soft tissue infections. Surg Clin North Am. 2009;89(two):403–420.

five. Stevens DL, et al. Do guidelines for the diagnosis and direction of skin and soft tissue infections. Clin Infect Dis. 2014;59(ii):e10–e52.

6. Jones ME, et al. Epidemiology and antibody susceptibility of bacteria causing skin and soft tissue infections in the The states and Europe. Int J Antimicrob Agents. 2003;22(iv):406–419.

7. Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections [published corrections appear in Clin Infect Dis. 2005;41(12):1830 and Clin Infect Dis. 2006;42(8):1219]. Clin Infect Dis. 2005;41(10):1373–1406.

8. U.S. Food and Drug Administration. Uncomplicated and complicated skin and skin structure infections—developing antimicrobial drugs for treatment. http://www.fda.gov/ohrms/dockets/98fr/2566dft.pdf. Accessed May 24, 2014.

9. Ki Five, et al. Bacterial skin and soft tissue infections in adults: a review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008;19(ii):173–184.

x. Gabillot-CarrĂ© G, et al. Acute bacterial skin infections and cellulitis. Curr Opin Infect Dis. 2007;xx(ii):118–123.

11. Kowalski TJ, et al. Epidemiology, treatment, and prevention of community-acquired methicillin-resistant Staphylococcus aureus infections. Mayo Clin Proc. 2005;80(9):1201–1207.

12. May L, et al. Cocky-reported incidence of pare and soft tissue infections amongst deployed Us armed forces. Travel Med Infect Dis. 2011;9(4):213–220.

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14. Suaya JA, et al. Skin and soft tissue infections and associated complications among commercially insured patients aged 0–64 years with and without diabetes in the U.S. PLoS 1. 2013;8(four):e60057.

15. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 5th ed. New York, NY: Mosby; 2010:335–381.

16. Jeng A, et al. The role of beta-hemolytic streptococci in causing diffuse, nonculturable cellulitis. Medicine (Baltimore). 2010;89(4):217–226.

17. Moet GJ, et al. Contemporary causes of skin and soft tissue infections in North America, Latin America, and Europe: report from the Scout Antimicrobial Surveillance Program (1998–2004). Diagn Microbiol Infect Dis. 2007;57(1):7–13.

18. Wall DB, et al. Objective criteria may help in distinguishing necrotizing fasciitis from nonnecrotizing soft tissue infection. Am J Surg. 2000;179(1):17–21.

19. Wong CH, et al. The LRINEC (Laboratory Adventure Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(vii):1535–1541.

20. Mills AM, et al. Are claret cultures necessary in adults with cellulitis? Ann Emerg Med. 2005;45(five):548–549.

21. Perl B, et al. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. 1999;29(six):1483–1488.

22. Businesswoman EJ, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases. Clin Infect Dis. 2013;57(4):e22–e121.

23. Abrahamian FM, et al. Use of routine wound cultures to evaluate cutaneous abscesses for community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2007;l(one):66–67.

24. Schmid MR, et al. Differentiation of necrotizing fasciitis and cellulitis using MR imaging. AJR Am J Roentgenol. 1998;170(3):615–620.

25. Malghem J, et al. Necrotizing fasciitis: contribution and limitations of diagnostic imaging. Articulation Bone Spine. 2013;fourscore(two):146–154.

26. Marin JR, et al. Emergency ultrasound-assisted test of skin and soft tissue infections in the pediatric emergency department. Acad Emerg Med. 2013;xx(6):545–553.

27. Micromedex ii.0. http://www.micromedexsolutions.com (subscription required). Accessed May 25, 2014.

28. Williams DJ, et al. Comparative effectiveness of antibiotic treatment strategies for pediatric pare and soft-tissue infections. Pediatrics. 2011;128(3):e479–e487.

29. Duong Thousand, et al. Randomized, controlled trial of antibiotics in the direction of customs-acquired pare abscesses in the pediatric patient. Ann Emerg Med. 2010;55(5):401–407.

30. Hankin A, et al. Are antibiotics necessary later incision and drainage of a cutaneous abscess? Ann Emerg Med. 2007;50(1):49–51.

31. Wright TN, et al. Minimally invasive drainage of subcutaneous abscesses reduces hospital cost and length of stay. South Med J. 2013;106(12):689–692.

32. Liu C, et al. Clinical exercise guidelines past the Infectious Diseases Club of America for the handling of methicillin-resistant Staphylococcus aureus infections in adults and children [published correction appears in Clin Infect Dis. 2011;53(three):319]. Clin Infect Dis. 2011;52(three):e18–e55.

33. Hepburn MJ, et al. Comparison of short-course (five days) and standard (10 days) treatment for uncomplicated cellulitis. Arch Intern Med. 2004;164(15):1669–1674.

34. Chen AE, et al. Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric peel infections. Pediatrics. 2011;127(3):e573–e580.

35. Gurusamy KS, et al. Antibiotic therapy for the handling of methicillin-resistant Staphylococcus aureus (MRSA) infections in surgical wounds. Cochrane Database Syst Rev. 2013;(8):CD009726.

36. Corwin P, et al. Randomised controlled trial of intravenous antibiotic treatment for cellulitis at habitation compared with hospital. BMJ. 2005;330(7483):129–135.

37. Ellis R, et al. Canis familiaris and cat bites [published correction appears in Am Fam Physician. 2015;91(ten):676]. Am Fam Medico. 2014;90(iv):239–243.

38. Thomas M, et al. Safety antibiotics for the prevention of cellulitis (erysipelas) of the leg: results of the United kingdom of great britain and northern ireland Dermatology Clinical Trials Network'south PATCH II trial. Br J Dermatol. 2012;166(1):169–178.

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