A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

EXECUTIVE SUMMARY

Summarized below are the recommendations made in the new guidelines for skin and soft tissue infections (SSTIs). Figure 1 was developed to simplify the management of localized purulent staphylococcal infections such as skin abscesses, furuncles, and carbuncles in the age of methicillin-resistant Staphylococcus aureus (MRSA). In addition, Figure 2 is provided to simplify the approach to patients with surgical site infections. The panel followed a process used in the development of other Infectious Diseases Society of America (IDSA) guidelines, which included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system (Table 1) [14]. A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of the guidelines.
Table 1.

Strength of Recommendations and Quality of the Evidence

Strength of Recommendation and Quality of EvidenceClarity of Balance Between Desirable and Undesirable EffectsMethodological Quality of Supporting Evidence (Examples)Implications
Strong recommendation, high-quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research is unlikely to change our confidence in the estimate of effect?
Strong recommendation, moderate quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Strong recommendation, low-quality quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from observational studies, RCTs with serious flaws or indirect evidence?Recommendation may change when higher-quality evidence becomes available. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Strong recommendation, very low-quality evidence (very rarely applicable)?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Recommendation may change when higher-quality evidence becomes available; any estimate of effect for at least 1 critical outcome is very uncertain.?
Weak recommendation, high-quality evidence?Desirable effects closely balanced with undesirable effects?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?The best action may differ depending on circumstances or patient's or societal values. Further research is unlikely to change our confidence in the estimate of effect?
Weak recommendation, moderate-quality evidence?Desirable effects closely balanced with undesirable effects?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Alternative approaches likely to be better for some patients under some circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Weak recommendation, low-quality evidence?Uncertainty in the estimates of desirable effects, harms, and burden; desirable effects, harms, and burden may be closely balanced?Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence?Other alternatives may be equally reasonable. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Weak recommendation, very low-quality evidence?Major uncertainty in the estimates of desirable effects, harms, and burden; desirable effects may or may not be balanced with undesirable effects?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Other alternatives may be equally reasonable. Any estimate of effect, for at least 1 critical outcome, is very uncertain?
Strength of Recommendation and Quality of EvidenceClarity of Balance Between Desirable and Undesirable EffectsMethodological Quality of Supporting Evidence (Examples)Implications
Strong recommendation, high-quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research is unlikely to change our confidence in the estimate of effect?
Strong recommendation, moderate quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Strong recommendation, low-quality quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from observational studies, RCTs with serious flaws or indirect evidence?Recommendation may change when higher-quality evidence becomes available. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Strong recommendation, very low-quality evidence (very rarely applicable)?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Recommendation may change when higher-quality evidence becomes available; any estimate of effect for at least 1 critical outcome is very uncertain.?
Weak recommendation, high-quality evidence?Desirable effects closely balanced with undesirable effects?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?The best action may differ depending on circumstances or patient's or societal values. Further research is unlikely to change our confidence in the estimate of effect?
Weak recommendation, moderate-quality evidence?Desirable effects closely balanced with undesirable effects?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Alternative approaches likely to be better for some patients under some circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Weak recommendation, low-quality evidence?Uncertainty in the estimates of desirable effects, harms, and burden; desirable effects, harms, and burden may be closely balanced?Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence?Other alternatives may be equally reasonable. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Weak recommendation, very low-quality evidence?Major uncertainty in the estimates of desirable effects, harms, and burden; desirable effects may or may not be balanced with undesirable effects?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Other alternatives may be equally reasonable. Any estimate of effect, for at least 1 critical outcome, is very uncertain?

Abbreviation: RCT, randomized controlled trial.

Table 1.

Strength of Recommendations and Quality of the Evidence

Strength of Recommendation and Quality of EvidenceClarity of Balance Between Desirable and Undesirable EffectsMethodological Quality of Supporting Evidence (Examples)Implications
Strong recommendation, high-quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research is unlikely to change our confidence in the estimate of effect?
Strong recommendation, moderate quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Strong recommendation, low-quality quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from observational studies, RCTs with serious flaws or indirect evidence?Recommendation may change when higher-quality evidence becomes available. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Strong recommendation, very low-quality evidence (very rarely applicable)?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Recommendation may change when higher-quality evidence becomes available; any estimate of effect for at least 1 critical outcome is very uncertain.?
Weak recommendation, high-quality evidence?Desirable effects closely balanced with undesirable effects?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?The best action may differ depending on circumstances or patient's or societal values. Further research is unlikely to change our confidence in the estimate of effect?
Weak recommendation, moderate-quality evidence?Desirable effects closely balanced with undesirable effects?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Alternative approaches likely to be better for some patients under some circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Weak recommendation, low-quality evidence?Uncertainty in the estimates of desirable effects, harms, and burden; desirable effects, harms, and burden may be closely balanced?Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence?Other alternatives may be equally reasonable. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Weak recommendation, very low-quality evidence?Major uncertainty in the estimates of desirable effects, harms, and burden; desirable effects may or may not be balanced with undesirable effects?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Other alternatives may be equally reasonable. Any estimate of effect, for at least 1 critical outcome, is very uncertain?
Strength of Recommendation and Quality of EvidenceClarity of Balance Between Desirable and Undesirable EffectsMethodological Quality of Supporting Evidence (Examples)Implications
Strong recommendation, high-quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research is unlikely to change our confidence in the estimate of effect?
Strong recommendation, moderate quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Recommendation can apply to most patients in most circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Strong recommendation, low-quality quality evidence?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from observational studies, RCTs with serious flaws or indirect evidence?Recommendation may change when higher-quality evidence becomes available. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Strong recommendation, very low-quality evidence (very rarely applicable)?Desirable effects clearly outweigh undesirable effects, or vice versa?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Recommendation may change when higher-quality evidence becomes available; any estimate of effect for at least 1 critical outcome is very uncertain.?
Weak recommendation, high-quality evidence?Desirable effects closely balanced with undesirable effects?Consistent evidence from well-performed RCTs or exceptionally strong evidence from unbiased observational studies?The best action may differ depending on circumstances or patient's or societal values. Further research is unlikely to change our confidence in the estimate of effect?
Weak recommendation, moderate-quality evidence?Desirable effects closely balanced with undesirable effects?Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies?Alternative approaches likely to be better for some patients under some circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate?
Weak recommendation, low-quality evidence?Uncertainty in the estimates of desirable effects, harms, and burden; desirable effects, harms, and burden may be closely balanced?Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence?Other alternatives may be equally reasonable. Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate?
Weak recommendation, very low-quality evidence?Major uncertainty in the estimates of desirable effects, harms, and burden; desirable effects may or may not be balanced with undesirable effects?Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence?Other alternatives may be equally reasonable. Any estimate of effect, for at least 1 critical outcome, is very uncertain?

Abbreviation: RCT, randomized controlled trial.

Figure 1.

Purulent skin and soft tissue infections (SSTIs). Mild infection: for purulent SSTI, incision and drainage is indicated. Moderate infection: patients with purulent infection with systemic signs of infection. Severe infection: patients who have failed incision and drainage plus oral antibiotics or those with systemic signs of infection such as temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (<12 000 or <400 cells/μL), or immunocompromised patients. Nonpurulent SSTIs. Mild infection: typical cellulitis/erysipelas with no focus of purulence. Moderate infection: typical cellulitis/erysipelas with systemic signs of infection. Severe infection: patients who have failed oral antibiotic treatment or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction. Two newer agents, tedizolid and dalbavancin, are also effective agents in SSTIs, including those caused by methicillin-resistant Staphylococcus aureus, and may be approved for this indication by June 2014. Abbreviations: C & S, culture and sensitivity; I & D, incision and drainage; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus; Rx, treatment; TMP/SMX, trimethoprim-sulfamethoxazole.

Figure 1.

Purulent skin and soft tissue infections (SSTIs). Mild infection: for purulent SSTI, incision and drainage is indicated. Moderate infection: patients with purulent infection with systemic signs of infection. Severe infection: patients who have failed incision and drainage plus oral antibiotics or those with systemic signs of infection such as temperature >38°C, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (<12 000 or <400 cells/μL), or immunocompromised patients. Nonpurulent SSTIs. Mild infection: typical cellulitis/erysipelas with no focus of purulence. Moderate infection: typical cellulitis/erysipelas with systemic signs of infection. Severe infection: patients who have failed oral antibiotic treatment or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction. Two newer agents, tedizolid and dalbavancin, are also effective agents in SSTIs, including those caused by methicillin-resistant Staphylococcus aureus, and may be approved for this indication by June 2014. Abbreviations: C & S, culture and sensitivity; I & D, incision and drainage; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus; Rx, treatment; TMP/SMX, trimethoprim-sulfamethoxazole.

Figure 2.

Algorithm for the management and treatment of surgical site infections (SSIs). *For patients with type 1 (anaphylaxis or hives) allergy to β-lactam antibiotics. If Gram stain not available, open and debride if purulent drainage present. Where the rate of infection with methicillin-resistant Staphylococcus aureus infection is high, consider vancomycin, daptomycin, or linezolid, pending results of culture and susceptibility tests. Adapted and modied with permission from Dellinger et al [96]. Abbreviations: GI, gastrointestinal; MRSA, methicillin-resistant Staphylococcus aureus; WBC, white blood cell count.

Figure 2.

Algorithm for the management and treatment of surgical site infections (SSIs). *For patients with type 1 (anaphylaxis or hives) allergy to β-lactam antibiotics. If Gram stain not available, open and debride if purulent drainage present. Where the rate of infection with methicillin-resistant Staphylococcus aureus infection is high, consider vancomycin, daptomycin, or linezolid, pending results of culture and susceptibility tests. Adapted and modied with permission from Dellinger et al [96]. Abbreviations: GI, gastrointestinal; MRSA, methicillin-resistant Staphylococcus aureus; WBC, white blood cell count.

I. What Is Appropriate for the Evaluation and Treatment of Impetigo and Ecthyma?

Recommendations

  1. Gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether Staphylococcus aureus and/or a β-hemolytic Streptococcus is the cause (strong, moderate), but treatment without these studies is reasonable in typical cases (strong, moderate).

  2. Bullous and nonbullous impetigo can be treated with oral or topical antimicrobials, but oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people to help decrease transmission of infection. Treatment for ecthyma should be an oral antimicrobial.

    • Treatment of bullous and nonbullous impetigo should be with either mupirocin or retapamulin twice daily (bid) for 5 days (strong, high).

    • Oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against S. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent) (strong, high). Because S. aureus isolates from impetigo and ecthyma are usually methicillin susceptible, dicloxacillin or cephalexin is recommended. When MRSA is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) is recommended (strong, moderate).

    • Systemic antimicrobials should be used for infections during outbreaks of poststreptococcal glomerulonephritis to help eliminate nephritogenic strains of S. pyogenes from the community (strong, moderate).

II. What Is the Appropriate Evaluation and Treatment for Purulent SSTIs (Cutaneous Abscesses, Furuncles, Carbuncles, and Inflamed Epidermoid Cysts)?

Recommendations

  1. Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases (strong, moderate).

  2. Gram stain and culture of pus from inflamed epidermoid cysts are not recommended (strong, moderate).

  3. Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles, mild (Figure 1) (strong, high).

  4. The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based upon presence or absence of systemic inflammatory response syndrome (SIRS), such as temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12 000 or <400 cells/μL (moderate; Figure 1) (strong, low). An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment or have markedly impaired host defenses or in patients with SIRS and hypotension (severe; Figure 1 and Table 2) (strong, low).

Table 2.

Antimicrobial Therapy for Staphylococcal and Streptococcal Skin and Soft Tissue Infections

Disease EntityAntibioticDosage, AdultsDosage, ChildrenaComment
Impetigob (Staphylococcus and Streptococcus)?Dicloxacillin?250 mg qid po?N/A?N/A?
Cephalexin?250 mg qid po?25–50 mg/kg/d in 3–4 divided doses po?N/A?
Erythromycin?250 mg qid poc?40 mg/kg/d in 3–4 divided doses po?Some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant.?
Clindamycin?300–400 mg qid po?20 mg/kg/d in 3 divided doses po?N/A?
Amoxicillin-clavulanate?875/125 mg bid po?25 mg/kg/d of the amoxicillin component in 2 divided doses po?N/A?
Retapamulin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
Mupirocin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
MSSA SSTI?Nafcillin or oxacillin?1-2 g every 4 h IV?100–150 mg/kg/d in 4 divided doses?Parental drug of choice; inactive against MRSA?
Cefazolin?1 g every 8 h IV?50 mg/kg/d in 3 divided doses?For penicillin-allergic patients except those with immediate hypersensitivity reactions. More convenient than nafcillin with less bone marrow suppression?
Clindamycin?600 mg every 8 h IV or
300–450 mg qid po?
25–40 mg/kg/d in 3 divided doses IV or
25–30 mg/kg/d in 3 divided doses po?
Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA?
Dicloxacillin?500 mg qid po?25–50 mg/kg/d in 4 divided doses po?Oral agent of choice for methicillin-susceptible strains in adults. Not used much in pediatrics?
Cephalexin?500 mg qid po?25–50 mg/kg/d 4 divided doses po?For penicillin-allergic patients except those with immediate hypersensitivity reactions. The availability of a suspension and requirement for less frequent dosing?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; efficacy poorly documented?
MRSA SSTI?Vancomycin?30 mg/kg/d in 2 divided doses IV?40 mg/kg/d in 4 divided doses IV?For penicillin allergic patients; parenteral drug of choice for treatment of infections caused by MRSA?
Linezolid?600 mg every 12 h IV or 600 mg bid po?10 mg/kg every 12 h IV or po for children <12 y?Bacteriostatic; limited clinical experience; no cross-resistance with other antibiotic classes; expensive?
Clindamycin?600 mg every 8 h IV or 300–450 mg qid po?25–40 mg/kg/d in 3 divided doses IV or 30–40 mg/kg/d in 3 divided doses po?Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA. Important option for children?
Daptomycin?4 mg/kg every 24 h IV?N/A?Bactericidal; possible myopathy?
Ceftaroline?600 mg bid IV?N/A?Bactericidal?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg/d (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; limited published efficacy data?
Non-purulent SSTI (cellulitis)?Adult dosage?Pediatric dosage?antimicrobial agents for patients with severe penicillin hypersensitivity?N/A?
Streptococcal skin infections?Penicillin 2–4 million units every 4–6 h IV
Clindamycin 600–900 mg every 8 h IV
Nafcillin 1–2 g every 4–6 h IV
Cefazolin 1 g every 8 h IV
Penicillin VK 250–500 mg every 6 h po
Cephalexin 500 mg every 6 h po?
Penicillin 60–100 000 units/kg/dose every 6 h
10–13 mg/kg dose every 8 h IV
50 mg/kg/dose every 6 h
33 mg/kg/dose every 8 h IV?
Clindamycin, vancomycin, linezolid, daptomycin, or telavancin. Clindamycin resistance is <1% but may be increasing in Asia?N/A?
Disease EntityAntibioticDosage, AdultsDosage, ChildrenaComment
Impetigob (Staphylococcus and Streptococcus)?Dicloxacillin?250 mg qid po?N/A?N/A?
Cephalexin?250 mg qid po?25–50 mg/kg/d in 3–4 divided doses po?N/A?
Erythromycin?250 mg qid poc?40 mg/kg/d in 3–4 divided doses po?Some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant.?
Clindamycin?300–400 mg qid po?20 mg/kg/d in 3 divided doses po?N/A?
Amoxicillin-clavulanate?875/125 mg bid po?25 mg/kg/d of the amoxicillin component in 2 divided doses po?N/A?
Retapamulin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
Mupirocin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
MSSA SSTI?Nafcillin or oxacillin?1-2 g every 4 h IV?100–150 mg/kg/d in 4 divided doses?Parental drug of choice; inactive against MRSA?
Cefazolin?1 g every 8 h IV?50 mg/kg/d in 3 divided doses?For penicillin-allergic patients except those with immediate hypersensitivity reactions. More convenient than nafcillin with less bone marrow suppression?
Clindamycin?600 mg every 8 h IV or
300–450 mg qid po?
25–40 mg/kg/d in 3 divided doses IV or
25–30 mg/kg/d in 3 divided doses po?
Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA?
Dicloxacillin?500 mg qid po?25–50 mg/kg/d in 4 divided doses po?Oral agent of choice for methicillin-susceptible strains in adults. Not used much in pediatrics?
Cephalexin?500 mg qid po?25–50 mg/kg/d 4 divided doses po?For penicillin-allergic patients except those with immediate hypersensitivity reactions. The availability of a suspension and requirement for less frequent dosing?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; efficacy poorly documented?
MRSA SSTI?Vancomycin?30 mg/kg/d in 2 divided doses IV?40 mg/kg/d in 4 divided doses IV?For penicillin allergic patients; parenteral drug of choice for treatment of infections caused by MRSA?
Linezolid?600 mg every 12 h IV or 600 mg bid po?10 mg/kg every 12 h IV or po for children <12 y?Bacteriostatic; limited clinical experience; no cross-resistance with other antibiotic classes; expensive?
Clindamycin?600 mg every 8 h IV or 300–450 mg qid po?25–40 mg/kg/d in 3 divided doses IV or 30–40 mg/kg/d in 3 divided doses po?Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA. Important option for children?
Daptomycin?4 mg/kg every 24 h IV?N/A?Bactericidal; possible myopathy?
Ceftaroline?600 mg bid IV?N/A?Bactericidal?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg/d (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; limited published efficacy data?
Non-purulent SSTI (cellulitis)?Adult dosage?Pediatric dosage?antimicrobial agents for patients with severe penicillin hypersensitivity?N/A?
Streptococcal skin infections?Penicillin 2–4 million units every 4–6 h IV
Clindamycin 600–900 mg every 8 h IV
Nafcillin 1–2 g every 4–6 h IV
Cefazolin 1 g every 8 h IV
Penicillin VK 250–500 mg every 6 h po
Cephalexin 500 mg every 6 h po?
Penicillin 60–100 000 units/kg/dose every 6 h
10–13 mg/kg dose every 8 h IV
50 mg/kg/dose every 6 h
33 mg/kg/dose every 8 h IV?
Clindamycin, vancomycin, linezolid, daptomycin, or telavancin. Clindamycin resistance is <1% but may be increasing in Asia?N/A?

Abbreviations: bid, twice daily; IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus; N/A, not applicable; po, by mouth; qid, 4 times daily; SSTI, skin and soft tissue infection; tid, 3 times daily.

a Doses listed are not appropriate for neonates. Refer to the report by the Committee on Infectious Diseases, American Academy of Pediatrics [246], for neonatal doses.

b Infection due to Staphylococcus and Streptococcus species. Duration of therapy is 7 days, depending on the clinical response.

c Adult dosage of erythromycin ethylsuccinate is 400 mg 4 times/d po.

d See [246] for alternatives in children.

Table 2.

Antimicrobial Therapy for Staphylococcal and Streptococcal Skin and Soft Tissue Infections

Disease EntityAntibioticDosage, AdultsDosage, ChildrenaComment
Impetigob (Staphylococcus and Streptococcus)?Dicloxacillin?250 mg qid po?N/A?N/A?
Cephalexin?250 mg qid po?25–50 mg/kg/d in 3–4 divided doses po?N/A?
Erythromycin?250 mg qid poc?40 mg/kg/d in 3–4 divided doses po?Some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant.?
Clindamycin?300–400 mg qid po?20 mg/kg/d in 3 divided doses po?N/A?
Amoxicillin-clavulanate?875/125 mg bid po?25 mg/kg/d of the amoxicillin component in 2 divided doses po?N/A?
Retapamulin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
Mupirocin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
MSSA SSTI?Nafcillin or oxacillin?1-2 g every 4 h IV?100–150 mg/kg/d in 4 divided doses?Parental drug of choice; inactive against MRSA?
Cefazolin?1 g every 8 h IV?50 mg/kg/d in 3 divided doses?For penicillin-allergic patients except those with immediate hypersensitivity reactions. More convenient than nafcillin with less bone marrow suppression?
Clindamycin?600 mg every 8 h IV or
300–450 mg qid po?
25–40 mg/kg/d in 3 divided doses IV or
25–30 mg/kg/d in 3 divided doses po?
Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA?
Dicloxacillin?500 mg qid po?25–50 mg/kg/d in 4 divided doses po?Oral agent of choice for methicillin-susceptible strains in adults. Not used much in pediatrics?
Cephalexin?500 mg qid po?25–50 mg/kg/d 4 divided doses po?For penicillin-allergic patients except those with immediate hypersensitivity reactions. The availability of a suspension and requirement for less frequent dosing?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; efficacy poorly documented?
MRSA SSTI?Vancomycin?30 mg/kg/d in 2 divided doses IV?40 mg/kg/d in 4 divided doses IV?For penicillin allergic patients; parenteral drug of choice for treatment of infections caused by MRSA?
Linezolid?600 mg every 12 h IV or 600 mg bid po?10 mg/kg every 12 h IV or po for children <12 y?Bacteriostatic; limited clinical experience; no cross-resistance with other antibiotic classes; expensive?
Clindamycin?600 mg every 8 h IV or 300–450 mg qid po?25–40 mg/kg/d in 3 divided doses IV or 30–40 mg/kg/d in 3 divided doses po?Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA. Important option for children?
Daptomycin?4 mg/kg every 24 h IV?N/A?Bactericidal; possible myopathy?
Ceftaroline?600 mg bid IV?N/A?Bactericidal?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg/d (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; limited published efficacy data?
Non-purulent SSTI (cellulitis)?Adult dosage?Pediatric dosage?antimicrobial agents for patients with severe penicillin hypersensitivity?N/A?
Streptococcal skin infections?Penicillin 2–4 million units every 4–6 h IV
Clindamycin 600–900 mg every 8 h IV
Nafcillin 1–2 g every 4–6 h IV
Cefazolin 1 g every 8 h IV
Penicillin VK 250–500 mg every 6 h po
Cephalexin 500 mg every 6 h po?
Penicillin 60–100 000 units/kg/dose every 6 h
10–13 mg/kg dose every 8 h IV
50 mg/kg/dose every 6 h
33 mg/kg/dose every 8 h IV?
Clindamycin, vancomycin, linezolid, daptomycin, or telavancin. Clindamycin resistance is <1% but may be increasing in Asia?N/A?
Disease EntityAntibioticDosage, AdultsDosage, ChildrenaComment
Impetigob (Staphylococcus and Streptococcus)?Dicloxacillin?250 mg qid po?N/A?N/A?
Cephalexin?250 mg qid po?25–50 mg/kg/d in 3–4 divided doses po?N/A?
Erythromycin?250 mg qid poc?40 mg/kg/d in 3–4 divided doses po?Some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant.?
Clindamycin?300–400 mg qid po?20 mg/kg/d in 3 divided doses po?N/A?
Amoxicillin-clavulanate?875/125 mg bid po?25 mg/kg/d of the amoxicillin component in 2 divided doses po?N/A?
Retapamulin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
Mupirocin ointment?Apply to lesions bid?Apply to lesions bid?For patients with limited number of lesions?
MSSA SSTI?Nafcillin or oxacillin?1-2 g every 4 h IV?100–150 mg/kg/d in 4 divided doses?Parental drug of choice; inactive against MRSA?
Cefazolin?1 g every 8 h IV?50 mg/kg/d in 3 divided doses?For penicillin-allergic patients except those with immediate hypersensitivity reactions. More convenient than nafcillin with less bone marrow suppression?
Clindamycin?600 mg every 8 h IV or
300–450 mg qid po?
25–40 mg/kg/d in 3 divided doses IV or
25–30 mg/kg/d in 3 divided doses po?
Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA?
Dicloxacillin?500 mg qid po?25–50 mg/kg/d in 4 divided doses po?Oral agent of choice for methicillin-susceptible strains in adults. Not used much in pediatrics?
Cephalexin?500 mg qid po?25–50 mg/kg/d 4 divided doses po?For penicillin-allergic patients except those with immediate hypersensitivity reactions. The availability of a suspension and requirement for less frequent dosing?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; efficacy poorly documented?
MRSA SSTI?Vancomycin?30 mg/kg/d in 2 divided doses IV?40 mg/kg/d in 4 divided doses IV?For penicillin allergic patients; parenteral drug of choice for treatment of infections caused by MRSA?
Linezolid?600 mg every 12 h IV or 600 mg bid po?10 mg/kg every 12 h IV or po for children <12 y?Bacteriostatic; limited clinical experience; no cross-resistance with other antibiotic classes; expensive?
Clindamycin?600 mg every 8 h IV or 300–450 mg qid po?25–40 mg/kg/d in 3 divided doses IV or 30–40 mg/kg/d in 3 divided doses po?Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA. Important option for children?
Daptomycin?4 mg/kg every 24 h IV?N/A?Bactericidal; possible myopathy?
Ceftaroline?600 mg bid IV?N/A?Bactericidal?
Doxycycline, minocycline?100 mg bid po?Not recommended for age <8 yd?Bacteriostatic; limited recent clinical experience?
Trimethoprim-sulfamethoxazole?1–2 double-strength tablets bid po?8–12 mg/kg/d (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po?Bactericidal; limited published efficacy data?
Non-purulent SSTI (cellulitis)?Adult dosage?Pediatric dosage?antimicrobial agents for patients with severe penicillin hypersensitivity?N/A?
Streptococcal skin infections?Penicillin 2–4 million units every 4–6 h IV
Clindamycin 600–900 mg every 8 h IV
Nafcillin 1–2 g every 4–6 h IV
Cefazolin 1 g every 8 h IV
Penicillin VK 250–500 mg every 6 h po
Cephalexin 500 mg every 6 h po?
Penicillin 60–100 000 units/kg/dose every 6 h
10–13 mg/kg dose every 8 h IV
50 mg/kg/dose every 6 h
33 mg/kg/dose every 8 h IV?
Clindamycin, vancomycin, linezolid, daptomycin, or telavancin. Clindamycin resistance is <1% but may be increasing in Asia?N/A?

Abbreviations: bid, twice daily; IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus; N/A, not applicable; po, by mouth; qid, 4 times daily; SSTI, skin and soft tissue infection; tid, 3 times daily.

a Doses listed are not appropriate for neonates. Refer to the report by the Committee on Infectious Diseases, American Academy of Pediatrics [246], for neonatal doses.

b Infection due to Staphylococcus and Streptococcus species. Duration of therapy is 7 days, depending on the clinical response.

c Adult dosage of erythromycin ethylsuccinate is 400 mg 4 times/d po.

d See [246] for alternatives in children.

III. What Is the Appropriate Treatment for Recurrent Skin Abscesses?

Recommendations

  1. A recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material (strong, moderate).

  2. Recurrent abscesses should be drained and cultured early in the course of infection (strong, moderate).

  3. After obtaining cultures of recurrent abscess, treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated (weak, low).

  4. Consider a 5-day decolonization regimen twice daily of intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items such as towels, sheets, and clothes for recurrent S. aureus infection (weak, low).

  5. Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood (strong, moderate).

IV. What Is Appropriate for the Evaluation and Treatment of Erysipelas and Cellulitis?

Recommendations

  1. Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended (strong, moderate).

  2. Cultures of blood are recommended (strong, moderate), and cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (weak, moderate).

  3. Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci (mild; Figure 1) (strong, moderate). For cellulitis with systemic signs of infection (moderate nonpurulent; Figure 1), systemic antibiotics are indicated. Many clinicians could include coverage against methicillin-susceptible S. aureus (MSSA) (weak, low). For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (severe nonpurulent; Figure 1), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (strong, moderate). In severely compromised patients as defined in question 13 (severe nonpurulent; Figure 1), broad-spectrum antimicrobial coverage may be considered (weak, moderate). Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen for severe infections (strong, moderate).

  4. The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period (strong, high).

  5. Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended (strong, moderate).

  6. In lower-extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection (strong, moderate).

  7. Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (mild nonpurulent; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (moderate or severe nonpurulent; Figure 1) (strong, moderate).

V. Should Anti-inflammatory Agents Be Used to Complement Antibiotic Treatment of Cellulitis?

Recommendation

  1. Systemic corticosteroids (eg, prednisone 40 mg daily for 7 days) could be considered in nondiabetic adult patients with cellulitis (weak, moderate).

VI. What Is the Preferred Evaluation and Management of Patients With Recurrent Cellulitis?

Recommendations

  1. Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities (strong, moderate). These practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis (strong, moderate).

  2. Administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4–52 weeks, or intramuscular benzathine penicillin every 2–4 weeks, should be considered in patients who have 3–4 episodes of cellulitis per year despite attempts to treat or control predisposing factors (weak, moderate). This program should be continued so long as the predisposing factors persist (strong, moderate).

VII. What Is the Preferred Management of Surgical Site Infections?

Recommendations

  1. Suture removal plus incision and drainage should be performed for surgical site infections (strong, low).

  2. Adjunctive systemic antimicrobial therapy is not routinely indicated, but in conjunction with incision and drainage may be beneficial for surgical site infections associated with a significant systemic response (Figure 2), such as erythema and induration extending >5 cm from the wound edge, temperature >38.5°C, heart rate >110 beats/minute, or white blood cell (WBC) count >12 000/μL (weak, low).

  3. A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong, low).

  4. A first-generation cephalosporin or an antistaphylococcal penicillin for MSSA, or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics), is recommended (strong, low). See also Tables 2 and 3.

  5. Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract (strong, low). See also Table 3.

Table 3.

Antibiotics for Treatment of Incisional Surgical Site Infections

Surgery of Intestinal or Genitourinary Tract
Single-drug regimens?
?Ticarcillin-clavulanate 3.1 g every 6 h IV?
?Piperacillin-tazobactam 3.375 g every 6 h or 4.5 g every 8 h IV?
?Imipenem-cilastatin 500 mg every 6 h IV?
?Meropenem 1 g every 8 h IV?
?Ertapenem 1 g every 24 h IV?
Combination regimens?
?Ceftriaxone 1 g every 24 h + metronidazole 500 mg every 8 h IV?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h + metronidazole 500 mg every 8 h IV?
?Levofloxacin 750 mg IV every 24 h + metronidazole 500 mg every 8 h IV?
?Ampicillin-sulbactam 3 g every 6 h + gentamicin or tobramycin 5 mg/kg every 24 h IV?
Surgery of trunk or extremity away from axilla or perineum?
?Oxacillin or nafcillin 2 g every 6 h IV?
?Cefazolin 0.5–1 g every 8 h IV?
?Cephalexin 500 mg every 6 h po?
? SMX-TMP 160–800 mg po every 6 h?
?Vancomycin 15 mg/kg every 12 h IV?
Surgery of axilla or perineuma?
?Metronidazole 500 mg every 8 h IV?
?plus?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h IV po?
?Levofloxacin 750 mg every 24 h IV po?
?Ceftriaxone 1 g every 24 h?
Surgery of Intestinal or Genitourinary Tract
Single-drug regimens?
?Ticarcillin-clavulanate 3.1 g every 6 h IV?
?Piperacillin-tazobactam 3.375 g every 6 h or 4.5 g every 8 h IV?
?Imipenem-cilastatin 500 mg every 6 h IV?
?Meropenem 1 g every 8 h IV?
?Ertapenem 1 g every 24 h IV?
Combination regimens?
?Ceftriaxone 1 g every 24 h + metronidazole 500 mg every 8 h IV?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h + metronidazole 500 mg every 8 h IV?
?Levofloxacin 750 mg IV every 24 h + metronidazole 500 mg every 8 h IV?
?Ampicillin-sulbactam 3 g every 6 h + gentamicin or tobramycin 5 mg/kg every 24 h IV?
Surgery of trunk or extremity away from axilla or perineum?
?Oxacillin or nafcillin 2 g every 6 h IV?
?Cefazolin 0.5–1 g every 8 h IV?
?Cephalexin 500 mg every 6 h po?
? SMX-TMP 160–800 mg po every 6 h?
?Vancomycin 15 mg/kg every 12 h IV?
Surgery of axilla or perineuma?
?Metronidazole 500 mg every 8 h IV?
?plus?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h IV po?
?Levofloxacin 750 mg every 24 h IV po?
?Ceftriaxone 1 g every 24 h?

Abbreviations: IV, intravenous; po, by mouth; SMX-TMP, sulfamethoxazole-trimethoprim.

a May also need to cover for methicillin-resistant Staphylococcus aureus with vancomycin 15 mg/kg every 12 h.

Table 3.

Antibiotics for Treatment of Incisional Surgical Site Infections

Surgery of Intestinal or Genitourinary Tract
Single-drug regimens?
?Ticarcillin-clavulanate 3.1 g every 6 h IV?
?Piperacillin-tazobactam 3.375 g every 6 h or 4.5 g every 8 h IV?
?Imipenem-cilastatin 500 mg every 6 h IV?
?Meropenem 1 g every 8 h IV?
?Ertapenem 1 g every 24 h IV?
Combination regimens?
?Ceftriaxone 1 g every 24 h + metronidazole 500 mg every 8 h IV?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h + metronidazole 500 mg every 8 h IV?
?Levofloxacin 750 mg IV every 24 h + metronidazole 500 mg every 8 h IV?
?Ampicillin-sulbactam 3 g every 6 h + gentamicin or tobramycin 5 mg/kg every 24 h IV?
Surgery of trunk or extremity away from axilla or perineum?
?Oxacillin or nafcillin 2 g every 6 h IV?
?Cefazolin 0.5–1 g every 8 h IV?
?Cephalexin 500 mg every 6 h po?
? SMX-TMP 160–800 mg po every 6 h?
?Vancomycin 15 mg/kg every 12 h IV?
Surgery of axilla or perineuma?
?Metronidazole 500 mg every 8 h IV?
?plus?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h IV po?
?Levofloxacin 750 mg every 24 h IV po?
?Ceftriaxone 1 g every 24 h?
Surgery of Intestinal or Genitourinary Tract
Single-drug regimens?
?Ticarcillin-clavulanate 3.1 g every 6 h IV?
?Piperacillin-tazobactam 3.375 g every 6 h or 4.5 g every 8 h IV?
?Imipenem-cilastatin 500 mg every 6 h IV?
?Meropenem 1 g every 8 h IV?
?Ertapenem 1 g every 24 h IV?
Combination regimens?
?Ceftriaxone 1 g every 24 h + metronidazole 500 mg every 8 h IV?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h + metronidazole 500 mg every 8 h IV?
?Levofloxacin 750 mg IV every 24 h + metronidazole 500 mg every 8 h IV?
?Ampicillin-sulbactam 3 g every 6 h + gentamicin or tobramycin 5 mg/kg every 24 h IV?
Surgery of trunk or extremity away from axilla or perineum?
?Oxacillin or nafcillin 2 g every 6 h IV?
?Cefazolin 0.5–1 g every 8 h IV?
?Cephalexin 500 mg every 6 h po?
? SMX-TMP 160–800 mg po every 6 h?
?Vancomycin 15 mg/kg every 12 h IV?
Surgery of axilla or perineuma?
?Metronidazole 500 mg every 8 h IV?
?plus?
?Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h IV po?
?Levofloxacin 750 mg every 24 h IV po?
?Ceftriaxone 1 g every 24 h?

Abbreviations: IV, intravenous; po, by mouth; SMX-TMP, sulfamethoxazole-trimethoprim.

a May also need to cover for methicillin-resistant Staphylococcus aureus with vancomycin 15 mg/kg every 12 h.

VIII. What Is the Preferred Evaluation and Treatment of Necrotizing Fasciitis, Including Fournier Gangrene?

Recommendations

  1. Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (severe nonpurulent; Figure 1) (strong, low).

  2. Empiric antibiotic treatment should be broad (eg, vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem; or plus ceftriaxone and metronidazole), as the etiology can be polymicrobial (mixed aerobic–anaerobic microbes) or monomicrobial (group A streptococci, community-acquired MRSA) (strong, low). See also Table 4.

  3. Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis (strong, low). See Figures 1, 2, and Table 4.

Table 4.

Treatment of Necrotizing Infections of the Skin, Fascia, and Muscle

Type of InfectionFirst-line Antimicrobial AgentAdult DosagePediatric Dosage Beyond the Neonatal PeriodAntimicrobial Agent for Patients With Severe Penicillin Hypersensitivity
Mixed infections?Piperacillin-tazobactam
plus
vancomycin?
3.37 g every 6–8 h IV
30 mg/kg/d in 2 divided doses?
60–75 mg/kg/dose of the piperacillin component every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Clindamycin or metronidazolea with an aminoglycoside or fluoroquinolone?
Imipenem-cilastatin?1 g every 6–8 h IV?N/A?N/A?
Meropenem?1 g every 8 h IV?20 mg/kg/dose every 8 h IV?
Ertapenem?1 g daily IV?15 mg/kg/dose every 12 h IV for children 3 mo-12 y?
Cefotaxime
plus
metronidazole
or
clindamycin?
2 g every 6 h IV
500 mg every 6 h IV
600–900 mg every 8 h IV?
50 mg/kg/dose every 6 h IV
7.5 mg/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
N/A?
Streptococcus?Penicillin
plus
clindamycin?
2–4 million units every 4–6 h IV (adult)
600–900 mg every 8 h IV?
60 000–100 000 units/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Staphylococcus aureus?Nafcillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Oxacillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?
Cefazolin?1 g every 8 h IV?33 mg/kg/dose every 8 h IV?
Vancomycin (for resistant strains)?30 mg/kg/d in 2 divided doses IV?15 mg/kg/dose every 6 h IV??
Clindamycin?600–900 mg every 8 h IV?10–13 mg/kg/dose every 8 h IV?Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSAb?
Clostridium species?Clindamycin
plus penicillin?
600–900 mg every 8 h IV
2–4 million units every 4–6 h IV (adult)?
10–13 mg/kg/dose every 8 h IV
60 000–100 00 units/kg/dose every 6 h IV?
N/A?
Aeromonas hydrophila?Doxycycline
plus
ciprofloxacin
or
ceftriaxone?
100 mg every 12 h
IV
500 mg every 12 h
IV
1 to 2 g every 24 h IV?
Not recommended for children but may need to use in life-threatening situations?N/A?
Vibrio vulnificus?Doxycycline
plus
ceftriaxone
or
cefotaxime?
100 mg every 12 h
IV
1 g qid IV
2 g tid IV?
Not recommended for children but may need to use in life-threatening situations?N/A?
Type of InfectionFirst-line Antimicrobial AgentAdult DosagePediatric Dosage Beyond the Neonatal PeriodAntimicrobial Agent for Patients With Severe Penicillin Hypersensitivity
Mixed infections?Piperacillin-tazobactam
plus
vancomycin?
3.37 g every 6–8 h IV
30 mg/kg/d in 2 divided doses?
60–75 mg/kg/dose of the piperacillin component every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Clindamycin or metronidazolea with an aminoglycoside or fluoroquinolone?
Imipenem-cilastatin?1 g every 6–8 h IV?N/A?N/A?
Meropenem?1 g every 8 h IV?20 mg/kg/dose every 8 h IV?
Ertapenem?1 g daily IV?15 mg/kg/dose every 12 h IV for children 3 mo-12 y?
Cefotaxime
plus
metronidazole
or
clindamycin?
2 g every 6 h IV
500 mg every 6 h IV
600–900 mg every 8 h IV?
50 mg/kg/dose every 6 h IV
7.5 mg/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
N/A?
Streptococcus?Penicillin
plus
clindamycin?
2–4 million units every 4–6 h IV (adult)
600–900 mg every 8 h IV?
60 000–100 000 units/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Staphylococcus aureus?Nafcillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Oxacillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?
Cefazolin?1 g every 8 h IV?33 mg/kg/dose every 8 h IV?
Vancomycin (for resistant strains)?30 mg/kg/d in 2 divided doses IV?15 mg/kg/dose every 6 h IV??
Clindamycin?600–900 mg every 8 h IV?10–13 mg/kg/dose every 8 h IV?Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSAb?
Clostridium species?Clindamycin
plus penicillin?
600–900 mg every 8 h IV
2–4 million units every 4–6 h IV (adult)?
10–13 mg/kg/dose every 8 h IV
60 000–100 00 units/kg/dose every 6 h IV?
N/A?
Aeromonas hydrophila?Doxycycline
plus
ciprofloxacin
or
ceftriaxone?
100 mg every 12 h
IV
500 mg every 12 h
IV
1 to 2 g every 24 h IV?
Not recommended for children but may need to use in life-threatening situations?N/A?
Vibrio vulnificus?Doxycycline
plus
ceftriaxone
or
cefotaxime?
100 mg every 12 h
IV
1 g qid IV
2 g tid IV?
Not recommended for children but may need to use in life-threatening situations?N/A?

Abbreviations: IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; N/A, not applicable; qid, 4 times daily; tid, 3 times daily.

a If staphylococcus present or suspected, add an appropriate agent.

b If MRSA is present or suspected, add vancomycin not to exceed the maximum adult daily dose.

Table 4.

Treatment of Necrotizing Infections of the Skin, Fascia, and Muscle

Type of InfectionFirst-line Antimicrobial AgentAdult DosagePediatric Dosage Beyond the Neonatal PeriodAntimicrobial Agent for Patients With Severe Penicillin Hypersensitivity
Mixed infections?Piperacillin-tazobactam
plus
vancomycin?
3.37 g every 6–8 h IV
30 mg/kg/d in 2 divided doses?
60–75 mg/kg/dose of the piperacillin component every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Clindamycin or metronidazolea with an aminoglycoside or fluoroquinolone?
Imipenem-cilastatin?1 g every 6–8 h IV?N/A?N/A?
Meropenem?1 g every 8 h IV?20 mg/kg/dose every 8 h IV?
Ertapenem?1 g daily IV?15 mg/kg/dose every 12 h IV for children 3 mo-12 y?
Cefotaxime
plus
metronidazole
or
clindamycin?
2 g every 6 h IV
500 mg every 6 h IV
600–900 mg every 8 h IV?
50 mg/kg/dose every 6 h IV
7.5 mg/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
N/A?
Streptococcus?Penicillin
plus
clindamycin?
2–4 million units every 4–6 h IV (adult)
600–900 mg every 8 h IV?
60 000–100 000 units/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Staphylococcus aureus?Nafcillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Oxacillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?
Cefazolin?1 g every 8 h IV?33 mg/kg/dose every 8 h IV?
Vancomycin (for resistant strains)?30 mg/kg/d in 2 divided doses IV?15 mg/kg/dose every 6 h IV??
Clindamycin?600–900 mg every 8 h IV?10–13 mg/kg/dose every 8 h IV?Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSAb?
Clostridium species?Clindamycin
plus penicillin?
600–900 mg every 8 h IV
2–4 million units every 4–6 h IV (adult)?
10–13 mg/kg/dose every 8 h IV
60 000–100 00 units/kg/dose every 6 h IV?
N/A?
Aeromonas hydrophila?Doxycycline
plus
ciprofloxacin
or
ceftriaxone?
100 mg every 12 h
IV
500 mg every 12 h
IV
1 to 2 g every 24 h IV?
Not recommended for children but may need to use in life-threatening situations?N/A?
Vibrio vulnificus?Doxycycline
plus
ceftriaxone
or
cefotaxime?
100 mg every 12 h
IV
1 g qid IV
2 g tid IV?
Not recommended for children but may need to use in life-threatening situations?N/A?
Type of InfectionFirst-line Antimicrobial AgentAdult DosagePediatric Dosage Beyond the Neonatal PeriodAntimicrobial Agent for Patients With Severe Penicillin Hypersensitivity
Mixed infections?Piperacillin-tazobactam
plus
vancomycin?
3.37 g every 6–8 h IV
30 mg/kg/d in 2 divided doses?
60–75 mg/kg/dose of the piperacillin component every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Clindamycin or metronidazolea with an aminoglycoside or fluoroquinolone?
Imipenem-cilastatin?1 g every 6–8 h IV?N/A?N/A?
Meropenem?1 g every 8 h IV?20 mg/kg/dose every 8 h IV?
Ertapenem?1 g daily IV?15 mg/kg/dose every 12 h IV for children 3 mo-12 y?
Cefotaxime
plus
metronidazole
or
clindamycin?
2 g every 6 h IV
500 mg every 6 h IV
600–900 mg every 8 h IV?
50 mg/kg/dose every 6 h IV
7.5 mg/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
N/A?
Streptococcus?Penicillin
plus
clindamycin?
2–4 million units every 4–6 h IV (adult)
600–900 mg every 8 h IV?
60 000–100 000 units/kg/dose every 6 h IV
10–13 mg/kg/dose every 8 h IV?
Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Staphylococcus aureus?Nafcillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin?
Oxacillin?1–2 g every 4 h IV?50 mg/kg/dose every 6 h IV?
Cefazolin?1 g every 8 h IV?33 mg/kg/dose every 8 h IV?
Vancomycin (for resistant strains)?30 mg/kg/d in 2 divided doses IV?15 mg/kg/dose every 6 h IV??
Clindamycin?600–900 mg every 8 h IV?10–13 mg/kg/dose every 8 h IV?Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSAb?
Clostridium species?Clindamycin
plus penicillin?
600–900 mg every 8 h IV
2–4 million units every 4–6 h IV (adult)?
10–13 mg/kg/dose every 8 h IV
60 000–100 00 units/kg/dose every 6 h IV?
N/A?
Aeromonas hydrophila?Doxycycline
plus
ciprofloxacin
or
ceftriaxone?
100 mg every 12 h
IV
500 mg every 12 h
IV
1 to 2 g every 24 h IV?
Not recommended for children but may need to use in life-threatening situations?N/A?
Vibrio vulnificus?Doxycycline
plus
ceftriaxone
or
cefotaxime?
100 mg every 12 h
IV
1 g qid IV
2 g tid IV?
Not recommended for children but may need to use in life-threatening situations?N/A?

Abbreviations: IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus; N/A, not applicable; qid, 4 times daily; tid, 3 times daily.

a If staphylococcus present or suspected, add an appropriate agent.

b If MRSA is present or suspected, add vancomycin not to exceed the maximum adult daily dose.

IX. What Is the Appropriate Approach to the Management of Pyomyositis?

Recommendations

  1. Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis of pyomyositis. Computed tomography (CT) scan and ultrasound studies are also useful (strong, moderate).

  2. Cultures of blood and abscess material should be obtained (strong, moderate).

  3. Vancomycin is recommended for initial empirical therapy. An agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or following open trauma to the muscles (strong, moderate).

  4. Cefazolin or antistaphylococcal penicillin (eg, nafcillin or oxacillin) is recommended for treatment of pyomyositis caused by MSSA (strong, moderate). See Table 2.

  5. Early drainage of purulent material should be performed (strong, high).

  6. Repeat imaging studies should be performed in the patient with persistent bacteremia to identify undrained foci of infection (strong, low).

  7. Antibiotics should be administered intravenously initially, but once the patient is clinically improved, oral antibiotics are appropriate for patients in whom bacteremia cleared promptly and there is no evidence of endocarditis or metastatic abscess. Two to 3 weeks of therapy is recommended (strong, low).