Guidelines for the Management of Skin and Soft Tissue Infections in Adults
Antimicrobial Stewardship Subcommittee · Pharmacy and Therapeutics Committee · University of Kentucky Health Care
Guideline pending approval by the Antimicrobial Stewardship Team Subcommittee and P&T Committee
| Authors | Jeffrey Lin, DO; Evelyn Villacorta, MD; Katie Landmesser, PharmD; Ryan Mynatt, PharmD, BCPS; Jeremy VanHoose, PharmD, BCPS; Nicole Leedy, MD; Thein Myint, MD |
|---|---|
| Target Population | Adult with Skin and Soft Tissue Infections |
| Overview | This guideline provides evidence-based management of Skin and Soft Tissue Infections |
| Effective Date | 06/08/20 |
| Revised Date | 06/08/20 |
| Expiration Date | 06/08/22 |
| Schedule for Periodic Review | Every 2 years |
Purpose of guidelines
To provide evidence-based guidelines for the treatment of skin and soft tissue infections at the University of Kentucky Health Care
Goals:
- Early diagnosis and treatment
- Evidence based use of antibiotics
- Prompt referral/consult for severe infections including necrotizing fasciitis
Background
Skin and soft tissue infections (SSTI) are the second most common type of infection leading to hospitalization in the United States.[1] In 2014 the Infectious Diseases Society of America (IDSA) released an updated practice guideline for the diagnosis and management of skin and soft tissue infections (SSTIs).[2] These guidelines were created to improve patient outcomes and use of health care resources while limiting the unintended consequences of unnecessary antibiotic use.[3, 4] An institutional guideline has been developed to adapt the IDSA guidelines and existing literature into practice for the management of SSTIs. Please note that diabetic foot ulcers and skin infections involving bones and joints are not addressed in this guideline.
Target Population
Adult patients with SSTIs
Diagnosis and Initial Workup of Skin and Soft Tissue Infections (SSTIs)
Diagnosis of SSTIs are predominantly clinical with features including erythema, warmth, edema, pain among others. They can be generally placed into two categories of purulent (furuncles, carbuncles, abscess) and non-purulent (erysipelas, cellulitis, necrotizing fasciitis, myonecrosis) and further divided into subcategories of mild, moderate and severe based upon degree of systemic system involvement. There are other SSTI classification schemes proposed based upon patient presentations that have been used in other countries but none yet approved or widely adopted in the United states to date.[5]
For purulent SSTIs, the mainstay of treatment is incision and drainage with gram stain and culture and adjunctive antibiotics for moderate and severe cases. For non-purulent SSTIs, the mainstay of treatment is antibiotics, with emergent or urgent surgical debridement (with gram stain and cultures) in moderate and severe cases. Generally, empiric antibiotics, blood cultures, and cultures of skin biopsy or aspirate are recommended in patients who are septic, immunocompromised, malignancy, or have unusual predisposing factors including but not limited to immersion injury, animal bites, neutropenia or severe cell-mediated immunodeficiency. Consider early infectious disease consultation in patients with bacteremia, anticipation of greater than two weeks of anti-infective treatment, immunocompromising conditions, history of multi-drug resistant organisms, or recurrence of infection.
Penicillin allergies
Assessment of beta-lactam allergies should include the type of reaction, date of occurrence, treatment measure taken, and any antibiotics tolerated since the reaction occurred. Cross-reactivity between penicillins and meropenem in patients with type I reactions (anaphylaxis, angioedema, or urticaria) is estimated at 0.5% based on recent studies. Due to poor activity against many nosocomial gram-negative organisms, aztreonam should be reserved for allergy histories compatible with severe type I reactions.
Table 1: Definitions and Common Pathogens
Impetigo and Folliculitis
| Definitions | Common Pathogens |
|---|---|
| Impetigo: Lesions begin as erythematous papules; vesicles rupture and discharge forms honey-colored crusts on an erythematous base; may be bullous or non-bullous | Bullous: Staphylococcus aureus, typically MSSA Non-bullous: Staphylococcus aureus including MRSA, Streptococcus pyogenes (GAS) |
| Folliculitis: Infections of the hair follicle; superficial inflammation and purulence limited to the epidermis | Staphylococcus aureus, Pseudomonas aeruginosa (hot tub) |
Cellulitis and Erysipelas
| Definitions | Common Pathogens |
|---|---|
| Cellulitis: Area of skin with erythema, edema, and warmth; extends to deep subcutaneous tissue; less distinct borders | Streptococcus [S. dysgalactiae, S. pyogenes (GAS), S. agalactiae (GBS)], rarely Staphylococcus aureus |
| Erysipelas: Erythematous, indurated plaque with clearly demarcated border; involves upper dermis; more superficial and raised than cellulitis, acute onset typically with a rash on legs, toes, face, arms, and/or fingers |
Necrotizing Fasciitis, Fournier's Gangrene, and Ludwig's Angina
| Definitions | Common Pathogens |
|---|---|
Necrotizing fasciitis: Aggressive, subcutaneous infection that tracks along the superficial fascia and comprises the tissue between the skin and underlying muscles.
|
Type I: Polymicrobial infection; most commonly associated with perineal abscess, penetrating abdominal trauma, surgical procedures involving the bowel, decubitus ulcers, or injection sites in persons who inject drugs (PWID). Mixed aerobic and anaerobic poly-microbial infection, bowel or genitourinary flora Type II: Monomicrobial infection; typically occurs in the limbs. Streptococcus pyogenes (GAS), Staphylococcus aureus including MRSA, and anaerobic streptococci (Peptostreptococcus) Water-related: Vibrio vulnificus, Aeromonas hydrophila |
| Clostridial Gas Gangrene or Myonecrosis: Infection involving deeper tissue such as a muscle, leading to a rapidly spreading infection along tissue planes. Usually arise in traumatized tissue but also can arise spontaneously. | Clostridium perfringens, Clostridium novyi, Clostridium histolyticum, Clostridium septicum |
Abscesses, Furuncles, and Carbuncles
| Definitions | Common Pathogens |
|---|---|
| Abscess: Collection of pus within the dermis and deeper skin tissues, clinically manifests as painful, tender, fluctuant, and erythematous nodules. | Staphylococcus aureus, including community-acquired MRSA, Streptococcus pyogenes (GAS) |
| Furuncles (boils): Infection of hair follicles; purulence extends into subcutaneous tissue, creating a small abscess. | |
| Carbuncle: Infection of multiple adjacent follicles, frequently localized on the back of the neck, shoulders, or thighs; usually has one or more openings that drain purulence onto the skin. |
Abbreviations: GAS, group-A Streptococcus; GBS, group-B Streptococcus; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible Staphylococcus aureus
Figure 1. Management of Skin and Soft Tissue Infections
On a narrow screen, scroll horizontally to view the full flowchart.
** Infectious Disease consultation recommended in patients with bacteremia, anticipation of greater than 2 weeks of anti-infective treatment, immunocompromising conditions, history of multi-drug resistant organisms, or recurrence of infection
For definitions of mild, moderate, and severe:
– Non-purulent cellulitis: please see table 3
– Purulent cellulitis: please see table 6
Adapted from the IDSA guideline for use at UKHC [2]
(a) See table 2; (b) If purulent with surrounding cellulitis, follow purulent algorithm; (c) Linezolid preferred in combination with piperacillin/tazobactam as it provides anti-toxin activity and significantly reduces risk for acute kidney injury (AKI); (d) Due to increased rates of clindamycin-resistance, metronidazole must be maintained in combination therapy; (d) Type I reaction includes anaphylaxis, angioedema, or urticaria; Recommend stopping clindamycin if toxin producing disease ruled out. ¥Clindamycin added for anti-toxin effect; #Vibrio and Aeromonas should be considered in patients with wound exposure to fresh or brackish water; Abbreviations: C & S, culture and sensitivity; I & D, incision and drainage; MRSA, methicillin-resistant S. aureus; MSSA, methicillin-susceptible S. aureus; Rx, treatment; TMP/SMX, trimethoprim-sulfamethoxazole
Table 2: Treatment of Impetigo and Folliculitis
| Classification | Severity | Recommendations and Treatment |
|---|---|---|
| Impetigo | Limited disease |
|
| Extensive disease |
|
|
| Folliculitis | No systemic antibiotics needed |
(a) Type I reaction includes anaphylaxis, angioedema, or urticaria; in patients with minor penicillin allergies (non-specific rashes, intolerance, etc.), cross reactivity with cephalosporins is low (<3%)[6, 7]
Table 3: Treatment of Non-purulent Skin and Soft Tissue Infections
Cellulitis and Erysipelas
| Severity | Recommendations | Antibiotics |
|---|---|---|
| MILD (a)Typical cellulitis or erysipelas with no focus of purulence |
|
|
| MODERATE (c)Typical cellulitis/erysipelas with systemic signs of infection (d) |
|
|
| SEVERE (c)Cellulitis/erysipelas in patients who have failed oral antibiotic treatment, those with signs of systemic infection(d), or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction |
|
|
Abbreviations: [PTD] = pharmacist to dose
(a) Consider prednisone 40mg q24h for 7 days in nondiabetic patients for 5 days to hasten clinical improvement in select patients with mild cellulitis.[8]
(b) Type I reaction includes anaphylaxis, angioedema, or urticaria; in patients with minor penicillin allergies (non-specific rashes, intolerance, etc.), cross reactivity with cephalosporins is low (<3%)[6, 7]
(c) Consider Infectious Disease consultation in patients with bacteremia, anticipation of greater than 2 weeks of anti-infective treatment, immunocompromising conditions, history of multi-drug resistant organisms, or recurrence of infection.
(d) Signs of systemic infection include: 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.
Table 4: Treatment of Necrotizing Fasciitis, Fournier's gangrene, Ludwig's angina
Recommendations:
- Immediate surgical debridement, obtain deep tissue culture and blood cultures.
- Antimicrobial therapy should be administered until further debridement is no longer necessary, the patient has improved clinically, and fever has been absent for 48–72 hours
| Regimen | Details |
|---|---|
| Traditional empiric regimen:Consider de-escalation of antibiotics after 72-hrs when specific culture data becomes available and no further debridement is required. The combination of IV vancomycin and piperacillin/tazobactam is associated with significantly increased risk of acute kidney injury (AKI). If a patient has risk factors for AKI development or has AKI at basline please see renal sparing regimen(s) below. |
|
| Renal sparing empiric regimen:The utilization of linezolid, in place of vancomycin, provides the following benefits: Excellent coverage of gram(+) organisms of concern; Mitigation of the risk of additive nephrotoxicity; Anti-toxin effect |
|
| Pathogen-specific regimen: |
Type I (mixed aerobic and anaerobic flora): De-escalate therapy based on culture data Type II (monomicrobial):
|
Abbreviations: [PTD] = pharmacist to dose
(a) Type I reaction includes anaphylaxis, angioedema, or urticaria; in patients with minor penicillin allergies (non-specific rashes, intolerance, etc.), cross reactivity with cephalosporins is low (<3%)[6, 7]
(b) Vibrio and Aeromonas should be considered in patients with wound exposure to fresh or brackish water
Table 5: Treatment of Clostridial Gas Gangrene or Myonecrosis
Recommendations: Immediate surgical debridement, deep tissue culture, blood cultures & consider Infectious Disease consultation in patients with bacteremia, anticipation of greater than 2 weeks of anti-infective treatment, immunocompromising conditions, history of multi-drug resistant organisms, or recurrence of infection.
| Regimen | Details |
|---|---|
| Empiric regimen:In the absence of a definitive etiologic diagnosis, broad spectrum antibiotic treatment |
|
| Pathogen-specific regimen: | Clostridium sp.
|
Abbreviations: [PTD], pharmacist to dose
φ: Recommend stopping clindamycin if it is a mixed infection or infection other than Clostridium spp.
Table 6: Treatment of Purulent Skin and Soft Tissue Infections
Abscess, Furuncles, and Carbuncles
| Severity | Comment | Antibiotic |
|---|---|---|
| MildNo signs of systemic infection |
|
|
| ModeratePatients with signs of systemic infection |
|
Oral antibiotic treatment(a):
|
| Severe (c)Patients who previously failed I&D plus oral antibiotics, immunocompromised patients, or patients with signs of systemic infection |
|
Empiric therapy
S. aureus (MRSA): see empiric S. aureus (MSSA):
|
Abbreviations: [PTD], pharmacy to dose; PWID: people who inject drugs
(a) Therapy may need to be extended based on response to treatment
(b) For additional information visit: http://careweb/ICISdocs/Dalbavancin_Protocol_10092018.pdf
(c) Consider Infectious Disease consultation in patients with bacteremia, anticipation of greater than 2 weeks of anti-infective treatment, immunocompromising conditions, history of multi-drug resistant organisms, or recurrence of infection.
(d) Other agents active against MRSA include Daptomycin OR Linezolid OR Ceftaroline
(e) Type I reaction includes anaphylaxis, angioedema, or urticaria; in patients with minor penicillin allergies (non-specific rashes, intolerance, etc.), cross reactivity with cephalosporins is low (<3%)[6, 7]
Superficial / Deep Incisional Surgical Site Infections
Suture removal plus incision and drainage should be performed for surgical site infections
- Adjunctive antibiotics are not routinely recommended
- Empiric antibiotic treatment should be started in the following cases:
- Significant systemic response (temperature >38.5° C, heart rate >110 beats/minute, or white blood cell (WBC) count >12,000/µL)
- Erythema and induration extending >5cm from the wound edge
Figure 2. Algorithm for the management and treatment of surgical site infections
On a narrow screen, scroll horizontally to view the full flowchart.
*For patients with allergy to PCN antibiotics. Abbreviations: GI, gastrointestinal; MRSA, methicillin-resistant Staphylococcus aureus; WBC, white blood cell count; PCN, penicillin. Adapted from Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America
Table 7: Treatment of Superficial/Deep Incisional Surgical Site Infections
| Empiric Antibiotic treatment | Regimen |
|---|---|
| Surgery of trunk, head/neck, extremity(away from axillae, perineum) |
If MRSA risk factors(a):
|
| Surgery of GI tract/intra-abdominal, female genital tract, axillae, perineum (d) |
|
Abbreviations: [PTD], pharmacy to dose
(a) MRSA risk factors include: Nasal or rectal colonization, prior MRSA infection, residence in long term care facility, recent or long-term antibiotic use, chronic renal dialysis, invasive procedures, etc
(b) May consider q8h dosing to achieve dose of at leat 5 mg/kg/day TMP component (max dose: 320 mg TMP)
(c) Alternatives: linezolid 600 mg PO/IV q12h
(d) Type I reaction includes anaphylaxis, angioedema, or urticaria; in patients with minor penicillin allergies (non-specific rashes, intolerance, etc.), cross reactivity with cephalosporins is low (<3%)[6, 7]
References
- Edelsberg, J., et al., Trends in US hospital admissions for skin and soft tissue infections. Emerg Infect Dis, 2009. 15(9): p. 1516-8.
- Stevens, D.L., et al., Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis, 2014. 59(2): p. e10-52.
- Golan, Y., Current Treatment Options for Acute Skin and Skin-structure Infections. Clin Infect Dis, 2019. 68(Suppl 3): p. S206-S212.
- Haran, J.P., et al., Deviating from IDSA treatment guidelines for non-purulent skin infections increases the risk of treatment failure in emergency department patients. Epidemiol Infect, 2018: p. 1-7.
- Hashem, N.G., et al., Management of skin and soft-tissue infections at a community teaching hospital using a severity-of-illness tool. J Antimicrob Chemother, 2016. 71(11): p. 3268-3275.
- Pichichero, M.E. and R. Zagursky, Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol, 2014. 112(5): p. 404-12.
- Kuruvilla, M., et al., A Streamlined Approach to Optimize Perioperative Antibiotic Prophylaxis in the Setting of Penicillin Allergy Labels. J Allergy Clin Immunol Pract, 2020. 8(4): p. 1316-1322.
- Dall, L., et al., Rapid resolution of cellulitis in patients managed with combination antibiotic and anti-inflammatory therapy. Cutis, 2005. 75(3): p. 177-80.
- Mulla, Z.D., Treatment options in the management of necrotising fasciitis caused by Group A Streptococcus. Expert Opin Pharmacother, 2004. 5(8): p. 1695-700.
- Andreoni, F., et al., Clindamycin Affects Group A Streptococcus Virulence Factors and Improves Clinical Outcome. J Infect Dis, 2017. 215(2): p. 269-277.
- Daum, R.S., et al., A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. N Engl J Med, 2017. 376(26): p. 2545-2555.
- Talan, D.A., et al., Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med, 2016. 374(9): p. 823-32.
- W. Cliff Rutter, PharmD, Donna R. Burgess, RPh, Jeffery C. Talbert, PhD, David S. Burgess, PharmD, Acute kidney injury in patients treated with vancomycin and piperacillin-tazobactam: A retrospective cohort analysis. J. Hosp. Med. 2017 February;12(2):77-82
Guideline pending approval by the Antimicrobial Stewardship Team Subcommittee and P&T Committee