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 | | Drug Therapy | |
- In patients with cellulitis or soft tissue infection, stratify their infection according to severity and complicating comorbidities as a means to determine the need for oral or parenteral antimicrobials.
- Treat patients with mild, uncomplicated cellulitis who are not at high risk for MRSA with oral antibiotics that have activity against both staphylococci and streptococci.
- Treat patients with mild, uncomplicated cellulitis who are at risk for MRSA infection with oral antimicrobials that have activity against MRSA and streptococci.
- Treat patients with moderate to severe cellulitis with systemic manifestations of infection, who are at risk for MRSA, with more potent antimicrobial agents that have activity against MRSA and streptococcal infections.
- Treat patients with MSSA soft tissue infections that are moderate to severe with a semisynthetic penicillin or one of a number of other options.
- Administer prompt antimicrobial therapy and thorough surgical debridement to patients who have evidence of gangrene.
- Treat infections due to human bites with appropriate antibiotics.
- Treat infections due to animal bites with appropriate antimicrobial agents.
- Treat impetigo with topical or oral antibiotics.
- Recognize the need to extend antimicrobial coverage to gram-negative bacilli in the treatment of soft tissue infections in immunocompromised patients, such as those rendered neutropenic from chemotherapy.
- Switch from parenteral to oral antimicrobials and discontinue them when appropriate.
- Consider that many patients with recurrent infection carry MRSA in their nares or perineal area.
- Treat traumatic and surgical wounds with appropriate antibiotics.
| | Drug Treatment for Soft Tissue Infections (table)
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In patients with cellulitis or soft tissue infection, stratify their infection according to severity and complicating comorbidities as a means to determine the need for oral or parenteral antimicrobials.  |
- Evaluate the severity of the patient's infection and comorbidities to determine the need for oral or parenteral antimicrobials
- Treat abscesses <5 cm in diameter by incision and drainage; antimicrobials may be optional in patients without complicating comorbidities.
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Treat patients with mild, uncomplicated cellulitis who are not at high risk for MRSA with oral antibiotics that have activity against both staphylococci and streptococci.  |
- Treat patients on an outpatient basis with mild, uncomplicated cellulitis without systemic manifestation who are not at high risk for MRSA infection with appropriate antimicrobials.
- Treat patients with MSSA using:
- Dicloxacillin or cloxacillin
- An oral cephalosporin (cephalexin or cefuroxime)
- Clindamycin (if allergic to penicillin)
- An advanced fluoroquinolone (moxifloxacin, gatifloxacin, levofloxacin) if intolerant to the above drugs
- Prevent frequent recurrences with prophylactic antimicrobials in patients with chronic lymphedema.
| Background | Back to top
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Treat patients with mild, uncomplicated cellulitis who are at risk for MRSA infection with oral antimicrobials that have activity against MRSA and streptococci. |
- Treat patients with mild, uncomplicated cellulitis without systemic manifestations who are risk for MRSA infection with an appropriate antimicrobial.
- Treat patients with MRSA using:
- Clindamycin (if sensitive)
- Trimethoprim-sulfamethoxazole
- Minocycline or doxycycline (if allergic to sulfa)
- An advanced fluoroquinolone (moxifloxacin, gatifloxacin, levofloxacin) if intolerant to the above drugs
| Background | Back to top
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Treat patients with moderate to severe cellulitis with systemic manifestations of infection, who are at risk for MRSA, with more potent antimicrobial agents that have activity against MRSA and streptococcal infections. |
- Treat patients with moderate to severe cellulitis with risk factors for MRSA infection:
- Recent antibiotic use
- Recent hospitalization
- Hemodialysis
- IV drug use
- Diabetes
- Previous MRSA infection or colonization
- Treat moderate to severe MRSA infection with:
- Clindamycin (if sensitive)
- Vancomycin
- Linezolid
- Daptomycin
- Tigecycline
- Telavancin
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Treat patients with MSSA soft tissue infections that are moderate to severe with a semisynthetic penicillin or one of a number of other options. |
- Treat patients with appropriate antibiotics for MSSA:
- Semisynthetic penicillin (nafcillin, oxacillin)
- Cephalosporin (cefazolin or ceftriaxone)
- If penicillin-allergic:
- Clindamycin if sensitive
- Fluoroquinolone (moxifloxacin, gatifloxacin; levofloxacin)
- Advanced macrolide (clarithromycin, azithromycin)
- Oxazolidinone (linezolid)
- Vancomycin, daptomycin, dalbavancin, tigecycline
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Administer prompt antimicrobial therapy and thorough surgical debridement to patients who have evidence of gangrene.  |
- Perform immediate and thorough debridement if a necrotizing process (types 1, 2, or 3) is present at the time of surgical exploration:
- Debride friable fascia and dark muscle that does not bleed or twitch
- Continue debridement until viable tissue is reached
- Repair compromised vascular supply
- Obtain vascular evaluation for diabetics with limb infections who manifest decreased pedal pulses.
- Treat initially with broad-spectrum coverage until the etiologic agent is identified and sensitivities are known.
- Treat community-acquired necrotizing limb infections in diabetics (type 1 necrotizing fasciitis) either with ampicillin/sulbactam, cefoxitin, cefotetan, ticarcillin/clavulanate, piperacillin/tazobactam, or a carbapenem (such as meropenem, imipenem, ertapenem, or doripenem) until cultures return.
- Treat patients who have necrotizing fasciitis or myonecrosis caused by C. perfingens, C. septicum, or S. pyogenes with clindamycin plus penicillin.
- Treat patients who have a necrotizing fasciitis due to MSSA or MRSA with clindamycin (if sensitive). If resistant use linezolid for MSSA and MRSA.
- Use linezolid for patients with severe infection where MRSA is suspected; or
- Consider hyperbaric oxygen therapy for gas gangrene (type 3 necrotizing fasciitis).
- Consider adding intravenous immunoglobulin to treat patients with type 2 necrotizing fasciitis, especially if accompanied by toxic shock syndrome.
- See table Treatment of Necrotizing Fasciitis
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Treat infections due to human bites with appropriate antibiotics. |
- Hospitalize patients who require either surgical intervention or close observation.
- Treat patients with intravenous ampicillin/sulbactam or oral amoxicillin/clavulanate.
- Treat with moxifloxacin plus clindamycin or trimethoprim-sulfamethoxazole plus metronidazole if they are allergic to penicillin.
- Consult hand surgeons or plastic surgeons if the infection is moderate or severe for closed fist injuries.
- Update tetanus toxoid immunization status.
- See table Treatment of Human and Animal Bites
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Treat infections due to animal bites with appropriate antimicrobial agents. |
- Clean open wounds with antibacterial soap.
- Consult a surgeon to manage complex wounds or those with deep penetration.
- Surgically debride jagged, open wounds.
- Monitor capillary refill and observe for severe swelling to avoid a compartment syndrome.
- Do not suture these wounds closed except for facial wounds.
- Treat with intravenous ampicillin/sulbactam or oral amoxicillin/clavulanate
- Treat with doxycycline, advanced fluoroquinolones, or trimethroprim/sulfamethoxazole in patients allergic to penicillin.
- Consider adding anaerobic coverage, such as metronidazole or clindamycin.
- See table Treatment of Human and Animal Bites
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Treat impetigo with topical or oral antibiotics. |
- Treat impetigo with cephalexin orally or mupirocin ointment topically.
- If there is no response to cephalexin, consider MRSA coverage with an antimicrobial (see Treatment of Mild Cellulitis).
- Treat patients with MSSA using:
- Dicloxacillin or cloxacillin
- An oral cephalosporin (cephalexin or cefuroxime)
- Clindamycin (if allergic to penicillin)
- An advanced fluoroquinolone (moxifloxacin, gatifloxacin, levofloxacin) if intolerant to the above drugs
- Treat patients with MRSA using:
- Clindamycin (if sensitive)
- Trimethoprim-sulfamethoxazole
- Minocycline or doxycycline (if allergic to sulfa)
- An advanced fluoroquinolone (moxifloxacin, gatifloxacin, levofloxacin) if intolerant to the above drugs
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Recognize the need to extend antimicrobial coverage to gram-negative bacilli in the treatment of soft tissue infections in immunocompromised patients, such as those rendered neutropenic from chemotherapy. |
- Use blood culture results, antigen tests, and radiographic imaging, with biopsy of infected areas, when necessary, to optimize the recovery of an etiologic agent.
- Empirical therapy should be initiated quickly based on patient-specific clinical parameters and the statistically most likely pathogens.
- Initiate empirical antimicrobials with activity against gram-positive as well as gram-negative bacteria in neutropenic patients with soft tissue infections.
- Use initially a β-lactam antibiotic with anti-Pseudomonas activity such as cefepime, ceftazidime, piperacillin/tazobactam, meropenem, doripenem, or imipenem, as initial therapy.
- In penicillin-allergic patients consider a fluoroquinolone, such as ciprofloxacin, moxifloxacin, gatifloxacin, or levofloxacin, or a monobactam such as aztreonam.
- Consider adding MRSA coverage using vancomycin, linezolid, daptomycin, tigecycline, or dalbavancin in such patients who are critically ill or who fail to respond to the above antimicrobials.
- Avoid aminoglycosides such as gentamicin, tobramycin, or amikacin, if possible, in view of their ototoxicity and nephrotoxicity.
- Discontinue empiric vancomycin treatment if blood cultures of neutropenic patients remain negative after 72 to 96 hours.
- Consider adding an antifungal agent to neutropenic patients who fail to respond to these antimicrobials; these include triazoles such as voriconazole, echinocandins such as caspofungin, micafungin, and anidulafungin, as well as amphotericin B or liposomal amphotericin.
- See table Drug Treatment for Soft Tissue Infections.
| Background | Back to top
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Switch from parenteral to oral antimicrobials and discontinue them when appropriate. |
- Switch patients who are being treated with parenteral antimicrobials for moderate to severe cellulitis, to oral antibiotics when their infection has stabilized, the leukocyte count is trending toward normal, and when they can take them orally without nausea or diarrhea.
- Discontinue antibiotics when most of the signs of inflammation have decreased, although all signs may not have resolved.
- Consider the addition of steroids and nonsteroidal anti-inflammatory agents to hasten the regression of inflammation.
| Background | Back to top
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Consider that many patients with recurrent infection carry MRSA in their nares or perineal area. |
- Culture the nares of patients with recurrent infection who are suspected of carrying MRSA.
- Treat carriers with mupirocin to the nares twice a day for 7 days.
- Recommend to carriers that they wash daily with chlorhexidine.
- For relapses of the above regimen, prescribe antimicrobials that penetrate nasopharyngeal secretions, such as rifampin combined with either trimethoprim-sulfamethoxazole, clindamycin, or minocycline/doxycycline.
| Background | Back to top
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Treat traumatic and surgical wounds with appropriate antibiotics. |
- Categorize surgical site infection according to status:
- Superficial incisional infection
- Deep incisional infection
- Organ/space infection
- Recognize that infection usually presents between 5 and 20 days postoperatively.
- Drain abscesses when present,
- Prescribe appropriate antimicrobials:
- Prescribe drugs active against S. aureus in clean procedures
- Prescribe drugs active against anaerobes and gram-negative bacilli in procedures involving the gastrointestinal tract or perinuem
- Cefoxitin
- Piperacillin/tazobactam
- Ampicillin/sulbactam
- Ticaricillin/clavulanate
- If penicillin-allergic, ciprofloxacin OR aztreonam AND clindamycin OR metronidazole OR tigecycline
| Background | Back to top
| | | FAQs |
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| Dennis L. Stevens, PhD, MD has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Lawrence J. Eron, MD, FACP has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Steven E. Weinberger, MD, FACP, Acting Editor, PIER, has stock holdings in Glaxosmithkline and Abbott. |
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PIER is copyrighted (c) 2009 by the American College of Physicians,
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Cellulitis and Soft Tissue Infections
