Skin and Soft Tissue Infections
: The most common etiology of cellulitis with purulent drainage is S. aureus, although
Group A streptococci and other streptococcal species can also present in this manner.

The following regimens include coverage for MSSA, community-acquired MRSA (CA-
MRSA), and streptococci
. Coverage for gram negative organisms is not needed except in very
specific patient populations (outlined below).

Oral Regimens
● Doxycycline 100 mg PO BID PLUS Cephalexin 500 mg PO QID OR Amoxicillin 500 mg
TMP/SMX 1-2 DS tab PO BID PLUS Amoxicillin 500 mg PO TID*
Clindamycin 300 mg PO TID
*TMP/SMX and doxycycline have poor activity against Group A streptococci and should be
combined with Amoxicillin or Cephalexin.
Parenteral Regimens
● Vancomycin (moderate to severe disease or nosocomial acquisition) ● Clindamycin 600 mg IV q8h (mild disease)
Duration: 7-10 days. May step down to oral therapy when patient is improving.

surrounding cellulitis, see “oral regimens” above S. aureus, including I&D CA-MRSA - If surrounding cellulitis, systemic symptoms, and/or multiple lesions, see “oral regimens” above - If gangrene, immunocompromised, extensive surrounding cellulitis, or severe systemic symptoms: -Consider surgical treatment -Vancomycin S. aureus, including - Warm water soak CA-MRSA, S. S. pyogenes, rarely - PCN VK 250-500 mg (characterized S. aureus, or S. surrounding skin, with a clear demarcation between involved and uninvolved tissue) S. aureus, including Mild: see “oral CA-MRSA, S. 875 mg PO BID OR
negative organisms Ciprofloxacin 500 mg in PO BID] PLUS
3.375 g IV q6h OR
Meropenem 500 mg IV
q8h. If concern for
MRSA, add vancomycin
-Severe PCN allergy:
Ciprofloxacin +
Clindamycin OR
Aztreonam + Clindamycin. If concern for MRSA, use vancomycin instead of clindamycin and add anaerobic coverage with metronidazole.

S. aureus and Streptococci (especially Group A) ● Rare causes of cellulitis are discussed below
● Always elevate the affected extremity. Treatment failure is more commonly due to failure ● Improvement of erythema can take days, especially in patients with venous stasis or lymphedema, because dead bacteria in the skin continue to induce inflammation. ● The microbiology laboratory routinely tests S. aureus isolates for inducible Clindamycin resistance and this testing is reflected in the reported susceptibility data. If no culture data to guide therapy and high risk or suspicion of CA-MRSA or failure to improve on clindamycin, change clindamycin to alternate active agent such as bactrim or doxycycline. ● Resistance to fluoroquinolones in S. aureus is common and develops quickly. The vast majority of MRSA isolates are resistant to fluoroquinolones. Therapy with fluoroquinolones for S. aureus infections is not recommended. ● Rifampin should NEVER be used as monotherapy because resistance develops rapidly.
● There is NO EVIDENCE that linezolid or daptomycin are superior to TMP/SMX,
doxycycline, or clindamycin for the management of skin and soft tissue infections. Linezolid or daptomycin should only be considered when the S. aureus isolate is resistant to other agents or the patient is intolerant of these agents. ● Elimination or prevention of interdigital tinea is important for cases of relapsing lower ● Specialty referral should be considered in cases of lymphedema, refractory tinea pedis, chronic dermopathies, venous insufficiency, or post-surgical cellulitis.
Other causes of cellulitis in select patient populations

● With bullae, vesicles, and ulcers after exposure to seawater or raw oysters, consider Vibrio vulnificus, especially in patients with chronic liver disease. Rare, but rapidly fatal if
untreated. Treat with ceftriaxone 1 g IV q24h PLUS doxycycline 100 mg PO BID.
● Neutropenic, solid organ transplant, and cirrhotic patients may have cellulitis due to gram-negative organisms. Consider expanding coverage in these cases. Gram-negative cellulitis is exceedingly rare in other patient populations and routine gram-negative coverage is unnecessary. ● If an eschar is present, consider angioinvasive organisms (Pseudomonas, aspergillosis, mold). Infectious Diseases consult is advised. ● Animal and human bites: Pasteurella multocida should be covered for cat and dog bites. Treat with Amoxicillin/clavulanate 875 mg PO BID OR Ampicillin/sulbactam 1.5-3 g IV
q6h. If PCN allergy: Ciprofloxacin 500 mg PO / 400 mg IV q24h PLUS Clindamycin 300
mg PO TID/600 mg IV q8h. Remember to consider tetanus booster and/or rabies
Cutaneous Abscess
● Incision and drainage (I&D) is the primary treatment for a cutaneous abscess. ● Lesions that appear superficial can often have associated abscess formation that is not clearly appreciated without debridement of the wound or, on occasion, additional imaging. ● At the time of I&D, a sample should be obtained for culture and sensitivity testing. A superficial wound swab of purulent drainage prior to I&D is of limited utility. ● Antibiotics are an adjunct to I&D in the management of uncomplicated skin abscesses ● Indications for antimicrobial therapy in patients with cutaneous abscesses: ○ Severe or rapidly progressive infections ○ The presence of extensive associated cellulitis ○ Signs and symptoms of systemic illness ○ Diabetes or other immune suppression (e.g., solid organ transplant) ○ Location of the abscess in an area where complete drainage is difficult ● Antibiotic therapy should be given before I&D in patients with prosthetic heart valves or
other conditions placing them at high risk for endocarditis.
If antibiotic treatment is thought to be necessary due to one of the above indications, regimens
are the same as for cellulitis above. If CA-MRSA is strongly suspected or confirmed, consider
NOT adding Amoxicillin or Cephalexin to TMP/SMX, Doxycycline, or Clindamycin.
Recurrent MRSA Skin Infections
1. Patient education regarding approaches to personal and hand hygiene
○ Practice frequent hand hygiene with soap and water and/or alcohol-based hand gels, especially after touching infected skin or wound bandages. ○ Cover draining wounds with clean, dry bandages. ○ Do not share personal items (e.g. razors, used towels or clothing before ○ Launder clothing, sheets, towels in hot water. ○ Clean all personal sporting clothing/equipment. 2. Decontamination of the environment
○ Clean high-touch areas in the bathroom with a disinfectant active against S. aureus daily (e.g. Clorox bleach wipes) 3. Topical decolonization (consider if a patient has ≥ 2 episodes per year or other
househould members develop infection)
○ Mupirocin applied to nares twice daily for 5 days may be considered in patients with documented evidence of MRSA nasal colonization; Mupirocin therapy should be initiated after resolution of acute infection. Mupirocin should not be used in patients who are not documented to have MRSA nasal colonization. ○ Bathing or showering with chlorhexidine (Hibiclens) or dilute bleach baths ever other day for 1 week then twice weekly; patients should be instructed not to get these substances into ears or eyes. ○ Systemic antibiotics are NOT recommended solely for decolonization. 4. Evaluation of family members
○ Intra-family transmission should be assessed and if present, all members should participate in hygiene and decolonization strategies above, starting at the same time and after the acute infection is controlled.
Data on efficacy and durability of the decontamination and decolonization strategies
described above are limited.
References: IDSA Guidelines for Skin and Soft Tissue Infections. CID 2005; 41:1373-406 TMP/SMX for MRSA: Ann Intern Med 1992;117:390-8. Management of CA-MRSA: Diabetic Foot Infections
Treatment depends on clinical severity

Clinical Manifestations
Presence of purulence and ≥ 1 signs of inflammation* and cellulitis (if present) ≤ 2 cm around ulcer limited to skin or superficial subcutaneous tissue Same as mild PLUS ≥ 1 of the
following: > 2 cm of cellulitis,
lymphangitic streaking, spread
beneath the superficial fascia,
deep tissue abscess, gangrene,
involvement of muscle, tendon,
joint, or bone.
Any of the above PLUS systemic
*Erythema, pain, tenderness, warmth, induration
Oral Regimens

Clindamycin 300 mg PO TID (covers MRSA)
Amoxicillin/clavulanate 875 mg PO BID

Parenteral Regimens
● Clindamycin 600 mg IV q8h (covers CA-MRSA if no inducible Clindamycin resistance)
Ciprofloxacin 500 mg PO BID / 400 mg IV q12h PLUS EITHER Clindamycin 600 mg IV
q8h/300 mg PO TID OR Metronidazole 500 mg IV/PO TID
Avoid fluoroquinolones in patients who were on them as outpatients.
If patient at risk for MRSA, add Vancomycin to regimens that do not include Clindamycin
● History of colonization or infection with MRSA ● Recent (within 3 months) or current prolonged hospitalization > 2 weeks ● Transfer from a nursing home or subacute facility
● Ciprofloxacin 400 mg IV q12h PLUS Clindamycin 600 mg IV q8h
● BUT avoid fluoroquinolones in patients who were on them as outpatients. If patient at risk for CA-MRSA (see above) ● Pipercillin/tazobactam 4.5 g IV q6h PLUS Vancomycin (see dosing section)
● Ciprofloxacin 400 mg IV q12h PLUS Metronidazole 500 mg IV q8h PLUS Vancomycin
● BUT avoid fluoroquinolones in patients who were on them as outpatients.

● A multidisciplinary approach to management should include wound care consultation, podiatry consult, assessment of vascular supply, vascular and/or general surgery consultation and infectious diseases consultation. ● Consider necrotizing fasciitis in patients who are severely ill. ● Antibiotic therapy should be narrowed based on culture results. Microbiology
Cellulitis without open wound or infected ulcer, antibiotic naive: beta-hemolytic
Infected ulcer, chronic or previously treated with antibiotics: S. aureus, beta-hemolytic
Exposure to soaking, whirlpool, hot tub: usually polymicrobial, can involve Pseudomonas
Chronic wounds with prolonged exposure to antibiotics: aerobic gram positive cocci,
diptheroids, Enterobacteriaceae, other gram negative rods including Pseudomonas Necrosis or gangrene: mixed aerobic gram positive cocci and gram negative rods,
● Cultures of the ulcer base after debridement can help guide therapy. Avoid swabbing ● Ulcer floor should be probed carefully. If bone can be touched with a metal probe then the patient should be treated for osteomyelitis with antibiotics in addition to possible surgical debridement. ● A deep foot-space infection can be present. Consider imaging to look for deep ● Putrid discharge is diagnostic for the presence of anaerobes. ● MRI is more sensitive and specific than other rmodalities for detection of soft-tissue Duration
● Duration of treatment will depend on rapidity of response and presence of adequate ● Likely need shorter treatment with adequate surgical intervention (7-10 days post-op) ● Change to an oral regimen when patient is stable. Reference: IDSA Guidelines: Clin Infect Dis 2004;39:885-910. Surgical Site Infections (SSI)
Infections following clean procedures
(e.g. orthopedic joint replacements, open reduction of
closed fractures, vascular procedures, median sternotomy, craniotomy, breast and hernia
PCN allergy: Clindamycin 600 mg IV q8h
● Involvement of hardware: Vancomycin (see dosing section) Exception: Saphenous vein graft harvest site infections should be treated with ertapenem 1 g
IV q24h.

Infections following contaminated procedures (GI/GU procedures, oropharyngeal
procedures, OB/GYN procedures)

Patients not on broad-spectrum antibiotics at time of surgery and not severely ill
Severe PCN allergy: Ciprofloxacin 500 mg PO BID/400 mg IV q12h) PLUS Clindamycin
Patients on broad-spectrum antibiotics at time of surgery or severely ill ● Piperacillin/tazobactam 3.375 g IV q6h PLUS Vancomycin (see dosing section), if
hardware present or MRSA suspected
● PCN allergy: Vancomycin (see dosing section) PLUS Ciprofloxacin 500 mg PO BID/400
mg IV q12h) PLUS Metronidazole 500 mg PO/IV q8h

Deep fascia involvement
Treat as necrotizing fasciitis (see dedicated section)


● Following clean procedures (no entry of GI/GU tracts) ○ Staphylococcus aureus (including MRSA) ○ Streptococci, group A (esp with early onset, < 72 hours) ● Following clean-contaminated and contaminated procedures (entry of GI/GU tracts with ○ Anaerobes (consider Clostridia spp in early-onset infections, 1-2 days) ● Generally, empiric use of Vancomycin is NOT indicated because the percentage of SSIs ● History of colonization or infection with MRSA ● Recent (within 3 months) or current prolonged hospitalization >2 weeks ● Transfer from a nursing home or subacute facility
Other management issues
● Many advocate that ALL infected wounds be explored both to debride and to assess the ● Superficial infections may be adequately treated with debridement alone. ● Deeper infections (cellulitis, panniculitis) need adjunctive antibiotics. ● Patients with hypotension should have their wounds explored even they are Necrotizing Fasciitis (serious, deep-tissue infections)
Infectious Diseases should be consulted for all cases of necrotizing fasciitis.
TREATMENT (adjunct to surgery)
Vancomycin (see dosing section) PLUS [Piperacillin/tazobactam 3.375 g IV q6h OR
Cefepime 1 g IV q8h] PLUS Clindamycin 600-900 mg IV q8h
● PCN allergy: Vancomycin (see dosing section) PLUS Ciprofloxacin 400 mg IV q12h
PLUS Clindamycin 600-900 mg IV q8h
If confirmed beta-hemolytic streptococci: ● Penicillin G 24 Million Units as continuous infusion PLUS Clindamycin 600-900 mg IV
● PCN allergy: Vancomycin (see dosing section) PLUS Clindamycin 600-900 mg IV q8h

Conventional nomenclature and microbiology
(purulent infection of skeletal muscle, usually with abscess formation)
S. aureus most commonly ● Clostridial myonecrosis - Clostridia spp (esp C. perfringens) Fasciitis (infection of the subcutaneous tissue that results in progressive destruction of fascia
and fat, but may spare the skin)
● Type 1 - Polymicrobial infections with anaerobes, streptococci and gram-negative rods (Fournier’s gangrene is a type 1 necrotizing fasciitis of the perineum) ● Cases of fasciitis caused by community-acquired MRSA have been reported ● Case-cohort studies and case reports have suggested some benefit to treatment with intraveous immunoglobulin (IVIG) in specific circumstances (e.g., streptococcal toxic shock). However, due to the lack of randomized controlled trials, IVIG should probably be reserved for select patients. Infectious Diseases consult is advised.
● Can be difficult - gas production is not universal and is generally absent in streptococcal ● Can follow minor or major trauma, especially when risk factors are present. ● Maintain high index of suspicion when: ○ Patients are very ill from cellulitis (hypotension, toxic) ○ Pain out of proportion to exam findings. ○ Risk factors such as diabetes, recent surgery, or obesity ○ Findings such as skin necrosis or bullae ○ Putrid discharge with thin, “dishwater” pus ● CT scan can help with diagnosis but if suspicion is moderate to high, surgical exploration is the preferred diagnostic test. DO NOT delay surgical intervention to obtain CT. ● Initial histopathologic findings may be of prognostic importance. A poor neutrophil response with numerous organisms seen on routine stains implies a poor prognosis.


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