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ABX – Soft Tissue Infection

Cellulitis – Community acquired – Group A strep MSSA

Nafcillin 1–2 g every 4 h IV (Dicloxacillin 500 mg orally 4 times per day)

OR

Cefazolin 1 g every 8 h IV (Cephalexin 500 mg orally 4 times per day)

OR

Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 mg orally 4 times per day).

Most cases of cellulitis are caused by Group A strep unless there is a portal of entry such as furuncles, carbuncles, abscesses or penetrating trauma in which case staph aureus is probably the cause. CDC data reveals that 99.5% of Group A strep strains remain susceptible to clindamycin, and 100% are susceptible to penicillin.

Cellulitis – Community acquired – MRSA suspected*

TMP-SMZ 2 double-strength tablets orally twice
per day.

OR

Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 mg orally 4 times per day).

*Risk factors for Community acquired MRSA= Injection drug users, Homeless populations, Children, Jail and prison inmates, Military recruits, Native populations, Men who have sex with men, contact sports, HIV+ patients. Clindamycin has excellent antistaphylococcal activity, but there is the potential for emergence of inducible resistance to clindamycin if erythromycin resistance is present.

Cellulitis – Nosocomial – MRSA suspected*

Vancomycin 30 mg/kg/day IV every 12 hours.

*Risk Factors for Nosocomial MRSA= frequent hospitalization, nursing home resident, dialysis, immunocompromised.

NECROTIZING SKIN AND SOFT-TISSUE INFECTIONS

Clues: (1) pain disproportionate to physical findings, (2) violaceous bullae, (3) cutaneous hemorrhage, (4) skin sloughing, (5) skin anesthesia, (6) rapid progression, and (7) gas in tissue Surgical intervention is the major therapeutic
modality in cases of necrotizing fasciitis, also CT scanning and measurement of the serum creatine kinase (CK). The rationale for clindamycin is based on in vitro studies demonstrating both toxin suppression and modulation of cytokine (i.e., TNF) production.

Necrotizing Fasciitis

Ampicillin-sulbactam 1.5 g IV every 6 hours (3g if >100 Kg) + clindamycin 600–900 mg every 8 h iv

OR

Imipenem/cilastatin 1 g every 6–8 h iv

Monomicrobial infection caused by group A streptococcus (Streptococcus pyogenes) or clostridium. Predisposing factors: blunt trauma, varicella (chickenpox), injection drug use, a penetrating injury, surgical procedures, childbirth, burns, nonsteroidal antiinflammatory drugs.

OR

Mixed polymicrobial infection caused by aerobic and anaerobic bacteria. Predisposing risk Factors: immunocompromised, surgical procedures, diabetes, peripheral vascular disease, co-morbidities, decubitus ulcers, and spontaneous mucosal tears of the gastrointestinal or gastrourinary tract (i.e., Fournier gangrene).

Bites – Animal and Human

Ampicillin-sulbactam 1.5–3.0 g IV every 6h
(Amoxicillin/clavulanate 500/875 mg twice per day)

Bites – Animal and Human with PCN allergy

Clindamycin 600–900 mg IV every 8 h + Levaquin 500 mg IV once daily

Pasteurella species are isolated from 50% of dog bite wounds and 75% of cat bite wounds. Human bites reflect oral flora of the biter and tend to be more serious: strep viridans, Eikenella corrodens, Fusobacterium species, peptostreptococci, and Prevotella. Both Ampicillin-sulbactam and Fluroquinolones have activity against Pasteurella.

Diabetic Foot – Mild soft tissue infections AND no previous antibiotics

Nafcillin 1–2 g every 4 h IV
(Dicloxacillin 500 mg orally 4 times per day)

OR

Cefazolin 1 g every 8 h IV
(Cephalexin 500 mg orally 4 times per day)

OR

Clindamycin 600 mg every 8 h IV (Clindamycin 300–450 mg orally 4 times per day).

In mild diabetic soft tissue infections: therapy should be directed against aerobic gram positive organisms particularly, coagulase-negative staphylococci and S. aureus.

Diabetic Foot – Moderate soft tissue infections AND/OR previous antibiotic exposure

Ampicillin-sulbactam 1.5–3.0 g IV every 6h
(Amoxicillin/clavulanate 500/875 mg PO twice per day)

OR

Clindamycin 600–900 mg IV every 8 h + Levaquin 500 mg IV once daily

Initial oral broad-spectrum antimicrobial therapy should be directed at gram-positive, gram-negative, and anaerobic organisms.
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Ref. Stevens DL, Bisno A, Chambers H et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections Clin Infect Dis 2005; 41:1373–406
IDSA guidelines for the diagnosis and treatment of diabetic foot infections: Clinical Infectious Diseases 2004; 39:885-910.

Written by phil

July 15th, 2006 at 3:36 pm

Posted in Antibiotics