Skin and soft tissue antibiotics

Erysipelas

Coverage for S. pyogenes

  • Penicillin G 300K U/d IM for <30 kg, 600K to 1 million U/d IM for >30 kg (first line therapy[1]) OR
  • Clindamycin 450mg (5mg/kg) PO q8hrs x 10 days (if PCN allergic) OR
  • Cephalexin 500mg (6.25mg/kg) PO q6hrs x 10 days OR
  • Ceftriaxone 1g (50mg/kg) IV once daily x 10 days OR
  • Levofloxacin 500mg PO/IV daily x 10 days OR
  • Augmentin 500mg PO BID x 10 days (generally reserved for failure of first line therapy)

Bullous Erysipela or MRSA suspected: trimethoprim-sulfamethoxazole, clindamycin, doxycycline, or minocycline

Cellulitis/Superficial Abscess with Cellulitis

Tailor antibiotics by regional antibiogram[2]

Outpatient

Coverage primarily for Strep

MRSA coverage only necessary if cellulitis associated with: purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS[3]

  • 5 day treatment duration, unless symptoms do not improve within that timeframe[3]
    • Cephalexin 500mg PO q6hrs OR
      • Add TMP/SMX DS 1 tab PO BID[4] if MRSA is suspected
      • Most cases of non-purulent cellulitis are caused by Strep. In these cases, the addition of TMP/SMX has been demonstrated to offer no clinical benefit over cephalexin alone.[5]
    • Clindamycin 450mg PO TID covers both Strep and Staph
    • Tetracyclines (like Doxycycline) should be avoided in non-purulent cellulitis due to high rates of Strep resistance[6]

Inpatient

coverage extended for Vibrio vulnificus

coverage extended for Aeromonas sp

Impetigo

Coverage for MSSA, MRSA, Group A Strep

Topical therapy
  • Mupirocin (Bactroban) 2% ointment q8hrs x 5 days
    • For nonbullous impetigo, topic antibiotics are as effective as oral antibiotics

Oral Therapy

Mastitis
  • No need to routinely interrupt breastfeeding with puerperal mastitis.
  • For mild symptoms <24 hours, supportive care may be sufficient[7]
    • Effective milk removal (frequent breast feeding - use pumping to augment milk removal)
    • Analgesia (NSAIDs)

Treatment directed at S. aureus and Strep and E. coli

  • Uncomplicated mastitis → 10 days of antibiotics (regardless of MRSA suspicion)[8]
  • Dicloxacillin 500mg PO q6hrs, considered first line if breastfeeding given safety for infant OR
  • Cephalexin 500mg PO q6hrs OR
    • Add TMP/SMX 2DS tabs PO q12hrs if suspect MRSA
  • Clindamycin 450mg PO q8hrs (also provides MRSA coverage) OR
  • Amoxicillin/Clavulanate 875mg PO q12hrs OR
  • Azithromycin 500mg PO x1 on day 1, then 250mg PO daily for days 2-5

See Also

Antibiotics by diagnosis

For antibiotics by organism see Microbiology (Main)

References
  1. Linke M, Booken N. Risk factors associated with a reduced response in the treatment of erysipelas. J Dtsch Dermatol Ges. 2015 Mar;13(3):217-25.
  2. Stevens D, 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):e10-e52
  3. Stevens D, 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):e10-e52
  4. Cadena J, et al. Dose of trimethoprim-sulfamethoxazole to treat skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus. Antimicrobial agents and chemotherapy 55.12 (2011): 5430-5432.
  5. Pallin D, et al. Clinical trial: comparative effectiveness of cephalexin plus trimethoprim-sulfamethoxazole versus cephalexin alone for treatment of uncomplicated cellulitis: a randomized controlled trial. Clinical infectious diseases 56.12 (2013): 1754-1762
  6. Traub, W and Leonhard, B. Comparative susceptibility of clinical group A, B, C, F, and G beta-hemolytic streptococcal isolates to 24 antimicrobial drugs. Chemotherapy 43.1 (1997):10-20.
  7. Amir LH. ABM Clinical Protocol #4: Mastitis, Revised March 2014. Breastfeeding Medicine. 2014;9(5):239-243. doi:10.1089/bfm.2014.9984.
  8. Levine BL. 2011 EMRA Antibiotic Guide. EMRA. Pg 78.
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