the Management of Skin and Soft Tissue Infections

- Executive summary

Summarized below are the recommendations made in the new guidelines for skin and soft tissue infections (SSTIs), to simplify the management of localized purulent staphylococcal infections such as skin abscesses, furuncles, and carbuncles in the age of methicillin-resistant Staphylococcus aureus (MRSA). In addition, it simplify the approach to patients with surgical site infections. The panel followed a process used in the development of other Infectious Diseases Society of America (IDSA) guidelines, which included a systematic weighting of the strength of recommendation and quality of evidence using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system.

·       Gram stain and culture of pus from carbuncles and abscesses are recommended in atypical cases, but treatment without these studies is reasonable in typical cases, (Strong recommendation).

·       We recommend against Gram stain and culture of pus from inflamed epidermoid cysts, (Strong recommendation).

·       Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles, (Strong recommendation).

·       The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based upon presence or absence of: systemic inflammatory response syndrome (SIRS), (Strong recommendation).

·       An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment or have markedly impaired host defenses or in patients with SIRS, (Strong recommendation).

·       In case of a recurrent abscess at a site of previous infection, we recommend a search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material, (Strong recommendation).

·       Recurrent abscesses should be drained and cultured early in the course of infection, (Strong recommendation).

·       After obtaining cultures of recurrent abscess, we advise to treat it with a 5- to 10-day course of an antibiotic active against the pathogen isolated, (Conditional recommendation).

·       For recurrent S. aureus infection, we advise a 5-day decolonization regimen twice daily of intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items such as towels, sheets, and clothes, (Conditional recommendation).

·       Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood, (Strong recommendation).

·       We recommend against routine cultures of blood or cutaneous aspirates, biopsies, or swabs, (Strong recommendation).

·       In patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites, we advise performing cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs, (Conditional recommendation).

·       Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci, (Strong recommendation).

·       For cellulitis with systemic signs of infection (moderate non-purulent), we advise prescribing systemic antibiotics. Coverage against methicillin-susceptible S. aureus (MSSA) may be included, (Conditional recommendation).

·       For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (severe non-purulent), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended, (Strong recommendation).

·       In severely compromised patients as defined in severe non-purulent, we advise prescribing broad-spectrum antimicrobial coverage, (Conditional recommendation).

·       Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen for severe infections, (Strong recommendation).

·       The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period, (Strong recommendation).

·       Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended, (Strong recommendation).

·       In lower-extremity cellulitis, we recommend careful examination of the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection, (Strong recommendation).

·       Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability, (mild non-purulent), (Strong recommendation).

·       Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing, (moderate or severe non-purulent), (Strong recommendation).

·       Identifying and treating predisposing conditions for recurrent cellulitis is recommended, (Strong recommendation).

·       We advise administration of prophylactic antibiotics in patients who have 3–4 episodes of cellulitis per year despite attempts to treat or control predisposing factors, (Conditional recommendation).

·       We recommend suture removal plus incision and drainage for surgical site infections, (Strong recommendation).

·       We advise against routine adjunctive systemic antimicrobial therapy in SSI, except in the presence of manifestations of SIRS, (Conditional recommendation).

·       A brief course of systemic antimicrobial therapy is recommended in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection, (Strong recommendation).

·       Prophylactic antibiotic is recommended before the operation according to the type of operation, (Strong recommendation).

·       Prompt surgical intervention is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (severe non-purulent), (Strong recommendation).

·       Empiric antibiotic treatment should be broad, (Strong recommendation).

·       Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis, (Strong recommendation).

·       We recommend performing imaging studies for diagnosis of pyomyositis, (Strong recommendation).

·       We recommend cultures of blood and abscess, followed by administration of initial empirical therapy in patients with pyomyositis, (Strong recommendation).

·       We recommend early drainage of purulent material in pyomyositis, (Strong recommendation).

·       We recommend repeating imaging studies in the patient with persistent bacteremia to identify undrained foci of infection, (Strong recommendation).

·       Antibiotics should be administered intravenously initially, but once the patient is clinically improved, oral antibiotics are appropriate, (Strong recommendation).

·       We recommend urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue, (severe non-purulent), (Strong recommendation).

·       In the absence of a definitive etiologic diagnosis, we recommend administration of broad-spectrum antibiotic, (Strong recommendation).

·       We recommend against hyperbaric oxygen (HBO) therapy, because it has not been proven as a benefit to the patient and may delay resuscitation and surgical debridement, (Strong recommendation).