the Management of Skin and Soft Tissue Infections

- Recommendations

Section 1: Evaluation and treatment for purulent SSTIs (cutaneous abscesses, furuncles, carbuncles, and inflamed epidermoid cysts):

·       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, moderate certainty evidence, ⁽³⁾).

·       We recommend against Gram stain and culture of pus from inflamed epidermoid cysts, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles, (Strong recommendation, high certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).

Section 2: Treatment of recurrent skin abscess:

·       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, moderate certainty evidence, ⁽³⁾).

·       Recurrent abscesses should be drained and cultured early in the course of infection, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).

·       Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

Section 3: Evaluation and treatment of erysipelas and cellulitis:

·       We recommend against routine cultures of blood or cutaneous aspirates, biopsies, or swabs, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, moderate certainty evidence, ⁽³⁾).

·       Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).

·       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, moderate certainty evidence, ⁽³⁾).

·       In severely compromised patients as defined in severe non-purulent, we advise prescribing broad-spectrum antimicrobial coverage, (Conditional recommendation, moderate certainty evidence, ⁽³⁾).

·       Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen for severe infections, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, high certainty evidence, ⁽³⁾).

·       Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, moderate certainty evidence, ⁽³⁾).

·       Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability, (mild non-purulent), (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, moderate certainty evidence, ⁽³⁾).

Section 4: Evaluation and management of patients with recurrent cellulitis:

·       Identifying and treating predisposing conditions for recurrent cellulitis is recommended, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       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, moderate certainty evidence, ⁽³⁾).

Section 5: Management of surgical site infections:

·       We recommend suture removal plus incision and drainage for surgical site infections, (Strong recommendation, low certainty evidence, ⁽³⁾).

·       We advise against routine adjunctive systemic antimicrobial therapy in SSI, except in the presence of manifestations of SIRS, (Conditional recommendation, low certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).

·       Prophylactic antibiotic is recommended before the operation according to the type of operation, (Strong recommendation, low certainty evidence, ⁽³⁾).

Section 6: Evaluation and treatment of necrotizing fasciitis, including Fournier gangrene:

·       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, low certainty evidence, ⁽³⁾).

·       Empiric antibiotic treatment should be broad, (Strong recommendation, low certainty evidence, ⁽³⁾).

·       Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis, (Strong recommendation, low certainty evidence, ⁽³⁾).

Section 7: Management of pyomyositis:

·       We recommend performing imaging studies for diagnosis of pyomyositis, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       We recommend cultures of blood and abscess, followed by administration of initial empirical therapy in patients with pyomyositis, (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       We recommend early drainage of purulent material in pyomyositis, (Strong recommendation, high certainty evidence, ⁽³⁾).

·       We recommend repeating imaging studies in the patient with persistent bacteremia to identify undrained foci of infection, (Strong recommendation, low certainty evidence, ⁽³⁾).

·       Antibiotics should be administered intravenously initially, but once the patient is clinically improved, oral antibiotics are appropriate, (Strong recommendation, low certainty evidence, ⁽³⁾).

Section 8: Evaluation and treatment of clostridial gas gangrene or myonecrosis:

·       We recommend urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue, (severe non-purulent), (Strong recommendation, moderate certainty evidence, ⁽³⁾).

·       In the absence of a definitive etiologic diagnosis, we recommend administration of broad-spectrum antibiotic, (Strong recommendation, low certainty evidence, ⁽³⁾).

·       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, low certainty evidence, ⁽³⁾).