A Timely Update on Skin and Soft Tissue Infections

Skin and soft tissue infections are frequent problems in primary care offices. The Infectious Diseases Society of America recently updated their recommendations for the diagnosis and management of these common infections.¹ Although a hefty review (more than 40 pages long), it serves as a great source of information when needed. I probably refer to it at least once a week!

Let’s review some “high points” to whet your appetites:

• When Staphylococcus or Streptococcus is the infecting organism, what antibiotic should be used? Table 2¹ in the guidelines gives choices for topical mupirocin ointment as well as oral therapy (penicillin allergic and not), including erythromycin or clindamycin versus amoxicillin-clavulanate, dicloxacillin, and cephalexin respectively for impetigo. Doses are provided for adults and children. Table 2¹ in the guidelines has similar advice for methicillin-sensitive and methicillin-resistant staphylococci. 

• What is an appropriate evaluation for patients with recurrent cellulitis? We are aware of known predisposing conditions. For example, edema, obesity, eczema, venous insufficiency, and toe web abnormalities (ie, tinea pedis) are risks for recurrent cellulitis. Furthermore, if persons have more than 3 to 4 episodes of cellulitis per year, despite attempts at mitigating their risk factors, prophylactic antibiotics (eg, erythromycin twice a day for between 4 and 52 weeks) should be considered. 

• Should preemptive antibiotics be administered after dog or cat bites? Early antimicrobial therapy is indicated for the immunocompro-mised—individuals who are asplenic, have advanced liver disease, have edema of the affected area, have experienced moderate to severe injuries especially to the hands or face, or have sustained bites that penetrate the periosteum or joint capsule. 

• How should catscratch disease be managed? Azithromycin should be given to individuals >45 kg as follows: 500 mg on day 1, followed by 250 mg for 4 successive days. An adjusted dose schedule is provided for individuals <45 kg.

• What is appropriate treatment for recurrent skin abscesses? A search for a pilonidal cyst, hidradenitis suppurativa, or foreign material should be made. Consider a 5-day decolonization regimen with twice daily intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of towels, sheets, and clothes. 

• Table 4¹ in the guidelines offers treatment options for necrotizing infections of the skin, fascia, and muscle. The type of infecting organism—mixed, Streptococcus, Staphylococcus, Clostridium, and others, including Vibrio vulnificus—have recommended first-line regimens. 

• Antibiotic treatment of cellulitis can be accompanied by the addition of a nonsteroidal or prednisone (40 mg a day for 7 days). There is evidence that both additions result in faster clinical improvement as compared to antibiotics alone. Note: The prescribing clinician must be sure that a deep infection, such as necrotizing fasciitis is not present.

• When a deeper infection such as necrotizing fasciitis is present, prompt surgical intervention is strongly recommended. 

I have merely scratched the surface of a goldmine of useful and evidence-based information. Keep your copy at the ready. You will need it. ■

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

Reference:

1.Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Disease Society of America. Clin Infect Dis. 2014 Jun 18. [epub ahead of print]