CAEP - Skin and Soft Tissue Infections- BEST PRACTICES CHECKLIST

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Background Info

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Cellulitis

Diagnosis

Use clinical judgment to diagnose cellulitis. Typical physical exam findings suggestive of cellulitis are tenderness, erythema, increased warmth, edema, and induration. On occasion, there may be lymphangitis and/or fever.
Do not use existing decision tools or specific investigations (e.g., white blood cell count, Creactive protein) to diagnose cellulitis. Consider an alternative diagnosis in patients with bilateral symptoms (e.g., involvement of both legs).

Evidence

This recommendation is based on evidence from a systematic review. This key health question was not addressed by any of the included guidelines. We conducted a literature search and identified one systematic review by Patel et al.²⁶, which examined diagnostic criteria for lower limb cellulitis. This study included 8 observational studies, which examined the utility of biomarkers (N=5), imaging (N=2) and a clinical decision tool (N=1) to diagnose cellulitis. All included studies had a high risk of bias in at least one domain. Ultimately, this review found that there is insufficient evidence to support any diagnostic criteria or tools for lower limb cellulitis. We did not identify any high-quality reviews for cellulitis at other anatomical sites.

Recommendation: Do not routinely order blood cultures for systemically well patients with cellulitis.

Consider ordering blood cultures in patients with cellulitis who are:

systemically unwell (e.g., fever, lymphangitis, persistent tachycardia, tachypnea, hypotension); or
immunosuppressed (e.g., active malignancy receiving anticancer therapy, known or suspected neutropenia)

Evidence

This recommendation is based on modification of existing guideline recommendations. The Steering Committee accepted the IDSA4 and Korean5 guideline recommendations but with modi cations. We discussed that given the low yield (typically <5%)^27,28 for blood cultures in patients with cellulitis, blood cultures should not be routinely ordered for systemically well patients. Both guidelines discussed use of cutaneous aspirates, biopsies, or swabs in addition to blood cultures when making recommendations. The Steering Committee chose to remove mention of aspirates, biopsies, and swabs, as we felt these tests had no role in the assessment of ED patients with cellulitis. Both guidelines listed immunosuppression, neutropenia and receiving anticancer therapy as separate indications for blood cultures. For clarity, the Steering Committee opted to list receiving anticancer therapy and neutropenia as examples of immunosuppression.

Recommendation: Do not routinely order imaging for cellulitis. Perform bedside point-of-care ultrasound (POCUS) in cases where there is uncertainty in differentiating skin abscess from cellulitis.

Consider ordering imaging (e.g., X-ray, computed tomography [CT], ultrasound) in select cases:

suspected osteomyelitis
foreign bodies
uncertainty in differentiating from necrotizing fasciitis (note: imaging should never delay urgent surgical consultation if there is clinical suspicion).

Evidence

This recommendation is based on modification of an existing guideline recommendation. The Steering Committee accepted the Korean guideline⁵ recommendation with modi cations to suggest imaging (e.g., X-ray, CT, ultrasound) instead of CT alone as some EDs may not have access to one or more imaging modalities. Foreign bodies were added as an indication to consider imaging. The term uncertainty in di erentiating from necrotizing fasciitis was added, but with the caveat that this should never delay urgent surgical consultation if there is clinical suspicion. The recommendation to use POCUS is based on evidence from a meta-analysis by Gottlieb et al²⁹, which showed that POCUS had a high diagnostic accuracy for evaluation of skin abscesses in adults: sensitivity 98.7%, speci city 91.0%. The authors reported use of POCUS led to a correct change in management for 10.3% of cases, and an incorrect change in management in 0.7% of cases.

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Antibiotic Treatment

TABLE

DECISION TOOL

Diagnosis Treatment Disposition

Cellulitis

Treatment

Recommendation: Oral antibiotics are first line treatment. Please refer to the Cellulitis Antibiotic Treatment Recommendations.

Evidence

This recommendation is based on modification of existing guideline recommendations. All antibiotic treatment regimens were developed by the Steering Committee by reviewing existing guideline treatment recommendations and then adapting them specifically to the Canadian ED context. The Steering Committee members felt it was important to include patient factors useful to ED clinicians such as allergy, pregnancy, breastfeeding, and kidney impairment.

Recommendation: Treat with IV antibiotics in the following patients:

systemically unwell (e.g., fever, lymphangitis, persistent tachycardia, tachypnea, hypotension); or
failed oral antibiotic treatment (new/persistent fever, worsening pain, and/or spreading erythema despite at least 48-72 hours of oral antibiotics); or
cannot tolerate oral intake (e.g., vomiting, malabsorption syndrome, etc.)

Evidence

This recommendation is based on modification of an existing IDSA guideline4 recommendation. We added criteria for treatment failure and those that cannot tolerate oral intake was added as an indication.

Recommendation: Please refer to Table 1. See answer to Q4 for evidence.

Recommendation: Advise patients with limb cellulitis to elevate the affected area as this will hasten improvement by promoting gravity drainage of edema and inflammatory substances.

Evidence

This recommendation is based on an existing guideline (IDSA⁴) recommendation without modification.

Recommendation: Consider recommending or prescribing an oral NSAID for 5 – 7 days (if no contraindications) as an adjunct to antibiotic treatment in patients with cellulitis.

Evidence

This recommendation is based on evidence from a systematic review. The IDSA guideline recommendation states ‘systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) could be considered in nondiabetic adult patients with cellulitis’ – weak recommendation, moderate quality evidence.⁴ This was based on a single RCT in 1997 that included 112 inpatients randomized to a prednisolone taper or placebo.³⁰ The Steering Committee felt more evidence was required to answer this question. The Steering Committee Chair (KY) co-led a systematic review and meta-analysis^(ref), which identified 5 RCTs (N=331 participants) comparing an anti-inflammatory (corticosteroid or NSAID) to either placebo or no intervention as adjunct cellulitis treatment. For clinical response, there was a benefit with an oral NSAID (no data for corticosteroids) at day 3 (RR 1.81, 95%CI 1.42 – 2.31). There was no difference between groups for clinical cure up to 22 days. Given the best available evidence but acknowledging the small number of studies, the Steering Committee opted to recommend considering an oral NSAID, as this may improve early clinical response.

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Antibiotic Treatment

TABLE

DECISION TOOL

Diagnosis Treatment Disposition

Cellulitis

Disposition

Recommendation: Which ED patients with cellulitis should be considered for hospital admission?

Consider hospital admission in patients with any of the following:

challenges with adherence to therapy
immunosuppressed (e.g., active malignancy receiving anticancer therapy, known or suspected neutropenia)
failed outpatient antibiotic treatment (i.e., new/persistent fever, worsening pain, and/or spreading erythema despite at least 48-72 hours of antibiotic therapy)
systemically unwell (e.g., fever, lymphangitis, persistent tachycardia, tachypnea, hypotension)

Evidence

This recommendation is based on modification of an existing guideline recommendation. The IDSA guideline⁴ recommendation was accepted with modification. The criterion ‘severely immunocompromised’ was changed to immunosuppressed (with examples) as the Steering Committee felt this was clearer. The Steering Committee opted to add systemically unwell (with examples) as a criterion for considering hospital admission. The criterion ‘concern for a deeper or necrotizing infection’ was removed as the current key health question is based on a diagnosis of cellulitis having been made. In cases where there is concern for a necrotizing infection, separate recommendations are available (see SSTI Best Practices Checklist for Necrotizing Fasciitis).

Recommendation: Advise patients to see a healthcare provider 72 hours after antibiotic treatment is started if there is no improvement. Instruct patients to return to the ED before 72 hours if they develop severe pain out of proportion or rapidly spreading painful erythema.

Evidence

This recommendation is based on evidence from a systematic review and expert opinion. The NICE guideline¹⁷ discussed reassessing patients with cellulitis within 2-3 days for those that do not improve as an expert opinion. We conducted a literature search and identified a systematic review and meta-analysis by Yadav et al.³¹, which examined the impact of antibiotics on clinical response over time for uncomplicat-ed cellulitis (32 RCTs, N=13,576 participants). Time to improvement was: 5 days for 50% reduction of pain, 2–3 days for 33% reduction in erythema, and 2-4 days for a 30–50% reduction in edema. While the data must be interpreted with caution due to considerable heterogeneity and small number of included studies, the best available data suggest the optimal time to clinical reassessment is between 2–4 days. The Steering Committee felt that reassessment at 48 hours may be too soon to observe appropriate clinical response, which may lead to premature escalation or change in antibiotic treatment. Given this concern, we recommend 72 hours as the timepoint at which patients should be reassessed by a healthcare provider if having no improvement. As an expert opinion, we recommend patients should return to the ED before 72 hours if developing pain out of proportion or rapidly spreading painful erythema, which would be worrisome for a potential necrotizing infection.

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Diagnosis Treatment Disposition

Skin Abscess

Diagnosis

Recommendation: Use clinical judgment to diagnose a skin abscess. Typical physical exam findings are like non-purulent cellulitis (pain, erythema, increased warmth, edema, and induration) plus a palpable area of fluctuance that may represent an underlying purulent collection).

In cases where there is uncertainty about an underlying collection on physical exam, use point of care ultrasound (POCUS) as an adjunct (see Q2).

Evidence

This recommendation is an expert opinion. None of the included guidelines addressed the question of how a skin abscess should be diagnosed. We conducted a literature search of systematic reviews and identified a study by Patel et al.²⁶ that addressed diagnosis of cellulitis, but no data were available for skin abscess. The Steering Committee decided that given the lack of available evidence, the emphasis should be on clinical diagnosis of skin abscess while highlighting key physical exam features unique to skin abscess (palpable area of fluctuance).

Recommendation: Use POCUS in all cases where there is uncertainty in differentiating skin abscess from cellulitis. POCUS will identify the presence of an underlying collection in patients with a skin abscess.

Evidence

This recommendation is based on evidence from a systematic review. The potential role of POCUS was not addressed in any of the included guidelines. Following a literature search, we identified five abstracts. On full text review, one article was removed (conference abstract with no full manuscript published). The four remaining systematic reviews were assessed using AMSTAR-2.²⁵ Following this, a systematic review and meta-analysis by Gottlieb et al.²⁹ was chosen as the highest quality of evidence to answer this key health question. This systematic review included 14 studies (N=2,656 participants), of which 13 studies were conducted in the ED setting. All studies were observational (13 prospective, 1 retrospective). POCUS had a high diagnostic accuracy for evaluation of skin abscesses, particularly in adults: sensitivity 98.7%, specificity 91.0%, positive likelihood ratio 10.9, negative likelihood ratio 0.01. The authors reported use of POCUS led to a correct change in management for 10.3% of cases, and an incorrect change in management in 0.7% of cases. Based on this evidence, the Steering Committee recommend-ed the use of bedside POCUS in all cases where there is uncertainty differentiating skin abscess from cellulitis.

Recommendation: Do not routinely order blood cultures for patients with a skin abscess.

Consider ordering blood cultures in patients with skin abscess who are:

systemically unwell (e.g., fever, lymphangitis, persistent tachycardia, tachypnea, hypotension)
immunosuppressed (e.g., active malignancy receiving anticancer therapy, known or suspected neutropenia)

Evidence

This recommendation is an expert opinion. While included guidelines recommended against routinely ordering blood cultures for patients with cellulitis, they did not separately address this question for skin abscesses. We conducted a literature search and did not identify any systematic reviews about the utility of blood cultures in patients with skin abscess. The Steering Committee discussed that given the low yield (typically <5%)^27,28 for blood cultures in patients with cellulitis, there was no evidence to suggest that the yield would be any higher for patients with skin abscess. Thus, we recommend that blood cultures should not be routinely ordered but may be considered in patients who are systemically unwell or immunosuppressed.

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Antibiotic Treatment

TABLE

DECISION TOOL

Diagnosis Treatment Disposition

Skin Abscess

Treatment

Recommendation: Perform a bedside incision and drainage (I&D) for abscesses. Do not perform needle aspiration.

Evidence

This recommendation for I&D is based on an existing guideline recommendation (IDSA⁴ ) with modification. We removed mention of inflamed epidermoid cysts, carbuncles, and large furuncles for simplicity. We added a recommen-dation not to perform needle aspiration based on a randomized controlled trial (RCT) that showed overall success with ultrasound-guided needle aspiration was 26% (95%CI 18% to 44%) compared to 80% (95%CI 66% to 89%) for I&D.³²

Recommendation: Do not routinely pack skin abscess cavities following bedside I&D.

Evidence

This recommendation is based on evidence from a systematic review. The IDSA guideline states “some clinicians close the wound with sutures or pack it with gauze or other absorbent material. One small study, however, found that packing caused more pain and did not improve healing when compared to just covering the incision site with sterile gauze”.⁴ This was not an explicit guideline recommendation and this key health question was not addressed by any of the other included guidelines. We conducted a literature search and identified two abstracts – one study was excluded because it was a conference abstract without the full manuscript being published. We included a systematic review and meta-analysis by Mohamedahmed et al.³³, which included 8 RCTs (N=485 participants). Three RCTs assessed anorectal abscesses only, whereas five RCTs included abscesses at various anatomical sites. Oral antibiotics were routinely given in four RCTs, selectively given in one RCT, not given in one RCT, and it was unclear if antibiotics were given in the remaining two RCTs. There was no difference in risk of recurrence for packing versus no packing (relative risk 1.31, P=0.56). The included trials had small sample sizes which limit the strength of conclusions that can be drawn. However, this study is the best available evidence that demonstrates comparable outcomes between groups. Given no strong evidence to favour packing of abscess cavities, the Steering Committee agreed with the authors’ suggestion that no packing may be more favourable given the pain patients experience.³⁴

Recommendation: Prescribe antibiotics as an adjunct to I&D in cases of extensive cellulitis near the purulent lesion or in patients with systemic symptoms such as fever. Consider antibiotics for patients that are immunosuppressed (e.g., active malignancy receiving anticancer therapy, known or suspected neutropenia).

Evidence

This recommendation is based on modification of existing guideline recommendations. The Steering Committee accepted both the Korean⁵ and IDSA⁴ guideline recommendations with modifications. The present statement was modified to emphasize that use of antibiotics is an adjunct to I&D. The Steering Committee favoured the Korean guideline suggestion of recommending antibiotics in patients with systemic symptoms such as fever instead of the IDSA guideline recommendation which suggested use of antibiotics in patients with “systemic inflammatory response syndrome (SIRS)”.

Recommendation: Please refer to Table 2. If antibiotics are prescribed, oral antibiotics are first line.

Evidence

This recommendation is based on modification of existing guideline recommendations. All antibiotic treatment regimens were developed by the Steering Committee by reviewing existing guideline treatment recommendations and then adapting them specifically to the Canadian ED context. The Steering Committee members felt it was important to include patient factors useful to ED clinicians such as methicillin resistant Staphylococcus aureus (MRSA) risk factors, allergy, pregnancy, breastfeeding, and kidney impairment.

Administer IV antibiotics for patients for whom antibiotics are indicated but who:

have had treatment failure following I&D plus appropriate oral antibiotics (treatment failure defined as new/persistent fever, worsening pain, and/or spreading erythema despite at least 48-72 hours of oral antibiotics); or
have had treatment failure following I&D plus appropriate oral antibiotics (treatment failure defined as new/persistent fever, worsening pain, and/or spreading erythema despite at least 48-72 hours of oral antibiotics); or
cannot tolerate oral intake (e.g., vomiting, malabsorption syndrome, etc.)

Evidence

This recommendation is based on modification of an existing guideline recommendation. The Steering Committee accepted the IDSA guideline⁴ recommendation with modifications. We wished to emphasize that IV antibiotics should be considered in those that have failed to improve following I&D plus appropriate oral antibiotics. The Steering Committee opted to use the term systemically unwell (with examples) instead of SIRS criteria and added cannot tolerate oral intake (with examples) as an additional criterion for requiring IV antibiotics.

Recommendation: Please refer to Table 2. See answer to Q7 for evidence.

have had treatment failure following I&D plus appropriate oral antibiotics (treatment failure defined as new/persistent fever, worsening pain, and/or spreading erythema despite at least 48-72 hours of oral antibiotics); or
have had treatment failure following I&D plus appropriate oral antibiotics (treatment failure defined as new/persistent fever, worsening pain, and/or spreading erythema despite at least 48-72 hours of oral antibiotics); or
cannot tolerate oral intake (e.g., vomiting, malabsorption syndrome, etc.)

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Antibiotic Treatment

TABLE

DECISION TOOL

Diagnosis Treatment Disposition

Skin Abscess

Disposition

Recommendation: Advise patients to see a healthcare provider 72 hours after I&D is performed if there is no improvement, recurrence, or worsening of symptoms.

Evidence

This recommendation is an expert opinion. None of the included guidelines addressed this key health question. Following a literature search, a systematic review and meta-analysis by Yadav et al.³¹ was identified, which suggested the optimal time to clinical reassessment for cellulitis was between 2 – 4 days. However, this review excluded patients with skin abscesses and no other reviews addressed time to reassessment specifically for skin abscesses. The Steering Committee felt that recommending a similar timeframe to reassessment for patients with skin abscesses as for cellulitis (i.e., at 3 days) was reasonable.

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Diagnosis Treatment Disposition

Necrotizing Fasciitis

Diagnosis

Recommendation: Use clinical judgment to decide if necrotizing fasciitis should be suspected. Suspect necrotizing fasciitis if a patient presents with features that suggest involvement of deeper tissues such as:

Severe pain that seems disproportional to the clinical findings.
The hard, wooden feel of the subcutaneous tissue, extending beyond the area of apparent skin involvement.
Systemic toxicity, often with altered mental status.
Edema or tenderness extending beyond the cutaneous erythema.
Crepitus, indicating gas in the tissues.
Bullous lesions.
Skin necrosis or ecchymoses.

Evidence

This recommendation is based on modification of an existing guideline recommendation. The Steering Committee accepted the IDSA guideline⁴ recommendation but with modification. Specifically, ‘failure to respond to initial antibiotic therapy’ was removed as a feature that may suggest involvement of deeper tissues.

Recommendation: Do not rely on imaging tests to help diagnose necrotizing fasciitis. Instead, use clinical judgment to help make the diagnosis. Imaging and blood tests should not delay urgent surgical consultation for patients with a high clinical suspicion, as definitive diagnosis is made in the operating room.

Evidence

This recommendation is based on evidence from a systematic review. The Steering Committee rejected the IDSA and Korean guideline statements about the potential role of radiologic investigations in diagnosing necrotizing fasciitis. Instead, a literature search for systematic reviews was undertaken to answer this question. A systematic review and meta-analysis by Fernando et al.³⁵ highlighted that plain x-ray is poorly sensitive for the diagnosis of necrotizing fasciitis. Whereas CT has superior sensitivity and specificity compared to plain X-ray, the authors of this review highlighted that even if available, CT imaging may delay definitive surgical diagnosis and management. MRI was not recommended based on lack of availability and risk of significant delay to surgical intervention. The Steering Committee felt it was important to emphasize the importance of clinical judgment so as not to delay urgent surgical consultation.

Recommendation: Do not routinely order blood cultures for patients with a skin abscess.

Obtain wound cultures (if appropriate) from infected tissue or abscess samples to help identify causative bacteria.
Order blood cultures as they are helpful to identify causative bacteria.
Do not use decision tools, such as the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score, to rule out the diagnosis. The LRINEC score is poorly sensitive for the diagnosis of necrotizing fasciitis.

Evidence

This recommendation is based on modification of an existing guideline recommendation and evidence from a systematic review. For the role of lab tests in the diagnosis of necrotizing fasciitis, the Steering Committee accepted the Korean guideline⁵ with modifications. We emphasized the importance of wound cultures (if appropriate) and blood cultures for identification of causative bacteria, which could help tailor downstream antibiotic treatment. With respect to the LRINEC score (which consists of six blood test laboratory values), in the aforementioned meta-analysis by Fernando et al.³⁵, the LRINEC score had poor sensitivity (using a cut-off score of ≥6, sensitivity = 68.2%, using a cut-off score of ≥8, sensitivity = 40.8%) for the diagnosis of necrotizing fasciitis.

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Antibiotic Treatment

TABLE

Diagnosis Treatment Disposition

Necrotizing Fasciitis

Treatment

Recommendation:

Request immediate surgical consultation.
Order intravenous (IV) antibiotic therapy (see Table 3). Do not delay antibiotic therapy while waiting for ancillary investigations or consultations.
Order cardiac monitoring, analgesia, IV fluid resuscitation and vasopressors if required for ongoing hemodynamic instability.

Evidence

This recommendation is based on modification of an existing guideline recommendation. The Steering Committee accepted the IDSA guideline4 recommendation about early surgical consultation with minor modification. We emphasized the need for immediate surgical consultation. For treatment recommendations, the Steering Committee reviewed all included guidelines for antibiotic treatment of necrotizing fasciitis and then drafted antibiotic treatment recommendations specific to the Canadian ED context (see Table 3).

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Antibiotic Treatment

TABLE

Diagnosis Treatment Disposition

Advisory Committee Members›

References›

App Developers›

CellulitisSkin Abscess

Treatment

Antibiotic Treatment Recommendations for Non-Purulent CellulitisAntibiotic Treatment Recommendations for Purulent Cellulitis

Severe Penicillin allergyNon-severe Penicillin allergySevere Cephalosporin allergyNon-severe Cephalosporin allergyPregnancyBreastfeedingKidney impairmentKnown or suspected MRSA

Cephalexin
500-1000 mg Q6HNOTE: dose adjustment required

Cefadroxil
500-1000 mg Q12HNOTE: dose adjustment required

Cloxacillin
500-1000 mg Q6H
(take on empty stomach)NOTE: dose adjustment NOT required

Penicillin V
300-600 mg Q6HNOTE: dose adjustment required

Amoxicillin
500-1000 mg Q6H
(take on empty stomach)NOTE: dose adjustment required

Trimethoprim-Sulfamethoxazole
1 or 2 DS tabs Q12HNOTE: avoid in 1st trimester and near termNOTE: compatible in older (>2 months), healthy, full-term infants who are not G6PD deficientNOTE: dose adjustment required

Clindamycin
300-450 mg Q6-8HNOTE: dose adjustment NOT required

Doxycycline
100 mg Q12H
(take with full glass of water, stay upright (do not lie down) for 1-2 hours after administration. May be taken with food to minimize GI upset)NOTE: dose adjustment NOT required

Moxifloxacin
400 mg Q24HNOTE: dose adjustment NOT required

Levofloxacin 500 mg Q24HNOTE: dose adjustment required

Cefazolin
1-2g Q8HNOTE: risk of allergic reaction to cefazolin in patients with penicillin allergy is low (1-2%)NOTE: dose adjustment required

Ceftriaxone
1-2g Q24HNOTE: risk of allergic reaction to ceftriaxone in patients with penicillin allergy is low (1-2%)NOTE: dose adjustment NOT required

Vancomycin
15 mg/kg Q8-12HNOTE: dose adjustment required

Clindamycin
600 mg Q8HNOTE: dose adjustment NOT required

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Diagnosis Treatment DispositionDiagnosis Treatment Disposition

Cellulitis

Treatment

Antibiotic Treatment Recommendations for Cellulitis

NON-PURULENT CELLULITIS

Antibiotic duration: 5–7 days*

Recommended Regimens**

Oral options

First Line

Cephalexin 500–1000 mg Q6H
Cefadroxil 500–1000 mg Q12H
Cloxacillin 500–1000 mg Q6H^†

First-line options (unless known or suspected MRSA^§).

Erysipelas only

Penicillin V 300–600 mg Q6H^†
Amoxicillin 500–1000 mg Q8H

Penicillin and amoxicillin are indicated for mild erysipelas only. Erysipelas is a superficial skin infection with clear demarcation of involved skin.

Penicillin Allergy

Trimethoprim-sulfamethoxazole
1 or 2 double strength tablets Q12H
Clindamycin 300–450 mg Q6–8H
Doxycycline 100 mg Q12H^‡
Moxifloxacin 400 mg daily or
Levofloxacin 500 mg daily

These agents may be associated with higher antibiotic resistance rates, lower efficacy and/or a greater risk of adverse effects than the options above. Reserve for patients with severe (e.g., IgE-mediated) allergy or contraindications to penicillins and cephalosporins.

IV options

First Line

Cefazolin 1–2 g Q8H

First-line options (unless known or suspected MRSA^§).

Erysipelas only

Ceftriaxone 1–2 g Q24H

Ceftriaxone has less reliable activity for Staphylococcus aureus compared to Streptococcus sp.

Penicillin Allergy

Vancomycin 15 mg/kg Q8–12H
Clindamycin 600 mg Q8H

Reserve for patients with contraindications to cephalosporin options above.

*Consider 5 days duration for infections that are of mild severity.

**Higher dose in range may be used for more severe infections, obese patients (e.g., BMI 30). Caution: increased risk of GI side effects with larger oral doses.

^†Should be taken on an empty stomach.

^‡Administer with a full glass of water; patient should stay upright (not lie down) for 1 to 2 hours after administration. May be taken with food to minimize GI upset.

^§NOTE: most cases of non-purulent cellulitis are due to streptococci and should be treated with a b-lactam antibiotic. Suspect MRSA if: known MRSA colonization, prior MRSA infection, high-risk group (e.g., injection drug use, homeless in the last year, crowded living conditions, correctional facility), or failed adequate course of b-lactam therapy.

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Diagnosis Treatment Disposition

Skin Abscess

Treatment

Antibiotic Treatment Recommendations for Purulent Cellulitis (Skin Abscess)

SKIN ABSCESS

If antibiotic therapy required after incision and drainage

Antibiotic duration: 7–10 days

Antibiotics are not routinely required. They should be prescribed as an adjunct to I&D in cases of extensive c ellulitis near the purulent lesion or in patients that have systemic symptoms such as fever. Consider antibiotics for patients that are immunosuppressed (e.g., active malignancy receiving anticancer therapy, neutropenia).

Recommended Regimens*

Oral options

First Line

Cephalexin 500–1000 mg Q6H
Cefadroxil 500–1000 mg Q12H
Cloxacillin 500–1000 mg Q6H^†

First-line options (unless known or suspected MRSA^§).

Penicillin Allergy

Trimethoprim-sulfamethoxazole
1 or 2 double strength tablets Q12H
Clindamycin 300–450 mg Q6–8H
Doxycycline 100 mg Q12H^‡
Moxifloxacin 400 mg daily or
Levofloxacin 500 mg daily

IV options

First Line

Cefazolin 1–2 g Q8H

First-line options (unless known or suspected MRSA^§).

Erysipelas only

Ceftriaxone 1–2 g Q24H

Ceftriaxone has less reliable activity for Staphylococcus aureus compared to Streptococcus sp.

Penicillin Allergy

Vancomycin 15 mg/kg Q8–12H
Clindamycin 600 mg Q8H

Reserve for patients with contraindications to cephalosporin options above.

*Higher dose in range may be used for more severe infections, obese patients (e.g., BMI 30); caution increased risk of GI side effects with larger oral doses.

^†Should be taken on an empty stomach.

^‡Administer with a full glass of water; patient should stay upright (not lie down) for 1 to 2 hours after administration. May be taken with food to minimize GI upset. Some clinicians may add a ß-lactam agent (e.g., penicillin, amoxicillin, cephalexin) to doxycycline for improved Streptococcus coverage.

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Diagnosis Treatment Disposition

Necrotizing Fasciitis

Treatment

Antibiotic Treatment Recommendations for Necrotizing Fasciitis

NECROTIZING FASCIITIS

Recommended Regimen

First Line

Piperacillin-tazobactam 4.5 g IV Q6H
AND
Clindamycin 900 mg IV Q8H
AND
Vancomy cin 20–25 mg/kg IV loading dose

Subsequent doses of vancomycin (Q8-12H) are based on weight and kidney function.

Second Line (if Penicillin Allergy)

Carbapenem (e.g., ertapenem 1 g IV Q24H, meropenem 1 g IV Q8H,
or imipenem 500 mg IV Q6H)
AND
Clindamycin 900 mg IV Q8H
AND
Vancomycin 20–25 mg/kg IV loading dose

Use a carbapenem for patients with allergy to penicillin.

Subsequent doses of vancomycin (Q8-12H) are based on weight and kidney function.

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Diagnosis Treatment

References

Breyre A, Frazee BW. Skin and Soft Tissue Infections in the Emergency Department. Emerg Med Clin North Am. Nov 2018;36(4):723-750. doi:10.1016/j.emc.2018.06.005
Hua C, Urbina T, Bosc R, et al. Necrotising soft-tissue infections. Lancet Infect Dis. Mar 2023;23(3):e81-e94. doi:10.1016/s1473-3099(22)00583-7
Canadian Institute for Health Information, NACRS Emergency Department Visits and Lengths of Stay by Province/Territory, 2021-2022 (Q1 to Q4). Ottawa, ON: CIHI; August 2022.
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 Diseases Society of America. Research Support, Non-U.S. Gov't. Clin Infect Dis. Jul 15 2014;59(2):e10-52. doi: 10.1093/cid/ciu444.
Kwak YG, Choi SH, Kim T, et al. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Infect Chemother. Dec 2017;49(4):301-325. doi: 10.3947/ic.2017.49.4.301.
Clinical Resource Efficiency Support Team (2005) Guidelines on the management of cellulitis in adults. CREST, Belfast.
Esposito S, Bassetti M, Borre S, et al. Diagnosis and management of skin and soft-tissue infections (SSTI): a literature review and consensus statement on behalf of the Italian Society of Infectious Diseases and International Society of Chemotherapy. J Chemother. Oct 2011;23(5):251-62. doi:10.1179/joc.2011.23.5.251
Murray H, Stiell I, Wells G. Treatment failure in emergency department patients with cellulitis. CJEM. Jul 2005;7(4):228-34.
Peterson D, McLeod S, Woolfrey K, McRae A. Predictors of failure of empiric outpatient antibiotic therapy in emergency department patients with uncomplicated cellulitis. Acad Emerg Med. May 2014;21(5):526-31. doi:http://dx.doi.org/10.1111/acem.12371
Yadav K, Suh KN, Eagles D, et al. Predictors of Oral Antibiotic Treatment Failure for Non-Purulent Skin and Soft Tissue Infections in the Emergency Department. Acad Emerg Med. Jun 5 2018:13492.
Talan DA, Salhi BA, Moran GJ, et al. Factors associated with decision to hospitalize emergency department patients with skin and soft tissue infection. Research Support, U.S. Gov't, P.H.S. West J Emerg Med. Jan 2015;16(1):89-97. doi:http://dx.doi.org/10.5811/westjem.2014.11.24133
Harrison MB, Graham ID, van den Hoek J, Dogherty EJ, Carley ME, Angus V. Guideline adaptation and implementation planning: a prospective observational study. Implement Sci. May 8 2013;8:49. doi:10.1186/1748-5908-8-49
Harrison MB, van den Hoek J, Graham ID. CAN-IMPLEMENT: Planning for best-practice implementation. Lippincott Williams & Wilkins; 2014.
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