From the Guidelines
The most current clinical practice guidelines for soft tissue infections, specifically nonpurulent cellulitis, recommend a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care. This recommendation is based on the best practice advice from the American College of Physicians, as published in the Annals of Internal Medicine in 2021 1.
Key Considerations
- The treatment approach should be stepwise, based on the severity of the infection.
- For mild infections, oral antibiotics such as cephalexin or clindamycin are typically sufficient for 5-10 days.
- Moderate infections may require broader coverage with antibiotics like amoxicillin-clavulanate or trimethoprim-sulfamethoxazole plus cephalexin.
- Severe infections necessitate hospitalization and intravenous antibiotics, with considerations for vancomycin, piperacillin-tazobactam, or a carbapenem.
- Surgical debridement is crucial for necrotizing infections, abscesses, or infections with compartment syndrome.
- Wound care should include regular cleaning, dressing changes, and elevation of the affected area, with monitoring for signs of progression.
Pathogen Considerations
- Common pathogens include Staphylococcus aureus (including MRSA), Streptococcus species, and in polymicrobial infections, various anaerobes and gram-negative bacteria.
- Treatment should be adjusted based on culture results when available and clinical response, as recommended by guidelines including those from the National Institute for Health and Care Excellence (NICE) in 2019 1.
Evidence Basis
The recommendation for a 5- to 6-day course of antibiotics for nonpurulent cellulitis is supported by systematic reviews and guidelines that have found no significant differences in clinical outcomes between shorter and longer courses of therapy for uncomplicated cellulitis 1. This approach aims to balance efficacy with the need to minimize antibiotic resistance and side effects, prioritizing patient outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Current Guidelines for Soft Tissue Infections
The current guidelines for managing soft tissue infections emphasize the importance of a combination of surgical and antimicrobial strategies tailored to the type and severity of the infection 2, 3.
Surgical Management
Surgical management plays a crucial role in the treatment of uncomplicated soft tissue infections, with recent evidence indicating that a subgroup of patients, such as immunocompromised patients, may benefit from a postoperative course of antibiotic treatment of 5-7 days 2.
Antimicrobial Strategies
The choice of antimicrobial agents depends on the suspected or confirmed causative pathogen, with recommendations including:
- Oral beta-lactams for uncomplicated infections 4
- Agents effective against methicillin-resistant Staphylococcus aureus (MRSA) for complicated infections 4, 5
- Shorter courses of antibiotics, with developments focusing on using new antimicrobials and refining drug decision-making 3
Specific Infections
For specific types of soft tissue infections, such as:
- Diabetic foot infections, repeated debridement to remove necrotic tissue and control infection can prevent minor and major amputation 2
- Necrotizing soft tissue infections, early and aggressive surgical debridement is paramount, with prompt diagnosis and appropriate antimicrobial choice also being essential 6
Treatment Approaches
The management of soft tissue infections requires a collaborative approach, with the role of stewardship programs continuing to expand, and the surgical indication and its value being evident in many patients 3.