What are the recommended antibiotics for Skin and Soft Tissue Infections (SSTIs) coverage?

Recommended Antibiotics for Skin and Soft Tissue Infections (SSTIs)

For skin and soft tissue infections, empirical therapy should be guided by the type of infection (purulent vs. nonpurulent), severity, and risk for MRSA, with incision and drainage being the primary treatment for abscesses. 1

Classification of SSTIs

Purulent SSTIs (abscesses, furuncles, carbuncles)

• Primary treatment: Incision and drainage (I&D) 1
• When to add antibiotics:
  • Severe or extensive disease
  • Rapid progression with associated cellulitis
  • Systemic illness signs
  • Immunosuppression
  • Extremes of age
  • Difficult-to-drain areas (face, hand, genitalia)
  • Septic phlebitis
  • Lack of response to I&D alone 1

Nonpurulent SSTIs (cellulitis, erysipelas)

• Target primarily beta-hemolytic streptococci
• Consider MRSA coverage for treatment failures or systemic toxicity 1

Outpatient Treatment Options

For purulent infections (MRSA coverage):

• Oral options 1:
  • Clindamycin 300-450 mg TID (A-II)
  • Trimethoprim-sulfamethoxazole (TMP-SMX) DS BID (A-II)
  • Tetracyclines: doxycycline 100 mg BID or minocycline 100 mg BID (A-II)
  • Linezolid 600 mg BID (A-II)

For nonpurulent infections (streptococcal coverage):

• First-line: Beta-lactams
  • Dicloxacillin 500 mg QID
  • Cephalexin 500 mg QID 1
• For both streptococcal and MRSA coverage:
  • Clindamycin alone (A-II)
  • TMP-SMX or tetracycline plus beta-lactam (e.g., amoxicillin) (A-II)
  • Linezolid alone (A-II) 1

For impetigo/ecthyma:

• 7-day regimen with anti-staphylococcal agent
• For MSSA: dicloxacillin or cephalexin
• For MRSA: doxycycline, clindamycin, or TMP-SMX 1

Inpatient Treatment Options (Complicated SSTIs)

For hospitalized patients with complicated SSTIs:

• IV options 1:

  • Vancomycin IV (A-I)
  • Linezolid 600 mg IV/PO BID (A-I)
  • Daptomycin 4 mg/kg IV daily (A-I)
  • Telavancin 10 mg/kg IV daily (A-I)
  • Clindamycin 600 mg IV/PO TID (A-III)
  • Ceftaroline (A-I)
  • Dalbavancin (A-I)
  • Tigecycline (A-I)
  • Tedizolid (A-I)

• For nonpurulent cellulitis in hospitalized patients:

  • Beta-lactam (e.g., cefazolin) with modification to MRSA-active therapy if no clinical response 1

Duration of Therapy

• Purulent infections: 5-10 days, individualized based on clinical response 1
• Complicated SSTIs: 7-14 days, individualized based on clinical response 1

Special Considerations

Pediatric Patients

• For minor skin infections: mupirocin 2% topical ointment (A-III)
• Avoid tetracyclines in children <8 years (A-II)
• For hospitalized children with complicated SSTIs:
  • Vancomycin (A-II)
  • Clindamycin 10-13 mg/kg/dose IV q6-8h if low resistance rates (<10%) (A-II)
  • Linezolid (age-appropriate dosing) (A-II) 1

Surgical Site Infections

• For clean surgical sites: cefazolin or vancomycin (if MRSA risk)
• For perineum/GI/female genital tract wounds: cephalosporin + metronidazole, levofloxacin + metronidazole, or carbapenem 1

Common Pitfalls and Caveats

1. Rifampin should not be used as monotherapy or adjunctive therapy for SSTIs (A-III) 1

2. Culture recommendations:

   • Obtain cultures from abscesses and purulent SSTIs when:
     • Antibiotic therapy is being administered
     • Severe local infection or systemic illness
     • Inadequate response to initial treatment
     • Concern for outbreak 1

3. MRSA considerations:

   • Community-acquired MRSA (CA-MRSA) is increasingly common
   • Empiric MRSA coverage is warranted for purulent infections
   • For nonpurulent infections, add MRSA coverage only for treatment failures or systemic toxicity 1

4. Clindamycin resistance:

   • Check local resistance patterns before using clindamycin
   • Consider inducible clindamycin resistance (D-test) when using for MRSA 1

5. Vancomycin considerations:

   • Monitor levels for efficacy and to prevent toxicity
   • Consider alternative agents in areas with high vancomycin MICs 2

For recurrent SSTIs, consider decolonization strategies (mupirocin nasal ointment, chlorhexidine body wash) and environmental hygiene measures after optimizing wound care and personal hygiene 1.