What is the recommended treatment for simple skin infections?

Treatment of Simple Skin Infections

For simple skin infections, amoxicillin-clavulanate is the recommended first-line treatment as it provides coverage against both aerobic and anaerobic bacteria that commonly cause these infections. 1

Classification and Treatment Algorithm

1. Non-purulent Cellulitis (No abscess or purulent drainage)

• First-line therapy: Beta-lactam antibiotic active against streptococci

  • Penicillin, amoxicillin, dicloxacillin, or cephalexin 500 mg orally 4 times daily for 5 days 1
  • For adults: Cephalexin 500 mg orally every 12 hours for uncomplicated skin infections 2
  • For children: 25-50 mg/kg/day of cephalexin in divided doses 2

• For penicillin-allergic patients:

  • Clindamycin 300-450 mg orally 3 times daily for 5 days 1
  • Erythromycin 500 mg orally 4 times daily for 5 days 3

• Duration: 5 days is recommended, but treatment should be extended if infection has not improved within this period 1

2. Purulent Skin Infections (Abscess present)

• Primary treatment: Incision and drainage 1

• Antibiotics indicated if:

  • Systemic signs of infection present
  • Immunocompromised patient
  • Source control is incomplete
  • Significant surrounding cellulitis 1

• For MRSA coverage (if suspected):

  • Trimethoprim-sulfamethoxazole (TMP-SMX) 1
  • Doxycycline or minocycline 1
  • Clindamycin (if local resistance <10%) 1
  • Linezolid (for more severe cases) 1

3. Impetigo and Minor Skin Infections

• Localized cases: Topical mupirocin 2% ointment applied 3 times daily for 5-7 days 4
• Widespread cases: Oral antibiotics as per non-purulent cellulitis recommendations 5

Special Considerations

For Recurrent Skin Abscesses

1. Search for local causes (pilonidal cyst, hidradenitis suppurativa, foreign material) 1
2. Early drainage and culture 1
3. 5-10 day course of antibiotics active against the isolated pathogen 1
4. Consider decolonization regimen:
   • Intranasal mupirocin twice daily
   • Daily chlorhexidine washes
   • Daily decontamination of personal items 1

For High-Risk Patients

Preemptive early antimicrobial therapy for 3-5 days is recommended for patients who:

• Are immunocompromised
• Are asplenic
• Have advanced liver disease
• Have preexisting edema of the affected area
• Have moderate to severe injuries, especially to the hand or face
• Have injuries that may have penetrated periosteum or joint capsule 1

Adjunctive Measures

• Elevation of the affected area 1
• Treatment of predisposing factors (edema, underlying skin disorders) 1
• For lower extremity cellulitis: examine interdigital toe spaces and treat fissuring, scaling, or maceration 1
• Consider systemic corticosteroids (e.g., prednisone 40 mg daily for 7 days) in non-diabetic adult patients with cellulitis 1

Hospitalization Criteria

Hospitalization is recommended if:

• Concern for deeper or necrotizing infection
• Poor adherence to therapy expected
• Infection in severely immunocompromised patient
• Outpatient treatment is failing
• Systemic inflammatory response syndrome (SIRS)
• Altered mental status
• Hemodynamic instability 1

Common Pitfalls to Avoid

1. Overuse of broad-spectrum antibiotics: For typical cellulitis, narrow-spectrum antibiotics targeting streptococci are sufficient 1
2. Inadequate drainage of abscesses: Incision and drainage is the primary treatment for abscesses 1
3. Failure to address predisposing factors: Treating underlying conditions like edema or tinea pedis is crucial to prevent recurrence 1
4. Inappropriate MRSA coverage: MRSA is an unusual cause of typical cellulitis but should be considered with purulent drainage, penetrating trauma, or evidence of MRSA elsewhere 1
5. Insufficient treatment duration: While 5 days is often adequate, treatment should be extended if clinical improvement is not seen 1

By following this evidence-based approach to simple skin infections, clinicians can optimize outcomes while minimizing unnecessary antibiotic use and reducing the risk of treatment failure or recurrence.