What is the recommended treatment for skin wound infections?

Treatment of Skin Wound Infections

The primary treatment for skin wound infections includes wound irrigation, debridement of necrotic tissue, and appropriate antibiotic therapy based on the type of infection, with incision and drainage being the mainstay for purulent infections. 1, 2

Classification and Initial Management

Non-Purulent Infections

• Impetigo, Erysipelas, and Cellulitis
  • Require antibiotics against Gram-positive bacteria (primarily Staphylococcus aureus and Streptococcus species) 1
  • First-line options: Cephalosporins or anti-staphylococcal penicillins 2
  • Duration: 5-10 days for uncomplicated infections 2

Purulent Infections

• Simple Abscesses/Boils
  • Primary treatment: Incision and drainage 1, 2
  • Antibiotics generally not recommended for simple, drained abscesses 1

Complicated Infections

• Complex Abscesses, Infections in Damaged Skin, Surgical Wounds
  • Require both surgical intervention and broad-spectrum antibiotics 1, 2
  • Duration: 10-14 days for complicated infections 2

Wound Management Protocol

1. Wound Irrigation

   • Deep irrigation to remove foreign bodies and pathogens 1
   • Avoid irrigation under pressure (can spread bacteria into deeper tissues) 1

2. Debridement

   • Remove all necrotic tissue to reduce pathogen burden 1
   • For large abscesses, use multiple counter incisions rather than a single long incision 1

3. Topical Treatment

   • For minor superficial infections: Apply bacitracin 1-3 times daily, may cover with sterile bandage 3

Antibiotic Selection

For Non-Purulent Infections

• First-line: Cephalosporins or anti-staphylococcal penicillins 2
• Alternative: Clindamycin 150-300 mg every 6 hours (adults) for serious infections; 300-450 mg every 6 hours for more severe infections 4

For Complicated Infections

• Broad-spectrum coverage against Gram-positive, Gram-negative, and anaerobic organisms 1
• First-line: Vancomycin 15 mg/kg IV every 12 hours 2
• Alternatives: Linezolid, daptomycin, telavancin, or ceftaroline 2

MRSA Considerations

• Consider MRSA coverage when:
  • Local MRSA prevalence >20% 1
  • Patient has risk factors for MRSA 1
  • Patient fails to respond to initial therapy 1, 2
  • Patient has systemic signs of infection 1

Special Considerations

Bite Wounds

• High risk of infection: 30-50% of cat bites, 5-25% of dog bites, 20-25% of human bites 1
• Consider early antibiotic treatment (3-5 days) for:
  • Fresh, deep wounds
  • Wounds in critical areas (hands, feet, joints, face, genitals)
  • Persons with elevated infection risk or implants 1
• Do not give antibiotics if patient presents >24 hours after bite with no signs of infection 1

Burn Wounds

• Usually polymicrobial (initially Gram-positive, then Gram-negative within a week) 1
• Early excision of eschar is critical to prevent invasive infection 1
• Adjust antibiotic dosing to account for altered pharmacokinetics in burn patients 1

Pressure Ulcers

• Typically polymicrobial (aerobes and anaerobes) 1
• Combination of surgical debridement and antibiotics required 1
• Target therapy against Gram-positive, Gram-negative, and anaerobic organisms 1

Common Pitfalls and Caveats

1. Failing to drain purulent collections

   • Incision and drainage is the primary treatment for abscesses; antibiotics alone are insufficient 1, 2

2. Overuse of antibiotics

   • Simple abscesses that are adequately drained often don't require antibiotics 1
   • Universal prophylaxis with antibiotics is not recommended for most wounds 1

3. Inadequate debridement

   • Failure to remove all necrotic tissue can lead to persistent infection 1

4. Ignoring MRSA possibility

   • Consider MRSA coverage in areas with high prevalence or in patients not responding to initial therapy 1, 2, 5

5. Inappropriate duration of therapy

   • For streptococcal infections, continue treatment for at least 10 days 4
   • Most uncomplicated infections require 5-10 days of treatment 2

By following these evidence-based guidelines, clinicians can effectively manage skin wound infections while minimizing complications and reducing the risk of treatment failure.