What are the treatment options for skin infections?

Treatment Options for Skin Infections

First-Line Treatment Recommendations

For skin and soft tissue infections, amoxicillin-clavulanate is the first-line treatment option due to its excellent coverage against common pathogens including Staphylococcus aureus, streptococci, and anaerobic bacteria. 1

Classification of Skin Infections

Skin infections can be classified as:

• Uncomplicated SSTIs: Superficial infections carrying low risk for life-threatening complications

  • Examples: Impetigo, erysipelas, mild cellulitis, simple abscesses
  • Treatment: Empiric antibiotic therapy or drainage and debridement

• Complicated SSTIs: Deep infections with high risk for life-threatening complications

  • Examples: Necrotizing infections, infected ulcers, major abscesses, surgical/traumatic wound infections
  • Treatment: Broad-spectrum antibiotics and surgical intervention

Treatment Algorithm Based on Infection Type

1. Non-purulent Cellulitis (Likely Streptococcal)

• First-line: Penicillin V or amoxicillin
• Alternative: Cephalexin 500 mg four times daily for 7-10 days
• Penicillin-allergic patients: Clindamycin or doxycycline

2. Purulent Skin Infections (Likely Staphylococcal)

• Primary treatment: Incision and drainage for abscesses 2
• Antibiotic therapy:
  • MRSA not suspected: Dicloxacillin, cephalexin, or amoxicillin-clavulanate
  • MRSA suspected or confirmed: TMP-SMX, doxycycline, or minocycline 2

3. Mixed Infections (Animal Bites)

• First-line: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• Alternatives: Ampicillin-sulbactam, piperacillin-tazobactam, carbapenems
• Penicillin-allergic patients: Doxycycline or fluoroquinolones plus clindamycin 1

4. Complicated Skin Infections

• Inpatient treatment options:
  • Vancomycin IV 2
  • Linezolid 600 mg IV/PO twice daily 2, 3, 4
  • Daptomycin 4 mg/kg IV once daily 2
  • Telavancin 10 mg/kg IV once daily 2
  • Ceftaroline IV 2
  • Dalbavancin IV 2

5. Fungal Skin Infections

• Topical treatment: Clotrimazole, miconazole, or nystatin 2
• Keep affected areas dry 2

Special Considerations

MRSA Infections

• Oral options:

  • Trimethoprim-sulfamethoxazole (TMP-SMX) 2
  • Doxycycline or minocycline 2
  • Linezolid 600 mg twice daily 2
  • Tedizolid 2

• Intravenous options (for severe infections):

  • Vancomycin 2
  • Linezolid 2
  • Daptomycin 2
  • Ceftaroline 2

Animal Bites

• First-line: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days 1
• Immediate wound care: Gentle irrigation with water or dilute povidone-iodine solution 1
• Tetanus prophylaxis: If vaccination status outdated or unknown 1
• Rabies prophylaxis: Consider for wild animal bites; consult local health department 1

Duration of Therapy

• Uncomplicated infections: 5-7 days 1
• Complicated infections: 7-14 days, individualized based on clinical response 2
• Switch from IV to oral therapy when clinical stability is achieved 2

Common Pitfalls to Avoid

1. Failing to drain abscesses: Incision and drainage is the primary treatment for abscesses, with antibiotics being adjunctive therapy 2, 5

2. Inappropriate antibiotic selection: Consider local resistance patterns when selecting empiric therapy, particularly for MRSA coverage 2

3. Inadequate wound care: Proper wound irrigation and debridement are as important as antibiotics for preventing infection 1

4. Delayed treatment of necrotizing infections: These require immediate surgical debridement and broad-spectrum antibiotics 2

5. Suturing high-risk wounds: Avoid suturing animal bites and contaminated wounds as it increases infection risk 1

6. Overlooking special populations: Immunocompromised patients, diabetics, and those with peripheral vascular disease require more aggressive treatment and monitoring 2, 1