Treatment of Skin and Soft Tissue Infections
The treatment of skin and soft tissue infections requires prompt antimicrobial therapy with coverage for common pathogens, surgical intervention for abscesses or necrotizing infections, and duration of 7-14 days based on clinical response. 1
Classification and Assessment
- Skin and soft tissue infections (SSTIs) should be classified as either uncomplicated (superficial) or complicated (deep/necrotizing) to guide management decisions 1, 2
- Assess for systemic toxicity signs: fever >38.5°C, tachycardia >100 beats/min, hypotension (systolic BP <90 mmHg), elevated creatinine, low serum bicarbonate, elevated creatine phosphokinase, or C-reactive protein >13 mg/L 1
- Warning signs of necrotizing infections requiring immediate surgical consultation include: pain disproportionate to physical findings, violaceous bullae, cutaneous hemorrhage, skin sloughing, skin anesthesia, rapid progression, and gas in tissue 1, 2
Surgical Management
- Incision and drainage is the primary treatment for cutaneous abscesses, with antibiotics as adjunctive therapy 1
- Prompt surgical consultation is essential for patients with aggressive infections, signs of systemic toxicity, or suspicion of necrotizing fasciitis or gas gangrene 1, 2
- All necrotizing soft tissue infections require immediate surgical debridement as the primary intervention - delaying surgery increases mortality 1, 2
Antimicrobial Therapy
Uncomplicated SSTIs (Cellulitis, Small Abscesses)
- For mild community-acquired infections: semi-synthetic penicillin, first-generation or second-generation oral cephalosporins, macrolides, or clindamycin 1
- For MRSA coverage: trimethoprim-sulfamethoxazole (160-800 mg twice daily), doxycycline (100 mg twice daily), or clindamycin (300-450 mg three times daily) 1, 3
Complicated SSTIs (Deep Infections, Surgical Site Infections)
- For hospitalized patients with moderate to severe infections: vancomycin (15 mg/kg every 12 hours) plus either piperacillin-tazobactam (3.375 g every 6 hours or 4.5 g every 8 hours) or a carbapenem 1, 4
- For documented group A streptococcal necrotizing fasciitis: penicillin plus clindamycin 1, 2
- For polymicrobial necrotizing infections: broad-spectrum coverage with piperacillin-tazobactam, a carbapenem, or ampicillin-sulbactam plus vancomycin 1
Special Populations
- For diabetic foot infections: piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem, plus vancomycin if MRSA is suspected 1, 5
- For immunocompromised patients with neutropenia: broad-spectrum antibiotics plus consideration of antifungal therapy if fever persists 1
- For human or animal bite wounds: amoxicillin-clavulanate (875/125 mg twice daily) or ampicillin-sulbactam (1.5-3.0 g every 6 hours) 1
Duration of Therapy
- Treatment duration for most bacterial SSTIs should be 7-14 days 1, 6
- Longer courses may be needed for immunocompromised patients, diabetic foot infections with underlying osteomyelitis, or necrotizing infections 1, 2
- Clinical response should guide therapy - improvement typically occurs within 48-72 hours 3, 6
Monitoring and Follow-up
- Reassess patients within 24-48 hours to verify clinical response 1
- Adjust antibiotics based on culture results and clinical response 1, 3
- For patients with severe infections who improve clinically, transition from IV to oral therapy when possible 2, 5
Common Pitfalls to Avoid
- Delaying surgical consultation for potentially necrotizing infections 1, 2
- Failing to obtain appropriate cultures before initiating antibiotics in complicated infections 1, 6
- Not considering MRSA coverage in areas with high prevalence 1, 3
- Inadequate debridement of necrotic tissue in necrotizing infections 1, 2
- Overlooking the possibility of underlying osteomyelitis in diabetic foot infections 2, 5