What are the guidelines for skin and soft tissue infections?

From the Guidelines

Skin and soft tissue infection guidelines recommend empiric antibiotic therapy based on infection severity and suspected pathogens, with a focus on MRSA coverage. For mild to moderate infections, oral antibiotics such as linezolid, trimethoprim-sulfamethoxazole (TMP-SMX), or a tetracycline (doxycycline or minocycline) can be used for MRSA coverage, as suggested by the 2018 WSES/SIS-E consensus conference 1.

Key Considerations

• For severe infections, intravenous therapy with daptomycin, linezolid, or vancomycin is recommended, with consideration of the patient's clinical response and local resistance patterns 1.
• Purulent infections should be incised and drained, with cultures obtained to guide targeted therapy, as recommended by the Infectious Diseases Society of America (IDSA) guidelines 1.
• Treatment duration varies by infection type but typically ranges from 5-14 days, with longer courses for deeper or complicated infections, and should be individualized based on the patient's clinical response 1.

Antibiotic Options

• Oral antibiotics for MRSA coverage: linezolid, TMP-SMX, doxycycline, or minocycline 1.
• Intravenous antibiotics for MRSA coverage: daptomycin, linezolid, vancomycin, or tedizolid 1.

Special Considerations

• Diabetic foot infections require multidisciplinary care with appropriate wound care, offloading, and antibiotics targeting both aerobic and anaerobic organisms.
• Necrotizing infections require immediate surgical debridement alongside broad-spectrum antibiotics. The choice of antibiotic should be guided by the severity of the infection, suspected pathogens, and local resistance patterns, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Linezolid is an oxazolidinone-class antibacterial indicated in adults and children for the treatment of the following infections caused by susceptible Gram-positive bacteria: Nosocomial pneumonia (1.1); Community-acquired pneumonia (1.2); Complicated skin and skin structure infections, including diabetic foot infections, without concomitant osteomyelitis (1. 3); Uncomplicated skin and skin structure infections (1.4); Vancomycin-resistant Enterococcus faecium infections. (1.5)

Skin and Soft Tissue Infection Guidelines:

• Complicated skin and skin structure infections: 600 mg intravenous or oral every 12 hours for 14 to 28 days 2.
• Uncomplicated skin and skin structure infections:
  • Adults: 400 mg oral every 12 hours for 10 to 14 days 2.
  • Adolescents: 600 mg oral every 12 hours for 10 to 14 days 2.
  • Children less than 5 years: 10 mg/kg oral every 8 hours for 10 to 14 days 2.
  • Children 5 to 11 years: 10 mg/kg oral every 12 hours for 10 to 14 days 2.

From the Research

Skin and Soft Tissue Infection Guidelines

• The most common cause of complicated skin and soft tissue infections (cSSTIs) is Staphylococcus aureus, including methicillin-resistant S. aureus (MRSA) 3.
• Antibiotic choices for cSSTIs continue to evolve, with newer therapeutic options such as linezolid, quinupristin-dalfopristin, daptomycin, tigecycline, and vancomycin being developed to combat MRSA infections 3, 4.
• Linezolid is efficacious in the treatment of cSSTIs, including diabetic foot infections, caused by Gram-positive organisms, with a well-defined safety profile and straightforward dosing 3.
• Cephalexin remains an effective and highly useful antibiotic for the treatment of streptococcal and staphylococcal skin infections, with cure rates of 90% or higher achieved in clinical trials 5, 6.
• Current international and national guidelines for managing skin and soft tissue infections recommend using new antimicrobials, prescribing shorter antibiotic treatment courses, and refining drug decision-making based on the development of new drugs and current evidence 7.

Antibiotic Treatment Options

• Cephalexin and clindamycin are suitable options for infections caused by streptococcal species and methicillin-susceptible S. aureus 4.
• Parenteral cefazolin, nafcillin, or oxacillin can be used in hospitalized patients with nonpurulent cellulitis caused by streptococci and methicillin-susceptible S. aureus 4.
• Oral MRSA therapy options include clindamycin, doxycycline, trimethoprim-sulfamethoxazole, or linezolid 4.
• Intravenous options for MRSA infections that require patient hospitalization include vancomycin, linezolid, daptomycin, tigecycline, telavancin, and ceftaroline fosamil 4.

Management and Treatment

• Hospitalists play a crucial role in the management of skin and soft tissue infections, and their proper use of antibiotics is essential to slow the evolution of microbial resistance 4.
• Imaging tools and surgical exploration are important for diagnosing and treating skin and soft tissue infections, particularly necrotizing soft tissue infections 4.
• Shorter courses of antibiotics are recommended, and the role of stewardship programs will continue to expand in the management of skin and soft tissue infections 7.