Guidelines for the Diagnosis and Treatment of Skin and Soft Tissue Infections

Background and Objective

A multidisciplinary expert panel updated 2005 guidelines, addressing 24 questions regarding diagnosis and management of common and less common skin and soft tissue infections.

Key Points

Bullous and Nonbullous Impetigo

• Perform gram stain and culture to distinguish between Staphylococcus aureus and beta-hemolytic Streptococcus-associated infections.

• Treat with topical mupirocin, retapamulin (twice daily for 5 days), or oral antibiotics (7 days with dicloxacillin or cephalexin for methicillin-susceptible S. aureus [MSSA]; doxycycline, clindamycin, or sulfamethoxazole-trimethoprim if methicillin-resistant S. aureus [MRSA] is suspected).

• The same oral antibiotic regimen is recommended for ecthyma.

Cutaneous Abscesses, Furuncles, Carbuncles, Inflamed Epidermoid Cysts

• Strong evidence supports incision and drainage.

• Add antibiotics if systemic signs and symptoms of infection or elevated white blood count are present.

• Gram stain and culture is not necessary before antibiotic therapy in typical cases and is not recommended for inflamed epidermoid cysts.

Recurrent Abscesses

• Suggest an underlying cause (e.g., pilonidal cyst, hidradenitis suppurativa, foreign body, neutrophil disorder).

• If recurrent, consider 5-day decolonization, including intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of towels, sheets, and clothes.

Cellulitis and Erysipelas

• Cultures are not recommended unless patients are on chemotherapy, have severe neutropenia or cellular immunodeficiency, or after an immersion injury or animal bite.

• Treat for five days; extend treatment if no improvement.

• Use antibiotics against MRSA and streptococci when evidence suggests MRSA infection elsewhere, injection drug use, systemic signs of infection, or penetrating trauma.

• Evaluate underlying causes/predisposing conditions (e.g., edema, fissuring/maceration of interdigital spaces, eczema, venous insufficiency).

• Consider prophylactic penicillin or erythromycin for 4 to 52 weeks if cellulitis recurs >3 times within a year.

Immunocompromised Patients

• Skin lesions could be drug eruptions, chemotherapy- or radiation-induced reactions, cutaneous metastases, erythema multiforme, vasculitis, graft-versus-host disease, and bacterial, fungal, viral or parasitic diseases.

Surgical Site Infections

• Remove sutures; incise and drain.

• Adjunctive systemic antibiotics are not indicated absent signs of systemic infection or presence of erythema and induration at least 5 cm from the surgical site.

• If such signs are present, give antibiotics against MSSA (and MRSA, if risk factors are high).

• Also cover gram-negative bacteria and anaerobes for infections following surgery of axilla or perineum.