Skin and Soft Tissue

• Duration of therapy 5-7 days [guided by clinical progress]
• Without systemic (PO)
• With systemic  (IV => PO)
• Peripheral IV cannula infection

Common Pathogen(s)
Streptococcus pyogenes;
Staphylococcus aureus;
Occasionally Strep Grp B, C, G.

MRSA colonised must not be treated with Flucloxacillin.

Antibiotic – 1st line Flucloxacillin 1g q6h IV/ PO. Review after 48 hours and step down to oral therapy once margin of cellulitis begins to recede. Target treatment if significant positive culture results are available. Addition of Benzyl Penicillin or amoxicillin to Flucloxacillin is NOT required as flucloxacillin offers Streptococcal cover as well. Severe cases of skin/soft tissue infections/Penicillin allergy or high suspicion of MRSA  – Vancomycin IV (dosed as per trust vancomycin guideline)

 

2nd Line Clindamycin 600mg q6h IV/ PO. Review after 48 hours and step down to oral therapy once margin of cellulitis begins to recede. If response is poor consider resistance and call microbiology

Comment

Local data demonstrates higher dosage reduces  association with  C. difficile . Please note that where prior results are available these should be checked. If isolate is Erythromycin resistant then clindamycin should be used with caution and response checked as in such situation resistance can emerge rapidly.

Comment

• There are many causes of leg ulcers: underlying conditions, such as venous insufficiency and oedema, should be managed to promote healing.
• Most leg ulcers are not clinically infected but are likely to be colonised with bacteria
  ***** Avoid antibiotics *****

• Pseudomonas or Enterobacteriaceae from surface wound swabs may represent colonisation.
• Antibiotics do not help to promote healing when a leg ulcer is not clinically infected.
• Consider sending a sample from the leg ulcer (after cleaning) for microbiological testing if symptoms or signs of the infection are worsening or have not improved as expected.
• Use local cleansing and topical antiseptics if required.  Involve Tissue Viability Nurse.

If or signs of infection (for example, redness or swelling spreading beyond the ulcer, localised warmth, increased pain or fever). Take account of:

• the severity of symptoms or signs
• the risk of developing complications
• previous antibiotic use.

Treat as cellulitis and review antimicrobial choice with microbiological results

Reassess an infected leg ulcer in adults if:

• symptoms or signs of the infection worsen rapidly or significantly at any time, or do not start to improve within 2 to 3 days
• the person becomes systemically unwell or has severe pain out of proportion to the infection.

Be aware that it will take some time for a leg ulcer infection to resolve, with full resolution not expected until after the antibiotic course is completed.

Consider referring or seeking microbiologists during working hours for adults with an infected leg ulcer if:

• they have any symptoms or signs suggesting a more serious illness or condition, such as sepsis, necrotising fasciitis or osteomyelitis.
• have a higher risk of complications because of comorbidities, such as diabetes or immunosuppression
• have lymphangitis
• have spreading infection that is not responding to oral antibiotics
• cannot take oral antibiotics (exploring locally available options for giving intravenous or intramuscular antibiotics at home or in the community, rather than in hospital, where appropriate).

Reference:

NICE guideline NG 152. Leg ulcer infection: antimicrobial prescribing. Feb 2020 https://www.nice.org.uk/guidance/ng152

Duration of therapy 5 days 
Common Pathogen(s)
Staphylococcus aureus;
Streptococcus pyogenes.

Antibiotic – 1st line Mupirocin 2% ointment q8h topically or Hydrogen peroxide 1% cream q8h topically. If widespread: Flucloxacillin 500mg q6h PO.

 

2nd Line If widespread: Clarithromycin 500mg q12h PO.

Comment
Do NOT use topical Fucidin® empirically, most community MSSA are resistant

Most insect bites and stings do not need antibiotics – see NICE guidelines for further details

Reference:

NICE guideline NG 182. Insect bites and stings: antimicrobial prescribing https://www.nice.org.uk/guidance/ng182 <accessed 25/3/21>

• assess the type and severity of the bite, including what animal caused the bite, the site and depth of the wound, and whether it is infected
• assess the risk of tetanus, rabies or a bloodborne viral infection and take appropriate action
• manage the wound with irrigation and debridement as necessary
• be aware of potential safeguarding issues in vulnerable adults and children
• Seek advice from a microbiologist for bites from a wild or exotic animal (including birds and non-traditional pets) because the spectrum of bacteria involved may be different, and there may be a risk of other serious non-bacterial infections.
• Consider seeking specialist advice from a microbiologist for domestic animal bites (including farm animal bites), that you are unfamiliar with.

Treating infected bites:

• Take a swab for microbiological testing to guide treatment if there is discharge (purulent or non-purulent) from the human or animal bite wound.
• Offer an antibiotic for people with a human or animal bite if there are symptoms or signs of infection, such as increased pain, inflammation, fever, discharge or an unpleasant smell.

Review daily and be aware non-verbal signs of pain such as a change of behaviour.

Reference:

NICE. NG184. Human and animal bites:antimicrobial prescribing Nov 2020. https://www.nice.org.uk/guidance/ng184 <accessed 25/3/21>

Cat bites

• Do not offer antibiotic prophylaxis to people with a cat bite that has not broken the skin.
• Offer antibiotic prophylaxis to people with a cat bite that has broken the skin and drawn blood.
• Consider antibiotic prophylaxis for people with a cat bite that has broken the skin but not drawn blood if the wound could be deep.

Dog bites or other traditional pet (exclude cat bites)

• Do not offer antibiotic prophylaxis to people with a bite from a dog or other traditional pet (excluding cat bites) that:
  • has not broken the skin, or has broken the skin but not drawn blood.
• Offer antibiotic prophylaxis to people with a bite from a dog or other traditional pet (excluding cat bites) that has broken the skin and drawn blood if it:
  • has penetrated bone, joint, tendon or vascular structures, or
  • is deep, is a puncture or crush wound, or has caused significant tissue damage, or
  • is visibly contaminated (for example, if there is dirt or a tooth in the wound).
• Consider antibiotic prophylaxis for people with a bite from a dog or other traditional pet (excluding cat bites) that has broken the skin and drawn blood if it:
  • involves a high-risk area such as the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation, or
  • is in a person at risk of a serious wound infection because of a co-morbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease).

 Duration of therapy Prophylaxis (3 days) and treatment (5 days-7days based on clinical assessment e.g if significant tissue destruction or penetrated bone, joint, tendon or vascular structures)

 Common Pathogen(s)

P.multocida;

Capnocytophaga;

Staphylococcus aureus.

 

Antibiotic – 1st line Co-amoxiclav (Consider C difficile risk) 625 mg q8h PO.   Oral is preferred but if IV is needed Co-amoxiclav 1.2g IV q8h and review after 48hours

 

2nd Line Doxycycline 100mg q12h PO plus Metronidazole 400mg q8h PO.   Oral is preferred but if IV is needed and non-serious penicillin allergy (e.g. mild rash) Cefuroxime 1.5g IV q8h Plus                                         Metronidazole 500mg IV q8h   Review after 48hours

 

Comment

Topical cleansing, irrigation and debridement are significant and as indicated.

Is tetanus immunisation up-to-date?

Human bites

• Do not offer antibiotic prophylaxis to people with a human bite that has not broken the skin.
• Offer antibiotic prophylaxis to people with a human bite that has broken the skin and drawn blood.
• “Consider antibiotic prophylaxis for people with a human bite that has broken the skin but not drawn blood if it:
• involves a high-risk area such as the hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation, or
  • is in a person at risk of a serious wound infection because of a co-morbidity (such as diabetes, immunosuppression, asplenia or decompensated liver disease).”

Duration of therapy Prophylaxis (3 days) and treatment (5 days – 7days based on clinical assessment e.g if significant tissue destruction or penetrated bone, joint, tendon or vascular structures)

 

Common Pathogen(s)

Strept, Peptostrep, Bacteroides; Staphylococcus aureus

Antibiotic – 1st line Co-amoxiclav (Consider C difficile risk) 625 mg q8h PO.     Oral is preferred but if IV is needed Co-amoxiclav 1.2g IV q8h and review after 48hours

 

2nd Line Doxycycline 100mg q12h PO plus Metronidazole 400mg q8h PO.   Oral is preferred but if IV is needed and non-serious penicillin allergy (e.g. mild rash) Cefuroxime 1.5g IV q8h Plus                                         Metronidazole 500mg IV q8h   Review after 48hours

 
 Comment

Is Hepatitis B vaccine required?

• No symptoms or signs of infection  – IDSA infection severity  – uninfected

Infection present, as defined by the presence of at least 2 of the following items:

• Local swelling or induration
• Erythema
• Local tenderness or pain
• Local warmth
• Purulent discharge (thick, opaque to white or sanguineous secretion)

Common Pathogen(s)
Colonising skin flora.

Antibiotic – 1st line No antibacterial therapy.  Cleaning and topical antiseptics as advised by tissue viability team, podiatry or diabetic foot clinic

Local infection involving only the skin and the subcutaneous tissue (without involvement of deeper tissues and without systemic signs as described below – see PEDIS 4). If erythema, must be >0.5 cm to ≤2 cm around the ulcer.

Exclude other causes of an inflammatory response of the skin (eg, trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis).

IDSA Infection Severity – mild

Duration of therapy usually 2 weeks (subject to review)

Common Pathogen(s)
Staphylococcus aureus;
Strept. grp A, occ gp B.

Antibiotic – 1st line Flucloxacillin 1g q6h IV (500mg PO 6 hourly).

 

2nd Line Clindamycin 600mg q6h PO/IV

Local infection (as described above) with erythema > 2 cm, or involving structures deeper than skin and subcutaneous tissues (eg, abscess, osteomyelitis, septic arthritis, fasciitis), and No systemic inflammatory response signs (as described below)
IDSA Infection Severity – Moderate

Duration of therapy usually 2 to 3 weeks (subject to review/ clinical response).

Common Pathogen(s)
Staphylococcus aureus
Strept. grp A, occ B &coliforms

Antibiotic – 1st line Flucloxacillin 1g q6h IV plus Gentamicin (click here for full gentamicin policy) Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy. 5mg/kg IV q24h. (max 500mg): if <70 years and CrCl≥30mL/min  or 3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment) Round to nearest 20mg for ease of administration CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation. If patient is obese ie. 20% over ideal body weight – use adjusted body weight Review Gentamicin at 48Hours Or Co-amoxiclav(Consider C difficile risk) 1.2g q8h IV if severe renal impairment or 625mg q8h PO if for discharge

 

2nd Line Clindamycin PO 600mg q6h plus Gentamicin (click here for full gentamicin policy) Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy. 5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or 3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment) Round to nearest 20mg for ease of administration CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation. If patient is obese ie. 20% over ideal body weight – use adjusted body weight

Comment
If MRSA colonised/high risk, please refer to Treatment of MRSA infections section of policy.

Tissue sample/ frank pus is optimal specimen.

Blood culture if systemic effects; soft tissue biopsy in neuropathic ulcers; ulcer swabs from inflamed margin.

Local infection (as described above) with the signs of SIRS, as manifested by ≥2 of the following:

Temperature >38°C or <36°C

Heart rate >90 beats/min

Respiratory rate >20 breaths/min or PaCO2 <32 mm Hg

White blood cell count >12 x 10⁹ or < 4 x 10⁹  cells/L or ≥10% immature (band) forms IDSA infection severity – severe

Duration of therapy6-12 weeks

Common Pathogen(s)
Staphylococcus aureus;
Possibly Polymicrobial.

Antibiotic – 1st line Treatment based on culture/ sensitivity results

Comment
Blood culture if systemic effects; bone biopsy (whenever possible); deep soft tissue biopsy; deep soft tissue swabs (of limited use).

Urgent Surgical Review.
Debridement main stay of treatment.

 

Common Pathogen(s) Group A Strep; Staphylococcus aureus	Common Pathogen(s) Possibly polymicrobial
Antibiotic – 1st line Clindamycin 600mg q6h IV (900mg q8h IV) plus Benzylpenicillin 2.4g q6h IV. Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)  Clindamycin 600mg q6h IV (900mg q8h IV)Plus Vancomycin IV (dosed as per trust vancomycin guideline)	Amoxicillin 2g q8h IV plus Metronidazole 500mg q8h IV Plus Gentamicin (click here for full gentamicin policy)  Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70 years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min  or 3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment) Round to nearest 20mg for ease of administration CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation. If patient is obese ie. 20% over ideal body weight – use adjusted body weight Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)  Teicoplanin IV 10mg/kg q12h for 3 doses and then q24h (round to nearest 200mg or 400mg vial) plus Gentamicin as above plus Metronidazole 500mg q8h IV
Review  at 48 hours.

 

2nd Line Higher doses of Clindamycin/ immunoglobulin may be required in patients on intensive care. Urgent discussion with on-call microbiologist is required.

Comment
Theatre samples are precious and must be sent for culture & sensitivity. Clindamycin has additional Group A Strept toxin blocking action.