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Skin and Soft Tissue

Skin and Soft Tissue

Microbiological specimens

  • ALL HOSPITAL ADMISSIONS MUST RECEIVE A MSSA/MRSA SCREEN. Nose and perineal swab for chromogenic culture as per hospital policy (see CORP/PROC/408)
  • Deep tissue, pus/ aspirates are best specimens from wounds. Surface swabs are sub-optimal and if collected these should be obtained after cleaning wound surface with saline.
  • Blood culture [if signs of systemic sepsis].
  • If recurrent boils or severe sepsis present consider possibility of PVL MRSA or MSSA.  Discuss urgently with Consultant Microbiologist during work hours as standard regimes may be sub-optimal. (see CORP/PROC/612 link)
  • Gangrene/ necrotising fasciitis/ abscess: send tissue or aspirate.
  • The choice of agent should take into account the patient's risk for C. difficile infection.

 

Cellulitis

  • 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.

 

Leg ulcers / pressure sores
non diabetic

Comment

  • Avoid antibiotics
  • Use local cleansing and topical antiseptics if required.  Involve Tissue Viability Nurse.

If signs of infection, use Flucloxacillin or Clindamycin and discuss with Microbiologist during working hours. Pseudomonas or Enterobacteriaceae from surface wound swabs may represent colonisation.

 

Impetigo

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

 

Animal bites

Duration of therapy 5 days

Common Pathogen(s)
P. multocida;
Capnocytophaga;
Staphylococcus aureus.

Antibiotic - 1st line
Co-amoxiclav (Consider C difficile risk) 625 mg q8h PO.

2nd Line
Doxycycline 100mg q12h PO
plus
Metronidazole 400mg q8h PO.

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

Is tetanus immunisation up-to-date?

 

Human bites

Duration of therapy 5 days

Common Pathogen(s)
Strept, Peptostrep, Bacteroides; Staphylococcus aureus

Antibiotic - 1st line
Co-amoxiclav (Consider C difficile risk) 625 mg q8h PO.

2nd Line
Doxycycline 100mg q12h PO
plus
Metronidazole 400mg q8h PO.

Comment
Is Hepatitis B vaccine required?

 

Diabetic foot ulcers PEDIS grade 1

  • 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.

 

Diabetic foot ulcer PEDIS grade 2

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

 

Diabetic foot ulcer PEDIS grade 3

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.

Gentamicin*: 5mg/ kg  but for elderly patients or with moderate/severe renal impairment, may require 3mg/ kg or shorter duration treatment.

 

Diabetic foot ulcer PEDIS grade 4

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


2nd Line
Discuss with Microbiologist.

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

 

Necrotising fasciitis/
gas gangrene

Debridement main stay of treatment.

Common Pathogen(s)
Group A Strept;
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 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

 

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.
Gentamicin*: 5mg/ kg but for elderly patients or with moderate/severe renal impairment (CrCl <30ml/min), may require 3mg/ kg or shorter duration treatment.