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Skin and Soft tissue infections (SSTIs)

Skin and Soft Tissue Infections:

  • Superficial skin (and soft tissue) infections and chronic varicose ulcers usually do not require antibiotic therapy,
  • A disinfectant, such as aqueous chlorhexidine (Unisept®), applied to the lesion is often satisfactory
  • Topical antibiotics should not be used; if an antibiotic is required a systemic preparation should be prescribed
  • Microbiological swabs can indicate multiple pathogens and may reflect colonisation. Interpret within clinical context and target therapy against likely organisms.

Surgical Site Infection:

  • Surgical Site Infections should be classified and documented according to CDC definitions above
  • Antimicrobials in conjunction with wound exploration and drainage required for true infection
  • If abscess formation is suspected, drainage must be carried out, as antibiotic therapy alone will prolong the course of the infection without eradicating it.

Skin and Soft tissue infections - Table

Clinical Conditions (x) Likely Organisms Antimicrobial Dosage Approx Duration of Therapy

Comments

Empiric therapy

Mild (no evidence of systemic sepsis)

Beta-haemolytic strep Group A

Staph aureus

Benzylpenicillin 2.4g IV QDS

plus

Flucloxacillin 1-2g IV QDS

Contact Consultant Microbiologist.

Use clindamycin 450-600mg IV QDS in penicillin allergy.

Infection with  MRSA should be  suspected if:

  • MRSA Colonised
  • Recent hospitalisation in last 12 months
  • Transfer from another hospital or long-term care facility e.g. Nursing Home.
If MRSA a potential concern contact Consultant Microbiologist

Empiric therapy

Severe

Contact Consultant Microbiologist.

Surgical Site Infection (SSI)

Contact Russell (stacey).

Necrotising fasciitis

Mixed polymicrobial infection

Piperacillin/tazobactam IV 4.5g QDS

+

Clindamycin 900mg IV QDS

+/-

Gentamicin 5mg/kg IV once daily

  1. Early wound debridement as emergency procedure is the most appropriate treatment.
  2. Contact Consultant Microbiologist.
  3. If abdominal wall or groin involvement (likely organisms: anaerobes, gram negative bacilli), add Gentamicin, adjust Gentamicin dosage according to pre-dose levels.
  4. In penicillin allergy – Contact Consultant Microbiologist

Group A Streptococcus

Benzylpenicillin 2.4g IV QDS

+

Clindamycin 900mg IV QDS

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Respiratory Tract infections

Antimicrobial Treatment of Respiratory Tract Infections

Clinical Conditions (RTIs) Likely Organisms Antimicrobial and Dosage Approx Duration of Therapy Comments
Community acquired pneumonia


Empiric therapy

Strep pneumoniae

Haemophilus Influenzae

Atypical organisms

See Community-acquired pneumonia treatment algorithm

Community acquired pneumonia

Specific therapy 		Legionella sp.

Mild-Moderate Disease
Ciprofloxacin 500mg-750mg PO BD OR Clarithromycin 500mg PO BD +/- Rifampicin 300-600mg PO BD

Severe Disease

Clarithromycin 500mg IV BD +

Ciprofloxacin 400mg IV BD or Ciprofloxacin 500mg-750mg PO BD
  • Send sample for Legionella antigen test.
  • Contact Consultant Microbiologist

Healthcare-Associated Pneumonia (HAP) i.e.

  • In-patient >48 hours
  • Recent hospitalisation in last 3 months
  • Resident in long-term care facility or Nursing home
  • Dialysis patient

Empirical therapy

NB Change to appropriate organism-specific therapy if required once culture and sensitivity is obtained

Gram negative aerobes

Staph aureus

Piperacillin/tazobactam 4.5g IV TDS
  1. Contact Consultant Microbiologist in allcases.
  2. In penillin-allergic patients Contact Consultant Microbiologist.
  3. Take sputum sample where possible for culture.
  4. Take recent isolates from infected sites into account.
  5. Note previous antibiotic therapy.
  6. Early (<48 hours) post-operative pneumonia can be classified as community-acquired and treated with amoxicillin:clavulanic acid.

Acute tonsillitis
Viral
Antibiotics not indicated


Acute otitis media

Empirical therapy

Strep pneumoniae Haemophilus Influenzae Morhaxella

Amoxicillin 500mg PO TDS

In penicillin allergic patients:

Clarithromycin 500mg PO BD


Exacerbation of COPD

Empirical therapy


Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pneumoniae
Amoxicillin:Clavulanic acid 500mg:125mg PO TDS

In penicillin allergic patients:

Clarithromycin 500mg PO BD


Pneumonia in immunocompromised adult
Pneumocystis jirovecii (carinii)
Sulfamethoxazole:trimethoprim 90-120mg/kg either IV or PO daily in 2 to 4 divided doses
21 days
  1. Contact Consultant Microbiologist.
  2. Oral prophylactic therapy is necessary once course of treatment is complete.

Cytomegalovirus
Ganciclovir 5mg/kg IV BD
  1. Contact Consultant Microbiologist.
  2. Oral prophylactic therapy is necessary once course of treatment is complete.

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Urinary tract Infections

Urinary Tract Infection

  • Urinalysis and urine cultures should be interpreted along with clinical signs and symptoms of a UTI

  • Bacteriuria ( >100,000 organisms per ml of a single organism) indicates infection IF clinical signs and symptoms of a UTI also present. Lower colony counts may be considered significant in particular situations e.g. patients already receiving antibiotics, catheterised patients etc.

  • Asymptomatic bacteriuria does not usually require antimicrobial treatment (exceptions include pregnancy, pre-urologic surgery amongst others).

  • Pyuria (>30 WCC/Microlitre) in the setting of a negative urine culture or in patients with asymptomatic bacteriuria usually requires no treatment

  • Bacteriuria in the absence of a pyuria is likely a contamination

Catheter-Associated Urinary Tract Infection

The urine of patients with indwelling catheters frequently becomes colonised.

  • Asymptomatic bacteriuria in catheterised patients DOES NOT USUALLY require treatment and catheter should be removed if possible.

  • Symptomatic patients with a positive urine culture of >1000 organisms per ml should receive antimicrobial treatment for seven days if improving and remove or change catheter.

  • Prophylactic antimicrobials should not be administered routinely to patients at the time of catheter placement, replacement, or removal to reduce catheter-associated UTI (IDSA Guidelines 2009)

Antimicrobial Treatment of UTIs

Clinical Conditions

Likely Organisms Antimicrobial Dosage Approx Duration of Therapy Comments
Uncomplicated lower UTI
Empirical therapy
NB Discontinue empirical therapy and change to appropriate organism-specific therapy once culture and sensitivity is obtained 		Eschericia coli Enterococcus sp. Proteus sp. Staphylococcus sp. Klebsiella sp.

Amoxicillin:clavulanic acid 625mg PO TDS

or

Nitrofurantoin 100mg PO QDS (If GFR >60ml/min)

3 to 5 days

3 to 5 days

  1. Send urine sample for culture and sensitivity prior to commencing antibiotics.
  2. Intravenous therapy may be required in more severe infection.
  3. Adjust therapy based on sensitivities once available.
  4. Duration of therapy may be extended if patient has abnormality of the genito-urinary tract.
Acute pyelonephritis
Empirical therapy NB Discontinue empirical therapy and change to appropriate organism-specific therapy once culture and sensitivity is obtained 		Organism unknown Amoxicillin:clavulanic acid 1.2g IV TDS
+ Gentamicin 5mg/kg IV once daily 		14 days

5 to 7 days
  1. Take blood cultures.
  2. Longer treatment may be necessary in complicated pyelonephritis.
  3. Adjust Gentamicin dosage according to pre-dose levels.

Sepsis post genito-urinary surgery

Gram negative bacilli

Gentamicin 5mg/kg IV once daily

+

Amoxicillin 1g IV TDS

Adjust Gentamicin dosage according to pre-dose levels.

In Penicillin allergy use Gentamicin OR Ciprofloxacin monotherapy depending on sensitivities

Epididymo-orchitis British Association for Sexual Health and HIV (BASH) 2010 Guidelines

Most probably due to any sexually-transmitted organism:

Ceftriaxone 250mg IM single-dose PLUS

Doxycycline 100mg BD PO for 10-14 days

If most probably due to Chlamydia or non-gonococcal organisms:

Doxycycline 100mg BD PO for 10-14 days

Or

Ciprofloxacin 500mg BD PO for 10-14 days

If most probably due to enteric organisms:

Ciprofloxacin 500mg BD PO for 10-14 days