Lindberg, MD reviewing Obaitan I et al. Am J Emerg Med May 26 In trials of antibiotic treatment for cellulitis, failure rates are high and variable. Diagnosis of cellulitis is based on clinical pattern recognition rather than objective tests, and although classically thought to be caused by gram positive bacteria, the majority of cases are culture negative. Noting the high treatment failure rates in some studies that used potent antibiotics, these authors conducted a systematic review and meta-analysis to determine antibiotic treatment failure rates. They identified 20 randomized studies, including nearly patients, that compared antibiotic treatments for cellulitis. All antibiotics evaluated in these studies are known to be effective against streptococci.

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Stevens, Alan L. Bisno, Henry F. Chambers, E. Patchen Dellinger, Ellie J. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Sheldon L. Kaplan, Jose G. Montoya, James C. Wade For full document, including tables and references, please visit the Oxford University Press website. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis.

In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population.

These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion. Figure 1 was developed to simplify the management of localized purulent staphylococcal infections such as skin abscesses, furuncles, and carbuncles in the age of methicillin-resistant Staphylococcus aureus MRSA. In addition, Figure 2 is provided to simplify the approach to patients with surgical site infections.

A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of the guidelines. Recommendations Abridged Impetigo and Ecthyma I. Bullous and nonbullous impetigo can be treated with oral or topical antimicrobials, but oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people to help decrease transmission of infection.

Treatment for ecthyma should be an oral antimicrobial. Treatment of bullous and nonbullous impetigo should be with either mupirocin or retapamulin twice daily bid for 5 days strong, high. Oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against S. Because S. Systemic antimicrobials should be used for infections during outbreaks of poststreptococcal glomerulonephritis to help eliminate nephritogenic strains of S.

Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases strong, moderate. Gram stain and culture of pus from inflamed epidermoid cysts are not recommended strong, moderate.

Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles, mild Figure 1 strong, high. The decision to administer antibiotics directed against S. An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment or have markedly impaired host defenses or in patients with SIRS and hypotension severe; Figure 1 and Table 2 strong, low.

A recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material strong, moderate. Recurrent abscesses should be drained and cultured early in the course of infection strong, moderate. After obtaining cultures of recurrent abscess, treat with a 5- to day course of an antibiotic active against the pathogen isolated weak, low.

Consider a 5-day decolonization regimen twice daily of intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items such as towels, sheets, and clothes for recurrent S. Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood strong, moderate. Erysipelas and Cellulitis IV. Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended strong, moderate. Cultures of blood are recommended strong, moderate , and cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites weak, moderate.

Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci mild; Figure 1 strong, moderate. For cellulitis with systemic signs of infection moderate nonpurulent; Figure 1 , systemic antibiotics are indicated. Many clinicians could include coverage against methicillin-susceptible S. For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS severe nonpurulent; Figure 1 , vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended strong, moderate.

In severely compromised patients as defined in question 13 severe nonpurulent; Figure 1 , broad-spectrum antimicrobial coverage may be considered weak, moderate. The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period strong, high.

Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended strong, moderate. In lower-extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection strong, moderate. Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability mild nonpurulent; Figure 1 strong, moderate.

Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing moderate or severe nonpurulent; Figure 1 strong, moderate. Systemic corticosteroids eg, prednisone 40 mg daily for 7 days could be considered in nondiabetic adult patients with cellulitis weak, moderate.

Patients with Recurrent Cellulitis VI. Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities strong, moderate. These practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis strong, moderate.

Administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4—52 weeks, or intramuscular benzathine penicillin every 2—4 weeks, should be considered in patients who have 3—4 episodes of cellulitis per year despite attempts to treat or control predisposing factors weak, moderate. This program should be continued so long as the predisposing factors persist strong, moderate.

Suture removal plus incision and drainage should be performed for surgical site infections strong, low. A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection strong, low. A first-generation cephalosporin or an antistaphylococcal penicillin for MSSA, or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for MRSA are high nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics , is recommended strong, low.

See also Tables 2 and 3. Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections following operations on the axilla, gastrointestinal tract, perineum, or female genital tract strong, low. See also Table 3. Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene severe nonpurulent; Figure 1 strong, low.

Empiric antibiotic treatment should be broad eg, vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem; or plus ceftriaxone and metronidazole , as the etiology can be polymicrobial mixed aerobic—anaerobic microbes or monomicrobial group A streptococci, community-acquired MRSA strong, low.

See also Table 4. Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis strong, low. See Figures 1, 2, and Table 4. Pyomyositis IX. Magnetic resonance imaging MRI is the recommended imaging modality for establishing the diagnosis of pyomyositis. Computed tomography CT scan and ultrasound studies are also useful strong, moderate. Cultures of blood and abscess material should be obtained strong, moderate. Vancomycin is recommended for initial empirical therapy.

An agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or following open trauma to the muscles strong, moderate. Cefazolin or antistaphylococcal penicillin eg, nafcillin or oxacillin is recommended for treatment of pyomyositis caused by MSSA strong, moderate. See Table 2. Early drainage of purulent material should be performed strong, high. Repeat imaging studies should be performed in the patient with persistent bacteremia to identify undrained foci of infection strong, low.

Antibiotics should be administered intravenously initially, but once the patient is clinically improved, oral antibiotics are appropriate for patients in whom bacteremia cleared promptly and there is no evidence of endocarditis or metastatic abscess.

Two to 3 weeks of therapy is recommended strong, low. Urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue should be performed severe nonpurulent; Figure 1 strong, moderate. Definitive antimicrobial therapy with penicillin and clindamycin Figure 1 is recommended for treatment of clostridial myonecrosis strong, low. Hyperbaric oxygen HBO therapy is not recommended because it has not been proven as a benefit to the patient and may delay resuscitation and surgical debridement strong, low.

Preemptive early antimicrobial therapy for 3—5 days is recommended for patients who a are immunocompromised; b are asplenic; c have advanced liver disease; d have preexisting or resultant edema of the affected area; e have moderate to severe injuries, especially to the hand or face; or f have injuries that may have penetrated the periosteum or joint capsule strong, low.

Postexposure prophylaxis for rabies may be indicated; consultation with local health officials is recommended to determine if vaccination should be initiated strong, low. An antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate Table 5 should be used strong, moderate. Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years.

Tetanus, diptheria, and tetanus Tdap is preferred over Tetanus and diptheria Td if the former has not been previously given strong, low. Primary wound closure is not recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics strong, low.

Other wounds may be approximated weak, low. Oral penicillin V mg 4 times daily qid for 7—10 days is the recommended treatment for naturally acquired cutaneous anthrax strong, high.

Erythromycin mg qid or doxycycline mg bid for 2 weeks to 2 months is recommended for treatment of bacillary angiomatosis strong, moderate. What Is the Preferred Treatment for Erysipeloid?

Penicillin mg qid or amoxicillin mg 3 times daily [tid] for 7—10 days is recommended for treatment of erysipeloid strong, high.

What Is the Appropriate Treatment of Glanders? Ceftazidime, gentamicin, imipenem, doxycycline, or ciprofloxacin is recommended based on in vitro susceptibility strong, low. Bubonic plague should be diagnosed by Gram stain and culture of aspirated material from a suppurative lymph node strong, moderate.

Gentamicin could be substituted for streptomycin weak, low. Serologic tests are the preferred method of diagnosing tularemia weak, low. Tetracycline mg qid or doxycycline mg bid po is recommended for treatment of mild cases of tularemia strong, low. Notify the microbiology laboratory if tularemia is suspected strong, high. In addition to infection, differential diagnosis of skin lesions should include drug eruption, cutaneous infiltration with the underlying malignancy, chemotherapy- or radiation-induced reactions, Sweet syndrome, erythema multiforme, leukocytoclastic vasculitis, and graft-vs-host disease among allogeneic transplant recipients strong, high.

Differential diagnosis for infection of skin lesions should include bacterial, fungal, viral, and parasitic agents strong, high. Biopsy or aspiration of the lesion to obtain material for histological and microbiological evaluation should always be implemented as an early diagnostic step strong, high.


NEJM Journal Watch

Stevens, Alan L. Bisno, Henry F. Chambers, E. Patchen Dellinger, Ellie J. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Sheldon L.



June 5, Overdiagnosis of Cellulitis Allan S. Now, two prospective studies provide additional insight. In a randomized trial, patients with presumed cellulitis who were admitted to an inpatient hospital unit or an emergency department ED observation unit received either mandatory dermatology consultation within 24 hours or no consultation. In a prospective cohort study, patients with presumed cellulitis who were seen in the ED or were hospitalized received dermatology consultation within 24 hours.





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