Sandbox ID Skin and Soft Tissues

Staphylococcal and streptococcal skin and soft tissue infections

(table 2)

• Impetigo (Staphylococcus and Streptococcus), adult

• Preferred regimen (1): Dicloxacillin 250 mg PO qid
• Preferred regimen (2): Cephalexin 250 mg PO qid
• Preferred regimen (3): Erythromycin 250 mg qid PO (Some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant)
• Preferred regimen (4): Clindamycin 300–400 mg qid PO
• Preferred regimen (5): Amoxicillin-Clavulanate 875/125 mg bid po
• Preferred regimen (6): Retapamulin ointment applied to lesions bid (for patients with limited number of lesions)
• Preferred regimen (7): Mupirocin ointment applied to lesions bid (for patients with limited number of lesions)

• Impetigo (Staphylococcus and Streptococcus), pediatric

• Preferred regimen (1): Cephalexin 25–50 mg/kg/d in 3–4 divided doses PO
• Preferred regimen (2): Erythromycin 40 mg/kg/d in 3–4 divided doses PO (some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant)
• Preferred regimen (3): Clindamycin 20 mg/kg/d in 3 divided doses PO
• Preferred regimen (4): Amoxicillin-Clavulanate 25 mg/kg/d of the amoxicillin component in 2 divided doses PO
• Preferred regimen (5): Retapamulin ointment applied to lesions bid (for patients with limited number of lesions)
• Preferred regimen (6): Mupirocin ointment applied to lesions bid (for patients with limited number of lesions)

• MSSA SSTI, adult

• Preferred regimen (1): Nafcillin 1-2 g every 4 h IV OR oxacillin 1-2 g every 4 h IV (Parental drug of choice; inactive against MRSA)
• Preferred regimen (2): Cefazolin 40 mg/kg/d in 3–4 divided doses PO (some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant)
• Preferred regimen (3): Clindamycin 600 mg every 8 h IV OR 300–450 mg qid po (Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
• Preferred regimen (4): Dicloxacillin 500 mg qid po (Oral agent of choice for methicillin-susceptible strains in adults. Not used much in pediatrics)
• Preferred regimen (5): Cephalexin 500 mg qid po (For penicillin-allergic patients except those with immediate hypersensitivity reactions. The availability of a suspension and requirement for less frequent dosing)
• Preferred regimen (6): Doxycycline, minocycline 100 mg bid po (Bacteriostatic; limited recent clinical experience)
• Preferred regimen (7): Trimethoprim-sulfamethoxazole 1–2 doublestrength tablets bid po (Bactericidal; efficacy poorly documented)

• MSSA SSTI, pediatric

• Preferred regimen (1): Nafcillin 100–150 mg/kg/d in 4 divided doses IV OR oxacillin 100–150 mg/kg/d in 4 divided doses IV (Parental drug of choice; inactive against MRSA)
• Preferred regimen (2): Cefazolin 40 mg/kg/d in 3–4 divided doses PO (some strains of Staphylococcus aureus and Streptococcus pyogenes may be resistant)
• Preferred regimen (3): Clindamycin 25–40 mg/kg/d in 3 divided doses IV OR 25–30 mg/kg/d in 3 divided doses po (Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
• Preferred regimen (4): Dicloxacillin 25–50 mg/kg/d in 4 divided doses po (Oral agent of choice for methicillin-susceptible strains in adults. Not used much in pediatrics)
• Preferred regimen (5): Cephalexin 25–50 mg/kg/d 4 divided doses po (For penicillin-allergic patients except those with immediate hypersensitivity reactions. The availability of a suspension and requirement for less frequent dosing)
• Preferred regimen (6): Doxycycline, minocycline Not recommended for age <8 y (Bacteriostatic; limited recent clinical experience)

• Preferred regimen (7): Trimethoprim-sulfamethoxazole 8–12 mg/kg (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po (Bactericidal; efficacy poorly documented)

• MRSA SSTI, adult

• Preferred regimen (1): Vancomycin 30 mg/kg/d in 2 divided doses IV (For penicillin allergic patients; parenteral drug of choice for treatment of infections caused by MRSA)
• Preferred regimen (2): Linezolid 600 mg every 12 h IV or 600 mg bid po (Bacteriostatic; limited clinical experience; no crossresistance with other antibiotic classes; expensive)
• Preferred regimen (3): Clindamycin 600 mg every 8 h IV or 300–450 mg qid po (Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)
• Preferred regimen (4): Daptomycin 4 mg/kg every 24 h IV (Bactericidal; possible myopathy)
• Preferred regimen (5): Ceftaroline 600 mg bid IV (Bactericidal)
• Preferred regimen (6): Doxycycline, minocycline 100 mg bid po (Bacteriostatic; limited recent clinical experience)
• Preferred regimen (7): Trimethoprim-sulfamethoxazole1–2 doublestrength tablets bid po (Bactericidal; limited published efficacy data)

• MRSA SSTI, pediatric

• Preferred regimen (1): Vancomycin 40 mg/kg/d in 4 divided doses IV (For penicillin allergic patients; parenteral drug of choice for treatment of infections caused by MRSA)
• Preferred regimen (2): Linezolid 10 mg/kg every 12 h IV or po for children <12 y (Bacteriostatic; limited clinical experience; no crossresistance with other antibiotic classes; expensive)
• Preferred regimen (3): Clindamycin 25–40 mg/kg/d in 3 divided doses IV or 30–40 mg/kg/d in 3 divided doses po (Bacteriostatic; potential of cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA. Important option for children)
• Preferred regimen (4): Doxycycline, minocycline Not recommended for age <8 y (Bacteriostatic; limited recent clinical experience)
• Preferred regimen (5): Trimethoprim-sulfamethoxazole 8–12 mg/kg/d (based on trimethoprim component) in either 4 divided doses IV or 2 divided doses po

• Streptococcal skin infections, adult

• Preferred regimen (1): Penicillin 2–4 million units every 4–6 h IV
• Preferred regimen (2): Clindamycin 600–900 mg every 8 h IV
• Preferred regimen (3): Nafcillin 1–2 g every 4– 6 h IV
• Preferred regimen (4): Cefazolin 1 g every 8 h IV
• Preferred regimen (5): Penicillin VK 250–500 mg every 6 h po
• Preferred regimen (6): Cephalexin 500 mg every 6 h po

• Streptococcal skin infections, pediatric

• Preferred regimen (1): Penicillin 60– 100 000 units/kg/ dose every 6 h 10–13 mg/kg dose every 8 h IV 50 mg/kg/dose every 6 h 33 mg/kg/dose every 8 h IV

---

Incisional surgical site infections

(table 3)

• Surgery of intestinal or genitourinary tract

• Single-drug regimens

• Preferred regimen (1): Ticarcillin-clavulanate 3.1 g every 6 h IV
• Preferred regimen (2): Piperacillin-tazobactam 3.375 g every 6 h OR 4.5 g every 8 h IV
• Preferred regimen (3): Imipenem-cilastatin 500 mg every 6 h IV
• Preferred regimen (4): Meropenem 1 g every 8 h IV
• Preferred regimen (5): Ertapenem 1 g every 24 h IV

• Combination regimens

• Preferred regimen (1): Ceftriaxone 1 g every 24 h AND metronidazole 500 mg every 8 h
• Preferred regimen (2): IV Ciprofloxacin 400 mg IV every 12 h or 750 mg po every 12 h AND metronidazole 500 mg every 8 h
• Preferred regimen (3): IV Levofloxacin 750 mg IV every 24 h AND metronidazole 500 mg every 8 h
• Preferred regimen (4): IV Ampicillin-sulbactam 3 g every 6 h AND gentamicin OR tobramycin 5 mg/kg every 24 h IV

• Surgery of trunk or extremity away from axilla or perineum

• Preferred regimen (1): Oxacillin or nafcillin 2 g every 6 h IV
• Preferred regimen (2): Cefazolin 0.5–1 g every 8 h IV
• Preferred regimen (3): Cephalexin 500 mg every 6 h po
• Preferred regimen (4): SMX-TMP 160–800 mg po every 6 h
• Preferred regimen (5): Vancomycin 15 mg/kg every 12 h IV

• Surgery of axilla or perineum

• Preferred regimen: Metronidazole 500 mg every 8 h IV AND (Ciprofloxacin 400 mg IV every 12 h OR Ciprofloxacin 750 mg po every 12 h OR Levofloxacin 750 mg every 24 h IV/PO OR Ceftriaxone 1 g every 24 h)

---

Necrotizing infections of the skin, fascia, and muscle

(table 4)

• Mixed infections, adult

• Preferred regimen (1): Piperacillin-tazobactam 3.37 g every 6–8 h IV AND vancomycin IV 30 mg/kg/d in 2 divided doses (Severe Pencillin allergy: Clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
• Preferred regimen (2): Imipenem-cilastatin 1 g every 6–8 h IV
• Preferred regimen (3): Meropenem 1 g every 8 h IV
• Preferred regimen (4): Ertapenem 1 g daily IV
• Preferred regimen (5): Cefotaxime2 g every 6 h IV AND (metronidazole500 mg every 6 h IV OR clindamycin600–900 mg every 8 h IV)

• Mixed infections, pediatric

• Preferred regimen (1): Piperacillin-tazobactam 60–75 mg/kg/dose of the piperacillin component every 6 h IV AND vancomycin 10–13 mg/kg/dose every 8 h IV (Severe Pencillin allergy: Clindamycin or metronidazole with an aminoglycoside or fluoroquinolone)
• Preferred regimen (2): Meropenem 20 mg/kg/dose every 8 h IV
• Preferred regimen (3): Ertapenem 15 mg/kg/dose every 12 h IV for children 3 mo-12 y
• Preferred regimen (4): Cefotaxime50 mg/kg/dose every 6 h IVAND (metronidazole7.5 mg/kg/dose every 6 h IVOR clindamycin10–13 mg/kg/dose every 8 h IV)

• Streptococcus, adult

• Preferred regimen: Penicillin 2–4 million units every 4–6 h IV (adult) AND clindamycin 600–900 mg every 8 h IV (Severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)

• Streptococcus, pediatric

• Preferred regimen: Penicillin60 000–100 000 units/kg/dose every 6 h IV AND clindamycin 10–13 mg/kg/dose every 8 h IV (Severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)

• Staphylococcus aureus, adult

• Preferred regimen (1): Nafcillin 1–2 g every 4 h IV (Severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)
• Preferred regimen (2): Oxacillin 1–2 g every 4 h IV
• Preferred regimen (3): Cefazolin 1 g every 8 h IV
• Preferred regimen (4): Vancomycin 30 mg/kg/d in 2 divided doses IV
• Preferred regimen (5): Clindamycin 600–900 mg every 8 h IV

• Staphylococcus aureus, pediatric

• Preferred regimen (1): Nafcillin 50 mg/kg/dose every 6 h IV (Severe Pencillin allergy: Vancomycin, linezolid, quinupristin/dalfopristin, daptomycin)
• Preferred regimen (2): Oxacillin 50 mg/kg/dose every 6 h IV
• Preferred regimen (3): Cefazolin 33 mg/kg/dose every 8 h IV
• Preferred regimen (4): Vancomycin 15 mg/kg/dose every 6 h IV
• Preferred regimen (5): Clindamycin 10–13 mg/kg/dose every 8 h IV (Bacteriostatic; potential cross-resistance and emergence of resistance in erythromycin-resistant strains; inducible resistance in MRSA)

• Clostridium species, adult

• Preferred regimen: Clindamycin 600–900 mg every 8 h IV AND penicillin 2–4 million units every 4–6 h IV

• Clostridium species, pediatric

• Preferred regimen: Clindamycin 10–13 mg/kg/dose every 8 h IV AND penicillin 60 000–100 00 units/kg/dose every 6 h IV

• Aeromonas hydrophila, adult

• Preferred regimen: Doxycycline 100 mg every 12 h IV AND (ciprofloxacin 500 mg every 12 h IV OR ceftriaxone 1 to 2 g every 24 h IV)

• Aeromonas hydrophila, pediatric

(Not recommended for children but may need to use in life-threatening situations)

• Vibrio vulnificus, adult

• Preferred regimen: Doxycycline 100 mg every 12 h IV AND ceftriaxone 1 g qid IV OR cefotaxime 2 g tid IV

• Vibrio vulnificus, pediatric

Not recommended for children but may need to use in life-threatening situation

---

Infections following animal or human bites

(table 5)

• Animal bite

• Preferred regimen (1): Amoxicillin-clavulanate 875/125 mg PO bid (Some gram-negative rods are resistant; misses MRSA)
• Preferred regimen (2): Ampicillin-sulbactam 1.5–3.0 g IV every 6–8 h (Some gram-negative rods are resistant; misses MRSA)
• Preferred regimen (3): Piperacillin-tazobactam 3.37 g IV every 6–8 h (Misses MRSA)
• Preferred regimen (4): Doxycycline 100 mg PO bid OR 100 mg IV every 12 h (Excellent activity against Pasteurella multocida; some streptococci are resistant)
• Preferred regimen (5): Penicillin AND Dicloxacillin 500 mg oral
• Preferred regimen (6): sulfamethoxazole-Trimethoprim 160–800 mg PO bid OR IV 5–10 mg/kg/day of TMP component (Good activity against aerobes; poor activity against anaerobes)
• Preferred regimen (7): Metronidazole 250–500 mg PO tid OR 500 mg IV every 8 h (Good activity against anaerobes; no activity against aerobes)
• Preferred regimen (8): Clindamycin 300 mg PO tid OR 600 mg IV every 6–8 h (Good activity against staphylococci, streptococci, and anaerobes; misses P. multocida)
• Preferred regimen (9): Cefuroxime 500 mg PO bid OR 1 g IV every 12 h
• Preferred regimen (10): Cefoxitin 1g IV every 6–8 h
• Preferred regimen (11): Ceftriaxone 1g IV every 12 h
• Preferred regimen (12): Cefotaxime 1–2 g IV every 6–8 h
• Preferred regimen (13): Ciprofloxacin 500–750 mg PO bid OR 400 mg IV every 12 h
• Preferred regimen (14): Levofloxacin 750 mg PO daily OR 750 mg IV daily
• Preferred regimen (15): Moxifloxacin 400 mg PO daily OR 400 mg IV daily (Monotherapy; good for anaerobes also)

• Human bite

• Preferred regimen (1): Amoxicillin-clavulanate 875/125 mg PO bid (Some gram-negative rods are resistant; misses MRSA)
• Preferred regimen (2): Ampicillin-sulbactam 1.5–3.0 g IV every 6 h (Some gram-negative rods are resistant; misses MRSA)
• Preferred regimen (3): Doxycycline PO 100 mg bid (Good activity against Eikenella species, staphylococci, and anaerobes; some streptococci are resistant)

---

Cat scratch disease

• Cat scratch disease in patients > 45 kg

• Preferred regimen: Azithromycin 500 mg on day 1 followed by 250 mg for 4 additional days

• Cat scratch disease in patients < 45 kg

• Preferred regimen: Azithromycin 10 mg/kg on day 1 and 5 mg/kg for 4 more days

---

Bacillary angiomatosis

• Bacillary angiomatosis

• Preferred regimen: Erythromycin 500 mg PO qid for 2 weeks to 2 months OR Doxycycline 100 mg PO bid for 2 weeks to 2 months

---

Erysipeloid

• Erysipeloid

• Preferred regimen: Penicillin 500 mg qid for 7–10 days OR Amoxicillin 500 mg tid for 7–10 days

---

Glanders

• Glanders

• Preferred regimen: Ceftazidime OR Gentamicin OR Imipenem OR Doxycycline OR Ciprofloxacin is recommended based on in vitro susceptibility

---

Bubonic plague

• Bubonic Plague

• Preferred regimen: Streptomycin 15 mg/kg IM every 12 hours OR Doxycycline 100 mg bid PO OR Gentamicin could be substituted for streptomycin

---

Tularemia

• Tularemia

• Preferred regimen (1): Streptomycin 15 mg/kg every 12 hours IM OR Gentamicin 1.5 mg/kg every 8 hours IV
• Preferred regimen (2): Tetracycline 500 mg qid OR doxycycline 100 mg bid PO (for mild cases)

---

Cutaneous anthrax

• Cutaneous anthrax

• Preferred regimen (1): Penicillin V 500 mg PO qid for 7–10 days
• Preferred regimen (2): Ciprofloxacin 500 mg PO bid OR Levofloxacin 500 mg IV/PO every 24 hours for 60 days is recommended for bioterrorism cases because of presumed aerosol exposure

---

Seborrheic Dermatitis

• Antifungal agents

• Preferred regimen (1): Ketoconazole 2% in shampoo, foam, gel, or cream‡ Scalp: twice/wk for clearance, then once/wk or every other wk for maintenance; other areas: from twice daily to twice/wk for clearance, then from twice/wk to once every other wk for maintenance

• Preferred regimen (2): Bifonazole 1% in shampoo or cream Scalp: 3 times/wk for clearance; other areas: once daily for clearance

• Preferred regimen (3): Ciclopirox olamine (also called ciclopirox) 1.0% or 1.5% in shampoo or cream Scalp: twice to 3 times/wk for clearance, then once/wk or every 2 wk for maintenance; other areas: twice daily for clearance, then once daily for maintenance

• Corticosteroids

• Preferred regimen (1): Hydrocortisone 1% in cream Areas other than scalp: once or twice daily

• Preferred regimen (2): Betamethasone dipropionate 0.05% in lotion Scalp and other areas: once or twice daily

• Preferred regimen (3): Clobetasol 17- butyrate 0.05% in cream Areas other than scalp: once or twice daily

• Preferred regimen (4): Clobetasol dipro- pionate 0.05% in shampoo Scalp: twice weekly in a short- contact fashion (up to 10 min application, then washing)

• Preferred regimen (5): Desonide 0.05% in lotion Scalp and other areas of skin: twice daily

• Lithium salts

• Preferred regimen: Lithium succinate AND zinc sulfate Ointment containing 8% lithium succinate plus 0.05% zinc sulfate
• Preferred regimen: Lithium gluconate 8% in gel Areas other than scalp: twice daily

---

Mastitis

• Preferred regimen (1): Amoxicillin/clavulanate (Augmentin), 875 mg twice daily

• Preferred regimen (2): Cephalexin (Keflex), 500 mg four times daily

• Preferred regimen (3): Ciprofloxacin (Cipro),* 500 mg twice daily

• Preferred regimen (4): Clindamycin (Cleocin),* 300 mg four times daily

• Preferred regimen (5): Dicloxacillin (Dynapen, brand no longer available in the United States), 500 mg four times daily

• Preferred regimen (6): Trimethoprim/sulfamethoxazole (Bactrim, Septra),*† 160 mg/800 mg twice daily