Sandbox ID Skin and Soft Tissues

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Acne vulgaris

  • Earliest form, No inflammation
* Preferred regimen (1) : Topical tretinoin (cream 0.025 or 0.05%) or (gel 0.01 or 0.025%) once 24 hrs
* Alternative regimen (1): Topical adapalene 0.1 % gel OR azelaic acid 20% cream OR tazarotene 0.1% cream once 24hrs
  • Mild inflammation
* Preferred regimen (1) : Topical erythro 3% AND benzoyl peroxide 5% bid
* Alternative regimen (1): Topical clindamycin 1% gel bid AND benzoyl peroxide 5% bid
  • Inflammation
* Preferred regimen (1) : Topical erythro 3% AND benzoyl peroxide 5% bid AND/ OR oral antibiotic
* Alternative regimen (1): Oral doxycycline 50mg bid OR minocycline 50 mg bid
* Alternative regimen (2): Expensive extended release: once daily minocycline 1mg/kg/d

Acne rosacea

  • Facial erythema
* Preferred regimen : Brimonidine gel applied to the affected area bid
  • Papulopustular rosacea:
* Preferred regimen : Azelaic acid gel bid topical OR Metronidazole topical cream once daily.

Anthrax, cutaneous

  • 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

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

Bite wounds

Lyme disease, cutaneous

  • 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

Bubonic plague

Carbuncle

Cat scratch disease

Cellulitis

Ecthyma

Erysipelas

Erysipeloid

Erythrasma

Fournier gangrene

Furuncle

Gas gangrene

Glanders

Impetigo

  • Impetigo, adult
  • Empiric antimicrobial therapy (covering methicillin-susceptible Staphylococcus aureus and β-hemolytic streptococci)
  • Limited number of lesions
  • Numerous lesions or outbreaks of post streptococcal glomerulonephritis
  • Culture-directed antimicrobial therapy
  • Streptococcus alone
  • Preferred regimen: Penicillin V 250–500 mg PO qid for 7 days
  • Alternative regimen (for penicillin-allergic patients): Erythromycin 250 mg PO qid for 7 days OR Clindamycin 300–400 mg PO qid for 7 days
  • Methicillin-resistant Staphylococcus aureus
  • Impetigo, pediatric
  • Empiric antimicrobial therapy (covering methicillin-susceptible Staphylococcus aureus and β-hemolytic streptococci)
  • Limited number of lesions
  • Numerous lesions or outbreaks of poststreptococcal glomerulonephritis
  • Culture-directed antimicrobial therapy
  • Streptococcus alone
  • Preferred regimen: Penicillin V 60,000–100,000 U/kg PO qid for 7 days
  • Alternative regimen (for penicillin-allergic patients): Erythromycin 40 mg/kg/day PO tid–qid for 7 days OR Clindamycin 20 mg/kg/day PO tid for 7 days
  • Methicillin-resistant Staphylococcus aureus

Lyme disease, cutaneous

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

Necrotizing fasciitis

  • Mixed infections, adult
  • Mixed infections, pediatric
  • Streptococcus, adult
  • Streptococcus, pediatric
  • Staphylococcus aureus, adult
  • Staphylococcus aureus, pediatric
  • 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
  • Aeromonas hydrophila, pediatric

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

  • Vibrio vulnificus, adult
  • Vibrio vulnificus, pediatric

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

Pilonidal cyst

Pyomyositis

Seborrheic dermatitis

Skin and soft tissue infection in neutropenic fever

Skin and soft tissue infection in cellular immunodeficiency

Surgical site infection

Tularemia

Vascular insufficieny ulcer

Vibrio infection

Wound infection

Yaws


Staphylococcal and streptococcal skin and soft tissue infections

  • 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 OR Minocycline 100 mg bid po (bacteriostatic; limited recent clinical experience)
  • Preferred regimen (7): Trimethoprim-Sulfamethoxazole 1–2 double strength 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 OR 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 OR Minocycline 100 mg bid po (bacteriostatic; limited recent clinical experience)
  • Preferred regimen (7): Trimethoprim-Sulfamethoxazole 1–2 double strength 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 OR 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 60,000–100,000 units/kg/dose q6h

Incisional surgical site infections

(table 3)

  • Surgery of intestinal or genitourinary tract
  • Single-drug regimens
  • Combination regimens
  • 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

Necrotizing infections of the skin, fascia, and muscle

(table 4)

  • Mixed infections, adult
  • Mixed infections, pediatric
  • Streptococcus, adult
  • Streptococcus, pediatric
  • Staphylococcus aureus, adult
  • Staphylococcus aureus, pediatric
  • 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
  • Aeromonas hydrophila, pediatric

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

  • Vibrio vulnificus, adult
  • 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

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

Glanders

  • Glanders

Bubonic plague

  • Bubonic Plague

Tularemia

  • Tularemia

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 (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

Mastitis

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

Yaws

  • Preferred regimen (4): Azithromycin Single-dose; 30 mg/kg (maximum dose 2 g)

Lyme disease

  • Preferred oral regimens adults
* Preferred regimen (1): Amoxicillin 500 mg 3 times per day
* Preferred regimen (2): Doxycycline 100 mg twice per day
* Preferred regimen (3): Cefuroxime axetil 500 mg twice per day 30 mg/kg per day in 2 divided doses (maximum, 500 mg per dose)
  • Alternative oral regimens adults
* Preferred regimen (1): Doxycycline, 200 mg in a single dose
  • Preferred parenteral regimen adults
* Preferred regimen (1): Ceftriaxone 2 g intravenously once per day
  • Alternative parenteral regimens adults
* Preferred regimen (1): Cefotaxime 2 g intravenously every 8 hd d
* Preferred regimen (2): Penicillin G 18–24 million U per day intravenously, divided every 4 h
  • Preferred oral regimens pediatrics
* Preferred regimen (1): Amoxicillin 50 mg/kg per day in 3 divided doses (maximum, 500 mg per dose)
* Preferred regimen (2): Doxycycline Not recommended for children aged !8 years. For children aged 8 years, 4 mg/kg per day in 2 divided doses (maximum, 100 mg per dose)
* Preferred regimen (3): Cefuroxime axetil 30 mg/kg per day in 2 divided doses (maximum, 500 mg per dose)
  • Alternative oral regimens pediatrics
* Preferred regimen (1): Doxycycline, (4 mg/kg in children <8 years of age)
  • Preferred parenteral regimen pediatrics
* Preferred regimen (1): Ceftriaxone 50–75 mg/kg intravenously per day in a single dose (maximum, 2 g)
  • Alternative parenteral regimens pediatrics
* Preferred regimen (1): Cefotaxime 150–200 mg/kg per day intravenously in 3–4 divided doses (maximum, 6 g per day)
* Preferred regimen (2): Penicillin G 200,000–400,000 U/kg per day divided every 4 h (not to exceed 18–24 million U per day)

Bacillary angiomatosis

* Preferred regimen (1): Erythromycin, 30--50 mg/kg body weight (max 2 g/day) per day orally divided into 2--4 doses, or if unable to take oral medication, 15--50 mg/kg body weight (max 2 g/day) per day IV in divided doses 4 times a day (AH)
* Preferred regimen (2): Doxycycline, 2--4 mg/kg body weight (max 100--200 mg/day) per day orally or IV once daily or divided into 2 doses (AII) for 3 mos CNS infections, bacillary peliosis, osteomyelitis
* Alternate regimen (1): Azithromycin, 5--12 mg/kg body weight (max 600 mg/day) orally once daily (BIII)
* Alternate regimen (2): Clarithromycin, 15 mg/kg body weight (max 1 g/day) per day orally divided into 2 doses (BIII)
* Alternate regimen (3): Rifampin, 20 mg/kg body weight (max 600 mg/day) per day orally or IV once daily or divided into 2 doses can be used in combination with erythromycin or doxycycline in patients with more severe infections (BIII)
  • Severe infections:
* Preferred regimen : Doxycycline, 2--4 mg/kg body weight (max 100--200 mg/day) per day orally or IV once daily or divided into 2 doses (AIII) for 4 mos

Acne vulgaris

  • Earliest form, No inflammation
* Preferred regimen (1) : Topical tretinoin (cream 0.025 or 0.05%) or (gel 0.01 or 0.025%) once 24 hrs
* Alternative regimen (1): Topical adapalene 0.1 % gel OR azelaic acid 20% cream OR tazarotene 0.1% cream once 24hrs
  • Mild inflammation
* Preferred regimen (1) : Topical erythro 3% AND benzoyl peroxide 5% bid
* Alternative regimen (1): Topical clindamycin 1% gel bid AND benzoyl peroxide 5% bid
  • Inflammation
* Preferred regimen (1) : Topical erythro 3% AND benzoyl peroxide 5% bid AND/ OR oral antibiotic
* Alternative regimen (1): Oral doxycycline 50mg bid OR minocycline 50 mg bid
* Alternative regimen (2): Expensive extended release: once daily minocycline 1mg/kg/d

Acne Rosacea

  • Facial erythema
* Preferred regimen : Brimonidine gel applied to the affected area bid
  • Papulopustular rosacea:
* Preferred regimen : Azelaic acid gel bid topical OR Metronidazole topical cream once daily.

References

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