Cellulitis medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{CMG}}; {{AE}} {{M.P}}
{{CMG}}; {{AE}} {{AL}}, {{M.P}}, {{Faizan}}
{{Cellulitis}}
{{Cellulitis}}


==Overview==
==Overview==


The treatment for [[cellulitis]] consists of oral or intravenous antibiotics. The usual drug of choice are [[beta-lactam]] antibiotics, as most of the cases of [[cellulitis]] are caused either by ''[[Staphylococcus aureus]]'' or ''[[Streptococcus]]''.  Bed rest and elevation of the affected limbs are recommended as adjuvant therapy. In patients with edema of the extremities, compressive stockings may be beneficial in treating the fluid accumulation.  If a small abscess is surrounding the affected tissue, it can be treated with a simple incision and drainage of the fluid.
The mainstay of therapy for cellulitis is antimicrobial therapy. [[Beta-lactam]] antibiotics are the usual drugs of choice, since most of the cases of [[cellulitis]] are caused either by ''[[Staphylococcus aureus]]'' or ''[[Streptococcus]]''.  Supportive therapy includes bed rest, compression stockings, and elevation of the affected limb.  If a small abscess is surrounding the affected tissue, it may be treated with incision and drainage.


==Empiric Therapy<SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Clinical Practice Guidelines CID 2011<ref name="Mathews-2010">{{Cite journal | last1 = Mathews | first1 = CJ. | last2 = Weston | first2 = VC. | last3 = Jones | first3 = A. | last4 = Field | first4 = M. | last5 = Coakley | first5 = G. | title = Bacterial septic arthritis in adults. | journal = Lancet | volume = 375 | issue = 9717 | pages = 846-55 | month = Mar | year = 2010 | doi = 10.1016/S0140-6736(09)61595-6 | PMID = 20206778 }}</ref> and Guidelines for Skin and Soft-Tissue Infections CID 2005<ref>{{Cite journal
==Medical Therapy==
  | author = [[Dennis L. Stevens]], [[Alan L. Bisno]], [[Henry F. Chambers]], [[E. Dale Everett]], [[Patchen Dellinger]], [[Ellie J. C. Goldstein]], [[Sherwood L. Gorbach]], [[Jan V. Hirschmann]], [[Edward L. Kaplan]], [[Jose G. Montoya]] & [[James C. Wade]]
'''Empiric Therapy''' <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Clin Infect Dis. 2011;52(3):e18-55<ref name="LiuBayer2011">{{cite journal|last1=Liu|first1=C.|last2=Bayer|first2=A.|last3=Cosgrove|first3=S. E.|last4=Daum|first4=R. S.|last5=Fridkin|first5=S. K.|last6=Gorwitz|first6=R. J.|last7=Kaplan|first7=S. L.|last8=Karchmer|first8=A. W.|last9=Levine|first9=D. P.|last10=Murray|first10=B. E.|last11=Rybak|first11=M. J.|last12=Talan|first12=D. A.|last13=Chambers|first13=H. F.|title=Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children|journal=Clinical Infectious Diseases|volume=52|issue=3|year=2011|pages=e18–e55|issn=1058-4838|doi=10.1093/cid/ciq146}}</ref> and Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name=IDSA2005>{{Cite journal
  | author = Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade
  | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections
  | title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections
  | journal = [[Clinical infectious diseases : an official publication of the Infectious Diseases Society of America]]
  | journal = Clinical infectious diseases: an official publication of the Infectious Diseases Society of America
  | volume = 41
  | volume = 41
  | issue = 10
  | issue = 10
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  | pmid = 16231249
  | pmid = 16231249
}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
[[Clinical practice guideline]]s direct management.<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref>


* Empiric therapy would depend on the clinical presentation of the [[cellulitis]].  
*Empiric therapy depends on the clinical presentation of the [[cellulitis]].<ref name="pmid24973422">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= e10-52 | pmid=24973422 | doi=10.1093/cid/ciu444 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24973422  }} </ref>
** Non-purulent [[cellulitis]] refers to the infection without purulent drainage or [[exudate]] and not associated with an [[abscess]].  
**Non-purulent [[cellulitis]] refers to the infection without purulent drainage or [[exudate]] and not associated with an [[abscess]].  
** Purulent [[cellulitis]] is associated with purulent drainage or exudate in the absence of a drainable [[abscess]], and it is associated to [[Staphylococcus aureus]].  
**Purulent [[cellulitis]] is associated with purulent drainage or exudate in the absence of a drainable [[abscess]], and it is associated to [[Staphylococcus aureus]].  
** Complicated cellulitis refers to a deeper soft-tissue infection and/or the association with necrotizing fasciitis, septic arthritis, or osteomyelitis.
**Complicated cellulitis refers to a deeper soft-tissue infection and/or the association significant coexisting diseases (including diabetes mellitus, immunocompromised patients, and obesity), the need for significant surgical intervention or the involvement of the perianal area.
*Patients with complicated cellulitis also present with surgical site infection, necrotizing soft-tissue infection, and signs of systemic toxicity.
* For patients with  purulent [[cellulitis]], cultures are recommended and empirical therapy for Community Associated-MRSA (CA-MRSA) should be started.
* For patients with non-purulent [[cellulitis]], empirical therapy for β-hemolytic [[streptococci]] should be started; if the patient does not respond to B-lactam antibiotics, empirical coverage for CA-MRSA should be initiated. Per 2014 [[clinical practice guideline]]s, antibiotics for outpatients should be "an antimicrobial agent that is active against streptococci...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)".<ref name="pmid24973422">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= e10-52 | pmid=24973422 | doi=10.1093/cid/ciu444 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24973422  }} </ref>


* For patients with  purulent [[cellulitis]], cultures are recommended and empirical therapy for Community Associated-MRSA (CA-MRSA) should be started.
* For patients with non-purulent [[cellulitis]], empirical therapy for β-hemolytic [[streptococci]] should be started; if the patient does not respond to B-lactam antibiotics, empirical coverage for CA-MRSA should be initiated. 
* The duration of the therapy should be individualized for the clinical response of each patient; 5-10 days is usually recommended.
* The duration of the therapy should be individualized for the clinical response of each patient; 5-10 days is usually recommended.
* The treatment of [[cellulitis]] in neonates usually requires hospitalization and parenteral therapy.  Oral therapy is given for completion of the treatment when the pathogen is unknown.
* The treatment of [[cellulitis]] in neonates usually requires hospitalization and parenteral therapy.  Oral therapy is given for completion of the treatment when the pathogen is unknown.
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* [[Doxycycline]] is not recommended for children <8 years of age.  
* [[Doxycycline]] is not recommended for children <8 years of age.  


* Studies have shown an increase in treatment failure with [[TMP-SMX]] compared to other agents for [[cellulitis]] in children, reflecting [[TMP-SMX]] less action against [[Group A streptococcus]].<ref name="pmid19470525">{{cite journal| author=Elliott DJ, Zaoutis TE, Troxel AB, Loh A, Keren R| title=Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. | journal=Pediatrics | year= 2009 | volume= 123 | issue= 6 | pages= e959-66 | pmid=19470525 | doi=10.1542/peds.2008-2428 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19470525  }} </ref>
* Studies have shown an increase in treatment failure with [[TMP-SMX]] compared to other agents for [[cellulitis]] in children, reflecting a decreased efficacy of [[TMP-SMX]] against [[Group A streptococcus]].<ref name="pmid19470525">{{cite journal| author=Elliott DJ, Zaoutis TE, Troxel AB, Loh A, Keren R| title=Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. | journal=Pediatrics | year= 2009 | volume= 123 | issue= 6 | pages= e959-66 | pmid=19470525 | doi=10.1542/peds.2008-2428 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19470525  }} </ref>


<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
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</div>
</div>


<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children age >28 days'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Complicated Cellulitis†'''
</font>
</div>
 
<div class="mw-customtoggle-table10" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adults'''
</font>
</div>
 
<div class="mw-customtoggle-table11" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children age >28 days'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children age >28 days'''
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==Special Considerations <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from N Engl J Med 2004;350:904-12.<ref>{{Cite journal
==Special Considerations <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from N Engl J Med 2004;350:904-12.<ref>{{Cite journal
  | author = [[Morton N. Swartz]]
  | author = Morton N. Swartz
  | title = Clinical practice. Cellulitis
  | title = Clinical practice. Cellulitis
  | journal = [[The New England journal of medicine]]
  | journal = The New England journal of medicine
  | volume = 350
  | volume = 350
  | issue = 9
  | issue = 9
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}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==


For the following conditions, an additional antibiotic therapy should be added to the usual regimen in order to cover specific pathogens associated to those circumstances.
* For the certain anatomical locations (buccal, facial and periorbital) a specific therapy should be given due to the predisposition of certain bacteria.
* For certain conditions, such as salt or fresh water wound exposure, or if the patient is a butcher, fisherman or veterinarian, an additional antibiotic therapy should be added to the usual regimen in order to cover specific pathogens associated to those circumstances.


<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
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<div class="mw-customtoggle-table12" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<div class="mw-customtoggle-table12" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Buccal'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Buccal Cellulitis'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table13" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<div class="mw-customtoggle-table13" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Facial'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Facial Cellulitis'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table14" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Orbital'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Orbital Cellulitis'''
</font>
</font>
</div>
</div>


<div class="mw-customtoggle-table22" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<div class="mw-customtoggle-table15" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Sal Water Wound Exposure'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Salt Water Wound Exposure'''
</font>
</font>
</div>
</div>


<div class="mw-customtoggle-table23" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<div class="mw-customtoggle-table16" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Fresh Water Wound Exposure'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Fresh Water Wound Exposure'''
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</div>
</div>


<div class="mw-customtoggle-table24" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<div class="mw-customtoggle-table17" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Butcher, Fisherman, Veterinarian'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Butcher, Fisherman, Veterinarian'''
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|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min) ''''' <br> OR <br> ▸ '''''[[Imipenem/cilastatin]] 250-1000 mg IV (max: 50mg/kg/day)'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min) ''''' <br> OR <br> ▸ '''''[[Imipenem/cilastatin]] 250-1000 mg IV (max: 50mg/kg/day)'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table13" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Facial Cellulitis}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left | <small>Adapted from N Engl J Med 2004;350:904-12.<ref>{{Cite journal
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
| author = [[Morton N. Swartz]]
|-
| title = Clinical practice. Cellulitis
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Vancomycin]] 15-20 mg/kg IV q8-12h'''''<small> (trough 15—20 μg/mL)</small>  
| journal = [[The New England journal of medicine]]
|-
| volume = 350
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
| issue = 9
|-
| pages = 904–912
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h''''' <br> OR <br> ▸ '''''[[Linezolid]] 600mg IV q12h'''''
| year = 2004
| month = February
| doi = 10.1056/NEJMcp031807
| pmid = 14985488
}}</ref></small>
|}
|}
|}
|}
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|}
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{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table13" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table15" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Salt Water Wound Exposure <br> ''(Vibrio vulnificus)''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Doxycycline]] 200 mg IV initial dose, then 50-100 mg IV q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 1-2 g IV/IM q8-12 (up to 2 g q4-6h)''''' <br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8-12h  x 7-14 days'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 500-750 mg PO q8-12h  x 7-14 days'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table16" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Fresh Water Wound Exposure <br> ''(Aeromonas spp)''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 400mg IV q12h''''' <br> OR <br> ▸ '''''[[Ceftazidime]] 0.5 -2 g IV q8h''''' <BR> PLUS <BR>
▸ '''''[[Gentamicin]] 3-5 mg/kg/day IV/IM divided q6-8h or 4-7 mg/kg IV q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)''''' <br> OR <br>  ▸ '''''[[Imipenem/cilastatin]] 250-1000 mg IV  (max: 50mg/kg/day)'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table17" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Facial Cellulitis}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Butcher, Fisherman, Veterinarian <br> ''(Erysipelothrix rhusiopathiae)''}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Vancomycin]] 15-20 mg/kg IV q8-12h'''''<small> (trough 15—20 μg/mL)</small>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 500 mg PO q8hr'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h''''' <br> OR <br> ▸ '''''[[Linezolid]] 600mg IV q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Cefotaxime]] 1-2 g IV/IM q8-12 (up to 2 g q4-6h)''''' <br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8-12h  x 7-14 days'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 500-750 mg PO q8-12h  x 7-14 days''''' <br> OR <br>  ▸ '''''[[Imipenem]]-cilastatin 250-1000 mg IV  (max: 50mg/kg/day)'''''
|}
|}
|}
 
==Diabetic Foot Ulcer <small><small><small><small><small>Adapted from ''Diabetes Care. 2013;36(9):2862-71.''<ref name="pmid23970716">{{cite journal| author=Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG et al.| title=Inpatient management of diabetic foot disorders: a clinical guide. | journal=Diabetes Care | year= 2013 | volume= 36 | issue= 9 | pages= 2862-71 | pmid=23970716 | doi=10.2337/dc12-2712 | pmc=PMC3747877 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23970716  }} </ref> and ''Clin Infect Dis. 2012;54(12):e132-73.''<ref name="pmid22619242">{{cite journal| author=Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG et al.| title=2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 12 | pages= e132-73 | pmid=22619242 | doi=10.1093/cid/cis346 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22619242  }} </ref></small></small></small></small></small>==
 
{{Further|'''[[Diabetic foot medical therapy|Mangement of Diabetic Foot Infection]]'''}}
 
* Appropriate wound care is essential for the management of all diabetic foot ulcers.
* Uninfected diabetic ulcers do not require antibiotic therapy.
* For acutely infected wounds, empiric antibiotic with efficacy against [[Gram-positive bacteria|Gram-positive cocci]] should be initiated after obtaining a post-[[debridement]] specimen for [[aerobic]] and [[anaerobic]] culture.
* Infections with antibiotic-resistant organisms and those that are chronic, previously treated, or severe usually require broader spectrum regimens.
 
===Empiric Therapy===
 
<SMALL><font color="#FF4C4C"> ▸ '''Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
| valign=top |
 
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Uninfected (Grade 1)'''
</font>
</div>
 
<div class="mw-customtoggle-table18" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''No Evidence of Infection'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Mild (Grade 2)'''
</font>
</div>
 
<div class="mw-customtoggle-table19" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Acute Infection Without Recent Antibiotic Use'''
</font>
</div>
 
<div class="mw-customtoggle-table20" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for MRSA'''
 
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Moderate to Severe (Grade 3–4)'''
</font>
</div>
 
<div class="mw-customtoggle-table21" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Chronic Infection or Recent Antibiotic Use'''
</font>
</div>
 
<div class="mw-customtoggle-table22" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for MRSA'''
</font>
</div>
 
<div class="mw-customtoggle-table23" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for ''Pseudomonas aureuginosa'''''
</font>
</div>
 
<div class="mw-customtoggle-table24" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Polymicrobial Infection'''
</font>
</div>
 
| valign=top |
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table18" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Uninfected Wound, No Evidence of Infection}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Uninfected wounds should be managed with appropriate wound care.'''''<BR> ▸ '''''Antibiotic therapy is <u>not</u> recommended.'''''
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table19" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, Acute Infection Without Recent Antibiotic Use}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Dicloxacillin]] 125–250 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 150–300 mg PO qid''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Cephalexin]] 500 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg PO qd'''''<BR> OR <BR> ▸ '''''[[Amoxicillin-Clavulanate]] 500 mg PO bid (or 250 mg PO tid)''''' <sup>‡</sup>
|-
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Usually active against community-associated MRSA, but check macrolide sensitivity and consider ordering a D-test before using for MRSA.<BR><sup>‡</sup> Relatively broad-spectrum oral agent that includes anaerobic coverage.
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table20" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, High Risk for MRSA}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg PO q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[TMP-SMX|TMP–SMX]] 80-160 mg/400-800 mg PO q12h''''' <sup>†</sup>
|-
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Active against many MRSA & some gram-negatives; uncertain against streptococci.
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table21" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, Chronic Infection or Recent Antibiotic Use}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Cefoxitin]] 1 g IV q4h (or 2 g IV q6–8h)'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 1–2 g/day IV/IM q12–24h'''''<BR> OR <BR> ▸ '''''[[Ampicillin-Sulbactam|Ampicillin–Sulbactam]] 1.5–3 g IV/IM q6h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<BR> OR <BR> ▸ '''''[[Tigecycline]] 100 mg IV, then 50 mg IV q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Imipenem-Cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h''''' <sup>‡</sup>
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 600–1200 mg/day IV q6–12h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 1200–2700 mg IV q6–12h (for more severe cases)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 150–300 mg PO qid'''''
|-
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Active against MRSA.<BR> <sup>‡</sup> Not active against MRSA; consider when ESBL-producing pathogens suspected.
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table22" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table22" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, High Risk for MRSA}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h'''''<BR> OR <BR> ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table23" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, High Risk for ''Pseudomonas aeruginosa''}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Piperacillin-Tazobactam|Piperacillin–Tazobactam]] 3.375 g IV q6–8h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table24" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, Polymicrobial Infection}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Piperacillin-Tazobactam|Piperacillin–Tazobactam]] 3.375 g IV q6–8h'''''<BR> OR <BR> ▸ '''''[[Imipenem-Cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 1 g IV q8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Aztreonam]] 2 g IV q6–8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metronidazole]] 15 mg/kg IV, then 7.5 mg/kg IV q6h'''''
|}
|}
|}
==Neutropenic Patients<small><small><small><small> Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name=IDSA2005>{{Cite journal | author = Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade
| title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections
| journal = Clinical infectious diseases: an official publication of the Infectious Diseases Society of America
| volume = 41
| issue = 10
| pages = 1373–1406
| year = 2005
| month = November
| doi = 10.1086/497143
| pmid = 16231249
}}</ref></small></small></small></small>==
* Patients with neutropenia require an antimicrobial therapy with a broader coverage.
* The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
{| style="border: 2px solid #696969;"
|+ <SMALL>''Recommended Duration of Antimicrobial Therapy Based on the Microorganism.''</SMALL>
| style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px"| '''Microorganism''' || style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px" | '''Duration of Therapy'''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Gram-negative bacteria|Gram-negative Bacteria]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 7-14 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Gram-positive bacteria|Gram-positive Bacteria]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 7-10 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Fungi]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' Until clinical resolution'''''
|-
|}
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Neutropenia'''
</font>
</div>
<div class="mw-customtoggle-table25" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Gram-Negative Bacteria'''
</font>
</div>
<div class="mw-customtoggle-table26" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Gram-Positive Bacteria'''
</font>
</div>
<div class="mw-customtoggle-table27" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Fungi'''
</font>
</div>
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table25" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gram-Negative Bacteria}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)'''''<br> OR <br> ▸ '''''[[Imipenem/cilastatin]] 0.5–1 g IV q6–8h(max: 50mg/kg/day)'''''<br> OR <br> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<br> OR <br> ▸ '''''[[Cefepime]] 2g IV q8h'''''<br> OR <br> ▸ '''''[[Ceftazidime]] 2g IV q8h'''''<br> OR <br> ▸ '''''[[Piperacillin/tazobactam]] 3.375 g IV q6–8h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1 '''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amikacin]] 15 mg/kg/day IV/IM divided q8-12h (max: 15 mg/kg/day)'''''<br> OR <br> ▸ '''''[[Gentamicin]] 3-5 mg/kg/day IV/IM divided q6-8h'''''<br> OR <br> ▸ '''''[[Gentamicin]] 4-7 mg/kg/day IV q24h <small>(adjust dosage based on serum concentrations)</small>'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Cefepime]] 2g IV q8h'''''<br> OR <br> ▸ ''''' [[Piperacillin/tazobactam]] 3.375 g IV q6–8h (max 24 g/day)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 2 '''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ ''''' [[Piperacillin/tazobactam]] 3.375 g IV q6–8h (max 24 g/day)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ ''''' [[Ciprofloxacin]] 400mg IV q8h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table26" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Salt Water Wound Exposure <br> ''(Vibrio vulnificus)''}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Gram-Positive Bacteria}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen '''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]]† 15-20 mg/kg IV q8-12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR>  ▸ '''''[[Daptomycin]] 4mg/kg IV q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5;" align=left | <small>† Vancomycin should be discontinued if culture results remain negative after 72-96 hrs </small>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table27" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Fungi}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Liposomal Amphotericin B]] 3 mg/kg/day IV × 1-2 weeks'''''  <br> OR <br> ▸ '''''[[Amphotericin B]] deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks'''''<br> OR <br> ▸ '''''[[Amphotericin B lipid complex]] 5 mg/kg/day IV × 1-2 weeks'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Voriconazole]] 6 mg/kg IV q12h x 1 day, then 3 mg/kg IV q12h'''''<br> OR <br> ▸ '''''[[Voriconazole]] 200 mg PO q12h''''' <br> OR <br> ▸ '''''[[Caspofungin]] 70 mg IV once, then 50 mg IV q24h x ≥ 14 days'''''
|}
|}
|}
 
==Cellular Immune Deficient Patients<small><small><small><small> Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name=IDSA2005>{{Cite journal| author = Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade
| title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections
| journal = Clinical infectious diseases: an official publication of the Infectious Diseases Society of America
| volume = 41
| issue = 10
| pages = 1373–1406
| year = 2005
| month = November
| doi = 10.1086/497143
| pmid = 16231249
}}</ref></small></small></small></small>==
* Patients with cellular immunodeficiency require a pathogen-specific antimicrobial therapy.
* The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
 
{| style="border: 2px solid #696969;"
|+ <SMALL>''Recommended Duration of Antimicrobial Therapy Based on the Microorganism.''</SMALL>
| style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px"| '''Microorganism''' || style="background: #A5B2D6; border: 0px solid #696969; padding: 0 5px; width: 200px" | '''Duration of Therapy'''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Nocardia|Nocardia spp]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 3-12 months'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Atypical mycobacteria]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 6-12 months'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Cryptococcus|Cryptococcus spp]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 8-12 weeks'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Histoplasma|Histoplasma spp]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | '''''≥ 12 months'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Varicella-zoster virus]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 7-10 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Herpes simplex virus]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 7 days'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #F5F5F5" align=left |&nbsp;▸&nbsp;'''''[[Cytomegalovirus]]''''' || style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ''''' 21 days'''''
|-
|}
 
 
 
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Bacteria'''
</font>
</div>
 
<div class="mw-customtoggle-table28" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Nocardia spp'''
</font>
</div>
 
<div class="mw-customtoggle-table29" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Atypical mycobacteria'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Fungi'''
</font>
</div>
 
<div class="mw-customtoggle-table30" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Cryptococcus spp'''
</font>
</div>
 
<div class="mw-customtoggle-table31" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Histoplasma spp'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Viruses'''
</font>
</div>
 
<div class="mw-customtoggle-table32" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Varicella-zoster virus'''
</font>
</div>
 
<div class="mw-customtoggle-table33" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Herpes simplex virus'''
</font>
</div>
 
<div class="mw-customtoggle-table34" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 250px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Cytomegalovirus'''
</font>
</div>
 
| valign=top |
{|class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table28" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Nocardia spp}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[TMP-SMX]] x 3-12 months'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Sulfadiazine]] 2-4 g PO 1 dose'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | FOLLOWED BY
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Sulfadiazine]] 2-4 g/day PO q4-8h x 3-12 months'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen 1'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Imipenem]] 250-500 mg IV q6-8h x 3-12 months '''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table29" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Atypical mycobacteria†}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Clarithromycin]] 500 mg PO q12h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Ethambutol]] 15 mg/kg PO q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | WITH OR WITHOUT
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Rifabutin]] 300 mg PO q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Azithromycin]] 500 mg PO q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Ethambutol]] 15 mg/kg PO q24h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | WITH OR WITHOUT
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Rifabutin]] 300-450 mg PO q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center |<small>† Adapted from Am J Respir Crit Care Med Vol 175. pp 367–416, 2007<ref name="GriffithAksamit2007">{{cite journal|last1=Griffith|first1=David E.|last2=Aksamit|first2=Timothy|last3=Brown-Elliott|first3=Barbara A.|last4=Catanzaro|first4=Antonino|last5=Daley|first5=Charles|last6=Gordin|first6=Fred|last7=Holland|first7=Steven M.|last8=Horsburgh|first8=Robert|last9=Huitt|first9=Gwen|last10=Iademarco|first10=Michael F.|last11=Iseman|first11=Michael|last12=Olivier|first12=Kenneth|last13=Ruoss|first13=Stephen|last14=von Reyn|first14=C. Fordham|last15=Wallace|first15=Richard J.|last16=Winthrop|first16=Kevin|title=An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases|journal=American Journal of Respiratory and Critical Care Medicine|volume=175|issue=4|year=2007|pages=367–416|issn=1073-449X|doi=10.1164/rccm.200604-571ST}}</ref></small>
 
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table30" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cryptococcus spp}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Moderate Severe to Severe Disease
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Liposomal Amphotericin B]] 3 mg/kg/day IV × 1-2 weeks'''''  <br> OR <br> '''''[[Amphotericin B]] deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks'''''<br> OR <br> ▸ '''''[[Amphotericin B lipid complex]] 5 mg/kg/day IV × 1-2 weeks'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | FOLLOWED BY
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Itraconazole]] 200 mg PO q12h x ≥12 months'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Mild to Moderate Disease
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Itraconazole]] 200 mg PO q12h x ≥12 months'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL>Adapted from ''Clin Infect Dis. 2007;45(7):807-25.''<ref name="Wheat-2007">{{Cite journal  | last1 = Wheat | first1 = LJ. | last2 = Freifeld | first2 = AG. | last3 = Kleiman | first3 = MB. | last4 = Baddley | first4 = JW. | last5 = McKinsey | first5 = DS. | last6 = Loyd | first6 = JE. | last7 = Kauffman | first7 = CA. | title = Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America. | journal = Clin Infect Dis | volume = 45 | issue = 7 | pages = 807-25 | month = Oct | year = 2007 | doi = 10.1086/521259 | PMID = 17806045 }}</ref></SMALL>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table31" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Histoplasma spp}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Liposomal Amphotericin B]] 3 mg/kg/day x  1- 2 weeks''''' <br> OR <br>
▸ '''''[[Amphotericin B lipid complex]] 5 mg/kg/day x  1- 2 weeks'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | FOLLOWED BY
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Itraconazole]] 200mg q8h x 3 days '''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | FOLLOWED BY
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Itraconazole]] 200mg q12h x 6-12 months'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table32" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Varicella-zoster virus}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Doxycycline]] 200 mg IV initial dose, then 50-100 mg IV q12h'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Acyclovir]] 10-12 mg/kg IV (infusion over 1 hour) q8h x 7-10 days'''''  
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefotaxime]] 1-2 g IV/IM q8-12 (up to 2 g q4-6h)''''' <br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8-12h  x 7-14 days'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 500-750 mg PO q8-12h x 7-14 days'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Famciclovir]] 500 mg PO x 7-10 days''''' <br> OR <br> ▸ '''''[[Valacyclovir]] 500 mg PO  x 7-10 days'''''
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table23" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table33" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Fresh Water Wound Exposure <br> ''(Aeromonas spp)''}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Herpes simplex virus}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 400mg IV q12h''''' <br> OR <br> ▸ '''''[[Ceftazidime]] 0.5 -2 g IV q8h''''' <BR> PLUS <BR>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Acyclovir]] 10 mg/kg IV (infusion over 1 hour) q8h x 7-10 days'''''  
▸ '''''[[Gentamicin]] 3-5 mg/kg/day IV/IM divided q6-8h or 4-7 mg/kg IV q24h'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Meropenem]] 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)''''' <br> OR <br> ▸ '''''[[Imipenem/cilastatin]] 250-1000 mg IV  (max: 50mg/kg/day)'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Famciclovir]] 500 mg PO x 7 days''''' <br> OR <br> ▸ '''''[[Valacyclovir]] 500 mg PO x 7 days'''''
|}
|}
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table24" style="background: #FFFFFF;"
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table34" style="background: #FFFFFF;"
| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Butcher, Fisherman, Veterinarian <br> ''(Erysipelothrix rhusiopathiae)''}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cytomegalovirus}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin]] 500 mg PO q8hr'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ganciclovir]] 5 mg/kg IV q12h x 21 days'''''
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |▸ '''''[[Cefotaxime]] 1-2 g IV/IM q8-12 (up to 2 g q4-6h)''''' <br> OR <br> ▸ '''''[[Ciprofloxacin]] 400 mg IV q8-12h  x 7-14 days'''''<br> OR <br> ▸ '''''[[Ciprofloxacin]] 500-750 mg PO q8-12h  x 7-14 days''''' <br> OR <br>   ▸ '''''[[Imipenem]]-cilastatin 250-1000 mg IV  (max: 50mg/kg/day)'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Valganciclovir]] 900 mg PO q12h x 21 days'''''
|-
|}
|}
|}
 
==Bites<small><small><small><small>Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005<ref name=IDSA2005>{{Cite journal
| author = Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade
| title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections
| journal = Clinical infectious diseases: an official publication of the Infectious Diseases Society of America
| volume = 41
| issue = 10
| pages = 1373–1406
| year = 2005
| month = November
| doi = 10.1086/497143
| pmid = 16231249
}}</ref></small></small></small></small>==
 
{{Further|'''[[Bite#Treatment|Mangement of Bites]]'''}}
 
*All bite [[wounds]] should be cleaned profusely with iodide soap and water.
 
*Bites are contaminated by a polimicrobial flora and antibiotic prophylaxis treatment is recommended to avoid subsequent infection.
 
*The [[route of administration]] depends on the depth and severity of the [[wound]], as well as the time that has passed since the bite.
 
 
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></small>
 
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Antibiotic Prophylaxis'''
</font>
</div>
 
<div class="mw-customtoggle-table00" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Any Type of Bite'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Specific Therapy'''
</font>
</div>
 
<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Cat Bite'''
</font>
</div>
 
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Dog Bite'''
</font>
</div>
 
<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Human Bite'''
</font>
</div>
 
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table00" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Antibiotic Prophylaxis}}
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | Preferred Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin-clavulanate]] 500-875/125 PO q8-12h'''''
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | Alternative Regimen
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clindamycin]] 300 mg q8h'''''<br> OR <br> ▸ '''''[[Metronidazole]] 500 mg PO q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Doxycycline]] 100 mg q12h'''''<br> OR <br> ▸ '''''[[TMP-SMX]] 160/800 mg PO q12h'''''<br> OR <br> ▸ '''''[[Penicillin VK]] 500 mg PO q6h'''''<br> OR <br> ▸ '''''[[Cefuroxime]] 500 mg PO q12h'''''<br> OR <br> ▸ '''''[[Moxifloxacin]] 400 mg PO q24h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Human Bite}}
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ampicillin sulbactam]] 1.5 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Cefoxitin]] 2 gm IV q8h'''''<BR> OR <BR> ▸ '''''[[Ticarcillin clavulanate]] 3.1 g IV q6h'''''<BR> OR <BR> ▸ '''''[[Piperacillin-tazobactam]] 3.375 g IV q6-8h'''''
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | '''''Alternative Regimen (beta-lactam allergy)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clindamycin]] 300 mg PO q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 500-750 mg IV q12h''''' <br> OR <br> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h''''' <br> OR <br> ▸ '''''[[TMP-SMX]] 160/800 mg q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Dog Bite}}
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin-clavulanate]] 500-875/125 PO q8-12h'''''
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | '''''Alternative Regimen (beta-lactam allergy)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Clindamycin]] 300 mg PO q8h'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Ciprofloxacin]] 500-750 mg IV q12h''''' <br> OR <br> ▸ '''''[[Moxifloxacin]] 400 mg IV q24h''''' <br> OR <br> ▸ '''''[[Gatifloxacin]] 400 mg q24h'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Cat Bite}}
|-
|  style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Amoxicillin-clavulanate]] 500-875/125 PO q8-12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center  | '''''Alternative Regimen (beta-lactam allergy)'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cefuroxime]] 500 mg q12h''''' <br> OR <br>▸ '''''[[Doxycycline]] 100 mg q12h'''''  
|-
|}
|}
|}
|}
|}
|}
==Treatment Regimen==
* Cellulitis<ref name="pmid24947530">{{cite journal| author=Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL et al.| title=Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. | journal=Clin Infect Dis | year= 2014 | volume= 59 | issue= 2 | pages= 147-59 | pmid=24947530 | doi=10.1093/cid/ciu296 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24947530  }} </ref>
:* '''Non purulent Cellulitis'''
::* '''Mild (typical cellulitis/erysipelas with no focus of purulence)'''
:::* Preferred regimen (1): [[Penicillin VK]] 500 mg PO bid
:::* Preferred regimen (2): [[Cephalosporin]]
:::* Preferred regimen (3): [[Dicloxacillin]]
:::* Preferred regimen (4): [[Clindamycin]] 600-900 mg IV q6-8h
::* '''Moderate (typical cellulitis/erysipelas with systemic signs of infection)'''
:::* Preferred regimen (1): [[Penicillin VK]] 500 mg PO bid
:::* Preferred regimen (2): [[ceftriaxone]] 1-2 g q4-8h 
:::* Preferred regimen (3): [[cefazolin]]
:::* Preferred regimen (4): [[clindamycin]] 600-900 mg IV q6-8h
::* '''Severe infection'''
:::* Patients who have failed incision and drainage plus oral antibiotics
:::* Those with systemic signs of infection such as temperature >38°C,
:::* Tachycardia (heart rate >90 beats per minute),
:::* Tachypnea (respiratory rate >24 breaths per minute) or
:::* Abnormal white blood cell count (<12 000 or <400 cells/µL), or
:::* Immunocompromised patients
:::* Preferred regimen: [[Vancomycin]] {{and}} [[piperacillin-tazobactam]]
* '''Purulent Celluitits'''
:* '''Mild (typical cellulitis/erysipelas with no focus of purulence)'''
::* Preferred regimen: Incision and Drainage
:* '''Moderate (typical cellulitis/erysipelas with systemic signs of infection)'''
::* Incision and Drainage
::* Empiric regimen : [[TMP-SMX]] {{or}} [[doxycycline]]
::* MRSA : [[TMP-SMX]]
::* MSSA : [[Dicloxacillin]] {{or}} [[cephalexin]]
:*Severe infection: patients who have failed oral antibiotic regimen or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction.
::*Incision and Drainage
::*Empiric regimen : [[Vancomycin]] {{or}} [[daptomycin]] {{or}} [[linezolid]] {{or}} [[televancin]] {{or}} [[ceftaroline]]
::*MRSA : [[Vancomycin]] {{or}} [[daptomycin]] {{or}} [[linezolid]] {{or}} [[televancin]] {{or}} [[ceftaroline]]
*'''Buccal Cellulitis'''
:*'''1. Empiric antimicrobial therapy'''
::*Preferred regimen: [[Cefuroxime]] 50 mg/kg IV q8h {{or}} [[Cefuroxime]] 10–15 mg/kg PO q12h (maximum dose is 1 g/day) {{or}} [[Ceftriaxone]] 50 mg/kg IV q24h
::*Alternative regimen: [[Amoxicillin-Clavulanate]] 90 mg/kg/day PO q12h
::*Note: In case of suspected meningitis, increase [[Cefuroxime]] dose to 80 mg/kg IV q8h, or [[Ceftriaxone]] dose to 50 mg/kg IV q24h.


==Non-Antibiotic Therapy==
==Non-Antibiotic Therapy==
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[[Category:Disease]]
[[Category:Disease]]
[[Category:Infectious disease]]
 
[[Category:Dermatology]]
[[Category:Dermatology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
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[[Category:Diseases involving the fasciae]]
[[Category:Diseases involving the fasciae]]
[[Category:Inflammations]]
[[Category:Inflammations]]
[[Category: Infectious Disease Project]]

Latest revision as of 15:47, 15 January 2021

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2], Mugilan Poongkunran M.B.B.S [3], Faizan Sheraz, M.D. [4]

Cellulitis Microchapters

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Overview

The mainstay of therapy for cellulitis is antimicrobial therapy. Beta-lactam antibiotics are the usual drugs of choice, since most of the cases of cellulitis are caused either by Staphylococcus aureus or Streptococcus. Supportive therapy includes bed rest, compression stockings, and elevation of the affected limb. If a small abscess is surrounding the affected tissue, it may be treated with incision and drainage.

Medical Therapy

Empiric Therapy Adapted from Clin Infect Dis. 2011;52(3):e18-55[1] and Guidelines for Skin and Soft-Tissue Infections CID 2005[2]== Clinical practice guidelines direct management.[3]

  • Empiric therapy depends on the clinical presentation of the cellulitis.[4]
    • Non-purulent cellulitis refers to the infection without purulent drainage or exudate and not associated with an abscess.
    • Purulent cellulitis is associated with purulent drainage or exudate in the absence of a drainable abscess, and it is associated to Staphylococcus aureus.
    • Complicated cellulitis refers to a deeper soft-tissue infection and/or the association significant coexisting diseases (including diabetes mellitus, immunocompromised patients, and obesity), the need for significant surgical intervention or the involvement of the perianal area.
  • Patients with complicated cellulitis also present with surgical site infection, necrotizing soft-tissue infection, and signs of systemic toxicity.
  • For patients with purulent cellulitis, cultures are recommended and empirical therapy for Community Associated-MRSA (CA-MRSA) should be started.
  • For patients with non-purulent cellulitis, empirical therapy for β-hemolytic streptococci should be started; if the patient does not respond to B-lactam antibiotics, empirical coverage for CA-MRSA should be initiated. Per 2014 clinical practice guidelines, antibiotics for outpatients should be "an antimicrobial agent that is active against streptococci...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)".[4]
  • The duration of the therapy should be individualized for the clinical response of each patient; 5-10 days is usually recommended.
  • The treatment of cellulitis in neonates usually requires hospitalization and parenteral therapy. Oral therapy is given for completion of the treatment when the pathogen is unknown.
  • The optimal dose should be based on determination of serum concentrations and patients with renal insufficiency may require dose adjustment in case of cephalosporins.
  • Clindamycin is an alternate therapy for patients at risk of severe hypersensitivity reaction to penicillins and cephalosporins.
  • Doxycycline is not recommended for children <8 years of age.

▸ Click on the following categories to expand treatment regimens.

Non-Purulent Cellulitis

  ▸  Adults

  ▸  Children age >28 days

Purulent Cellulitis

  ▸  Adults

  ▸  Children age >28 days


Non-Purulent Cellulitis - Adults
Preferred Regimen
Cephalexin 500 mg PO q6h x5-10 days
OR
Dicloxacillin 500 mg PO q6h x5-10 days
OR
Clindamycin 300-450 mg PO q8h
OR
Amoxicillin 500 mg PO q8h
OR
TMP-SMX 80-160 mg/400-800 mg PO q12h
OR
Doxycycline 100 mg PO q12h
OR
Linezolid 600 mg PO q12h
Non-Purulent Cellulitis - Children
Preferred Regimen
Cephalexin 25 mg/kg/day PO divided q6h x 5-10 days
OR
Dicloxacillin 25 mg/kg/day PO divided q6h x 5-10 days
OR
Clindamycin 10-13 mg/kg IV q6-8h (max:40 mg/kg/day)
OR
TMP-SMX 4-6 mg/kg PO q12h (TMP component)
OR
Doxycycline¶ 2 mg/kg PO q12h†
OR
Linezolid 10 mg/kg PO q8h (max: 600mg/dose)
Not recommended for children < 8 years of age
For children ≤45 kg. Children >45 kg receive adult dosing.
Purulent Cellulitis - Adults
Preferred Regimen
Linezolid 600 mg PO q12h
OR
Clindamycin 300 - 450 mg PO q8h
OR
Minocycline 200 mg PO 1 dose, then 100 mg PO q12h
OR
Doxycycline 100 mg PO q12h
OR
TMP-SMX 80-160 mg/400-800 mg PO q12h
Purulent Cellulitis - Children
Preferred Regimen
Linezolid 10 mg/kg PO q8h (max: 600mg/dose)
OR
Clindamycin 10-13 mg/kg IV q6-8h (max:40 mg/kg/day)
OR
Minocycline 4 mg/kg PO 1 dose, then2 mg/kg/dose PO q12h
OR
Doxycycline¶ 2 mg/kg PO q12h†
OR
TMP-SMX 4-6 mg/kg PO q12h (TMP component)
Not recommended for children < 8 years of age
For children ≤45 kg. Children >45 kg receive adult dosing.
Complicated Cellulitis - Adults
Preferred Regimen
Vancomycin 15-20 mg/kg IV q8-12h
OR
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4mg/kg IV q24h
OR
Telavancin 10mg/kg IV q24h
Alternative Regimen
Clindamycin 600 mg IV/PO q8h
Complicated Cellulitis - Children
Preferred Regimen
Vancomycin 15 mg/kg IV q6h
OR
Linezolid 10 mg/kg IV/PO q8h (max: 600mg/dose)
Alternative Regimen
Clindamycin 10-13 mg/kg IV/PO q6-8h (max:40 mg/kg/day)

Special Considerations Adapted from N Engl J Med 2004;350:904-12.[6]

  • For the certain anatomical locations (buccal, facial and periorbital) a specific therapy should be given due to the predisposition of certain bacteria.
  • For certain conditions, such as salt or fresh water wound exposure, or if the patient is a butcher, fisherman or veterinarian, an additional antibiotic therapy should be added to the usual regimen in order to cover specific pathogens associated to those circumstances.

▸ Click on the following categories to expand treatment regimens.

Special Considerations

  ▸  Buccal Cellulitis

  ▸  Facial Cellulitis

  ▸  Orbital Cellulitis

  ▸  Salt Water Wound Exposure

  ▸  Fresh Water Wound Exposure

  ▸  Butcher, Fisherman, Veterinarian


Buccal Cellulitis
(H. influenzae)
Preferred Regimen
Ceftriaxone 1-2 g IV q24h
Alternative Regimen
Meropenem 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)
OR
Imipenem/cilastatin 250-1000 mg IV (max: 50mg/kg/day)
Facial Cellulitis
Preferred Regimen
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
Alternative Regimen
Daptomycin 4 mg/kg IV q24h
OR
Linezolid 600mg IV q12h
Orbital Cellulitis
Preferred Regimen 1
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
PLUS
Ceftriaxone 2g IV q24h
PLUS
Metronidazole 1g IV q12h
Preferred Regimen 2
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
PLUS
Piperacillin-tazobactam 4.5g IV q8h
Alternative Regimen
(if penicillin or cephalosporin allergic)
Vancomycin 15-20 mg/kg IV q8-12h (trough 15—20 μg/mL)
PLUS
Levofloxacin 750 mg IV q24h
Salt Water Wound Exposure
(Vibrio vulnificus)
Preferred Regimen
Doxycycline 200 mg IV initial dose, then 50-100 mg IV q12h
Alternative Regimen
Cefotaxime 1-2 g IV/IM q8-12 (up to 2 g q4-6h)
OR
Ciprofloxacin 400 mg IV q8-12h x 7-14 days
OR
Ciprofloxacin 500-750 mg PO q8-12h x 7-14 days
Fresh Water Wound Exposure
(Aeromonas spp)
Preferred Regimen
Ciprofloxacin 400mg IV q12h
OR
Ceftazidime 0.5 -2 g IV q8h
PLUS

Gentamicin 3-5 mg/kg/day IV/IM divided q6-8h or 4-7 mg/kg IV q24h

Alternative Regimen
Meropenem 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)
OR
Imipenem/cilastatin 250-1000 mg IV (max: 50mg/kg/day)
Butcher, Fisherman, Veterinarian
(Erysipelothrix rhusiopathiae)
Preferred Regimen
Amoxicillin 500 mg PO q8hr
Alternative Regimen
Cefotaxime 1-2 g IV/IM q8-12 (up to 2 g q4-6h)
OR
Ciprofloxacin 400 mg IV q8-12h x 7-14 days
OR
Ciprofloxacin 500-750 mg PO q8-12h x 7-14 days
OR
Imipenem-cilastatin 250-1000 mg IV (max: 50mg/kg/day)

Diabetic Foot Ulcer Adapted from Diabetes Care. 2013;36(9):2862-71.[7] and Clin Infect Dis. 2012;54(12):e132-73.[8]

  • Appropriate wound care is essential for the management of all diabetic foot ulcers.
  • Uninfected diabetic ulcers do not require antibiotic therapy.
  • For acutely infected wounds, empiric antibiotic with efficacy against Gram-positive cocci should be initiated after obtaining a post-debridement specimen for aerobic and anaerobic culture.
  • Infections with antibiotic-resistant organisms and those that are chronic, previously treated, or severe usually require broader spectrum regimens.

Empiric Therapy

Click on the following categories to expand treatment regimens.

    Uninfected (Grade 1)

  ▸  No Evidence of Infection

    Mild (Grade 2)

  ▸  Acute Infection Without Recent Antibiotic Use

  ▸  High Risk for MRSA

    Moderate to Severe (Grade 3–4)

  ▸  Chronic Infection or Recent Antibiotic Use

  ▸  High Risk for MRSA

  ▸  High Risk for Pseudomonas aureuginosa

  ▸  Polymicrobial Infection

Uninfected Wound, No Evidence of Infection
Uninfected wounds should be managed with appropriate wound care.
Antibiotic therapy is not recommended.
Mild DFI, Acute Infection Without Recent Antibiotic Use
Preferred Regimen
Dicloxacillin 125–250 mg PO qid
OR
Clindamycin 150–300 mg PO qid
OR
Cephalexin 500 mg PO qid
OR
Levofloxacin 750 mg PO qd
OR
Amoxicillin-Clavulanate 500 mg PO bid (or 250 mg PO tid)
Usually active against community-associated MRSA, but check macrolide sensitivity and consider ordering a D-test before using for MRSA.
Relatively broad-spectrum oral agent that includes anaerobic coverage.
Mild DFI, High Risk for MRSA
Preferred Regimen
Doxycycline 100 mg PO q12h
OR
TMP–SMX 80-160 mg/400-800 mg PO q12h
Active against many MRSA & some gram-negatives; uncertain against streptococci.
Moderate to Severe DFI, Chronic Infection or Recent Antibiotic Use
Preferred Regimen
Levofloxacin 750 mg IV/PO q24h
OR
Cefoxitin 1 g IV q4h (or 2 g IV q6–8h)
OR
Ceftriaxone 1–2 g/day IV/IM q12–24h
OR
Ampicillin–Sulbactam 1.5–3 g IV/IM q6h
OR
Moxifloxacin 400 mg IV/PO q24h
OR
Ertapenem 1 g IV/IM q24h
OR
Tigecycline 100 mg IV, then 50 mg IV q12h
OR
Imipenem–Cilastatin 0.5–1 g IV q6–8h
Alternative Regimen
Levofloxacin 750 mg IV/PO q24h
OR
Ciprofloxacin 600–1200 mg/day IV q6–12h
OR
Ciprofloxacin 1200–2700 mg IV q6–12h (for more severe cases)
PLUS
Clindamycin 150–300 mg PO qid
Active against MRSA.
Not active against MRSA; consider when ESBL-producing pathogens suspected.
Moderate to Severe DFI, High Risk for MRSA
Preferred Regimen
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4 mg/kg IV q24h
OR
Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
Moderate to Severe DFI, High Risk for Pseudomonas aeruginosa
Preferred Regimen
Piperacillin–Tazobactam 3.375 g IV q6–8h
Moderate to Severe DFI, Polymicrobial Infection
Preferred Regimen
Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
OR
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4 mg/kg IV q24h
PLUS
Piperacillin–Tazobactam 3.375 g IV q6–8h
OR
Imipenem–Cilastatin 0.5–1 g IV q6–8h
OR
Ertapenem 1 g IV/IM q24h
OR
Meropenem 1 g IV q8h
Alternative Regimen
Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
OR
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4 mg/kg IV q24h
PLUS
Ceftazidime 2 g IV q8h
OR
Cefepime 2 g IV q8h
OR
Aztreonam 2 g IV q6–8h
PLUS
Metronidazole 15 mg/kg IV, then 7.5 mg/kg IV q6h

Neutropenic Patients Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[2]

  • Patients with neutropenia require an antimicrobial therapy with a broader coverage.
  • The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
Recommended Duration of Antimicrobial Therapy Based on the Microorganism.
Microorganism Duration of Therapy
 ▸ Gram-negative Bacteria 7-14 days
 ▸ Gram-positive Bacteria 7-10 days
 ▸ Fungi Until clinical resolution

▸ Click on the following categories to expand treatment regimens.

Neutropenia

  ▸  Gram-Negative Bacteria

  ▸  Gram-Positive Bacteria

  ▸  Fungi


Gram-Negative Bacteria
Preferred Regimen
Meropenem 0.5-1 g IV q8h (infuse over 15-30 min or in bolus over 3-5 min)
OR
Imipenem/cilastatin 0.5–1 g IV q6–8h(max: 50mg/kg/day)
OR
Ertapenem 1 g IV/IM q24h
OR
Cefepime 2g IV q8h
OR
Ceftazidime 2g IV q8h
OR
Piperacillin/tazobactam 3.375 g IV q6–8h
Alternative Regimen 1
Amikacin 15 mg/kg/day IV/IM divided q8-12h (max: 15 mg/kg/day)
OR
Gentamicin 3-5 mg/kg/day IV/IM divided q6-8h
OR
Gentamicin 4-7 mg/kg/day IV q24h (adjust dosage based on serum concentrations)
PLUS
Cefepime 2g IV q8h
OR
Piperacillin/tazobactam 3.375 g IV q6–8h (max 24 g/day)
Alternative Regimen 2
Piperacillin/tazobactam 3.375 g IV q6–8h (max 24 g/day)
PLUS
Ciprofloxacin 400mg IV q8h
Gram-Positive Bacteria
Preferred Regimen
Vancomycin† 15-20 mg/kg IV q8-12h
Alternative Regimen
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4mg/kg IV q24h
† Vancomycin should be discontinued if culture results remain negative after 72-96 hrs
Fungi
Preferred Regimen
Liposomal Amphotericin B 3 mg/kg/day IV × 1-2 weeks
OR
Amphotericin B deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks
OR
Amphotericin B lipid complex 5 mg/kg/day IV × 1-2 weeks
Alternative Regimen
Voriconazole 6 mg/kg IV q12h x 1 day, then 3 mg/kg IV q12h
OR
Voriconazole 200 mg PO q12h
OR
Caspofungin 70 mg IV once, then 50 mg IV q24h x ≥ 14 days

Cellular Immune Deficient Patients Adapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[2]

  • Patients with cellular immunodeficiency require a pathogen-specific antimicrobial therapy.
  • The duration of antimicrobial therapy should be individualized in accordance with patient's clinical response.
Recommended Duration of Antimicrobial Therapy Based on the Microorganism.
Microorganism Duration of Therapy
 ▸ Nocardia spp 3-12 months
 ▸ Atypical mycobacteria 6-12 months
 ▸ Cryptococcus spp 8-12 weeks
 ▸ Histoplasma spp ≥ 12 months
 ▸ Varicella-zoster virus 7-10 days
 ▸ Herpes simplex virus 7 days
 ▸ Cytomegalovirus 21 days


Bacteria

  ▸  Nocardia spp

  ▸  Atypical mycobacteria

Fungi

  ▸  Cryptococcus spp

  ▸  Histoplasma spp

Viruses

  ▸  Varicella-zoster virus

  ▸  Herpes simplex virus

  ▸  Cytomegalovirus

Nocardia spp
Preferred Regimen
TMP-SMX x 3-12 months
Alternative Regimen 1
Sulfadiazine 2-4 g PO 1 dose
FOLLOWED BY
Sulfadiazine 2-4 g/day PO q4-8h x 3-12 months
Alternative Regimen 1
Imipenem 250-500 mg IV q6-8h x 3-12 months
Atypical mycobacteria†
Preferred Regimen
Clarithromycin 500 mg PO q12h
PLUS
Ethambutol 15 mg/kg PO q24h
WITH OR WITHOUT
Rifabutin 300 mg PO q24h
Alternative Regimen
Azithromycin 500 mg PO q24h
PLUS
Ethambutol 15 mg/kg PO q24h
WITH OR WITHOUT
Rifabutin 300-450 mg PO q24h
† Adapted from Am J Respir Crit Care Med Vol 175. pp 367–416, 2007[9]
Cryptococcus spp
Preferred Regimen
Moderate Severe to Severe Disease
Liposomal Amphotericin B 3 mg/kg/day IV × 1-2 weeks
OR
Amphotericin B deoxycholate 0.7-1 mg/kg/day IV × 1-2 weeks
OR
Amphotericin B lipid complex 5 mg/kg/day IV × 1-2 weeks
FOLLOWED BY
Itraconazole 200 mg PO q12h x ≥12 months
Mild to Moderate Disease
Itraconazole 200 mg PO q12h x ≥12 months
Adapted from Clin Infect Dis. 2007;45(7):807-25.[10]
Histoplasma spp
Preferred Regimen
Liposomal Amphotericin B 3 mg/kg/day x 1- 2 weeks
OR

Amphotericin B lipid complex 5 mg/kg/day x 1- 2 weeks

FOLLOWED BY
Itraconazole 200mg q8h x 3 days
FOLLOWED BY
Itraconazole 200mg q12h x 6-12 months
Varicella-zoster virus
Preferred Regimen
Acyclovir 10-12 mg/kg IV (infusion over 1 hour) q8h x 7-10 days
Alternative Regimen
Famciclovir 500 mg PO x 7-10 days
OR
Valacyclovir 500 mg PO x 7-10 days
Herpes simplex virus
Preferred Regimen
Acyclovir 10 mg/kg IV (infusion over 1 hour) q8h x 7-10 days
Alternative Regimen
Famciclovir 500 mg PO x 7 days
OR
Valacyclovir 500 mg PO x 7 days
Cytomegalovirus
Preferred Regimen
Ganciclovir 5 mg/kg IV q12h x 21 days
Alternative Regimen
Valganciclovir 900 mg PO q12h x 21 days

BitesAdapted from Guidelines for Skin and Soft-Tissue Infections CID 2005[2]

  • All bite wounds should be cleaned profusely with iodide soap and water.
  • Bites are contaminated by a polimicrobial flora and antibiotic prophylaxis treatment is recommended to avoid subsequent infection.


▸ Click on the following categories to expand treatment regimens.

Antibiotic Prophylaxis

  ▸  Any Type of Bite

Specific Therapy

  ▸  Cat Bite

  ▸  Dog Bite

  ▸  Human Bite


Antibiotic Prophylaxis
Preferred Regimen
Amoxicillin-clavulanate 500-875/125 PO q8-12h
Alternative Regimen
Clindamycin 300 mg q8h
OR
Metronidazole 500 mg PO q8h
PLUS
Doxycycline 100 mg q12h
OR
TMP-SMX 160/800 mg PO q12h
OR
Penicillin VK 500 mg PO q6h
OR
Cefuroxime 500 mg PO q12h
OR
Moxifloxacin 400 mg PO q24h
Human Bite
Preferred Regimen
Ampicillin sulbactam 1.5 g IV q6h
OR
Cefoxitin 2 gm IV q8h
OR
Ticarcillin clavulanate 3.1 g IV q6h
OR
Piperacillin-tazobactam 3.375 g IV q6-8h
Alternative Regimen (beta-lactam allergy)
Clindamycin 300 mg PO q8h
PLUS
Ciprofloxacin 500-750 mg IV q12h
OR
Moxifloxacin 400 mg IV q24h
OR
TMP-SMX 160/800 mg q12h
Dog Bite
Preferred Regimen
Amoxicillin-clavulanate 500-875/125 PO q8-12h
Alternative Regimen (beta-lactam allergy)
Clindamycin 300 mg PO q8h
PLUS
Ciprofloxacin 500-750 mg IV q12h
OR
Moxifloxacin 400 mg IV q24h
OR
Gatifloxacin 400 mg q24h
Cat Bite
Preferred Regimen
Amoxicillin-clavulanate 500-875/125 PO q8-12h
Alternative Regimen (beta-lactam allergy)
Cefuroxime 500 mg q12h
OR
Doxycycline 100 mg q12h

Treatment Regimen

  • Non purulent Cellulitis
  • Mild (typical cellulitis/erysipelas with no focus of purulence)
  • Moderate (typical cellulitis/erysipelas with systemic signs of infection)
  • Severe infection
  • Patients who have failed incision and drainage plus oral antibiotics
  • Those with systemic signs of infection such as temperature >38°C,
  • Tachycardia (heart rate >90 beats per minute),
  • Tachypnea (respiratory rate >24 breaths per minute) or
  • Abnormal white blood cell count (<12 000 or <400 cells/µL), or
  • Immunocompromised patients
  • Preferred regimen: Vancomycin AND piperacillin-tazobactam
  • Purulent Celluitits
  • Mild (typical cellulitis/erysipelas with no focus of purulence)
  • Preferred regimen: Incision and Drainage
  • Moderate (typical cellulitis/erysipelas with systemic signs of infection)
  • Severe infection: patients who have failed oral antibiotic regimen or those with systemic signs of infection (as defined above under purulent infection), or those who are immunocompromised, or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction.
  • Buccal Cellulitis
  • 1. Empiric antimicrobial therapy

Non-Antibiotic Therapy

  • Elevation of the affected area facilitates gravity drainage of edema and inflammatory substances. Compressive stockings and diuretic therapy may help patients with edema.
  • The skin should be sufficiently hydrated to avoid dryness and cracking without maceration.

References

  1. Liu, C.; Bayer, A.; Cosgrove, S. E.; Daum, R. S.; Fridkin, S. K.; Gorwitz, R. J.; Kaplan, S. L.; Karchmer, A. W.; Levine, D. P.; Murray, B. E.; Rybak, M. J.; Talan, D. A.; Chambers, H. F. (2011). "Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children". Clinical Infectious Diseases. 52 (3): e18–e55. doi:10.1093/cid/ciq146. ISSN 1058-4838.
  2. 2.0 2.1 2.2 2.3 Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Dale Everett, Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Edward L. Kaplan, Jose G. Montoya & James C. Wade (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 41 (10): 1373–1406. doi:10.1086/497143. PMID 16231249. Unknown parameter |month= ignored (help)
  3. 3.0 3.1 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America". Clin Infect Dis. 59 (2): 147–59. doi:10.1093/cid/ciu296. PMID 24947530.
  4. 4.0 4.1 Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL; et al. (2014). "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America". Clin Infect Dis. 59 (2): e10–52. doi:10.1093/cid/ciu444. PMID 24973422.
  5. Elliott DJ, Zaoutis TE, Troxel AB, Loh A, Keren R (2009). "Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus". Pediatrics. 123 (6): e959–66. doi:10.1542/peds.2008-2428. PMID 19470525.
  6. Morton N. Swartz (2004). "Clinical practice. Cellulitis". The New England journal of medicine. 350 (9): 904–912. doi:10.1056/NEJMcp031807. PMID 14985488. Unknown parameter |month= ignored (help)
  7. Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.
  8. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
  9. Griffith, David E.; Aksamit, Timothy; Brown-Elliott, Barbara A.; Catanzaro, Antonino; Daley, Charles; Gordin, Fred; Holland, Steven M.; Horsburgh, Robert; Huitt, Gwen; Iademarco, Michael F.; Iseman, Michael; Olivier, Kenneth; Ruoss, Stephen; von Reyn, C. Fordham; Wallace, Richard J.; Winthrop, Kevin (2007). "An Official ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Nontuberculous Mycobacterial Diseases". American Journal of Respiratory and Critical Care Medicine. 175 (4): 367–416. doi:10.1164/rccm.200604-571ST. ISSN 1073-449X.
  10. Wheat, LJ.; Freifeld, AG.; Kleiman, MB.; Baddley, JW.; McKinsey, DS.; Loyd, JE.; Kauffman, CA. (2007). "Clinical practice guidelines for the management of patients with histoplasmosis: 2007 update by the Infectious Diseases Society of America". Clin Infect Dis. 45 (7): 807–25. doi:10.1086/521259. PMID 17806045. Unknown parameter |month= ignored (help)