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EMPIRIC ANTIBIOTIC GUIDELINES FOR SKIN ... - Michigan …

EMPIRIC ANTIBIOTIC GUIDELINES FOR skin AND SOFT TISSUE INFECTIONS. IN PATIENTS ON PEDIATRIC SERVICES. This guideline is designed to provide guidance in pediatric patients with a primary skin and soft tissue infection (SSTI). Management of skin and soft tissue infections in patients <2 months of age, or presenting with sepsis or septic shock not related to necrotizing fasciitis is beyond the scope of these GUIDELINES . For sepsis or septic shock, refer to the Pediatric Sepsis GUIDELINES . Table of Contents Purulent Cellulitis or Abscesses Minor skin Infections Non-purulent Cellulitis (including folliculitis, furuncles, or carbuncles).

Cephalexin and cefazolin provide coverage for group A Streptococcus and MSSA. If lack of improvement or clinical worsening on >48 hours of initial antibiotic therapy, consider adding or changing to an agent with anti-MRSA activity. (i.e., TMP-SMX2 or doxycycline).

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Transcription of EMPIRIC ANTIBIOTIC GUIDELINES FOR SKIN ... - Michigan …

1 EMPIRIC ANTIBIOTIC GUIDELINES FOR skin AND SOFT TISSUE INFECTIONS. IN PATIENTS ON PEDIATRIC SERVICES. This guideline is designed to provide guidance in pediatric patients with a primary skin and soft tissue infection (SSTI). Management of skin and soft tissue infections in patients <2 months of age, or presenting with sepsis or septic shock not related to necrotizing fasciitis is beyond the scope of these GUIDELINES . For sepsis or septic shock, refer to the Pediatric Sepsis GUIDELINES . Table of Contents Purulent Cellulitis or Abscesses Minor skin Infections Non-purulent Cellulitis (including folliculitis, furuncles, or carbuncles).

2 Staphylococcal Scalded skin Traumatic Wound Infections Necrotizing Fasciitis Syndrome WITHOUT water exposure Traumatic Wound Infections WITH. Footnotes References water Exposure Setting EMPIRIC Therapy Duration/Comments Minor skin Infections Duration: 5 days Localized impetigo (non- bullous or bullous) Topical Therapy S. aureus isolates from impetigo are Secondarily infected skin Mupirocin 2% topical ointment applied BID. commonly methicillin susceptible lesions such eczema, (MSSA). ulcers, or lacerations Oral Therapy Folliculitis (small follicular 1st line: Michigan Medicine S. aureus abscess in epidermis) Cephalexin* 25 mg/kg/DOSE PO TID (max: 1 g/DOSE).

3 Resistance rates are lowest for TMP- SMX2 (2%) and doxycycline (3%), Topical therapy: Generally If MRSA coverage needed1 ADD TMP-SMX2,* 6 mg of compared to clindamycin (28% in preferred over oral therapy TMP/kg/DOSE PO BID (max: 320 mg TMP/DOSE). 2018). Methicillin-susceptible S. aureus (MSSA) and methicillin- Oral therapy: Indicated Alternative to TMP-SMX2 if sulfa allergy resistant S. aureus (MRSA) exhibit instead of topical therapy Doxycycline3 mg/kg/DOSE PO BID. similar rates of clindamycin for patients with numerous (max: 100 mg/DOSE). resistance. impetigo lesions or in outbreak settings to reduce Alternative for low/medium-risk allergy4 to cephalexin5, OR.

4 If worsening or not improving after transmission high-risk allergy6/contraindication7 to beta-lactams: 48 hours of oral ANTIBIOTIC therapy, Clindamycin 10 mg/kg/DOSE PO TID (max: 450 mg/DOSE). consider adding or changing to an Target Pathogens: agent with anti-MRSA activity ( , Staphylococcus aureus, group A Streptococcus TMP-SMX2 or doxycycline). Outpatient or Step-down (from IV to PO) Therapy: 1st Line: Cephalexin* 25 mg/kg/DOSE PO TID (max: 1 g/DOSE). If MRSA coverage needed1 ADD TMP-SMX2,* 6 mg of Duration: TMP/kg/DOSE PO BID (max: 320 mg TMP/DOSE). 5 days Non-Purulent Cellulitis May extend therapy up to 7- Alternative to TMP-SMX2 if sulfa allergy 10 days if lack of symptom Absence of purulent Doxycycline3 mg/kg/DOSE PO BID.

5 Resolution at 5 days. drainage or exudate, (max: 100 mg/DOSE). ulceration, and no Cephalexin and cefazolin provide associated abscess. Includes Alternative for low/medium-risk allergy4 to cephalexin5, OR. coverage for group A Streptococcus erysipelas. high-risk allergy6/contraindication7 to beta-lactams: and MSSA. Clindamycin 10 mg/kg/DOSE PO TID (max: 450 mg/DOSE). Target Pathogens: If lack of improvement or clinical Group A Streptococcus, Inpatient (IV) Therapy worsening on >48 hours of initial Staphylococcus aureus 1st Line: ANTIBIOTIC therapy, consider adding (the role of community- cefazolin * 33 mg/kg/DOSE IV q8h (max: 2 g/DOSE).)

6 Or changing to an agent with anti- acquired MRSA is MRSA activity. ( , TMP-SMX2 or unknown) Alternative for low/medium-risk allergy4 to cefazolin , OR high- doxycycline). risk allergy6/contraindication7 to beta-lactams (in patients without risk for MRSA): Clindamycin 10 mg/kg/DOSE IV q8h (max: 600 mg/DOSE). Alternative if need for MRSA coverage1: Vancomycin IV*. Page 2 of 7. Setting EMPIRIC Therapy Duration/Comments Duration: 5 days May extend therapy up to 7- 10 days if lack of symptom Incision and drainage (I&D) is recommended as primary resolution at 5 days. management for abscesses. Antibiotics** are (at a minimum).

7 Recommended if patient meets one of the following criteria: Cultures and susceptibilities are Purulent Cellulitis or Substantial surrounding cellulitis recommended when I&D is Abscesses including Abscess >2 cm in diameter; >1 cm in infants and young performed. Blood cultures are also Folliculitis, Furuncles, children recommended for patients with Carbuncles Inability to adequately drain the abscess fever, rapidly progressive cellulitis, Signs or symptoms of systemic illness ( , fever 38 C) and systemic illness. Abscess: Collection of pus Immunodeficiency within the dermis and Multiple sites Michigan Medicine S.

8 Aureus deeper skin tissues resistance rates are lowest for TMP- Outpatient Therapy or Step-down (from IV to PO) Therapy SMX2 (2%) and doxycycline (3%), Furuncle: Infection of the 1st Line: compared to clindamycin (28% in hair follicle with TMP-SMX2,* 6 mg of TMP/kg/DOSE PO BID 2018). Methicillin-susceptible S. suppuration extending (max: 320 mg TMP/DOSE) aureus (MSSA) and methicillin- through the dermis into resistant S. aureus (MRSA) exhibit subcutaneous tissue Alternative for Sulfa Allergy: similar rates of clindamycin Doxycycline3 mg/kg/DOSE PO BID (max: 100 mg/DOSE) resistance. Carbuncle: Confluence of furuncles with wider Inpatient (IV) Therapy Tailor ANTIBIOTIC therapy to results infiltration 1st Line: of Gram stain, culture and Vancomycin IV* sensitivities.

9 Target Pathogen: Staphylococcus aureus Alternative for vancomycin allergy (not vancomycin infusion (including MRSA) **Although ~70% of abscesses may reaction): resolve with I&D alone, an Linezolid8 PO/IV (PO preferred): additional 10% are more likely to <12 years: 10 mg/kg/DOSE TID (max: 600 mg/DOSE) resolve with the addition of 12 years: 10 mg/kg/DOSE BID (max: 600 mg/DOSE). antibiotics. Clinical context should be taken into account when deciding if antibiotics are appropriate. Page 3 of 7. Setting EMPIRIC Therapy Duration/Comments Duration: 1st Line: 10 days cefazolin * 33 mg/kg/DOSE IV q8h (max: 2 g/DOSE).

10 Consider discontinuing + Clindamycin 13 mg/kg/DOSE IV q8h (max: 900 mg/DOSE). clindamycin when patient is Staphylococcal Scalded skin clinically stable ( , vital signs Alternative if need for MRSA coverage1 or alternative for Syndrome (SSSS) within normal limits, no low/medium-risk allergy4 to cefazolin , OR high-risk vasopressor requirements) for allergy6/contraindication7 to beta-lactams: Results in loss of 24-48 hours and rash no longer Vancomycin IV*. keratinocyte cell adhesion progressing (usual duration of + Clindamycin 13 mg/kg/DOSE IV q8h (max: 900 mg/DOSE). and leads to blistering of 3-5 days).


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