Antibiotics for Skin and Soft Tissue Infections (Adult)

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Antibiotics for Skin and Soft Tissue Infections (Adult)
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2015-01-04 23:09:02
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Empiric antibiotic therapy for skin and soft tissue infections in adults.
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  1. Impetigo

    *systemic ANTX if: multiple/extensive/recurrent lesions, fever/constitutional S&S/lymphadenopathy, immunocompromised, valvular heart disease
    • Bullous: S. aureus
    • Non-bullous, honey crust lesions: Group A Streptococci

    • Limited involvement:
    • 1. mupirocin 2% TOP TID x7/7
    • 2. fusidic acid 2% TOP TID-QID x7/7

    • Unresponsive:
    • 1. cloxacillin 500mg PO QID x7/7
    • 2. cephalexin 500mg PO QID x7/7

    • B-lactam allergy:
    • 1. erythromycin 500mg PO QID x7/7
    • 2. clindamycin 300mg PO QID x7/7
  2. Folliculitis/Furunculosis

    *self-limiting
    **systemic ANTX if scalp folliculitis
    ***if unresolving, consider mycobacterial infections (see Carbuncles)
    • S. aureus:
    • 1. hot compresses and antiseptic cleanser

    • Unresponsive: 
    • 1. mupirocin 2% TOP TID x7/7
    • 2. fusidic acid 2% TOP TID-QID x7/7

    • Whirlpool/hot tub= Pseudomonas aeruginosa:
    • 1. hot compress and antiseptic cleanser
  3. Recurrent Furunculosis
    *if >6/year, suppressive therapy with clindamycin 150mg PO OD or azithromycin 500mg PO weekly x≥3/12
    • S. aereus:
    • Consider decolonization: 
    • 1. mupirocin 2% intranasally BID-TID x5/7 (repeat monthly for the first 5 days of each month x6-12/12)

    • Alternative:
    • 1. rifampin 600mg PO OD + TMP/SMX 1 DS PO BID x10/7
  4. Carbuncles

    *systemic ANTX if: debilitated elderly, immunosuppression/diabetes/concurrent malignancy, surrounding cellulitis/septic phlebitis, fever/constitutional S&S, location difficult to drain (face/genitalia)
    **increased incidence of community MRSA, so avoid clindamycin or FQ
    • S. aureus:
    • Limited disease:
    • 1. hot compresses and antiseptic cleanser

    • Unresponsive:
    • 1. cloxacillin 500mg PO QID x7/7
    • 2. cephalexin 500mg PO QID x7/7

    • B-lactam allergy: 
    • 1. TMP/SMX 1 DS PO BID x7/7
    • 2. doxycycline 100mg PO BID x7/7
    • 3. clindamycin 300mg QID x7/7

    • MRSA suspected:
    • 1. TMP/SMX 1-2 DS PO BID x7/7
    • 2. doxycycline 100mg PO BID x7/7
  5. Chicken Pox

    *most benefit if treated within 24h
    **treat even if >24h if: pneumonia or other visceral involvement (x10/7), pregnancy
    • Adults (immunocompetent)= Varicella zoster:
    • 1. famciclovir 500mg PO TID x5/7
    • 2. valacyclovir 1g PO TID x5/7
    • 3. acyclovir 800mg PO QID x5/7

    • Adults (immunocompromised)= Varicella zoster:
    • 1. famciclovir 500mg PO TID x7-10/7
    • 2. valacyclovir 1g PO TID x7-10/7
    • 3. acyclovir 800mg PO QID x7-10/7
    • Severe:
    • 1. acyclovir 10mg/kg IV Q8H x7-10/7
  6. Shingles

    *herpes zoster opthalmicus: affects nerve V1 in 10-25% of shingles cases
    **oral corticosteroids has some benefit in acute shingles but have significant AEs and doesn't decrease incidence of post-herpetic neuralgia (PHN)
    ***immunity is boosted once a person has herpes zoster; so recurrence rate is ≤5%
    ****start treatment within 72h of the onset of rash
    *****for shingles vaccine, antivirals should not be started 24h before or 14 days after vaccination
    • Adult (immunocompetent)= varicella zoster:
    • 1. famciclovir 500mg PO TID x7/7
    • 2. valacyclovir 1g PO TID or 1.5g PO BID x7/7
    • 3. acyclovir 800mg PO 5x/d x7/7
    • *famciclovir and valacyclovir are more effective in the treatment and resolution of PHN
    • **treat longer if: new vesicles forming, cutaneous/motor/neurologic/ocular complications

    • Adults (immunocompromised)= Varicella zoster:
    • Mild to moderate:
    • 1. famciclovir 500mg PO TID x7-10/7
    • 2. valacyclovir 1g PO TID x7-10/7
    • 3. acyclovir 800mg PO 5x/d x7-10/7

    • Severe/disseminated:
    • 1. acyclovir 10mg/kg IV Q8H x7-10/7

    • *in immunocompromised adults who can't receive shingles vaccinations, antiviral prophylaxis is recommended:
    • 1. acyclovir 400-800mg PO OD
    • 2. famciclovir 500mg PO OD
    • 3. valacyclovir 250-500mg PO OD
    • **duration is until end of immunosuppressive therapy and/or at least 1 year after transplant/leukaemia induction therapy
  7. Mucocutaneous Zoster Infection

    HSV1: primarily causes mouth, throat, face, eye, and central nervous system infections
    HSV2: primarily causes anogenital infections
    • Primary in immunocompetent (gingivo-stomatitis)= Herpes simplex:
    • 1. famciclovir 500mg PO BID x7/7
    • 2. valacyclovir 500mg-1g PO BID x7/7
    • 3. acyclovir 400mg PO TID x7/7

    • Recurrent in immunocompetent (fever, blisters, cold sores)= Herpes simplex: 
    • Suppressive:
    • 1. valacyclovir 500mg PO OD
    • 2. acyclovir 400mg PO BID

    • Symptomatic:
    • 1. famciclovir 1500mg PO OD x1/7
    • 2. valacyclovir 2g PO BID x1/7
    • 3. acyclovir 400mg PO TID x5/7
    • *no therapy indicated for recurrent HSV mucocutaneous infection unless: severe and ≥6/year
    • **initiate therapy at first sign of S&S. No benefit if lesions established

    • Mucocutaneous HSV infection in immunocompromised= Herpes simplex:
    • 1. famciclovir 500mg PO BID x7-10/7
    • 2. valacyclovir 500mg-1g PO BID x7-10/7
    • 3. acyclovir 400mg PO 5x/d x7-10/7
  8. Cellulitis

    *superficial skin culture not recommended except: subcutaneous abscess present, toe web intertrigo
    **blood culture recommended if septic: T≥38.5, immunocompromised, or diabetic
    ***if no response to antibiotic therapy in 5 days, consider other diagnoses and/or change ANTX regiment
    • Facial= Group A streptococci, S. aureus:
    • Mild:
    • 1. cloxacillin 500mg PO QID x7-10/7
    • 2. cephalexin 500mg PO QID x7-10/7

    • B-lactam allergy:
    • 1. clindamycin 300mg PO QID x7-10/7

    • Moderate to severe:
    • 1. cloxacillin 1-2g IV Q6H x10/7
    • 2. cefazolin 1-2g IV Q8H x10/7

    • B-lactam allergy:
    • 1. clindamycin 600mg IV Q8H or 300mg PO QID x10/7
    • *significant strep/staph resistance to clindamycin so monitor clinical response

    • Extremities= Group A streptococci, S. aureus, Group B/C/G streptococci:
    • Mild:
    • 1. cloxacillin 500mg PO QID x7-10/7
    • 2. cephalexin 500mg PO QID x7-10/7

    • B-lactam allergy:
    • 1. clindamycin 300mg PO QID x7-10/7

    • Moderate to severe:
    • 1. cloxacillin 1-2g IV Q6H x10/7
    • 2. cefazolin 1-2g IV Q8H x10/7
    • 3. cefazolin 2g IV OD and probenecid 2g PO OD or 1g PO BID (if 2g is not tolerated; give probenecid 3 monutes prior to cefazolin)
    • 4. ceftriaxone 1-2g IV OD x10/7
    • *switch to oral agent when: resolution of systemic S&S, no further progression of cellulitis
    • **probenecid for ClCr>50mL/min

    • B-lactam allergy:
    • 1. clindamycin 600mg IV Q8H or 300mg PO QID x10/7

    • MRSA suspected/purulent:
    • Mild: 
    • 1. Incision and drainage (I&D) if abscess +/-
    • cephalexin 500mg PO QID x7-10/7 + TMP/SMX 1-2 DS PO BID x7-10/7 OR doxycycline 100mg PO BID x7-10/7

    • Moderate to severe:
    • 1. I&D if abscess + vancomycin 15mg/kg IV Q8-12H x10/7
    • *desired vancomycin trough= 15-20mg/L
  9. Peri-rectal Cellulitis/Abscess
    • Polymicrobial= anaerobes, enterobacteriaceae, S. aureus, Group A streptococci:
    • Mild:
    • 1. amoxi-clav 875mg PO BID x7-10/7

    • Moderate to severe:
    • 1. cefazolin 2g IV Q8H x10/7 + metronidazole 500mg IV/PO Q12H x10/7
    • 2. clindamycin 600mg IV Q8H or 300mg PO QID x10/7 + ciprofloxacin 400mg IV Q12H or 500mg PO BID x10/7
    • 3. piperacillin-tazobactam 3.375g IV Q6H x10/7*
    • *if ESBL or Amp C known/suspected, use ertapenem 1g IV OD

    • MRSA suspected:
    • Mild: 
    • 1. amoxi-clav 875mg PO BID x7-10/7 + TMP/SMX 1-2 DS PO BID x7-10/7

    • Moderate to severe:
    • 1. vancomycin 15mg/kg IV Q8-12H x10/7 + ceftriaxone 1-2g IV OD x10/7 + metronidazole 500mg IV/PO Q12H x10/7
    • 2. vancomycin 15mg/kg Q8-12H x10/7 + PIPTAZO 3.375g IV Q6H x10/7
    • *desired vancomycin trough= 15-20mg/L
  10. Breast Abscess/Mastitis
    *ANTX not recommended for minimal S&S or prophylaxis
    • Post-partum= S. aureus:
    • Mild: 
    • 1. cloxacillin 500mg PO QID x7-10/7
    • 2. cephalexin 500mg PO QID x7-10/7

    • B-lactam allergy/MRSA:
    • 1. clindamycin 300mg PO QID x7-10/7

    • Moderate to severe:
    • 1. cloxacillin 1-2g IV Q6H x7-10/7
    • 2. cefazolin 1-2g IV Q8H x7-10/7

    • B-lactam allergy/MRSA:
    • 1. vancomycin 15mg/kg IV Q8-12H x7-10/7
    • *desired vancomycin trough= 15-20mg/L

    • Post-surgical= S. aureus, B-haemolytic streptococci (group A/B/C/G)
    • 1. cloxacillin 500mg PO QID x7-10/7
    • 2. cephalexin 500mg PO QID x7-10/7

    • B-lactam allergy/MRSA:
    • 1. clindamycin 300mg PO QID x7-10/7

    • Moderate to severe:
    • 1. cloxacillin 1-2g IV Q6H x7-10/7
    • 2. cefazolin 1-2g IV Q8H x7-10/7

    • Not post-partum, not surgical= S. aureus, anaerobes
    • 1. amoxi-clav 875mg PO BID x7-10/7
    • 2. clindamycin 300mg PO QID x7-10/7
  11. Animal Bites
    *irrigation and debridement necessary
    **primary closure not recommended if: puncture wounds, ≥ 12h post-injury
    ***cloxacillin, cephalexin/cefazolin, clindamycin and erythromycin NOT effective against Pasteurella spp or Eikenella spp
    • Cats= polymicrobial
    • Prophylaxis: only if within 12h
    • 1. amoxi-clav 875mg PO BID x3-5/7

    • B-lactam allergy:
    • 1. doxycycline 100mg PO BID x3-5/7 +/- metronidazole 500mg PO BID x3-5/7

    • Treatment: prolonged therapy required if associated with osteomyelitis (x4-6/52) or aseptic arthritis (x3-4/52)
    • 1. amoxi-clav 875mg PO BID x7-10/7
    • 2. cefuroxime axetil  500mg PO BID x7-10/7 +/- metronidazole 500mg PO BID x7-10/7

    • B-lactam allergy:
    • 1. doxycycline 100mg PO BID x7-10/7 +/- metronidazole 500mg PO BID x7-10/7
    • 2. clindamycin 300-450mg PO QID x7-10/7 +/- ciprofloxacin 500mg PO BID x7-10/7

    • Moderate:
    • 1. ceftriaxone 1-2g IV daily x7-10/7 + metronidazole 500mg PO BID x7-10/7

    • Severe/Limb-threatening:
    • 1. PIPTAZO 3.375g IV Q6H x10-14/7
    • 2. imipenem 500mg IV Q6H x10-14/7

    • Dogs= polymicrobial
    • Prophylaxis: infection rate= 20%
    • *prophylaxis within 12h if: moderate/severe, crush injury/edema, >50y/o, bone/joint involvement, injuries to hand/foot/face/genitalia, splenectomized patients, immunocompromised
    • 1. amoxi-clav 875mg PO BID x3-5/7

    • B-lactam allergy: 
    • 1. doxycycline 100mg PO BID x3-5/7 +/- metronidazole 500mg PO BID x3-5/7

    • Treatment: prolonged therapy required if associated with osteomyelitis (x4-6/52) or aseptic arthritis (x3-4/52)
    • 1. amoxi-clav 875mg PO BID x7-10/7
    • 2. cefuroxime axetil  500mg PO BID x7-10/7 +/- metronidazole 500mg PO BID x7-10/7

    • B-lactam allergy:
    • 1. doxycycline 100mg PO BID x7-10/7 +/- metronidazole 500mg PO BID x7-10/7
    • 2. clindamycin 300-450mg PO QID x7-10/7 +/- ciprofloxacin 500mg PO BID x7-10/7

    • Moderate:
    • 1. ceftriaxone 1-2g IV daily x7-10/7 + metronidazole 500mg PO BID x7-10/7

    • Severe/Limb-threatening:
    • 1. PIPTAZO 3.375g IV Q6H x10-14/7
    • 2. imipenem 500mg IV Q6H x10-14/7

    • Human bites= polymicrobial
    • *amoxi-clav is the DOC
    • **cloxacillin, cephalexin/cefazolin, clindamycin, and macrolides NOT effective against Eikenella spp
    • *risk factors for developing osteomyelitis: delay in initial debridement, inadequate debridement, primary closure of wound
    • Prophylaxis:
    • 1. amoxi-clav 875mg PO BID x3-5/7

    • B-lactam allergy: 
    • 1. doxycycline 100mg PO BID x3-5/7 +/- metronidazole 500mg PO BID x3-5/7

    • Treatment: prolonged therapy required if associated with osteomyelitis (x4-6/52) or aseptic arthritis (x3-4/52)
    • 1. amoxi-clav 875mg PO BID x7-10/7
    • 2. cefuroxime axetil  500mg PO BID x7-10/7 +/- metronidazole 500mg PO BID x7-10/7

    • B-lactam allergy:
    • 1. doxycycline 100mg PO BID x7-10/7 +/- metronidazole 500mg PO BID x7-10/7
    • 2. clindamycin 300-450mg PO QID x7-10/7 +/- ciprofloxacin 500mg PO BID x7-10/7

    • Moderate:
    • 1. ceftriaxone 1-2g IV daily x7-10/7 + metronidazole 500mg PO BID x7-10/7

    • Severe/Limb-threatening:
    • 1. PIPTAZO 3.375g IV Q6H x10-14/7
    • 2. imipenem 500mg IV Q6H x10-14/7
  12. Diabetic Foot Infection
    *osteomyelitis is more likely if: ulcer>2cm2, exposed bone or ulcer overlies bony prominence, positive probe to bone, ESR>60, abnormal plain x-ray
    **P. aeruginosa Tx if: tropical/warm climate, soaking of feet, failed nonpseudomonal therapy, limb-threatening infection
    ***MRSA coverage if: previous (prior 12 months)/current colonization/infection with MRSA, recent ANTX use, recent hospitalization
    Simple cellulitis: see Cellulitis

    • Ulcer, Drainage, Fistula= polymicrobial
    • *if osteomyelitis, treat x6/52
    • Mild:
    • 1. cephalexin 500mg PO QID x7-14/7 + metronidazole 500mg PO BID x7-14/7
    • 2. amoxiclav 875mg PO BID x7-14/7
    • 3. doxycycline 100mg PO BID x7-14/7 + metronidazole 500mg PO BID x7-14/7
    • 4. cefazolin 2g IV Q8H x7-14/7 + metronidazole 500mg PO BID x7-14/7

    • MRSA suspected:
    • 1. doxycycline 100mg PO BID x7-14/7 + metronidazole 500mg PO BID x7-14/7 
    • 2. OR add TMP/SMX 2 DS PO BID x7-14/7 to mild Tx

    • Moderate-Severe: 
    • 1. clindamycin 600mg IV Q8H x2-3/52 + ciprofloxacin 750mg PO BID x2-3/52
    • 2. clindamycin 300-350mg PO QID x2-3/52 + ciprofloxacin 750mg PO BID x2-3/52

    • Outpatient and failure of oral therapy or known/suspected ESBL/Amp C-producing organisms:
    • 1. Ertapenem 1g IV daily x2-3/52
    • *ertapenem doesn't cover P. aeruginosa or Enterococcus spp.

    • MRSA suspected moderate-severe:
    • 1. vancomycin 15mg/kg IV Q8-12H x2-3/52 + ceftriaxone 1-2g IV daily x2-3/52 + metronizadole 500mg PO/IV Q12H x2-3/52
    • *desired vancomycin trough= 15-20mg/L
    • **If known/suspected P. aeruginosa, use ciprofloxacin or ceftazidime instead of ceftriaxone

    • Limb-threatening:
    • 1. PIPTAZO 3.375g IV Q6H x2-3/52 + vancomycin 15mg/kg IV Q8-12H x2-3/52
    • 2. imipenem 500mg IV Q6H x2-3/52 + vancomycin 15mg/kg IV Q8-12H x2-3/52
    • *if P. aeruginosa cultured, use PIPTAZO 4.5g IV Q6H if renal function allows
    • **use imipenem if known/suspected ESBL/Amp C-producing organisms
  13. Pressure/decubitus ulcers/ulcers 2o to PVD

    *TOP ANTX= no proven evidence
    **No evidence of infection= local wound management (ie. cleansing, debridement, dressing)
    ***evidence of infection: cellulitis, regional adenopathy, extensive ulceration, fever
    ****MRSA coverage if: previous (prior 12 months)/current colonization/infection with MRSA, recent ANTX use, recent hospitalization
    • Mild:
    • *if osteomyelitis, treat x6/52
    • 1. cephalexin 500mg-1g PO QID x7-14/7 + metronidazole 500mg PO BID x7-14/7
    • 2. amoxi-clav 875mg PO BID x7-14/7
    • 3. doxycycline 100mg PO BID x7-14/7 + metronidazole 500mg PO BID x7-14/7

    • MRSA suspected:
    • 1. doxycycline 100mg PO BID x7-14/7 + metronidazole 500mg PO BID x7-14/7 
    • 2. OR add TMP/SMX 1-2 DS PO BID to mild Tx

    • Moderate-Severe:
    • 1. clindamycin 300-450mg PO QID x2-3/52 + ciprofloxacin 750mg PO BID x2-3/52

    For parenteral regimens, see Diabetic foot infection.
  14. Post-operative wounds (SSI)
    *fever in the first 48h post-op unlikely to represent wound infection
    **most important Tx= incision, pus drainage, dressing changes
    *** little evidence in the use of ANTX in mild SSI
    • Involving trunk, neck, head, extremity= S. aureus/MRSA, Group A Streptococci
    • Mild (<5cm erythema/induration):
    • Temp<38.5oC and pulse <100BPM: 
    • 1. local management. No ANTX required.

    • Temp>38.5oC or pulse>100BPM:
    • 1. cephalexin 500mg PO QID x24-48h
    • *add SMX/TMP or doxycycline if MRSA suspected

    • B-lactam allergy:
    • 1. clindamycin 300mg PO QID x24-48h
    • *add SMX/TMP or doxycycline if MRSA suspected

    • Moderate-Severe:
    • 1. cefazolin 1-5g IV Q8H x7-10/7
    • *add SMX/TMP or doxycycline if MRSA suspected
    • **switch to PO after 48-72h if clinical improvement

    • B-lactam allergy/MRSA suspected:
    • 1. vancomycin 15mg/kg IV Q8-12H x7-10/7
    • *desired trough= 15-20mg/L

    • Involving perineum, GI tract, female genital tract, axilla= polymicrobial (S. aureus/MRSA, B-haemolytic Steptococci group A/B/C/G, Enterococcus spp., Enterobacteriaceae, Anaerobes)
    • *all regimens= 5-10/7 or until patient afebrile and wound granulating
    • **anaerobic coverage recommended
    • ***cephalosporin and clindamycin have no activity against Enterococcus spp.
    • Mild:
    • 1. amoxi-clav 875mg PO BID 
    • *add SMX/TMP or doxycycline if MRSA suspected

    • B-lactam allergy:
    • 1. clindamycin 300mg PO QID + ciprofloxacin 500-750mg PO BID
    • *add SMX/TMP or doxycycline if MRSA suspected

    • B-lactam allergy and MRSA suspected:
    • 1. clindamycin 300mg PO QID + SMX/TMP 1-2 DS PO BID

    • Moderate:
    • 1. cefazolin 2g IV Q8H + metronidazole 500mg PO BID
    • *add SMX/TMP or doxycycline if MRSA suspected
    • **switch to PO after 48-72h if clinical improvement

    • Severe:
    • 1. PIPTAZO 3.375g IV Q6H
    • *switch to PO after 48-72h if clinical improvement

    • Severe and MRSA suspected:
    • 1. PIPTAZO 3.375 IV Q6H + vancomycin 15mg/kg IV Q8-12H
    • *desired vancomycin trough= 15-20mg/L
    • **switch to PO after 48-72h if clinical improvement
  15. Rapidly progressive skin and soft tissue infections
    *predisposing factors: trauma/surgery, immunosuppression/malignancy, DM, chronic renal/hepatic disease, chicken pox, IVDU
    **early clinical findings: pain out of proportion to appearance, swelling, cellulitis, fever, tachycardia, induration, areas of anesthesia in affected skin
    ***late clinical findings: severe pain, skin discoloration (purple or black), blistering, hemorrhagic bullae, crepitus, "dishwater" gray drainage, systemic inflammatory response syndrome (SIRS)/sepsis, multi-organ failure/shock
    • Management:
    • S. pyogenes (Group A Strep):
    • 1. clindamycin 600-900mg IV Q8H x10-14/7 + ceftriaxone 2g IV daily x10-14/7

    • MRSA suspected:
    • 1. ADD vancomycin 15mg/kg IV Q8-12h to above
    • *desired trough: 15-20mg/L
    • 2. linezolid 600mg IV/PO Q12H x10-14/7 + ceftriaxone 2g IV daily x10-14/7

    • Polymicrobial:
    • 1. PIPTAZO 4.5g IV Q6H + linezolid 600mg IV/PO Q12H x10-14/7 OR vancomycin 15mg/kg Q8-12H x10-14/7
    • *if Vibrio suspected, add doxycycline
    • **if P. aeruginosa suspected, use regimen containing PIPTAZO, or imipenem

    • Necrotizing fasciitis/myositis, culture proven:
    • *use of IV immune globulin (1-2g/kg/d x2/7) could be considered if streptococcal toxic shock also present
    • S. pyogenes (Group A Strep): 
    • 1. clindamycin 600-900mg IV Q8H x10-14/7 + penicillin 4MU Q4H x10-14/7

    • S. agalactiae (Group B Strep), Group C/G strep, S. pneumoniae:
    • 1. clindamycin 600-900mg IV Q8H x10-14/7 + ceftriaxone 2g IV daily
    • *if penicillin MIC≤0.12ug/mL, switch ceftriaxone to penicillin

    • MSSA:
    • 1. clindamycin 600-900mg IV Q8H x10-14/7 + cloxacillin 2g IV Q4H x10-14/7

    • MRSA:
    • 1. vancomycin 15mg/kg IV Q8-12H x10-14/7
    • *desired trough= 15-20mg/L
    • 2. linezolid 600mg PO/IV Q12H x10-14/7 + clindamycin 600-900mg IV Q8H x10-14/7

    • Synergistic necrotizing cellulitis, Fournier's gangrene= polymicrobial (anaerobes, S. aureus/MRSA, Group A Streptococci, Enterobacteriaceae):
    • 1. imipenem 1g IV Q6H x10-14/7 +/- vancomycin 15/mg IV Q8-12H x10-14/7
    • *add vancomycin if MRSA suspected: previous (prior 12/12)/current MRSA colonization or infection, recent ANTX use, recent hospitalization
    • **desired vancomycin trough= 15-20mg/L

    • Gas gangrene= Clostridium spp.:
    • 1. clindamycin 600-900mg IV Q8H x10-14/7 + penicillin 4MU Q4H x10-14/7
    • 2. imipenem 1g IV Q6H x10-14/7

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