10. Skin and Soft tissue

It is essential to assess the severity of local and systemic signs and symptoms of infection, and to identify the presence of any risk factors like diabetes, neutropenia, drug abuse, human or animal bite, etc.

Antibiotic treatment can be modified based on culture results in consultation with microbiology.

Cellulitis

For mild cases, minor systemic symptoms

Oral amoxicillin 500mg tds PLUS oral flucloxacillin 500mg qds

If penicillin allergic, oral Erymax 500mg bd or clindamycin 450mg qds

For moderate and severe cases, significant systemic symptoms

IV benzylpenicillin 1.2g every 4 hours PLUS IV flucloxacillin 2g qds

If penicillin allergic, IV clindamycin 450mg qds or IV clarithromycin 500mg bd

Treat intravenously for 3-5 days or until clinical improvement

For oral switch, see as per mild cases.

For Group A Streptococcal cellulitis

IV benzylpenicillin 1.2g every 4 hours PLUS IV clindamycin 450mg qds

If penicillin allergic, IV clindamycin 450mg qds

Switch to oral treatment when appropriate improvement in condition.

Oral amoxicillin 500mg tds PLUS oral clindamycin 450mg qds

In penicillin allergic patients, oral Erymax 500mg bd or clindamycin 450mg qds.

For Necrotising fasciitis

Life threatening infection; early Microbiology consultation and surgical intervention ESSENTIAL.

IV cefotaxime 2g qds PLUS IV clindamycin 450 - 600mg qds +/- gentamicin

If history of severe penicillin allergy, IV clindamycin 450 - 600mg qds PLUS IV/Oral ciprofloxacin +/- gentamicin

For Diabetic foot ulcers

Assessment of depth of ulcer and bone involvement CRUCIAL for determining the duration of antibiotic treatment. Infections tend to be polymicrobial. MRSA status is important in the choice of antibiotics. Refer to microbiology for advice on MRSA infection.

Mild

Treat as mild cellulitis

Severe

Flucloxacillin IV 2g qds plus amoxacillin IV 1g tds plus gentamicin OD (5mg/kg) (see protocol)

Then

Oral flucloxacillin 1g qds plus amoxicillin 500mg tds plus ciprofloxacillin 500-750mg BD

NOTE: Add metronidazole 400mg tds (oral) or 500mg (IV) if necrosis or anaerobic infection suspected

IIf penicillin allergic

Clindamycin IV 600mg qds plus gentamicin OD (5mg/kg) (see protocol) or ciprofloxacin 500mg bd

Then

Oral clindamycin 300-450mg qds PLUS oral ciprofloxacin 500-750mg every 12 hours

For severe infections treat initially with IV therapy for at least 3-5 days until clinical improvement. Treatment duration may be prolonged, from 2-6 weeks depending on severity.

For Animal and human bites

IV Co-amoxiclav 1.2gm tds

Oral Co-amoxiclav 375mg tds when appropriate.

If penicillin allergic, oral clindamycin 450mg qds PLUS oral ciprofloxacin 500mg bd