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Skin and Soft Tissue Infections

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Treatment 4 Erysipelas and Cellulitis Î Cultures of blood or cutaneous aspirates, biopsies, or swabs are NOT routinely recommended (SR-M). Î Cultures of blood are recommended (SR-M), and cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (WR-M). Î Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci (See Fig. 1/Nonpurulent/MILD) (SR-M). For cellulitis with systemic signs of infection (See Fig. 1/Nonpurulent/MODERATE) systemic antibiotics are indicated. Many clinicians could include coverage against methicillin-susceptible S. aureus (MSSA) (WR-L). For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (See Fig. 1/Nonpurulent/SEVERE), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (SR-M). In severely compromised patients as defined above (See Fig. 1/Nonpurulent/SEVERE) broad-spectrum antimicrobial coverage may be considered (WR-M). Vancomycin plus either piperacillin-tazobactam or imipenem/meropenem is recommended as a reasonable empiric regimen for severe infections (SR-M). Î The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period (SR-H). Î Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended (SR-M). Î In lower extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection (SR-M). Î Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (See Fig. 1/ Nonpurulent/MILD) (SR-M). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient or if outpatient treatment is failing (See Fig. 1/Nonpurulent/ MODERATE or SEVERE) (SR-M).

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