IDSA Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections

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CONTINUE CLASSIFICATION

D) Infectious Diseases Society of America (IDSA) Classification :

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1- Superficial uncomplicated infection

(impetigo and cellulitis)

2- Necrotizing infection

3- Surgical site infections

4- Infections in the immunocompromised host.

I) The Appropriate Evaluation and Treatment Of Purulent Skin Lesions:

Cont.

Strong recommended for:

- Incision and drainage is the main treatment for mild inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles .

- The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage in moderate and sever cases should be made based upon presence or absence of SIRS, such as temperature >38°C or 24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12 000 or < 4000 cells/µL And adding agents active against MRSA is recommended for patients who have failed initial antibiotic treatment or in patients with SIRS and hypotension.

I) The Appropriate Evaluation and Treatment Of Purulent Skin Lesions:

Cont.

Strong recommended for:

- Recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst or foreign material (moderate).

- Recurrent abscesses should be drained and cultured early in the course of infection (moderate).

- Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood (moderate).

** Weak recommended to Consider decolonization agents and daily decontamination of personal items for recurrent S. aureus.

II) The Appropriate Evaluation and Treatment of Non-Purulent Skin Lesions:

Cont.

Strong recommended for:

- Not routinely Cultures of blood or cutaneous aspirates, biopsies, or swabs in non-purulent except blood cultures are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, and animal bites

- Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci, and in patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, or SIRS (severe) antimicrobial effective against both MRSA and streptococci is recommended (moderate).

II) The Appropriate Evaluation and Treatment

of Non-Purulent Skin Lesions:

Cont.

Strong recommended for:

- The duration of antimicrobial therapy is 5 days, but should be extended if the infection has not improved.

- Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended .

- Outpatient therapy for patients who do not have SIRS, altered mental status & HD stable and Hospitalization if there is concern for necrotizing infection, poor adherence to therapy, immunocompromised patient.

** weak recommendation for prophylactic antibiotics in pateint with recurrent cellulitis .

III) The Evaluation and Treatment of Necrotizing Fasciitis, Including Fournier Gangrene

Cont.

Strong recommended for

- urgent surgical consultation for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene .

- Broad spectrum empiric antibiotic t (eg, vancomycin or linezolid plus piperacillin-tazobactam or a carbapenem) as the etiology can be polymicrobial or monomicrobial .

Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis .

IV) The Preferred Management of Surgical Site Infections

Cont.

Strong recommended for

- Suture removal plus incision and drainage should be performed for surgical site infections.

- A first-generation cephalosporin or an antistaphylococcal penicillin for MSSA, or vancomycin, linezolid or daptomycin where risk factors for MRSA are high or Agents active against gram-negative bacteria and anaerobes following operations on the axilla, GI tract, perineum, or female genital tract.

V) The Appropriate Approach to Assess SSTIs in Immunocompromised Patients:

Cont.

Strong recommended for :

- Search for another differential diagnosis in addition to infection, e.g. drug eruption, and cutaneous infiltration with the underlying malignancy and graft-vs-host disease among allogeneic transplant recipients

- aggressively determine the etiology of the SSTI by aspiration and/or biopsy of skin and soft tissue lesions and submit these for thorough cytological/histological assessments, microbial staining, and cultures .

V) The Appropriate Approach to Assess SSTIs in Immunocompromised Patients:

Cont.

Strong recommended for :

- In Patients With Fever and Neutropenia to determine whether the current presentation is the patient’s initial episode or a recurrent episode (low) .

In initial febrile neutropenia to hospitalization and empiric antibacterial therapy with vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem and tazocin is recommended and the treatment duration for most bacterial SSTIs should be 7–14 days (high).

- In recurrent or persistent febrile neutropenia yeasts and molds remain the primary cause of infection therefore empiric antifungal therapy should be added to the antibacterial regimen (high).

V) The Appropriate Approach to Assess

SSTIs in Immunocompromised Patients:

Cont.

Strong recommended for:

- Acyclovir should be administered to patients suspected or confirmed to have cutaneous or disseminated varicella zoster virus infection .

- In Patients With Cellular Immunodeficiency the use of specific agents should be decided by multidisciplinary teams (primary team, dermatology, infectious disease, and other consulting teams .

Cont.