In the management of patients with SSTI, the site of care decision will depend on disease severity and social factors. Many patients without systemic signs of infection or unstable comorbidities may be managed safely as outpatients or with a brief stay in an observation unit. 2,3
An important component in the diagnosis of SSTI is establishing the severity of disease and the subsequent site of care decision. In addition to clinical judgment, severity scoring systems can assist clinicians in selecting the optimal site of care and may help avoid unnecessary hospital admissions, thereby reducing treatment costs and the risk of hospital-associated complications.3,4 Although not incorporated into current treatment SSTI treatment guidelines, the ERON criteria classifies SSTIs according to the severity of local and systemic signs and symptoms of infection, and the presence and stability of any comorbidities. The ERON criteria may serve as a useful guide to admission and treatment decisions for patients with SSTI.4,5
COPD, chronic obstructive pulmonary disease; OPAT, outpatient parenteral antimicrobial therapy; SIRS, systemic inflammatory response syndrome
Outpatient therapy is recommended for patients who do not have systemic inflammatory response syndrome, altered mental status, or hemodynamic instability.3 Hospitalization is recommended if there is concern for a deeper or necrotizing infection, or if patients have poor adherence to therapy, have failed outpatient therapy, or are severely immunocompromised.3
The microbial etiology of SSTI is usually unknown upon initial patient presentation. Treatment guidelines recommend empiric antibiotic regimens with a spectrum of activity against the most common pathogens.3 S. aureus, including methicillin-resistant S. aureus (MRSA), is the most common pathogen in purulent infections, whereas β-hemolytic streptococci including Streptococcus pyogenes are the most common pathogens in non-purulent infections.6,7
The IDSA SSTI treatment guidelines incorporate the presence or absence of purulence, along with clinical status. Patients with SSTI should be treated with empiric antibiotics along with local debridement or drainage when indicated.1-3
For patients with mild to moderate non-purulent infections, empiric treatment with an antibiotic with activity against streptococci is recommended. Patients with severe infections should receive broad-spectrum antibiotics along with surgical evaluation for necrotizing infection.3
Non-Purulent Infections (Cellulitis, Erysipelas, Necrotizing Infection) | |
|---|---|
| Recommended Treatment Regimen | |
| Mild disease |
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| Moderate disease |
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| Severe disease |
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For mild purulent infections, incision and drainage is indicated. For patients with moderate to severe purulent infections empiric treatment with an antibiotic with activity versus Methicillin-sensitive Staphylococcus aureus (MSSA) is recommended. Empiric antibiotic may be adjusted based on culture and sensitivity results especially if MSSA is isolated.3
Purulent Infections (Furuncle, Carbuncle, Abscess, Wound) | |
|---|---|
| Recommended Treatment Regimens | |
| Mild disease |
|
| Moderate disease |
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| Severe disease |
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The choice of antibiotic is in influenced by infection type and likely pathogens, local resistance patterns and patient characteristics.1-3 Important infection characteristics and patient conditions such as site of infection, allergy history, and renal or hepatic impairment should also inform the antibiotic choice and dosing. The choice of antibiotics should also seek to minimize the potential for treatment-related toxicities and collateral damage including Clostridioides difficile infection.3,8,9,10
The 2014 IDSA guideline for SSTIs predates the FDA approval of several newer antibiotics for the treatment of SSTI, which may offer alternatives in treating resistant organisms.3,11,12
The 2020 Surgical Infection Society Guideline recommends newer oral antibiotics as potential alternative treatment options for suspected or confirmed MRSA in complicated SSTIs including ABSSSI.13
For mild infections in the outpatient setting, 5 to 10 days of therapy is recommended. For patients hospitalized with more severe infections, 7 to 14 days of therapy is recommended.13 Patients should be treated with antibiotics for the shortest effective duration to minimize the potential for treatment-related adverse effects.8,9 Approved prescribing information should be consulted for dosing recommendations on individual agents.
Clinicians should routinely re-evaluate the empiric antibiotic regimen and de-escalate and/or transition from intravenous to oral antibiotics as new clinical and microbiological information becomes available and when clinically appropriate.1
