Skin and Soft Tissue Infections

 


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Am Fam Physician. 2015 Sep 15;92(6):474-483.

  Patient information: See related handout on skin and soft tissue infections, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Skin and soft tissue infections result from microbial invasion of the skin and its supporting structures. Management is determined by the severity and location of the infection and by patient comorbidities. Infections can be classified as simple (uncomplicated) or complicated (necrotizing or nonnecrotizing), or as suppurative or nonsuppurative. Most community-acquired infections are caused by methicillin-resistant Staphylococcus aureus and beta-hemolytic streptococcus. Simple infections are usually monomicrobial and present with localized clinical findings. In contrast, complicated infections can be mono- or polymicrobial and may present with systemic inflammatory response syndrome. The diagnosis is based on clinical evaluation. Laboratory testing may be required to confirm an uncertain diagnosis, evaluate for deep infections or sepsis, determine the need for inpatient care, and evaluate and treat comorbidities. Initial antimicrobial choice is empiric, and in simple infections should cover Staphylococcus and Streptococcus species. Patients with complicated infections, including suspected necrotizing fasciitis and gangrene, require empiric polymicrobial antibiotic coverage, inpatient treatment, and surgical consultation for debridement. Superficial and small abscesses respond well to drainage and seldom require antibiotics. Immunocompromised patients require early treatment and antimicrobial coverage for possible atypical organisms.

Skin and soft tissue infections (SSTIs) account for more than 14 million physician office visits each year in the United States, as well as emergency department visits and hospitalizations.1 The greatest incidence is among persons 18 to 44 years of age, men, and blacks.1,2 Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) accounts for 59% of SSTIs presenting to the emergency department.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Blood cultures seldom change treatment and are not required in healthy immunocompetent patients with SSTIs.

C

20

Uncomplicated purulent SSTIs in easily accessible areas without overlying cellulitis can be treated with incision and drainage only; antibiotic therapy does not improve outcomes.

C

29, 30

Inpatient treatment is recommended for patients with uncontrolled SSTIs despite adequate oral antibiotic therapy; those who cannot tolerate oral antibiotics; those who require surgery; those with initial severe or complicated SSTIs; and those with underlying unstable comorbid illnesses or signs of systemic sepsis.

C

3, 5

There is no evidence that any pathogen-sensitive antibiotic is superior to another in the treatment of MRSA SSTIs.

B

35

Treatment of necrotizing fasciitis involves early recognition and surgical debridement of necrotic tissue, combined with high-dose broad-spectrum intravenous antibiotics.

C

5


MRSA = methicillin-resistant Staphylococcus aureus ; SSTI = skin and soft tissue infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Blood cultures seldom change treatment and are not required in healthy immunocompetent patients with SSTIs.

C

20

Uncomplicated purulent SSTIs in easily accessible areas without overlying cellulitis can be treated with incision and drainage only; antibiotic therapy does not improve outcomes.

C

29, 30

Inpatient treatment is recommended for patients with uncontrolled SSTIs despite adequate oral antibiotic therapy; those who cannot tolerate oral antibiotics; those who require surgery; those with initial severe or complicated SSTIs; and those with underlying unstable comorbid illnesses or signs of systemic sepsis.

C

3, 5

There is no evidence that any pathogen-sensitive antibiotic is superior to another in the treatment of MRSA SSTIs.

B

35

Treatment of necrotizing fasciitis involves early recognition and surgical debridement of necrotic tissue, combined with high-dose broad-spectrum intravenous antibiotics.

C

5


MRSA = methicillin-resistant Staphylococcus aureus ; SSTI = skin and soft tissue infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN INFECTIOUS DISEASE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up.

American College of Emergency Ph

The Authors

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KALYANAKRISHNAN RAMAKRISHNAN, MD, is a professor of family and preventive medicine at the University of Oklahoma Health Sciences Center in Oklahoma City....

ROBERT C. SALINAS, MD, is an associate professor of family and preventive medicine at the University of Oklahoma Health Sciences Center.

NELSON IVAN AGUDELO HIGUITA, MD, is an assistant professor of infectious disease in the Internal Medicine Division at the University of Oklahoma Health Sciences Center.

Address correspondence to Kalyanakrishnan Ramakrishnan, MD, OUHSC, 900 NE 10th St., Oklahoma City, OK 73104 (e-mail: kramakrishnan@ouhsc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

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