Introduction
Classifications
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Class 1 patients with SSTI, but no signs or symptoms of systemic toxicity or co-morbidities.
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Class 2 patients are either systemically unwell with stable co-morbidities or systemically well, but with comorbidity (e.g., diabetes, obesity) that may complicate or delay resolution.
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Class 3 patients appear toxic and unwell (fever, tachycardia, tachypnoea, and/or hypotension).
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Class 4 patients have sepsis syndrome and life-threatening infection; for example, necrotizing fasciitis.
Principles of treatment
Principles of antibiotic therapy
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Minocycline 100 mg every 12 h
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Trimethoprim and sulfamethoxazole 160/800 or 320/1600 every 12 h
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Doxycycline 100 mg every 12 h
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Clindamycin 300–450 mg every 8 h (high resistance rate)
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Linezolid 600 mg every 12 h
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Tedizolid 200 mg every 24 h
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Clindamycin 600–900 mg every 8 h
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Trimethoprim and sulfamethoxazole 320/1600 every 12 h
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 12 h
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Tigecycline 100 mg IV as a single dose, then 50 mg IV every 12 h
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Linezolid 600 mg every 12 h
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Daptomycin 6 mg/kg every 24 h
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Ceftaroline 600 mg every 12 h
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Dalbavancin 1000 mg once followed by 500 mg after 1 week or 1500 mg one dose
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Tedizolid 200 mg every 24 h
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Telavancin 10 mg/kg every 24 h
Principles of source control
Simple abscess
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Incision and drainage
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Antibiotic therapy only in selected patients for 5 days. You may extend therapy up to 7–10 days if lack of symptom resolution at 5 days
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One of the following oral antibiotics
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Amoxicillin-clavulanate 1 g every 8 h
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Cephalexin 500 mg every 6 h
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In patients at risk for CA-MRSA including immunocompromised status, personal or household contact with MRSA infection or colonization in the past 12 months, with prior antibiotic use for 5 days during the last 90 days or who do not respond to first-line therapy add one of the following oral antibiotics
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Minocycline 100 mg every 12 h
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Doxycycline 100 mg every 12 h
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Trimethoprim and Sulfamethoxazole 160/800 mg every 12 h
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In patients with beta-lactam allergy
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Clindamycin 300 mg every 8 h
Erysipelas
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In erysipelas the lesions are raised above the level of the surrounding skin, and
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Erysipelas is characterized by a clear line of demarcation between involved and uninvolved tissue.
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Antibiotic therapy for 5 days. You may extend therapy up to 10 days if lack of symptom resolution at 5 days
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Use intravenous antibiotics if signs of systemic inflammation
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Target Pathogens: S. aureus and streptococci, CA-MRSA is unusual.
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One of the following oral antibiotics
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Amoxicillin-clavulanate 1 g every 8 h
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Cephalexin 500 mg every 6 h
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In patients at risk for CA-MRSA including immunocompromised status, personal or household contact with MRSA infection or colonization in the past 12 months, with prior antibiotic use for 5 days during the last 90 days or who do not respond to first-line therapy add one of the following oral antibiotics
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Trimethoprim and sulfamethoxazole 160/800–320/1600 mg every 12 h
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Minocycline 100 mg every 12 h
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Doxycycline 100 mg every 12 h
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In patients with beta-lactam allergy
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Clindamycin 300 mg every 8 h
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One of following intravenous antibiotics
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Cefazolin 2 g every 8 h
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Amoxicillin-clavulanate 1.2/2.2 gr every 8 h
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In patients at risk for CA-MRSA including critically ill and immunocompromised status, personal or household contact with MRSA infection or colonization in the past 12 months, with prior antibiotic use for 5 days during the last 90 days or who do not respond to first-line therapy add one of following intravenous antibiotics
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 12 h
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Linezolid 600 mg every 12 h
Cellulitis
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Antibiotic therapy for 5 days. You may extend therapy up to 7-10 days if lack of symptom resolution at 5 days.
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Incision and drainage in purulent cellulitis
Typical (non-purulent) cellulitis
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Target Pathogens: S. aureus and streptococci, CA-MRSA is unusual.
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One of the following oral antibiotics
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Amoxicillin-clavulanate 1 g every 8 h
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Cephalexin 500 mg every 6 h
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In patients at risk for CA-MRSA including immunocompromised status, personal or household contact with MRSA infection or colonization in the past 12 months, with prior antibiotic use for 5 days during the last 90 days, with cellulitis associated with penetrating trauma especially from illicit drug use or who do not respond to first-line therapy add one of the following oral antibiotics
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Trimethoprim and sulfamethoxazole 160/800–320/1600 mg every 12 h
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Minocycline 100 mg every 12 h
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Doxycycline 100 mg every 12 h
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In patients with beta-lactam allergy
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Clindamycin 300 mg every 8 h
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One of following intravenous antibiotics
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Cefazolin 2 g every 8 h
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Amoxicillin-clavulanate 1.2/2.2 gr every 8 h
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In patients at risk for CA-MRSA including critically ill and immunocompromised status, personal or household contact with MRSA infection or colonization in the past 12 months, with prior antibiotic use for 5 days during the last 90 days, with cellulitis associated with penetrating trauma especially from illicit drug use or who do not respond to first-line therapy one of the following intravenous antibiotics
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 12 h
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Linezolid 600 mg every 12 h
Purulent cellulitis
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Target Pathogen: S. aureus including CA-MRSA.
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One of the following oral antibiotics
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Amoxicillin-clavulanate 1 g every 8 h
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Cephalexin 500 mg every 6 h
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In a region or a population with a high prevalence of CA-MRSA, where > 10% of clinical S. aureus isolates are MRSA isolates or in patients at high risk for CA-MRSA
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Trimethoprim and sulfamethoxazole 160/800–320/1600 mg every 12 h
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Minocycline 100 mg every 12 h
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Doxycycline 100 mg every 12 h
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One of the following intravenous antibiotics
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 12 h
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Linezolid 600 mg every 12 h
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In patients at risk for Gram-negative infections or severe forms who do not respond to first-line therapy consider
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Piperacillin/tazobactam 4,5 g every 6 h.
Perianal and perirectal abscesses
Diagnosis
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CT
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EUS
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Incision and drainage + antibiotic therapy for 5 days in selected patients. You may extend therapy up to 7–10 days if lack of symptom resolution at 5 days.
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In perianal and perirectal abscesses identification of eventual fistula tract, and either proceed with primary fistulotomy to prevent recurrence (only in cases of low fistula not involving the sphincter muscle) or place a draining seton for future consideration. Fistulotomy can risk continence if too extensive and placement of seton should only be performed if the tract and openings are very clear, as there is risk of creating a false internal orifice and complicating the condition.
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Target Pathogen: Gram-positive and Gram-negative
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One of the following antibiotics
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Amoxicillin/clavulanate 1 g every 8 h
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In patients with beta-lactam allergy
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Ciprofloxacin 500 mg every 8 h + Metronidazole 500 mg every 8 h
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In patients at risk for CA-MRSA or who do not respond to first-line therapy add one of following oral antibiotics
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Minocycline 100 mg every 12 h
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Trimethoprim and sulfamethoxazole 160/800–320/1600 mg every 12 h
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Doxycycline 100 mg every 12 h
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One of following intravenous antibiotics
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Ceftriaxone 2 g every 24 h + Metronidazole 500 mg every 8 h
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Cefotaxime 2 g every 8 h + Metronidazole 500 mg every 8 h
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Piperacillin/tazobactam 4,5 g every 6 h
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In patients with beta-lactam allergy
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Ciprofloxacin 400 mg every 8 h + Metronidazole 500 mg every 8 h
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In patients at risk for CA-MRSA or who do not respond to first-line therapy add one of following intravenous antibiotics
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 12 h
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Linezolid 600 mg every 12 h
Infections developing in damaged skin
Bite wounds (animal and human bites)
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Irrigation of the wound and debridement of necrotic tissue
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Antibiotic prophylaxis as principle is not recommended. It is recommended in selected patients.
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Antibiotic therapy in selected patients for 5 days. You may extend therapy up to 7–10 days if lack of symptom resolution at 5 days.
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Tetanus prophylaxis in bite wounds
Pressure ulcers
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Prevention by pressure redistribution devices such as high‐specification foam mattresses or cushions, or both and by frequent patient repositioning
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Debridement of devitalized tissue and biofilm and abscess drainage
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Appropriate selection of dressings and topical agents
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Routine use of systemic antibiotics is not currently recommended for the treatment of uninfected pressure ulcers. Systemic antibiotics should be administered only when there are systemic signs of inflammation (serious infection), spreading cellulitis (deep skin infection) or underlying osteomyelitis.
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Medical and nutritional patient optimization
Burn wounds
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Early initiation of dressings and effective topical antimicrobial therapy
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Daily inspection of the wounds by a qualified surgeon or wound care expert
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Early excision of all full thickness and deep partial thickness burns
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Systemic antibiotic for infected wounds
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Graft and coverage options
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Target Pathogen: Gram-positive and Gram-negative
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One of the following antibiotics
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Amoxicillin/clavulanate 1 g every 8 h
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In patients with beta-lactam allergy
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Ciprofloxacin 500 mg every 12 h + Metronidazole 500 mg every 8 h
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First-generation cephalosporins, such as cephalexin, penicillinase-resistant penicillins, macrolides such as erythromycin, and clindamycin, all have poor in vitro activity against Pasteurella multocida and should be avoided in animal bites.
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In patients at risk for CA-MRSA or who do not respond to first-line therapy add
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One of following oral antibiotics
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Minocycline 100 mg every 12 h
-
Trimethoprim and sulfamethoxazole 160/800–320/1600 mg every 12 h
-
Doxycycline 100 mg every 12 h
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One of following intravenous antibiotics
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Ceftriaxone 2 g every 24 h + Metronidazole 500 mg every 8 h
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Cefotaxime 2 g every 8 h + Metronidazole 500 mg every 8 h
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Piperacillin/tazobactam 4,5 g every 6 h
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In patients with beta-lactam allergy
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Ciprofloxacin 200 mg every 8 h + Metronidazole 500 mg every 8 h
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In patients at risk for CA-MRSA or who do not respond to first-line therapy add
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 12 h
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Linezolid 600 mg every 12 h
Necrotizing infections
Diagnosis
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Edema
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Erythema
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Severe and crescendo pain out of proportion
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Skin bullae or necrosis (at a later stage)
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Swelling or tenderness
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Crepitus
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Fever
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Tachycardia
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Hypotension
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Shock
Variable (units) | Score points |
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C-reactive protein (CRP) (mg/L) | |
< 150 | 0 |
≥ 150 | 4 |
White blood cell count (per mm3) | |
< 15 | 0 |
15–25 | 1 |
> 25 | 2 |
Hemoglobin (g/dl) | |
> 13.6 | 0 |
11–13.5 | 1 |
< 10.9 | 2 |
Serum sodium (mmol/L) | |
≥ 135 | 0 |
< 135 | 2 |
Serum creatinine (mg/dl) | 0 |
≤ 1.6 | 0 |
> 1.6 | 2 |
Serum glucose (mg/dl) | |
≤ 180 | 0 |
> 180 | 1 |
Imaging
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CT
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MRI
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US
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Fascial biopsy with frozen section
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Finger test
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Surgical source control as soon as possible within 6 h after admission. Delay in early surgical increases mortality.
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Appropriate and effective debridement techniques. Skin-sparing debridement techniques focusing on tissue directly involved in necrosis.
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Re-explorations should be repeated until the time when very little or no debridement is required.
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Empiric antibiotic therapy optimizing Pharmacokinetics (PK) and Pharmacodynamics (PD) targets.
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Deep samples collected at the interface between healthy and necrotized tissues during initial debridement and blood cultures allow the identification of causative pathogens in most cases.
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De-escalation of antibiotic therapy be based on clinical improvement, cultured pathogens, and results of rapid diagnostic tests where available
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(Organ) supportive measures
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Hyperbaric oxygen therapy where it is available
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Intravenous immunoglobulin (IVIG) in patients with streptococcal NSTIs
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As soon as possible after diagnosing sepsis (organ dysfunctions) associated with a NSTI, administer a 1-L bolus of a balanced crystalloid solution over 30 min. In hypotensive patients or those with an elevated serum lactate level additional fluid should be administered to achieve 30 ml/kg of initial volume resuscitation. This should be administered within 3 h.
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In patients who do not achieve a MAP ≥ 65 mmHg with initial volume resuscitation within one hour, start a norepinephrine infusion and titrate as needed. This can initially be administered through a peripheral IV while central venous access is being obtained.
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Simultaneously, administer within 1-h broad spectrum antimicrobial agent(s) to cover potential pathogens.
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If the norepinephrine infusion increases to ≥ 15 mg/min, add low dose vasopressin at infusion rate of 0.03 U/min. Do not increase this dose of vasopressin.
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Start low dose steroids (hydrocortisone 50 mg q 6 h) in patients requiring ongoing high doses of norepinephrine and vasopressin to achieve MAP ≥ 65 mmHg.
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Additional fluid resuscitation (beyond the initial 30 ml/kg) will likely be needed but should be based on the assessment that the patient will be fluid responsive.
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Patients with impaired cardiac function should inotropic agent started. Dobutamine is the preferred agent but will cause hypotension in hypovolemic patients.
New agents to treat NSTIs
Wound management after source control
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One of the following antibiotics
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Amoxicillin/clavulanate 1.2/2.2 g every 8 h
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Ceftriaxone 2 g every 24 h + Metronidazole 500 mg every 8 h
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Cefotaxime 2 g every 8 h + Metronidazole 500 mg every 8 h
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+
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Clindamycin 600–900 mg every 8 h
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One of the following antibiotics
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Piperacillin/tazobactam 4.5 g every 6 h
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Meropenem 1 g every 8 h
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Imipenem/Cilastatin 500 mg every 6 h
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+
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One of the following antibiotics
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Linezolid 600 mg every 12 h
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Tedizolid 200 mg every 24 h
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Another anti-MRSA-antibiotic as
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 8 h
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Daptomycin 6–8 mg/kg every 24 h *
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Telavancin 10 mg/kg every 24 h
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+
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Clindamycin 600–900 mg every 8 h
Fournier’s gangrene
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edema.
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Erythema.
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Severe and crescendo pain out of proportion.
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Skin bullae or necrosis (at a later stage).
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Swelling or tenderness.
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Crepitus.
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Fever.
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Tachycardia.
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Hypotension.
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Shock.
Physiological variables | + 4 | + 3 | + 2 | + 1 | 0 | + 1 | + 2 | + 3 | + 4 |
---|---|---|---|---|---|---|---|---|---|
Temperature (C) | > 41 | 39–40 | – | 38–39 | 36–38.4 | 34–35.9 | 32–33.9 | 30–31.9 | < 29.9 |
Heart rate (bpm) | > 180 | 140–179 | 110–139 | – | 70–109 | – | 55–69 | 40–54 | < 39 |
Respiratory rate | > 50 | 35–49 | – | 25–34 | 12–24 | 10–11 | 6–9 | – | < 5 |
Serum K + (mmol/L) | > 7 | 6–6.9 | – | 5.5–5.9 | 3.5–5.4 | 3–3.4 | 2.5–2.9 | – | < 2.5 |
Serum Na+ (mmol/L) | > 180 | 160–179 | 155–159 | 150–154 | 130–149 | – | 120–129 | 110–119 | < 110 |
Serum creatinine (mg/1000 ml) (× 2 for acute renal failure) | > 3.5 | 2–3.4 | 1.5–1.9 | – | 0.6–1.4 | – | < 0.6 | – | – |
Hemotocrit (%) | > 60 | – | 50–59 | 46–49 | 30–35 | – | 20–29 | − < 20 | |
WBC (mm3) | > 40 | – | 20–39.9 | 15–19 | 3–14.9 | – | 1.2.9 | – | < 1 |
Serum bicarbonate venous (mmol/L) | > 52 | 41–51 | – | 32–40 | 22–31 | – | 18–21 | 15–17 | < 15 |
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Surgical source control as soon as possible. Re-explorations should be repeated until the time when very little or no debridement is required.
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Diverting colostomy or rectal diversion devices
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Antibiotic therapy
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(Organ) supportive measures
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One of the following antibiotics
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Amoxicillin/clavulanate 1.2/2.2 g every 8 h
-
Ceftriaxone 2 g every 24 h + Metronidazole 500 mg every 8 h
-
Cefotaxime 2 g every 8 h + Metronidazole 500 mg every 8 h
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+
-
Clindamycin 600–900 mg every 8 h
-
One of the following antibiotics
-
Piperacillin/tazobactam 4.5 g every 6 h
-
Meropenem 1 g every 8 h
-
Imipenem/Cilastatin 500 mg every 6 h
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+
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One of the following antibiotics
-
Linezolid 600 mg every 12 h
-
Tedizolid 200 mg every 24 h
-
Another anti-MRSA-antibiotic as
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Vancomycin 25–30 mg/kg loading dose then 15–20 mg/kg/dose every 8 h
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Teicoplanin LD 12 mg/kg 12-hourly for 3 doses, then 6 mg/kg every 12 h
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Daptomycin 6–8 mg/kg every 24 h *
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Telavancin 10 mg/kg every 24 h
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+
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Clindamycin 600–900 mg every 8 h