CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: AMBULATORY

GUIDELINE (> 2 MONTHS)

Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

Impetigo: Non-Purulent c Ambulatory Care Purulent

use definitive skin Cellulitis, Erysipelas, Atopic No Purulent? Yes Actively draining pus, history
culture data if available Dermatitis with superinfectiong of drainage, abscess present

Consider ED/Admission if:

Isolated lesions, Numerous **Cephalexin Via ED Incision and drainage
not widespread? lesions, 25 mg/kg/dose PO TID • Systemic illness/signs (aspiration not recommended)e
widespread, of sepsis NO packing! • Consider ultrasound if
(max: 500 mg/dose)
or • Rapid progression Consider a indeterminate
household wound • Warm compresses and
Topical: • Barrier to outpt I+D stent/wick f
outbreaks? soaks 3–4x/day
Mupirocin Consider Direct Admit
Responsive? (call 612-343-2121) • Elevate if extremity
BID x 5 days
• Treatment failure on
No > 48 hours of
appropriate antibiotics
Treat with Clindamycin
• Further surgical eval
Clindamycin 10 mg/kg/dose PO TID
needed
10 mg/kg/dose PO (max 600 mg/dose), or
• Barrier to outpt
TID (max 600 mg/dose) May consider no antibiotics
Yes treatment
{preferred if atopic based on clinical assessment
dermatitisg} together with provider
OR discretion
TMP-SMX 5 mg • Shared Decision Makingh
Laboratory Studies
TMP/kg/dose PO BID Meta-analysis revealed that antibiotics
(max 160 mg/dose) Wound: targeted to MRSA coverage
Culture if antibiotics will be started demonstrated modest improved rates
for abscess OR if recurrent abscess of cure and recurrence versus no
antibiotics regardless of abscess size.
If vesicles: Consider concurrent HSV
Total duration: 5 days or VZV infection—pcr testing(g)
Blood: Routine lab studies and
cultures are not recommended in Total duration: 5 days
**For PCN/Cephalosporin allergy: Use Clindamycin well-appearing patients.(a)

EXCLUSION GUIDELINES:
Patients excluded from this guideline:
Discharge: Follow up with PCP in 2–4 days
• Bites, surgical site infections, foreign body (e.g. drain/line)
• Immunodeficiency *Recurrent Abscesses: Consider ID outpt referral
• Hand, groin, perianal, head/neck or significant lymphedema for MSSA/MRSA Decolonization education
• Necrotizing infection or critically ill

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 1
 CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: EMERGENCY
GUIDELINE (> 2 MONTHS)

Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

Impetigo: Non-Purulent c ED care Purulent

use definitive skin Cellulitis, Erysipelas, Atopic No Purulent? Yes Actively draining pus, history
culture data if available Dermatitis with superinfectiong of drainage, abscess present

Consider Admission if:

Isolated lesions, Numerous **Cephalexin Via ED Incision and drainage
not widespread? lesions, PO 25 mg/kg/dose TID • Systemic illness/signs (aspiration not recommended)e
widespread, of sepsis NO packing! • Consider ultrasound if
(max: 500 mg/dose)
or • Rapid progression Consider a indeterminate
household wound • Warm compresses and
Topical: • Treatment failure on stent/wick f
outbreaks? soaks 3–4x/day
Mupirocin > 48 hours of
Responsive? appropriate antibiotics • Elevate if extremity
BID x 5 days
• Further surgical eval
No needed
• Barrier to outpt
treatment  reat with Clindamycin
T
Clindamycin 10 mg/kg/dose PO TID
See inpatient guideline for
10 mg/kg/dose PO (max 600 mg/dose), or
workup and management
TID (max 600 mg/dose) if admitting May consider no antibiotics
Yes
{preferred if atopic based on clinical assessment
dermatitisg} together with provider
OR discretion
TMP-SMX 5 mg • Shared Decision Makingh
Laboratory Studies
TMP/kg/dose PO BID Meta-analysis revealed that antibiotics
(max 160 mg/dose) Wound: targeted to MRSA coverage
Culture if antibiotics will be started demonstrated modest improved rates
of cure and recurrence versus no
for abscess OR if recurrent abscess antibiotics regardless of abscess size.
If vesicles: Consider concurrent HSV
Total duration: 5 days or VZV infection — pcr testing(g)
Blood: Routine lab studies and
cultures are not recommended in Total duration: 5 days
**For PCN/Cephalosporin allergy: Use Clindamycin well-appearing patients.(a)

EXCLUSION GUIDELINES:
Patients excluded from this guideline:
Discharge: Follow up with PCP in 2–4 days
• Bites, surgical site infections, foreign body (e.g. drain/line)
• Immunodeficiency *Recurrent Abscesses: Consider ID outpt referral
• Hand, groin, perianal, head/neck or significant lymphedema for MSSA/MRSA Decolonization education
• Necrotizing infection or critically ill

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 2
 CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: INPATIENT
GUIDELINE (> 2 MONTHS)

Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

Non-purulentc Inpatient Yes

Purulent
No
Cellulitis, Erysipelas Purulent? Actively draining pus, history
of drainage, abscess present

**Cefazolin
33 mg/kg/dose IV q8h (max 2000 mg/dose) Incision and drainage
NO packing! (aspiration not recommended)e
Consider a • Consider ultrasound if
wound
*Lack of improvement or stent/wick f
indeterminate
Responsive?* No
with significant disease • Warm compresses and
progression after 48 hours soaks 3–4x/day
Yes of appropriate therapyd • Elevate if extremity
• Consider surgery consult
(Consider NPO status)
Cephalexin
25 mg/kg/dose PO TID (max 500 mg/dose)

No
Assess source Consult ID Clindamycin
control. Consider to collaborate on IV: 13 mg/kg/dose IV
Total duration: +5 days from further imaging antibiotic adjustment, (max 900 mg/dose); or
clinical improvement (e.g. repeat US). broadening
Revisit differential differential diagnosis
PO: 10 mg/kg/dose PO TID
diagnosis.b +/- work-up. (max 600 mg/dose)

Laboratory Studies
Wound:
Culture if antibiotics will be started for abscess OR if Adjust antibiotics Responsive?*
Consult surgery
recurrent abscess if treatment failure is if possible abscess.
If vesicles: Consider concurrent HSV or VZV infection — suspected. Use Suggest keeping Yes
pcr testing(g) culture results as able. NPO prior to
[Vancomycin 15 mg/kg/
Blood: Routine lab studies and cultures are not dose IV Q6h; Age 18+:
their anticipated
recommended in well-appearing patients.(a) 15–20 mg/kg/dose q12h] evaluation time. Total duration: +5 days from
clinical improvement
Narrow antibiotics according
EXCLUSION GUIDELINES: to culture results as able
Patients excluded from this guideline:
• Bites, surgical site infections, foreign body (e.g. drain/line)
• Immunodeficiency Discharge: Follow up with PCP in 2–4 days
• Hand, groin, perianal, head/neck or significant lymphedema *Recurrent Abscesses: Consider ID outpt referral
• Necrotizing infection or critically ill for MSSA/MRSA Decolonization education
**For PCN/Cephalosporin allergy: Use Clindamycin
Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 3
 CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: ANTIBIOTICS AND
GUIDELINE LOCAL DATA (> 2 MONTHS)
Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

TABLE 1: Preferred antibiotic choices for suspected pathogens — TABLE 2: Children’s Minnesota Data: Minneapolis and St. Paul Emergency Departments
Empiric Treatment 2018–2020 SSTI (wound, abscess, and skin cultures) • Attn: MSSA and MRSA
Group A Strep MSSA MRSA # tested Clindamycin % TMP-SMX % Doxycycline %
pyogenes 2019–2020
susceptible susceptible susceptible
1st line choice Cephalexin or Cephalexin or *Clindamycin MSSA 357 86 76 93
Cefazolin Cefazolin
MRSA 172 96 95 94
2nd line choice Clindamycin *Clindamycin Vancomycin
(failed treatment- or TMP-SMX All Staph aureus 529 89 82 94
narrow with culture 2018–2019
sensitivities)
MSSA 437 86 81 91
*Based on Children’s MN skin/wound culture sensitivities recommend
Clindamycin for presumptive MRSA MRSA 202 94 95 94
All Staph aureus 639 90 88 92

TABLE 3: Skin & Soft Tissue Infection Antibiotics

Age: < 18 yo Antibiotic Single dosing Route Interval Max dose (mg)
ED Non-purulent
Cephalexin (Keflex) 25 mg/kg PO TID 500
Clindamycin 10 mg/kg PO TID 600
TMP-SMX (Bactrim) 5 mg/kg PO BID 160
ED Purulent
Clindamycin 10 mg/kg PO TID 600
Inpatient Non-purulent
Cefazolin 33 mg/kg IV Every 8 hours 2,000
Inpatient Purulent
Clindamycin 10 mg/kg PO TID 600
Clindamycin 13 mg/kg IV Every 8 hours 900
TMP-SMX (Bactrim) 5 mg/kg PO BID 160
Age: 18+
Cephalexin (Keflex) 500 mg PO 4x/day 500
Clindamycin 450 mg; or 600 mg PO 4x/day; or TID 600 (TID dosing)
Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 4
 CLINICAL SKIN AND SOFT TISSUE INFECTION (SSTI) CLINICAL GUIDELINES: OVERVIEW
GUIDELINE (> 2 MONTHS)

Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

The burden of SSTIs on US healthcare has continued to rise over the past several decades. In 2016, there
were ~490,000 ED visits and ~23,000 associated inpatient admissions for the < 18 years age group. A team drafted from across the continuum
Aggregate costs associated with this care was approx. $460 million.* Continued work on optimizing care of care at Children’s MN took part in the
delivery across the continuum, including epidemiological and public health spectra, drives motivation to revisionary processes of these guidelines.
own clinical outcomes at Children’s MN . Since the publication of the 2014 consensus guidelines from the • Interdisciplinary Stakeholders
Infectious Disease Society of America (IDSA), an array of published studies including meta-analyses have - Emergency Medicine: Kelly Bergmann
promoted revisionary processes associated with the identification, assessment, and treatment of SSTIs.
- General Surgery: Joshua Short
The goal of this revision is to provide the most updated recommendations surrounding:
- Hospital Medicine: Jodi O’Neill, Andrew
1. Diagnostic studies Rose, Gloria Swanson
2. Procedural processes - Infectious Disease: Bill Pomputius
3. Appropriate empiric therapy with local data considerations - Pharmacy: Christina Koutsari
4. Definitive therapy - Primary Care: Kent Wegmann
5. Care delivery across the continuum
• Organizational Stakeholders
- Medical-Surgical: Courtney Herring
- Quality Improvement: Gabi Hester

Key Outcome Measures

Lab reduction: Blood culture, CBC/diff, CRP
Empiric antibiotic stewardship: reduce Vancomycin first 48h use

Key Balancing Measures

Length of Stay
Unplanned revisits/readmissions in first 14 days

*https://hcupnet.ahrq.gov/#setup

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 5
 CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: SUPPLEMENTAL NOTES
GUIDELINE (> 2 MONTHS)

Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

NOTE 1
Blood cultures — Multiple studies have demonstrated that blood cultures
a)  Packing: Wound packing is associated with increased pain and equivocal
f) 
rarely demonstrate true pathogenic bacterial growth, and even positive outcomes; therefore, it is not recommended. For larger abscesses, wick
cultures do not change clinical management. placement or loop drainage may be considered for abscesses > 5 cm.9,14
a) Positive in 12.5% of immunocompetent children hospitalized with Atopic Dermatitis (Eczema) considerations:1,21
g) 
complicated SSTI11 Bacterial Infections: Approximately 80% to 90% of patients with AD
a) 
b) Positive in 0–2.9% of uncomplicated SSTIs 23 are carriers for S. aureus treatment should include coverage for both
S. aureus and Strep pyogenes.
Cellulitis may be a descriptor or symptom rather than a primary diagnosis in
b) 
Viral Infections:
b) 
some cases. Consider a broad differential including osteomyelitis, septic joint,
cutaneous lymphoma, tularemia, etc. Low threshold to consult with specialty a) Patients with AD are at a higher risk for eczema herpeticum (EH),
services such as ID. an acute, potentially life-threatening viral infection caused by the
herpes simplex virus. consider HSV DNA pcr if vesicles or papules
Considerations for empiric treatment:
c)  present.
a) 
Non-purulent: Streptococci, often group A, but also groups B, C, F, or b) Molluscum contagiosum (MC) is a benign viral skin infection that
G are most common pathogens. Staphylococcus aureus less frequently presents as flesh-colored, pink, or pearly white papules.
causes non-purulent SSTI. Recommended concurrent MRSA coverage
F ungal Infections: These may also invade compromised skin, leading
c) 
if: Penetrating trauma, evidence of MRSA infection elsewhere, MRSA
to colonization with tinea or yeast. Appropriate cultures may be needed in
nasal colonization, or injection drug use.
those patients who have risk factors for tinea or yeast colonization or who
b) 
Purulent: Staphylococcus aureus (including MRSA) is most common remain unresponsive to treatment.
pathogen.
Provider-guided Shared Decision Making (SDM): A shared-decision
h) 
Considerations re: failure of treatment — With cellulitis, particularly
d)  making process with caregivers is reasonable for using antibiotics for
Streptococcal pathogens, there may be an increase in erythema with extension adequately drained, small abscesses without systemic signs of illness.
beyond margins from ~ 24–36 hours after initiating appropriate antibiotics. While antibiotics have been shown to reduce rate of treatment failure and
This does not represent treatment failure. recurrence in small abscesses, antibiotics have risk for adverse side effects.5,20
Incision and Drainage: For small (< 1–2 cm), more superficial abscesses,
e) 
application of heat may lead to spontaneous drainage. However, primary
treatment for skin abscesses generally includes drainage. I&D is superior to
Consideration of the young infant:
US-guided needle aspiration with increased successful resolution at 7 days.4
While young infants < 2 months age are beyond the scope of this
current guideline, previous studies in this population — diagnosed
with SSTI — have shown that the rate of invasive bacterial infection
(bacteremia, meningitis, osteomyelitis) is low.2,6,12

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 6
 CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: SHARED DECISION MAKING
GUIDELINE — POST I&D ANTIBIOTICSS (AGE > 6 MONTHS)
Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

2406 Adult and

Pediatric subjects
with acute, simple,
cutaneous abscesses
that required I&D

TMP-SMX,
TMP-SMX v Clindamycin,
Placebo (3) or Placebo
4 RCTs (1)

Secondary
Primary
Outcomes:
Outcome:
recurrence, overall
treatment failure
adverse events,
within 21 days
and diarrhea

NNT NNH
• 14 To prevent • 23 To experience
treatment failure adverse events
• 10 To prevent
Figure source: Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for recurrence
uncomplicated skin abscesses: a clinical practice guideline. BMJ 2018;360:k243
Reprinted with permission from BMJ.
Source: Gottlieb M, Demott JM, Hallock M, Peksa GD. Systemic Antibiotics for
the Treatment of Skin and Soft Tissue Abscesses: A Systematic Review and Meta-
Analysis. Annals of Emergency Medicine 2019;73(1):8–16.

Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 7
 CLINICAL SKIN AND SOFT TISSUE INFECTION CLINICAL GUIDELINES: BIBLIOGRAPHY
GUIDELINE (> 2 MONTHS)

Aim: To improve patient outcomes and reduce unwarranted resource use in patients with SSTI.

1. Eichenfield, et al. Guidelines of care for the management of atopic dermatitis. J Am Acad Dermatol 2014;71:116-32
2. Foradori DM, Lopez MA, Hall M, Cruz AT, Markham JL, Colvin JD, Nead JA, Queen MA, Raphael JL, Wallace SS. Invasive Bacterial Infections in Infants Younger Than 60 Days With
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intersociety consensus on impetigo, abscess, and cellulitis treatment. Clinical Therapeutics, doi:10.1016/j.clinthera.2019.01.010
4. Gaspari RJ, Resop D, Mendoza M, Kang T, Blehar D. A randomized controlled trial of incision and drainage versus ultrasonographically guided needle aspiration for skin abscesses and
the effect of methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2011 May;57(5):483-91.e1. doi: 10.1016/j.annemergmed.2010.11.021. Epub 2011 Jan 15. PMID: 21239082.
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Medicine 2019;73(1):8–16.
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Epidemiol. 2018;39(8):936-940. doi:10.1017/ice.2018.124
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Sep 2015, 136 (3) 554-565; DOI: 10.1542/peds.2014-3678
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Surgery, 48(9), 1962-1965. doi:10.1016/j.jpedsurg.2013.01.027
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in adults and children [published correction appears in Clin Infect Dis. 2011 Aug 1;53(3):319]. Clin Infect Dis. 2011;52(3):e18-e55. doi:10.1093/cid/ciq146
11. Malone, et al. Blood Cultures in the Evaluation of Uncomplicated Skin and Soft Tissue Infections. PEDIATRICS Volume 132, Number 3, September 2013. doi:10.1542/peds.2013-1384
12. Markham JL, Hall M, Queen MA, et al. Variation in Antibiotic Selection and Clinical Outcomes in Infants <60 Days Hospitalized With Skin and Soft Tissue Infections. Hospital
Pediatrics. 2019 Jan;9(1):30-38. DOI: 10.1542/hpeds.2017-0237.
13. Nelson CE, Chen A, McAndrew L, Tay KY, Balamuth F. Management of Skin and Soft-Tissue Infections Before and After Clinical Pathway Implementation. Clin Pediatr (Phila).
2018;57(6):660-666. doi:10.1177/0009922817738329
14. O’Malley GF, Dominici P, Giraldo P, et al. Routine packing of simple cutaneous abscesses is painful and probably unnecessary. Acad Emerg Med. 2009;16:470-473.
15. Schuler CL, Courter JD, Conneely SE, et al. Decreasing Duration of Antibiotic Prescribing for Uncomplicated Skin and Soft Tissue Infections. Pediatrics. 2016;137(2):e20151223.
doi:10.1542/peds.2015-1223
16. Sloane AJ, Pressel DM. Culture Pus, Not Blood: Decreasing Routine Laboratory Testing in Patients With Uncomplicated Skin and Soft Tissue Infections DOI:10.1542/hpeds.2015-0186
17. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of
America [published correction appears in Clin Infect Dis. 2015 May 1;60(9):1448. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444
18. Talan DA, Mower WR, Krishnadasan A, et al. Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. N Engl J Med. 2016;374(9):823-832. doi:10.1056/
NEJMoa1507476
19. Trenchs V, Hernandez-Bou S, Bianchi C, Arnan M, Gene A, Luaces C. Blood Cultures Are Not Useful in the Evaluation of Children with Uncomplicated Superficial Skin and Soft Tissue
Infections. Pediatr Infect Dis J. 2015;34(9):924-927. doi:10.1097/INF.0000000000000768
20. Vermandere M, Aertgeerts B, Agoritsas T, et al. Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline. BMJ 2018;360:k243
21. Wang V, et al. The infectious complications of atopic dermatitis. Ann Allergy Asthma Immunol 126 (2021) 3e12. https://doi.org/10.1016/j.anai.2020.08.002
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jhm.2984
Disclaimer: This guideline is designed for general use with most patients; each clinician should use his or her own independent judgment to
meet the needs of each individual patient. This guideline is not a substitute for professional medical advice, diagnosis or treatment. Reviewer: Bergmann, Herring, Hester | Rev 4/21 | Exp 4/24 | Page 8