Infectious Diseases Society of America 2014 Practice Guidelines To Diagnose, Manage Skin, Soft Tissue Infections

Analysis

The updated SSTI guidelines provide hospitalists with a practical algorithm for the management of SSTIs, focusing on the presence or absence of purulence, systemic signs of infection, and host immune status to guide therapy. Whereas the 2005 guidelines provided clinicians with a list of recommended antibiotics based on spectrum of activity, the updated guidelines provide a short list of empiric antibiotics based on the type and severity of infection.⁶

The list of recommended antibiotics with MRSA activity has been updated to include ceftaroline and telavancin. Of note, since these guidelines have been published, three new antibiotics with MRSA activity (tedizolid, oritavancin, and dalbavancin) have been approved by the FDA for the treatment of SSTIs, although their specific role in routine clinical practice is not yet determined.

The treatment algorithm for surgical site infections remains largely unchanged, which reinforces the concept that fever in the first 48 hours is unlikely to represent infection unless accompanied by purulent wound drainage with a positive culture. Likewise, the guidelines recommend risk-stratifying patients with fever and a suspected wound infection more than four days after surgery by the presence or absence of systemic infection or evidence of surrounding cellulitis.

A comprehensive guide to the management of specific pathogens or conditions, such as tularemia, cutaneous anthrax, and bite wounds, is largely unchanged, although the update now includes focused summary statements to navigate through these recommendations more easily.

The updated guidelines provide a more robust yet focused set of recommendations for the diagnosis and treatment of bacterial, fungal, and viral skin infections in immunocompromised hosts, especially those with neutropenia.

HM Takeaways

The 2014 update to the IDSA practice guidelines for SSTIs contains a chart to help clinicians diagnose and manage common skin infections more effectively. The guidelines’ algorithm stratifies the severity of illness according to whether or not the patient has SIRS or is immunocompromised. The authors recommend against the use of antibiotics for mild purulent SSTIs and reserve the use of anti-MRSA therapy mainly for patients with moderate purulent SSTIs, those with severe SSTIs, or those at high risk for MRSA. Likewise, the use of broad spectrum gram-negative coverage is not recommended in most common, uncomplicated SSTIs and should be reserved for special populations, such as those with immune compromise.

The guidelines strongly recommend a short, five-day course of therapy for uncomplicated cellulitis. Longer treatment courses (i.e., 10 days) are unnecessary and do not improve efficacy for those exhibiting clinical improvement by day five.

Drs. Yogo and Saveli work in the division of infectious disease in the department of medicine at the University of Colorado School of Medicine in Aurora.

References

1. Edelsberg J, Taneja C, Zervos M, et al. Trends in the US hospital admissions for skin and soft tissue infections. Emerg Infect Dis. 2009;15(9):1516-1518.
2. Jenkins TC, Sabel AL, Sacrone EE, Price CS, Mehler PS, Burman WJ. Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship. Clin Infect Dis. 2010;51(8):895-903.
3. Jenkins TC, Knepper BC, Moore SJ, et al. Antibiotic prescribing practices in a multicenter cohort of patients hospitalized for acute bacterial skin and skin structure infection. Infect Control Hosp Epidemiol. 2014;35(10):1241-1250.
4. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed February 8, 2015.
5. 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. Clin Infect Dis. 2014;59(2):e10-52. Stevens DL, Bisno AL, Chambers HF, et al.
6. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.