Management of Skin-Soft Tissue Infections Materials

BEST PRACTICES FOR THE MANAGEMENT OF SKIN AND SOFT TISSUE INFECTIONS

Liz Fredrickson, PharmD, BCPS

Liz Fredrickson is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy.

Topic Overview

Skin and soft tissue infections (SSTIs) pose significant challenges for patients in community and hospital settings. The effective management of SSTIs requires a strong understanding of their associated risk factors and pathophysiology, as well as knowledge pertaining to diagnosis and effective management strategies. Pharmacy team members play crucial roles in preventing and managing SSTIs via interprofessional collaboration with healthcare teams and providing patient and caregiver education. This continuing education presentation will discuss common risk factors for SSTIs and related pathophysiology, etiology, and epidemiology. Additionally, this program will review the classification of SSTIs and management strategies in detail.

Accreditation Statement

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is 

Pharmacist  0669-0000-24-106-H01-P

Pharmacy Technician  0669-0000-24-107-H01-T

Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $6.99

Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation

Release Date: July 27, 2024 Expiration Date: July 27, 2027

Target Audience: This educational activity is for pharmacists and pharmacy technicians

How to Earn Credit: From July 27, 2024, through July 27, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe risk factors for the development of skin and soft tissue infections (SSTIs)

Classify SSTIs based on their severity, need for therapeutic intervention, and the presence of comorbidities

Describe treatment strategies for SSTIs

Compare and Contrast antibiotics utilized in the management of SSTIs in terms of mechanism of action, dosing, and side effects

Disclosures

The following individuals were involved in developing this activity: Liz Fredrickson, PharmD, BPCS, and Pamela Sardo, PharmD, BS. Pamela Sardo and Liz Fredrickson have no conflicts of interest or financial relationships regarding the subject matter discussed. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

Best Practices for the Management of Skin and Soft Tissue Infections Introduction

The management of skin and soft tissue infections requires a strong understanding of their associated risk factors and pathophysiology, as well as knowledge pertaining to diagnosis and effective management strategies. Pharmacy team members play crucial roles in preventing and managing SSTIs via interprofessional collaboration with healthcare teams and providing patient and caregiver education. This continuing education presentation will discuss common risk factors for SSTIs and related pathophysiology, etiology, and epidemiology. Additionally, this program will review the classification of SSTIs and management strategies in detail, focusing on folliculitis, furuncles and carbuncles, cellulitis, and necrotizing soft-tissue infections.

Classification of SSTIs

Skin and soft tissue infections (SSTIs) are a heterogeneous group of diseases that can pose significant challenges for patients in community and hospital settings.1 Although the incidence rate of SSTIs has remained stable, effective treatment of SSTIs can significantly reduce disease morbidity and the utilization of healthcare services.2

Skin and soft tissue infections are associated with important terminology (and abbreviations) with which pharmacy personnel should be familiar. These are defined in Table 1.2

Table 1

SSTI Terminology2-5

Skin and soft tissue infections can be categorized as primary or secondary (Table 2).3 In the case of primary bacterial skin infections, areas of skin that were once healthy are infected by a single pathogen.3 Conversely, secondary skin infections involve infection of previously damaged skin and are typically caused by multiple bacteria (polymicrobial).3 SSTIs can also be classified as uncomplicated (simple) or complicated (necrotizing or non- necrotizing).3,6 Examples of simple infections include cellulitis, erysipelas, folliculitis, furuncles, and carbuncles.6 With complicated infections, deeper skin structures, such as facia, are infected and patients often require surgery.2 Examples include deep abscesses, decubitus ulcers, and necrotizing fasciitis.6 Patients with complicated infections are also commonly immunocompromised

in some manner and may have conditions such as diabetes or human immunodeficiency virus (HIV).3

Table 2

Bacterial Classification of Skin and Soft-Tissue Infections3

Finally, these infections can be classified according to their severity, need for therapeutic intervention, and the presence of comorbidities. Table 3 details this classification system.

Table 3 Classification of SSTIs6

Etiology and Epidemiology

Within the United States (US), SSTIs result in over 14 million outpatient visits and nearly 900,000 inpatient admissions annually.2,3 Over the last few decades, there has been a rise in the incidence and associated costs of cellulitis, which has an incidence of approximately 200 cases per 100,000- person years.2,7 Cellulitis tends to occur more frequently during warmer months in nontropical regions.7

Skin and soft tissue infections contribute between 3% and 30% of all emergency department (ED) visits.2 Approximately 12-40% of SSTI cases in the ED are admitted to the hospital and 0.7% to the intensive care unit (ICU).2

Severe SSTIs with sepsis happen somewhat frequently and are estimated to be the cause of approximately 10% of all septic shock cases.2 Complicated SSTIs are the third most frequent cause of severe sepsis or septic shock, following pneumonia and abdominal infections.2

Current evidence indicates the primary pathogens of SSTIs are Staphylococcus aureus, which includes methicillin-resistant S. aureus (MRSA), and Streptococcus pyogenes, along with other β-hemolytic streptococci.2,3 Cellulitis is most commonly caused by beta-hemolytic streptococci, including groups A, B, C, G, and F.7 S. aureus and S. pyogenes are the most common cause of simple, community-acquired SSTIs.6 Up to 30% of individuals may be colonized with S. aureus.3 Gram-negative bacteria are far less common; however, in some regions, they are increasingly reported as the cause of these infections, accounting for up to 30% of cases in certain studies.3 P. aeruginosa, enterococcus, and E. coli are common causes among hospitalized patients.6 Common microorganisms of normal skin are summarized in Table 4.3

Table 4

Common Microorganisms of Normal Skin3

Bacteria

Gram-positive

Coagulase-negative staphylococci

Micrococci (Micrococcus luteus)

Corynebacterium species (diphtheroids)

Propionibacterium species

Gram-negative

Acinetobacter species

Fungi

Malassezia species

Candida species

Risk Factors of SSTIs

Numerous factors may place patients at risk of developing an SSTI. Examples of predisposing factors include reduced tissue vascularity, increased peripheral fluid stasis, and a decreased ability to fight off infections. Oftentimes, a patient’s comorbidities will assist in determining the bacterial cause of SSTIs.6 As an example, Pseudomonas aeruginosa is linked to intravenous drug use.6 Risk factor examples are presented in Table 5.

Table 5

Risk Factors for SSTIs

*Risk factor for community-acquired MRSA infection

+Predisposes patient to necrotizing fasciitis

~Risk factor for hospital-acquired methicillin-resistant S. aureus infection

Pathophysiology of SSTIs

Healthy skin is a primary defense mechanism against infections, serving as a barrier between humans and their environment.3 It supports a diverse microbiome of bacteria and fungi and several host factors that protect against infections.3 The continuous renewal of the epidermal layer leads to the shedding of skin bacteria, and sebaceous secretions are hydrolyzed to form free fatty acids, inhibiting bacterial growth.3 Additionally, the commensal skin microbiome prevents colonization by more pathogenic bacteria.3

Factors that can predispose a person to skin infections include the followin:3

High concentrations of bacteria (more than 105 microorganisms)

Excessive moisture of the skin

Inadequate blood supply

Availability of bacterial nutrients

Damage to the corneal layer, allowing bacterial penetration

Although the skin and subcutaneous tissues are typically highly resistant to infections and, under certain conditions, they can become vulnerable.3 Intact skin is the best defense against SSTIs, as most occur due to the disruption of normal host defenses through skin puncture, surgery, increased tissue tension secondary to fluid stasis, or underlying diseases such as diabetes.3,6 Skin and soft tissue infections can either initiate from a neighboring site or be due to embolic spread from a site further away.6

Clinical Presentation and Diagnosis

Patients with an SSTI may have either cellulitis or an abscess.7 Common signs and symptoms of SSTIs include erythema (redness), warmth, edema, and pain at the affected site.6 Patients may have systemic signs of infection as well, which is indicative of the severity and magnitude of the infection.6 Such signs include fever and other systemic manifestations.7

The diagnosis of SSTIs should begin with a thorough patient history to identify potential risk factors.6 The physical examination involves inspecting the affected area for signs of infection, including erythema, edema, tenderness, and the presence of any lesions or abscesses.6 Laboratory testing is not indicated for uncomplicated infections or for patients without complications or comorbidities.7 However, for patients with suspected severe infections includes such as complete blood count (CBC) with differential, C- reactive protein (CRP), and kidney and liver function tests.6 Clinicians can use the Laboratory Risk Factor Indicator for Necrotizing Fasciitis to stratify patients into either low or high risk categories for necrotizing fasciitis.6 This scoring system utilizes the following lab values: C-reactive protein, creatinine, glucose, hemoglobin, sodium, and total white blood cells.6 A score of at least six is indicative of necrotizing fasciitis while a score of eight or more is highly suggestive, with a positive predictive value of 93.4%.6

In healthy individuals (non-immunocompromised) blood cultures generally are not necessary, but they may be needed in patients presenting with severe infections or with signs suggestive of systemic involvement.6 Older patients and those who are immunocompromised may also require blood cultures, in addition to those with animal bites, or failure of antibiotic therapy.6,7 Wound cultures are useful for immunocompromised patients, patients with significant cellulitis, lymphangitis, sepsis, infection from a human or animal bite, and those with recurrent, large abscesses.6

Imaging is typically not required for simple SSTIs. Magnetic resonance imaging (MRI) is 100% sensitivity for necrotizing fasciitis and a specificity of 86%.6 The use of ultrasound can assist with determining the extent and depth of an infection, with a sensitivity of 77.6% and specificity of 43.7% for the extent of infection.6

General Management of SSTIs

The general management of SSTIs involves determining the severity and location of the infection.6 A patient’s comorbidities also need to be taken into consideration.6 The initial strategy depends on if there is purulence, the

acuity of the infection, and the type of infection.6 Mild-to-moderate infections can be treated with topical antibiotics, such as mupirocin.6 Adults with mild- moderate infections and no suppuration can utilize beta-lactam antibiotics.6 If the SSTI is mildly purulent and there is no significant cellulitis, incision and drainage may be all that is required.6

Abscesses with extensive cellulitis or that are rapidly progressing or do not respond to drainage will require use of antibiotics.6 If cellulitis is uncomplicated, the duration is five days.6 Treatment of severe infections requires inpatient management with initial use of broad-spectrum, intravenous antibiotics until pathogen-specific sensitivities have been obtained.6 Antibiotics should be continued for 7-14 days until the patient clinically improves and can tolerate oral intake.6

Folliculitis, Furuncles, and Carbuncles

Overview

Folliculitis is defined as inflammation of hair follicles that may be caused by infection, physical injury, or chemical irritation.3 This type of superficial infection involving pus occurs only in the epidermis.3

In contrast, furuncles and carbuncles are when follicular infections extend to the subcutaneous area of the skin.3 Furuncles, in particular, are walled-off masses of purulent material arising from hair follicles, while carbuncles occur when furuncles merge to form a single inflamed area.3 The most common cause of these infections is S. aureus.3 The clinical presentation of these infections is presented in Table 6.

Table 6

Clinical Presentation of Folliculitis, Furuncles, and Carbuncles

Treatment

The main goals of treating skin infections are to relieve discomfort, stop the infection from spreading, and prevent it from coming back.3 Managing recurrent furunculosis is crucial because chronic cases are challenging to treat.3 Additionally, pharmacists can work with the care team to ensure treatments are effective, affordable, and have minimal side effects.3

Management recommendations include the following:3

Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without cultures is reasonable in most patients

Carbuncles, abscesses, and large furuncles of mild severity should be treated with incision and drainage

Administration of antibiotics with activity against S. aureus as an adjunct to incision and drainage should be based on the presence or absence of systemic signs of infection

Antibiotics with activity against MRSA are recommended for patients with carbuncles or abscesses of higher severity who have failed initial antibiotic therapy, have severe systemic signs of infection, or are immunocompromised

Treating these infections involves using local care measures, such as warm, moist compresses.3 Topical therapies can be tried, including clindamycin, erythromycin, mupirocin, or benzoyl peroxide.3 These should be applied 2-4 times a day for one week.3 If furuncles are small, they can be treated with moist heat to encourage pus drainage, while larger furuncles and carbuncles may need to be incised and drained.3 More severe infections require antibiotic therapies. Options include trimethoprim-sulfamethoxazole, doxycycline, or minocycline for 5-10 days.3 These antibiotics will cover any potential MRSA.3 Oftentimes, these infections will resolve without the use of medical or surgical involvement.3 Patients who require but do not respond to systemic antibiotic therapies or have recurrent infections will need culture and sensitivity testing to guide further antibiotic therapies.3

Table 7 Treatment of Folliculitis

Table 8

Treatment of Furuncles and Carbuncles

Cellulitis

Overview

Cellulitis is a serious SSTI that begins in the epidermis and dermis and may spread to the superficial fascia, potentially spreading to the bloodstream.3 The most common bacterial causes include S. aureus and S. pyogenes; however, many different bacteria can be potential culprits.3 There has been a specific increase in the number of MRSA infections in both community and hospital settings.3 Depending on the patient’s comorbidities and risk factors, several other types of bacteria may be causal. Injection drug users may have cellulitis that are polymicrobial and caused by S. aureus, including MRSA, and/or anaerobic bacteria.3 Individuals with diabetes mellitus are also prone to polymicrobial infections.3 These can occur post-surgery or in areas with vascular insufficiency.3 Cellulitis tends to develop over the course of a few days.7 The clinical presentation of cellulitis is detailed in Table 9.

Table 9

Clinical Presentation of Cellulitis3

Treatment

Treatment goals for patients with acute bacterial cellulitis include quickly eradicating the infection and preventing further complications.3 The management of cellulitis involves decreasing swelling by elevating and immobilizing the affected area.3 Cool, sterile saline dressings can help decrease pain and swelling initially, and this can be followed by moist heat after one to three days.3 Uncomplicated cellulitis rarely requires surgical intervention, which may be essential for more severe cases.3 Antimicrobial therapy is guided by the type of bacteria identified or suspected, with particular attention to resistant pathogens like MRSA, Gram-negative bacteria, and anaerobes.3 In particular, clinicians should consider whether coverage is needed for MRSA or atypical bacteria.7 Empiric antibiotics should always cover MSSA and beta-hemolytic streptococci.7 Conditions that warrant MRSA coverage include systemic signs of toxicity (e.g., fever >100.5°F/38°C, hypotension, sustained tachycardia), cellulitis with purulent wound drainage, known MRSA colonization or infection, injection drug use, and high-risk neutropenia.7

Cellulitis can be categorized as purulent or non-purulent to determine treatment strategies.3 Purulent infections are associated with purulent drainage without a simple, drainable abscess.3 Per the IDSA, purulent cellulitis often requires incision and drainage, and systemic antibiotics may be unnecessary for mild cases.3 Oral antibiotics such as trimethoprim- sulfamethoxazole and doxycycline are recommended for moderate to severe purulent cellulitis, with linezolid or tedizolid as alternatives, though linezolid is more expensive.3 Severe purulent cellulitis, characterized by systemic infection signs or immunocompromised status, requires hospitalization and parenteral antibiotics such as vancomycin, daptomycin, linezolid or tedizolid, telavancin or ceftaroline.3 Antibiotics like dalbavancin and oritavancin—both glycopeptide drugs— have indications for treating complicated SSTI but are costly and best used for specific cases.3 Delafloxacin, a fluoroquinolone, and certain carbapenems may be options for severe polymicrobial infections, though their roles are not well-defined.3 Treatment duration typically ranges

from 5 to 14 days, which depends on the infection's severity and patient response.3

Non-purulent cellulitis, which lacks drainage or abscess, is typically treated with oral β-lactams such as penicillin VK or cephalexin for mild cases.3 Severe non-purulent cellulitis may require hospitalization and a combination of antibiotics effective against MRSA and streptococci.3 Treatment of cellulitis is summarized in Table 10, and doses are provided in Table 11.

Table 10

Treatment Strategies for Cellulitis

Table 11

Antibiotic Dosing for Cellulitis

In terms of follow-up, clinicians should thoroughly evaluate culture and sensitivity results to identify resistant organisms.3 High-quality additional samples may be needed for thorough microbiologic analysis. If there is no response to therapy, it might indicate an underlying local or systemic issue or a possible misdiagnosis.3

Pharmacists can assist with tailoring the appropriate selection and duration of antibiotics to individual patient needs with the goal of effectively treating the infection while minimizing resistance and adverse effects.3 Pharmacists can also assist the care team with avoiding the use of unnecessary antibiotics, thereby reducing antibiotic resistance and side effects, and keeping the cost of therapy low for the patient.3

Necrotizing Soft Tissue Infections

Overview

Necrotizing soft-tissue infections are extremely severe and are characterized by high morbidity and mortality.3 They require early surgical debridement along with appropriate antibiotics and supportive care.3 The epidermis, dermis, subcutaneous tissue, fascia, and muscle all may be involved.8,9 These infections include necrotizing forms of fasciitis, cellulitis, and myositis.10 They are classified based on predisposing conditions, symptom onset, pain, skin appearance, etiologic agents, gas production, muscle involvement, and systemic toxicity.3,8,9 The major clinical NSTIs include necrotizing fasciitis and clostridial myonecrosis, or gas gangrene.3

Necrotizing fasciitis is a rare and severe infection of the subcutaneous tissue.3 It is caused by aerobic and/or anaerobic bacteria, which progressively destroy superficial fascia and subcutaneous fat.3 Because muscle tissue has a sufficient blood supply, it is typically not infected.9 Type I necrotizing fasciitis typically follows trauma or surgery and is polymicrobial in nature, involving a mixture of anaerobes (i.e., Bacteroides, Clostridium, Peptostreptococcus) and facultative bacteria (i.e., E. Coli, enterococci).3 This type is more common among injection drug users.3 It tends to spread slower than Type II, which is

caused by virulent strains of S. pyogenes and is often referred to as streptococcal gangrene or “flesh-eating bacteria.”3 Type II infections are monomicrobial and progress rapidly, with extensive tissue necrosis, severe pain, systemic toxicity, and a high risk of shock and organ failure.3,8,9 They are typically caused by group A streptococci or another beta-hemolytic streptococcus, but may be caused by S. aureus.11 Critical risk factors for Type

1 infections include diabetes, particularly those with peripheral vascular disease.8,10 Type 2 necrotizing fasciitis may occur in individuals of any age, even those without comorbidities.12 Clostridial myonecrosis, or type III necrotizing fasciitis, involves skeletal muscle.3 Known as gas gangrene, it is characterized by gas production and muscle necrosis, advancing rapidly within hours.3 Most cases occur post-surgery or trauma, with Clostridium perfringens being the most common causative agent.3

The Table 12

Clinical Presentation of Necrotizing Fasciitis

Table 13

Features Associated with Necrotizing Skin Infections

Treatment

Therapy goals for necrotizing soft tissue infections include quick eradication of the infection, preventing complications, reducing mortality, avoiding unnecessary antibiotic use, and minimizing the side effects of antibiotic therapy.3

Patients should be quickly evaluated for surgery.2,3 Delays in initial surgical intervention, particularly beyond 14 hours after diagnosis, are associated with significantly increased mortality.3 Type I necrotizing fasciitis requires empiric broad-spectrum antibiotics covering gram-positive, gram- negative, and anaerobic bacteria.8 Options include a carbapenem, such as meropenem or piperacillin-tazobactam, plus an antibiotic with MRSA coverage, such as vancomycin or daptomycin plus clindamycin, which has antitoxin properties.8 The antibiotic regimen should be adjusted following gram stain, culture, and sensitivity results.8

If a GAS or beta-hemolytic infection is present, penicillin and clindamycin can be given. Vancomycin with a beta-lactam/beta-lactamase inhibitor or a carbapenem can be given for polymicrobial infections.8

If type II (streptococcal) or type III (clostridial) necrotizing fasciitis is diagnosed, therapy should switch to penicillin plus clindamycin.3 Clindamycin is more effective due to its inhibition of protein synthesis, reduced bacterial exotoxin production, and immunomodulatory properties.3 It is also effective against some MRSA strains.3 This combination can be continued for 48-72 hours, after which penicillin can be given alone.8 Linezolid may be considered but lacks extensive clinical data.3 While hyperbaric oxygen may benefit clostridial myonecrosis, and intravenous immunoglobulin (IVIG) may help necrotize streptococcal infections, neither is recommended due to insufficient evidence of improved outcomes.3

Table 14

Treatment of Necrotizing Fasciitis

The Roles of Pharmacy Teams

Pharmacists

Pharmacists play a crucial role in the treatment and prevention of SSTIs, working with other healthcare providers to ensure optimal patient outcomes and minimize complications of therapy. A vital role in medication management involves selecting appropriate empiric antibiotic therapy based on likely pathogens, local resistance patterns, and patient-specific factors such as allergies and comorbidities. Pharmacists can also work with physicians to assist with monitoring levels of antibiotics like vancomycin and switching from IV to PO therapies when appropriate. Additionally, they can educate patients and/or caregivers on proper medication use, the importance of completing antibiotic courses and recognizing side effects.

Pharmacy Technicians

Pharmacy technicians play a vital role in supporting patients with SSTIs by performing tasks that ensure the smooth functioning of pharmacy operations and enhance patient care. They assist pharmacists by accurately

filling prescriptions and ensuring that patients receive the correct medications in the appropriate doses. In addition to filling prescriptions, pharmacy technicians help manage inventory, ensuring that essential antibiotics and other related supplies are readily available. This involves monitoring stock levels, placing orders, and checking for expired medications, thereby maintaining a reliable supply of necessary treatments for SSTIs. By keeping the pharmacy well-stocked and organized, they help prevent treatment delays and contribute to the overall efficiency of pharmacy services.

In their administrative capacity, pharmacy technicians manage patient records, ensuring that all documentation is accurate and up to date. This meticulous record-keeping supports continuity of care, as accurate records are essential for monitoring treatment progress and making informed decisions about ongoing care. They also assist in billing and insurance processing, helping patients navigate the complexities of coverage for their medications, which can reduce financial barriers to accessing necessary treatments.

Summary

Skin and soft tissue infections pose significant challenges for patients in community and hospital settings. The effective management of SSTIs requires a strong understanding of their associated risk factors and pathophysiology, as well as knowledge pertaining to diagnosis and effective management strategies. Pharmacy team members play crucial roles in preventing and managing SSTIs via interprofessional collaboration with healthcare teams and providing patient and caregiver education.

Course Test

Of the following, which is the most significant risk factor for developing community-acquired methicillin-resistant S. aureus (MRSA) infections?

Being age 65 years or older

Having lymphedema

A recent exposure to the beach

Being a healthcare professional

Which of the following is most likely to predispose a patient to developing necrotizing fasciitis?

Alcohol misuse

Debility

Human bite

Obesity

Class 1 skin and soft tissue infections are defined as which of the following?

Simple infection with no systemic signs or symptoms indicating spread and no uncontrolled comorbidities that could complicate treatment. Infection is amenable to outpatient management with either topical or oral antimicrobials

Infection with systemic signs or symptoms indicating spread or with stable comorbidities or infection without systemic spread but with uncontrolled comorbidities. May require either inpatient treatment with parenteral antibiotics

Infection with signs and symptoms of systemic spread or uncontrolled comorbidities. Inpatient treatment with parenteral antibiotics is required.

Infection with signs of potentially fatal sepsis that requires parenteral antibiotics. Inpatient management is required, and surgery may be indicated.

Which of the following is a severe infection involving deeper soft tissue and rapid progression?

SSTI

cSSTI

ABSSI

NSTI

Which of the following is true regarding treating mild skin and soft tissue infections (SSTIs)?

Mild SSTIs should always be treated with systemic antibiotics

Mild SSTIs do not require treatment, and patients can undergo a “watch and wait” period

Mild SSTIs can typically be treated with topical antibiotics

Mild SSTIs require hospital admission and treatment with IV antibiotics

Which of the following is a potential treatment option for a patient with folliculitis?

Clindamycin applied topically twice daily

Cephalexin 500 mg given every 6-12 hours

Vancomycin 15 mg/kg IV Q8H

Amoxicillin 875 mg PO Q12H

Which of the following antibiotic combinations is recommended for confirmed type 3 (clostridial) necrotizing fasciitis?

Piperacillin/tazobactam + vancomycin

Penicillin + clindamycin

Linezolid + amoxicillin

Meropenem + ertapenem

Which of the following is associated with “red man syndrome” as a potential adverse effect?

Vancomycin

Clindamycin

Ertapenem

Linezolid

Which of the following inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins, preventing the final step of peptidoglycan synthesis and inhibiting cell wall biosynthesis?

Daptomycin

Ertapenem

Penicillin

Clindamycin

Which of the following is used to treat cellulitis and is dosed at 600 mg Q12H?

Amoxicillin

Cephalexin

Linezolid

Dicloxacillin

References

Bouza E, Burillo A. Current international and national guidelines for managing skin and soft tissue infections. Curr Opin Infect Dis. 2022;35(2):61-71. doi:10.1097/QCO.0000000000000814

Blanes Hernández R, Rodríguez Pérez M, Fernández Navarro J, Salavert Lletí M. Current approach to skin and soft tissue infections. Thinking about continuity of care. Rev Esp Quimioter. 2023;36 Suppl 1(Suppl 1):37-45. doi:10.37201/req/s01.10.2023

Fish DN. Skin and Soft Tissue Infections. In: DiPiro JT, Yee GC, Haines ST, Nolin TD, Ellingrod VL, Posey L. eds. DiPiro’s Pharmacotherapy: A Pathophysiologic Approach, 12th Edition. McGraw Hill; 2023.

Ki V, Rotstein C. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008;19(2):173-184. doi:10.1155/2008/846453

Wingate B, Kehr H. Management of Complicated Skin and Soft Tissue Infections in Hospitalized Patients. US Pharm. 2007;32(4):HS5-HS12

Ramakrishnan K et al. Skin and Soft Tissue Infections. Am Fam Physician. 2015;92(6):474-483.

Spelman D, et al. Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis. Uptodate. 2024.

Hua C, Urbina T, Bosc R, et al. Necrotising soft-tissue infections. Lancet Infect Dis. 2023;23(3):e81-e94. doi:10.1016/S1473-3099(22)00583-7

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. doi: 10.1093/cid/civ114. Dosage error in article text]. Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu444

Gozal D, Ziser A, Shupak A, Ariel A, Melamed Y. Necrotizing fasciitis. Arch Surg. 1986;121(2):233-235. doi:10.1001/archsurg.1986.01400020119015

Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. 2005;352(14):1445-1453. doi:10.1056/NEJMoa042683

Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85(8):1454- 1460.

DISCLAIMER

The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses are constantly changing, and any person taking this course understands that such person must make an independent review of medication information prior to any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.

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© RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.