CELLULITIS 抗生素選擇-200712050621

 2007120506212019-06-09  17:14 

https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540106/all/Cellulitis

因為醫院購買 uptodate 到期, 最近無法查詢uptodate. 只好先用 JOHNS HOSKINS 的指引

非化膿性蜂窩性組織炎抗生素選擇. 

化膿性蜂窩性組織炎抗生素選擇

TREATMENT
Terms and General Principles
• Classification (Based on 2014 IDSA Guidelines for Diagnosis and Management of Skin and Soft Tissue Infections)[1]
• For infection in which culture information is derived, use results to help guide therapy.
• Purulent: cellulitis associated with abscess, carbuncle, furuncle.
o Severe infection:
 Patients who have failed I&D plus oral antibiotics
 Presence of SIRS (≥ 2 of the following: T > 38°C, P > 90, RR > 24, WBC < 4,000 cells/υL or > 12,000 cells/υL)
 Immunocompromised patients
o Moderate infection:
 Purulent infection with signs of systemic inflammation
o Mild infection:
 Purulent infection, requires I&D (without the above)
• Non-purulent: cellulitis, necrotizing fasciitis, erysipelas.
o Severe infection:
 Failed oral antibiotics
 Presence of SIRS (≥ 2 of the following: T > 38°C, P > 90, RR > 24, WBC < 4,000 cells/υL or > 12,000 cells/υL)
 Immunocompromised patients
 Presence of skin sloughing or bullae
 Hypotension
 End organ dysfunction
o Moderate infection:
 Typical cellulitis or erysipelas + systemic signs of infection
o Mild infection:
 Typical cellulitis or erysipelas
 No evidence of purulence
Non-purulent Infections
• Duration of therapy is typically 5 -10 days depending on response
• Severe:
o Assess for potential necrotizing infection.
 Emergent surgical consultation, consideration for debridement.
o Empiric:
 Vancomycin 15 mg IV q 12h IV PLUS piperacillin/tazobacatam 3.375 g IV q 4-6h.
o Microbiology/special associations--pathogen-specific: see specific modules for details.
 Necrotizing group A streptococcal or clostridial infection: PCN G + clindamycin

o Also use this combination for streptococcal toxic shock
 Vibrio vulnificus: doxycycline + ceftazidime
 Aeromonas hydrophila: doxycycline + ciprofloxacin
 Polymicrobial: vancomycin + piperacillin/tazobacatam
• Moderate: intravenous therapy
o Adult:
 PCN G 2-4 million units IV q 4-6h
 Cefazolin 1-2 g IV q 8h
 Nafcillin 1-2 g IV q 4-6h
 Ceftriaxone 1-2 g IV q 24h
 Clindamycin 600-900 mg IV q 8h
o Alternatives: for severe beta-lactam allergy
 Vancomycin
 Clindamycin (note: resistance < 1% in streptococci, may be higher in Asia)
 Linezolid
 Tedizolid
 Daptomycin
 Telavancin
 Dalbavancin
 Ortavancin
o Pediatric
 PCN G 60-100,000 units/kg IV q 6h
 Clindamycin 10-13 mg/kg IV q 8 h
 Nafcillin 50 mg/kg IV q 6h
 Cefazolin 33 mg/kg IV q 8h
• Mild: oral therapy
o Adult:
 PCN Vk 250-500 mg PO four times daily
o Amoxicillin often preferred due to better bioavailability: 250-500 mg PO three times daily
 Cephalexin 500 mg PO four times daily
 Dicloxacillin 500 mg PO four times daily
 Clindamycin 300-540 mg PO four times daily
o Pediatric
 Amoxicillin 25-50 mg/kg/d divided twice or thrice daily doses (500 mg max per dose)
 Cephalexin 50 mg/kg/day PO divided four times daily
 Dicloxacillin 25-50 mg/kg/day PO divided four times daily
 Clindamycin 25-30 mg/kg/day PO divided three times daily
Purulent Infections
• All infections, perform thorough I&D.
• Severe: obtain culture from I&D; use IV abx--may convert to oral when stable/improved.
o Adult
 Empiric: to cover MRSA
o Vancomycin 15 mg/kg IV q 12h
o Linezolid 600 mg every 12h IV
o Daptomycin 6-8 mg/kg IV q 24h
o Telavancin 10 mg/kg IV once daily (infuse over 1 hr)
o Ceftaroline 600 mg IV q 8-12h (consider only if other options not available)
o Clindamycin: Not longer an option in most places due to increased resistance among MRSA and MSSA isolates (can be considered if prevalence of resistance < 10%)
 MSSA:
o Nafcillin or oxacillin 2 g IV q4h
o Cefazolin 2g IV q8h
 MRSA:

o See empiric selections above
• Pediatric
o Empiric
 Vancomycin 40 mg/kg/d in four divided doses
 Linezolid 10 mg/kg IV q 12h (children < 12 yrs)
o MSSA:
 Nafcillin or oxacillin 100-150 mg/kg/d IV in four divided doses IV
 Cefazolin 50 mg/kg/d IV in three divided doses
 Clindamycin 25-40 mg/kg/d IV in three divided doses
• Moderate: obtain culture from I&D. May use IV above or oral selection below based on clinical judgement.
o Adult:
 Empiric: IV from above or oral selection from below.
o TMP/SMX 1-2 DS tabs PO twice daily
o Doxycycline 100 mg PO twice daily
o MSSA: IV from above or oral from below

 Dicloxacillin 500 mg PO four times a day
 Cephalexin 500 mg PO four times a day
o MRSA: IV from above or oral below
 TMP/SMX 1-2 DS tabs twice daily PO
• Pediatric:
o Empiric: IV from above or oral from below.
 TMP/SMX 8-12 mg/kg/d (based on TMP) PO in two divided doses
o MSSA: IV from above or oral from below
 Dicloxacillin 25-50 mg/kg/d PO in four divided doses
 Cephalexin 25-50 mg/kg/d PO in four divided doses
• MRSA: IV from above or oral from below.
o TMP/SMX 8-12 mg/kg/d (based on TMP) PO in two divided doses
• Mild: no culture required, use oral options from above.
• β-lactam allergy: Vancomycin (above doses)
Adjunctive Therapy
• Erysipelas: consider prednisone 30mg with taper over 8 days to assist with inflammatory reaction (may want to avoid in diabetes).
• For infections of limbs, elevate affected site.
• Treat associated conditions (especially if recurrent infection): Tinea pedis, venous stasis, lymphedema, eczema, trauma sites.
o Dermatophytic infections: topical terbinafine or clotrimazole