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"Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America"

Published: Clinical Infectious Diseases ; 2014 ; 59 : 10 -52


A panel of national experts was convened by the Infectious Diseases Society of America (IDSA) to update the 2005 guidelines for the treatment of skin and soft tissue infections (SSTIs). The panel's recommendations were developed to be concordant with the recently published IDSA guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections. The focus of this guideline is the diagnosis and appropriate treatment of diverse SSTIs ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, because of an increasing number of immunocompromised hosts worldwide, the guideline addresses the wide array of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in promptly diagnosing SSTIs, identifying the pathogen, and administering effective treatments in a timely fashion.

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was published in June of 2014 and is the most current version.



I. What Is Appropriate for the Evaluation and Treatment of Impetigo and Ecthyma?


  1. Gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether Staphylococcus aureus and/or a β-hemolytic Streptococcus is the cause (strong, moderate), but treatment without these studies is reasonable in typical cases (strong, moderate).
  2. Bullous and nonbullous impetigo can be treated with oral or topical antimicrobials, but oral therapy is recommended for patients with numerous lesions or in outbreaks affecting several people to help decrease transmission of infection. Treatment for ecthyma should be an oral antimicrobial.
    • Treatment of bullous and nonbullous impetigo should be with either topical mupirocin or retapamulin twice daily (bid) for 5 days (strong, high).
    • Oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against S. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent) (strong, high). Because S. aureus isolates from impetigo and ecthyma are usually methicillin susceptible, dicloxacillin or cephalexin is recommended. When MRSA is suspected or confirmed, doxycycline, clindamycin, or sulfamethoxazole-trimethoprim (SMX-TMP) is recommended (strong, moderate).
    • Systemic antimicrobials should be used for infections during outbreaks of poststreptococcal glomerulonephritis to help eliminate nephritogenic strains of Streptococcus pyogenes from the community (strong, moderate).


II. What Is the Appropriate Evaluation and Treatment for Purulent SSTIs (Cutaneous Abscesses, Furuncles, Carbuncles, and Inflamed Epidermoid Cysts)? (Figure 1)


  1. Gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases (strong, moderate).
  2. Gram stain and culture of pus from inflamed epidermoid cysts are not recommended (strong, moderate).
  3. Incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses, and large furuncles (strong, high).
  4. The decision to administer antibiotics directed against S. aureus as an adjunct to incision and drainage should be made based on the presence or absence of systemic inflammatory response syndrome (SIRS) such as temperature >38°C or <36°C, tachypnea >24 breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12 000 or <400 cells/µL (moderate; Figure 1) (strong, low). An antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have markedly impaired host defenses and in patients with SIRS (Figure 1, Table 2) (strong, low).


III. What Is the Appropriate Treatment for Recurrent Skin Abscesses?


  1. A recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa, or foreign material (strong, moderate).
  2. Recurrent abscesses should be drained and cultured early in the course of infection (strong, moderate).
  3. Culture recurrent abscess and treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated (weak, low).
  4. Consider a 5-day decolonization regimen twice daily of intranasal mupirocin, daily chlorhexidine washes, and daily decontamination of personal items such as towels, sheets, and clothes for recurrent S. aureus infection (weak, low).
  5. Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood (strong, moderate).


IV. What Is Appropriate for the Evaluation and Treatment of Erysipelas and Cellulitis?


  1. Cultures of blood or cutaneous aspirates, biopsies, or swabs are not routinely recommended (strong, moderate).
  2. Cultures of blood are recommended (strong, moderate), and cutaneous and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (weak, moderate).
  3. Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci (mild; Figure 1) (strong, moderate). For cellulitis with systemic signs of infection (moderate nonpurulent SSTI; Figure 1) systemic antibiotics are indicated. Many clinicians could include coverage against MSSA (weak, low). For patients whose cellulitis is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injection drug use, purulent drainage, or SIRS (severe nonpurulent), vancomycin or another antimicrobial effective against both MRSA and streptococci is recommended (strong, moderate). In severely compromised patients (as defined in question 13), broad-spectrum antimicrobial coverage may be considered (weak, moderate). Vancomycin plus either piperacillin-tazobactam or imipenem-meropenem is recommended as a reasonable empiric regimen for severe infection (strong, moderate).
  4. The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period (strong, high).
  5. Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended (strong, moderate).
  6. In lower extremity cellulitis, clinicians should carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection (strong, moderate).
  7. Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability (mild nonpurulent; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (moderate or severe nonpurulent; Figure 1) (strong, moderate).

V. Should Anti-inflammatory Agents Be Used to Complement Antibiotic Treatment of Cellulitis?


  1. Systemic corticosteroids (eg, prednisone 40 mg daily for 7 days) could be considered in nondiabetic adult patients with cellulitis (weak, moderate).


VI. What Is the Preferred Evaluation and Management of Patients with Recurrent Cellulitis?


  1. Identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities (strong, moderate). These practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis (strong, moderate).
  2. Administration of prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4-52 weeks, or intramuscular benzathine penicillin every 2-4 weeks, should be considered in patients who have 3-4 episodes of cellulitis per year despite attempts to treat or control predisposing factors (weak, moderate). This program should be continued so long as the predisposing factors persist (strong, moderate).


VII. What Is the Preferred Management of Surgical Site Infections?


  1. Suture removal plus incision and drainage should be performed for surgical site infections (strong, low).
  2. Adjunctive systemic antimicrobial therapy is not routinely indicated, but in conjunction with incision and drainage may be beneficial for surgical site infections associated with a significant systemic response (Figure 2) such as erythema and induration extending >5 cm from the wound edge, temperature >38.5°C, heart rate >110 beats/minute, or white blood cell (WBC) count >12 000/µL (weak, low).
  3. A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection (strong, low).
  4. A first-generation cephalosporin or an antistaphylococcal penicillin for methicillin-susceptible Staphylococcus aureus (MSSA) or vancomycin, linezolid, daptomycin, telavancin, or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics) is recommended (strong, low).
  5. Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole are recommended for infections following operations on the axilla, gastrointestinal (GI) tract, perineum, or female genital tract (Table 2) (strong, low).


VIII. What Is the Preferred Evaluation and Treatment of Necrotizing Fasciitis, Including Fournier Gangrene?


  1. Prompt surgical consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (severe nonpurulent; Figure 1) (strong, low).
  2. Empiric antibiotic treatment should be broad (eg, vancomycin or linezolid plus piperacillin-tazobactam or plus a carbapenem, or plus ceftriaxone and metronidazole), as the etiology can be polymicrobial (mixed aerobic-anaerobic microbes) or monomicrobial (group A Streptococcus, community-acquired MRSA) (strong, low).
  3. Penicillin plus clindamycin is recommended for treatment of documented group A streptococcal necrotizing fasciitis (strong, low).


IX. What Is the Appropriate Approach to the Management of Pyomyositis?


  1. MRI is the recommended imaging modality for establishing the diagnosis of pyomyositis. CT scan and ultrasound studies are also useful (strong, moderate).
  2. Cultures of blood and abscess material should be obtained (strong, moderate).
  3. Vancomycin is recommended for initial empirical therapy. An agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or following open trauma to the muscles (strong, moderate).
  4. Cefazolin or antistaphylococcal penicillin (eg, nafcillin or oxacillin) is recommended for treatment of pyomyositis caused by MSSA (strong, moderate).
  5. Early drainage of purulent material should be performed (strong, high).
  6. Repeat imaging studies should be performed in the patient with persistent bacteremia to identify undrained foci of infection (strong, low).
  7. Antibiotics should be administered intravenously initially, but once the patient is clinically improved, oral antibiotics are appropriate for patients whose bacteremia cleared promptly and those with no evidence of endocarditis or metastatic abscess. Two to 3 weeks of therapy is recommended (strong, low).


X. What Is the Appropriate Approach to the Evaluation and Treatment of Clostridial Gas Gangrene or Myonecrosis?


  1. Urgent surgical exploration of the suspected gas gangrene site and surgical debridement of involved tissue should be performed (severe nonpurulent; Figure 1) (strong, moderate).
  2. In the absence of a definitive etiologic diagnosis, broad-spectrum treatment with vancomycin plus either piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem antimicrobial is recommended (strong, low). Definitive antimicrobial therapy along with penicillin and clindamycin is recommended for treatment of clostridial myonecrosis (strong, low).
  3. Hyperbaric oxygen (HBO) therapy is not recommended because it has not been proven as a benefit to the patient and may delay resuscitation and surgical debridement (strong, low).


XI. What Is the Role of Preemptive Antimicrobial Therapy to Prevent Infection for Dog or Cat Bites?


  1. Preemptive early antimicrobial therapy for 3-5 days is recommended for patients who (a) are immunocompromised, (b) are asplenic, (c) have advanced liver disease, (d) have preexisting or resultant edema of the affected area, (e) have moderate to severe injuries, especially to the hand or face, or (f) have injuries that may have penetrated the periosteum or joint capsule (strong, low).
  2. Postexposure prophylaxis for rabies may be indicated; consultation with local health officials is recommended to determine if vaccination should be initiated (strong, low).

XII. What Is the Treatment for Infected Animal Bite-Related Wounds?


  1. An antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate (Table 5) should be used (strong, moderate).

XIII. Should Tetanus Toxoid Be Administered for Animal Bite Wounds?


  1. Tetanus toxoid should be administered to patients without toxoid vaccination within 10 years. Tetanus, diphtheria, and pertussis (Tdap) is preferred over Tetanus and diphtheria (Td) if the former has not been previously given (strong, low).

XIV. In Which Patients Is Primary Wound Closure Appropriate for Animal Bite Wounds?


  1. Primary wound closure is not recommended for wounds, with the exception of those to the face, which should be managed with copious irrigation, cautious debridement, and preemptive antibiotics (strong, low). Other wounds may be approximated (weak, low).

XV. What Is the Appropriate Treatment of Cutaneous Anthrax?


  1. Oral penicillin V 500 mg 4 times daily (qid) for 7-10 days is the recommended treatment for naturally acquired cutaneous anthrax (strong, high).
  2. Ciprofloxacin 500 mg by mouth (po) bid or levofloxacin 500 mg intravenously (IV)/po every 24 hours × 60 days is recommended for bioterrorism cases because of presumed aerosol exposure (strong, low).

XVI. What Is the Appropriate Approach for the Evaluation and Treatment of Bacillary Angiomatosis and Cat Scratch Disease?


  1. Azithromycin is recommended for cat scratch disease (strong, moderate) according to the following dosing protocol:
    • Patients >45 kg: 500 mg on day 1 followed by 250 mg for 4 additional days (strong, moderate).
    • Patients <45 kg: 10 mg/kg on day 1 and 5 mg/kg for 4 more days (strong, moderate).
  2. Erythromycin 500 mg qid or doxycycline 100 mg bid for 2 weeks to 2 months is recommended for treatment of bacillary angiomatosis (strong, moderate).

XVII. What Is the Preferred Treatment for Erysipeloid?


  1. Penicillin (500 mg qid) or amoxicillin (500 mg 3 times daily [tid]) for 7-10 days is recommended for treatment of erysipeloid (strong, high).

XVIII. What Is the Appropriate Treatment of Glanders?


  1. Ceftazidime, gentamicin, imipenem, doxycycline, or ciprofloxacin is recommended based on in vitro susceptibility (strong, low).

XIX. What Is the Appropriate Diagnosis and Treatment of Bubonic Plague?


  1. Bubonic plague should be diagnosed by Gram stain and culture of aspirated material from a suppurative lymph node (strong, moderate). Streptomycin (15 mg/kg intramuscularly [IM] every 12 hours) or doxycycline (100 mg bid po) is recommended for treatment of bubonic plague (strong, low). Gentamicin could be substituted for streptomycin (weak, low).

XX. What Is Appropriate for Diagnosis and Treatment for Tularemia?


  1. Serologic tests are the preferred method of diagnosing tularemia (weak, low).
  2. Streptomycin (15 mg/kg every 12 hours IM) or gentamicin (1.5 mg/kg every 8 hours IV) is recommended for treatment of severe cases of tularemia (strong, low).
  3. Tetracycline (500 mg qid) or doxycycline (100 mg bid po) is recommended for treatment of mild cases of tularemia (strong, low).
  4. Notify the microbiology laboratory if tularemia is suspected (strong, high).

XXI. What Is the Appropriate Approach to Assess SSTIs in Immunocompromised Patients?


  1. In addition to infection, differential diagnosis of skin lesions should include drug eruption, cutaneous infiltration with the underlying malignancy, chemotherapy- or radiation-induced reactions, Sweet syndrome, erythema multiforme, leukocytoclastic vasculitis, and graft-vs-host disease among allogeneic transplant recipients (strong, high).
  2. Differential diagnosis for infection of skin lesions should include bacterial, fungal, viral, and parasitic agents (strong, high).
  3. Biopsy or aspiration of the lesion to obtain material for histological and microbiological evaluation should always be implemented as an early diagnostic step (strong, high).

XXII. What Is the Appropriate Approach to Assess SSTIs in Patients With Fever and Neutropenia?


  1. Determine whether the current presentation of fever and neutropenia is the patient's initial episode of fever and neutropenia, or persistent unexplained fever of their initial episode (after 4-7 days) or a subsequent episode of fever and neutropenia (recurrent) (strong, low).
  2. Aggressively determine the etiology of the SSTI by aspiration and/or biopsy of skin and soft tissue lesions and submit these for thorough cytological/histological assessments, microbial staining, and cultures (strong, low).
  3. Risk-stratify patients with fever and neutropenia according to susceptibility to infection: high-risk patients are those with anticipated prolonged (>7 days) and profound neutropenia (absolute neutrophil count <100 cells/µL) or with a Multinational Association for Supportive Care (MASCC) score of <21; low-risk patients are those with anticipated brief (<7 days) periods of neutropenia and few comorbidities (strong, low) or with a MASCC score of ≥21 (strong, moderate).
  4. Determine the extent of infection through a thorough physical examination, blood cultures, chest radiograph, and additional imaging (including chest CT) as indicated by clinical signs and symptoms (strong, low).

XXIII. What Is the Appropriate Antibiotic Therapy for Patients With SSTIs During the Initial Episode of Fever and Neutropenia?


  1. Hospitalization and empiric antibacterial therapy with vancomycin plus antipseudomonal antibiotics such as cefepime, a carbapenem (imipenem-cilastatin or meropenem or doripenem) or piperacillin-tazobactam is recommended (strong, high).
  2. Documented clinical and microbiologic SSTIs should be treated based on antimicrobial susceptibilities of isolated organisms (strong, high).
  3. It is recommended that the treatment duration for most bacterial SSTIs should be 7-14 days (strong, moderate).
  4. Surgical intervention is recommended for drainage of soft tissue abscess after marrow recovery or for a progressive polymicrobial necrotizing fasciitis or myonecrosis (strong, low).
  5. Adjunct colony-stimulating factor therapy (granulocyte colony-stimulating factor [G-CSF], granulocyte macrophage colony-stimulating factor [GM-CSF]) or granulocyte transfusions are not routinely recommended (weak, moderate).
  6. Acyclovir should be administered to patients suspected or confirmed to have cutaneous or disseminated varicella zoster virus (herpes simplex virus [HSV] or varicella zoster virus [VZV]) infection (strong, moderate).=

XXIV. What Is the Appropriate Antimicrobial Therapy for Patients With SSTIs During Persistent or Recurrent Episodes of Fever and Neutropenia?


  1. Yeasts and molds remain the primary cause of infection-associated with persistent and recurrent fever and neutropenia; therefore, empiric antifungal therapy (Table 6) should be added to the antibacterial regimen (strong, high).
  2. Empiric administration of vancomycin or other agents with gram-positive activity (linezolid, daptomycin, or ceftaroline, Table 7) should be added if not already being administered (strong, high).
  3. Candida species SSTIs should be treated with an echinocandin or, if Candida parapsilosis has been isolated, lipid formulation amphotericin B (strong, high) with fluconazole as an acceptable alternative (strong, moderate). Treatment should be administered for 2 weeks after clearance of bloodstream infection or resolution of skin lesions (strong, moderate).
  4. Aspergillus SSTIs should be treated with voriconazole (strong, high), or alternatively, lipid formulations of amphotericin B, posaconazole, or echinocandin for 6-12 weeks (strong, low). Mucor/Rhizopus infections should be treated with lipid formulation amphotericin B (strong, moderate) or posaconazole (strong, low) (Table 6). The addition of an echinocandin could be considered based on synergy in murine models of mucormycosis, and observational clinical data (weak, low).
  5. Fusarium species infections should be treated with high-dose IV voriconazole or posaconazole (strong, low).
  6. Begin treatment for antibiotic-resistant bacterial organisms (Table 7), in patients currently on antibiotics (strong, moderate).
  7. Intravenous acyclovir should be added to the patient's antimicrobial regimen for suspected or confirmed cutaneous or disseminated HSV or VZV infections (strong, moderate).
  8. Blood cultures should be obtained and skin lesions in this population of patients should be aggressively evaluated by culture aspiration, biopsy, or surgical excision, as they may be caused by resistant microbes, yeast, or molds (strong, moderate).
  9. The sensitivity of a single-serum fungal antigen test (1,3-β-D-glucan or galactomannan tests) is low particularly in patients receiving antifungal agents, and benefits from laboratory tests for fungal antigen or DNA detection remain inconsistent (strong, moderate).
  10. Polymerase chain reaction (PCR) in peripheral blood for HSV and VZV might be helpful in establishing a diagnosis of disseminated infection in patients with unexplained skin lesions (weak, moderate).

XXV. What Is the Appropriate Approach to Assess SSTIs in Patients With Cellular Immunodeficiency?


  1. Consider immediate consultation with a dermatologist familiar with cutaneous manifestations of infection in patients with cellular immune defects (eg, those with lymphoma, lymphocytic leukemia, recipients of organ transplants, or those receiving immunosuppressive drugs such as anti-tumor necrosis factors or certain monoclonal antibodies) (weak, low).
  2. Consider biopsy and surgical debridement early in the management of these patients (weak, low).
  3. Empiric antibiotics, antifungals, and/or antivirals should be considered in life-threatening situations (weak, moderate). The use of specific agents should be decided with the input of the primary team, dermatology, infectious disease, and other consulting teams (strong, moderate).

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