What are the IDSA treatment guidelines for skin and soft tissue infections (SSTIs), including cellulitis?

Updated: Jun 14, 2019
  • Author: Thomas E Herchline, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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In 2014, the Infectious Diseases Society of America (IDSA) published updated guidelines for the management of various skin and soft tissue infections (SSTIs), with emphasis on the clinical skills needed to properly treat the likely pathogens before and after culture results are available. [2]

The guidelines include a treatment algorithm that begins by determining whether the cellulitis is nonpurulent or purulent, as follows: [2]

  • Nonpurulent cellulitis includes rapidly spreading superficial cellulitis and erysipelas; typically involves groups A, B, C, and G beta-hemolytic streptococci and, occasionally, methicillin-susceptible Staphylococcus aureus (MSSA); these infections are diagnosed clinically, and cultures are not mandatory since there is usually no reliable and easily accessible source of specimen to culture
  • Purulent cellulitis includes cutaneous abscesses, carbuncles, furuncles, and sebaceous cyst infection typically involving S aureus, both MSSA and methicillin-resistant S aureus (MRSA); culture should be performed when possible to determine the pathogen’s presence and resistance pattern

Outpatient therapy with oral antibiotics is indicated for healthy individuals who have no evidence of systemic inflammatory response syndrome (SIRS). [2]

Inpatient therapy with parenteral antibiotics is recommended in patients with associated SIRS, hemodynamic instability, and/or mental status changes. Poor compliance, failure to respond to oral antibiotics, facial involvement, and immune suppression are additional indications for inpatient parenteral therapy until the patient is stable and improving. The initial antibiotic selection should cover MRSA in patients with coexisting penetrating and/or surgical trauma, evidence of MRSA infection elsewhere, known nasal MRSA colonization, and/or intravenous drug abuse. Coverage should also take into consideration the prevalence of MRSA in the patient’s hospital and community. [2]

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