Treatment of Multidrug-resistant Gram-Negative Skin and Soft Tissue Infections

Jean-Francois Jabbour; Sima L. Sharara; Souha S. Kanj


Curr Opin Infect Dis. 2020;33(2):146-154. 

In This Article

Empiric Management of Skin and Soft Tissue Infections Caused By Multidrug-resistant Gram-negative Bacteria

Prompt initiation of proper antimicrobial therapy is crucial for improving clinical outcomes in various infectious diseases, and delays can result in an increase in mortality.[4] Patients at risk for SSTI with an MDR pathogen should be managed early with debridement when indicated, broad-spectrum antimicrobial coverage, and wound care.[5] There are no clear recommendations for the empiric therapy of SSTIs caused by MDR-GNB. The recently updated 2018 guidelines of the World Society of Emergency Surgery (WSES) and the Surgical Infection Society Europe (SIS-E) for the management of SSTIs suggest in most cases coverage against Methicillin-Resistant Staphyloccocus aureus (MRSA) but do not address GNB coverage.[6] Therefore, considerations for appropriate empiric therapy against MDR-GNB should rely on the patient's history, risk factors, and prior antibiotic exposure, as well as the local epidemiology of the country and hospital, and - most importantly - the unit in which the patient is managed. There is not a single agent currently available that provides adequate coverage for the four most troublesome MDR-GNB, therefore, empiric coverage mostly relies on a combination of two to three drugs pending identification, susceptibility testing, and in some cases molecular typing, of the offending organisms.

Early escalation/de-escalation to a targeted therapy is of paramount importance in line with stewardship efforts (Figure 1).

Figure 1.

Algorithm for the management of multidrug resistant Gram-negative skin and soft tissue infections. CRAB, carbapenem-resistant Acinetobacter baumannii; CRE, carbapenem-resistant Enterobacteriaceae; CRPA, carbapenem-resistant Pseudomonas aeruginosa; GNB, Gram-negative bacteria; KPC, Klebsiella pneumoniae carbapenemase producers; MBL, metallo-β-lactamase; MDR, multidrug-resistant; SM, Stenotrophomonas maltophilia; SSTI, skin and soft tissue infection; TMPSMX, trimethoprim–sulfamethoxazole.