SSTI: Antibiotic Dosing

Penicillin allergies: For risk stratification see Penicillin ADR (HISTORICAL) Clinical Pathway

• For patients with a low risk of IgE-mediated reaction to penicillin, consider observed oral dose of the recommended treatment and continue therapy if tolerated.
• For patients with a high risk of IgE-mediated or severe delayed reaction to penicillin, refer to guidance below.

Cephalosporin allergies: For patients with history of anaphylaxis or severe delayed reaction, refer to guidance below.

Place in Therapy

Recommended Treatment

Additional Considerations

Paronychia

First-line

Incision and drainage + warm compresses

PLUS 

Topical mupirocin three times daily x 5 days

If concurrent cellulitis, refer to cellulitis or erysipelas management.

Folliculitis

First-line

Topical mupirocin x 5 days

If concurrent cellulitis, refer to cellulitis or erysipelas management.

Mild Impetigo

First-line

Topical mupirocin x 5 days

Extensive Impetigo (i.e. > 5 lesions, covering large areas of the body, or near the mouth)

First-line

Cephalexin 17 mg/kg/dose PO q8h x 7 days (max 500 mg/dose)

Cephalexin can be used in patients with penicillin allergies at a low risk for IgE-mediated reactions. Refer to Penicillin ADR Clinical Pathway for more information.

Cefazolin 25 mg/kg/dose IV q8h (max 2000 mg/dose); transition to PO at earliest opportunity to complete 7 days

Cefazolin can be used in patients with penicillin allergies at a low OR high risk for IgE-mediated reactions.  Refer to Penicillin ADR Clinical Pathway for more information.

MRSA risk factor 

OR

Penicillin allergy at a high risk for IgE-mediated or severe delayed reaction

Clindamycin 10 mg/kg/dose PO q8h x 7 days (max 450 mg/dose)

Clindamycin 10 mg/kg/dose IV q8h (max 600 mg/dose); transition to PO at earliest opportunity to complete 7 days

Trimethoprim-sulfamethoxazole 4 - 6 mg/kg/dose PO q12h x 7 days (max 160 mg/dose)

Dosed on trimethoprim component.

Controversial coverage of S. pyogenes.

Cellulitis or Erysipelas

First-line

Cephalexin 17 mg/kg/dose PO q8h x 5 days (max 500 mg/dose)

Cephalexin can be used in patients with penicillin allergies at a low risk for IgE-mediated reactions. Refer to Penicillin ADR Clinical Pathway for more information.

Cefazolin 25 mg/kg/dose IV q8h x 5 days (max 2000 mg/dose); transition to PO at earliest opportunity to complete 5 days

Cefazolin can be used in patients with penicillin allergies at a low OR high risk for IgE-mediated reactions.  Refer to Penicillin ADR Clinical Pathway for more information.

Alternative

Amoxicillin-clavulanate 22.5 mg/kg/dose PO q12h x 5 days (max 875 mg/dose)

Dosed on amoxicillin component. Refer to the Outpatient Antimicrobial Handbook's Dosing of Amoxicillin/Clavulanate guide (page 31) for which formulation to use.

Ampicillin-sulbactam 50 mg/kg/dose IV q6h (max 2000 mg/dose); transition to PO at earliest opportunity to complete 5 days  

Dosed on ampicillin component.

MRSA risk factor

OR

Penicillin allergy at a high risk for IgE-mediated or severe delayed reaction

Clindamycin 10 mg/kg/dose PO q8h x 5 days (max 450 mg/dose)

Clindamycin 10 mg/kg/dose IV q8h (max 600 mg/dose); transition to PO at earliest opportunity to complete 5 days

Clindamycin resistance for S. aureus and S. pyogenes has been increasing. Consider selecting an alternative if patient has a history of clindamycin-resistant S. aureus or changing to a narrow spectrum antibiotic if culture results show MSSA or S. pyogenes.

Abscess

First-line

Clindamycin 10 mg/kg/dose PO q8h x 5 days (max 450 mg/dose)

Clindamycin 10 mg/kg/dose IV q8h (max 600 mg/dose); transition to PO at earliest opportunity to complete 5 days

Clindamycin resistance for S. aureus and S. pyogenes has been increasing. Consider selecting an alternative if patient has a history of clindamycin-resistant S. aureus or changing to a narrow spectrum antibiotic if culture results show MSSA or S. pyogenes.

Trimethoprim-sulfamethoxazole 4 - 6 mg/kg/dose PO q12h x 5 days (max 160 mg/dose)

Dosed on trimethoprim component.