Skin and Soft Tissue Guideline

By Preeti Jaggi

Most antibiotics are prescribed in the outpatient setting and there are many opportunities for optimizing antimicrobial prescribing in this setting. Skin and soft tissue infections (SSTIs) are common presenting complaints in emergency department.  Infectious Disease Society of America guidelines recommend 5 days of initial treatment for non-purulent SSTI. In addition, randomized controlled trials have shown that cephalexin vs. both trimethoprim/sulfamethoxazole and cephalexin (to treat for presumed methicillin resistant Staphylococcus aureus as well as Group A streptococcus) are equally effective for non-purulent SSTI. This implies that cephalexin alone can be used for patients without abscesses. For patients presenting with purulent SSTIs, recent studies have shown comparable cure rates when trimethoprim/sulfamethoxazole or clindamycin are used for 7 instead of 10 days following I&D. 

In our system, we have found a wide range of variation in the outpatient management of SSTIs for both antibiotic choice and duration of treatment. For both purulent and non-purulent SSTIs, clindamycin or trimethoprim/sulfamethoxazole were generally being prescribed for 10 days, a longer duration than recommended. In a recent quality improvement project, we were able to improve antibiotic prescribing for both purulent and non-purulent SSTIs. Exclusion criteria were patients with impetigo, paronychia, preseptal and orbital cellulitis, cephalosporin allergy, and inpatient admission.