Table 2.

Empirical Treatment for Skin and Soft Tissue Infections in Long-Term Care Residents.

PRIMARY BACTERIAL INFECTIONS
Impetigo (non-bullous and bullous)
Severity	Route	Antimicrobials	Minimum Duration	Typical Organisms	Comments
Mild	oral	dicloxacillin or cephalexin	7 days	Staphylococcus aureus MSSA most common	if many lesions empiric Rx
		doxycycline or clindamycin or TMP/SMX		MRSA	culture known
		penicillin		GABHS	culture known
	topical	mupirocin	5 days	streptococci, S. aureus	empirical Rx
Non-purulent infections (cellulitis, erysipelas, necrotizing infection)
Mild*	oral	penicillin or dicloxacillin or cephalosporins or clindamycin	5 days	streptococci	cultures; aspirates not routinely recommended
Moderate**	IV	penicillin or ceftriaxone or cefazolin or clindamycin		streptococci	consider MSSA Rx; consider MRSA Rx if prior infection
Severe***	IV	vancomycin piperacillin/tazobactam		GABHS polymicrobial	transfer to hospital; emergent surgery; deep tissue culture
Purulent infections (furuncle, carbuncle, abscess)
Mild+	N/A	none	N/A	S. aureus MSSA, MRSA	incision & drainage; antibiotics if fails
Moderate++	oral	TMP/SMX or doxycycline	minimum 5 days	S. aureus MSSA, MRSA	incision & drainage; culture & susceptibility
	IV/oral	glycopeptides or daptomycin or ceftaroline or linezolid
Severe+++	IV	as above	N/A	S. aureus MSSA/MRSA	transfer to hospital; emergent surgery; deep tissue culture
Necrotizing fasciitis/gangrene
Severe	IV	vancomycin & piperacillin/tazobactam vancomycin & carbapenem or vancomycin & metronidazole & ceftriaxone	N/A	polymicrobial S. pyogenes S. aureus	transfer to hospital; emergent surgery; deep tissue culture
Pyomyositis
Severe	IV	vancomycin	N/A	S. aureus MSSA/MRSA	transfer to hospital; emergent imaging; deep tissue & blood culture
SECONDARY BACTERIAL INFECTIONS
Surgical Site Infection > 4 days post-operatively
Clean Site head, neck trunk, extremity	IV	vancomycin or cefazolin	N/A	S. aureus MSSA/MRSA	erythema > 5 cm from incision; T > 38°C; elevated WBC; begin dressing changes
Perineal wound or GI/GU surgery	IV	cephalosporin & metronidazole or levofloxacin & metronidazole or carbapenem		polymicrobial
Pressure Ulcer Infection: Stage III or IV
	PO	ciprofloxacin or levofloxacin & metronidazole or clindamycin		polymicrobial aerobes & anaerobes	optimize local care; debride necrotic tissue; deep tissue for culture; osteomyelitis evaluation
	IV	piperacillin-tazobactam or carbapenem or cephalosporin & metronidazole or clindamycin quinolone & metronidazole or clindamycin
		if MRSA suspected, add vancomycin
Superficial fungal infections
intertrigo, vaginitis thrush paronychia denture stomatitis	topical or oral	clotrimazole, nystatin fluconazole, itraconazole		Candida albicans	culture if no response; drug interactions are common with azoles; monitor hepatotoxicity
tinea pedis tinea capitis tinea ungiuum tinea cruris	topical or oral	clotrimazole, terbinafine itraconazole, terbinafine		dermatophytes	drug interactions are common with azoles; monitor hepatotoxicity
Herpesviruses
Shingles	IV oral	acyclovir acyclovir, famciclovir valaciclovir		varicella zoster virus (VZV)	VZV higher doses than HSV IV for disseminated infection adjust for renal function treat VZV-related PHN
Genitorectal herpes	oral	acyclovir, famciclovir valacyclovir		herpes simplex virus (HSV 1&2)	adjust for renal function
Ectoparasites
Scabies	topical oral	permethrin 5% ivermectin	12 hours		cover hairline to feet crusted scabies
Lice	topical	permethrin %	12 hours		retreat one week later
Bedbugs	N/A	N/A	NA		contact precautions launder clothing contact isolation disinfect mattress seek expert guidance

Adapted from (25–27)

MSSA = Methicillin-susceptible S. aureus

MRSA = Methicillin-resistant S. aureus

GABHS = group A beta-hemolytic streptococci

TMP-SMX = trimethoprim-sulfamethoxazole

IV = intravenous

WBC = white cell count

GI/GU = gastrointestinal/genitourinary

Systemic signs of infection = (T> 38°C, heart rate > 90 beats/minute, respiratory rate > 24 breaths per minute, WBC > 12,000 or < 400 cells/mm3.

Non-purulent Severity Index
Mild*	typical cellulitis /erysipelas without focus of purulence
Moderate**	typical cellulitis/erysipelas with systemic signs of infection
Severe***	residents who have failed oral therapy with systemic signs of infection, who are immunocompromised, or have signs of deeper infection such as bullae, skin sloughing, hypotension, or organ dysfunction

Purulent Severity Index
Mild+	purulent infection
Moderate++	purulent infection with systemic signs of infection
Severe+++	residents who have failed incision & drainage with oral antibiotics or have systemic signs of infection, or who are immunocompromised