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==Empiric Therapy<SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from Clinical Practice Guidelines CID 2011<ref name="Mathews-2010">{{Cite journal  | last1 = Mathews | first1 = CJ. | last2 = Weston | first2 = VC. | last3 = Jones | first3 = A. | last4 = Field | first4 = M. | last5 = Coakley | first5 = G. | title = Bacterial septic arthritis in adults. | journal = Lancet | volume = 375 | issue = 9717 | pages = 846-55 | month = Mar | year = 2010 | doi = 10.1016/S0140-6736(09)61595-6 | PMID = 20206778 }}</ref> and Guidelines for Skin and Soft-Tissue Infections CID 2005<ref>{{Cite journal
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
| author = [[Dennis L. Stevens]], [[Alan L. Bisno]], [[Henry F. Chambers]], [[E. Dale Everett]], [[Patchen Dellinger]], [[Ellie J. C. Goldstein]], [[Sherwood L. Gorbach]], [[Jan V. Hirschmann]], [[Edward L. Kaplan]], [[Jose G. Montoya]] & [[James C. Wade]]
|+
| title = Practice guidelines for the diagnosis and management of skin and soft-tissue infections
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Tuberculin Rection}}
| journal = [[Clinical infectious diseases : an official publication of the Infectious Diseases Society of America]]
! style="background: #4479BA; width: 450px;" | {{fontcolor|#FFF|Considered a Positive Result in:}}
| volume = 41
| issue = 10
| pages = 1373–1406
| year = 2005
| month = November
| doi = 10.1086/497143
| pmid = 16231249
}}</ref></SMALL></SMALL></SMALL></SMALL></SMALL>==
 
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
 
{|
| valign=top |
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Cellulitis'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Non-Purulent Cellulitis'''
</font>
</div>
 
<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adults'''
</font>
</div>
 
<div class="mw-customtoggle-table07" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children age >28 days'''
</font>
</div>
 
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Purulent Cellulitis'''
</font>
</div>
 
<div class="mw-customtoggle-table08" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adults'''
</font>
</div>
 
<div class="mw-customtoggle-table09" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children age >28 days'''
</font>
</div>
 
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
'''Complicated Cellulitis†'''
</font>
</div>
 
<div class="mw-customtoggle-table10" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Adults'''
</font>
</div>
 
<div class="mw-customtoggle-table11" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Children age >28 days'''
</font>
</div>
 
 
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #A1BCDD; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Non-Purulent Cellulitis}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
| style="padding: 5px 5px; background: #DCDCDC;" | '''≥ 5 mm '''
| style="padding: 5px 5px; background: #F5F5F5;" | 
*HIV-positive person
*Recent contacts of TB case
*Persons with nodular or fibrotic changes on CXR consistent with old healed TB
*Patients with organ transplants and other immunosuppressed patients
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cephalexin]] 500 mg PO q6h x5-10 days'''''<br> OR <br> ▸ '''''[[Dicloxacillin)]] 500 mg PO q6h x5-10 days'''''<br> OR <br>▸'''''[[Clindamycin]] 300-450 mg PO q8h'''''<br> OR <br> ▸ '''''[[Amoxicillin]] 500 mg PO q8h '''''<br> OR <br> ▸ '''''[[TMP-SMX]] 80-160 mg/400-800 mg  PO q12h'''''<br> OR <br>▸'''''[[Doxycycline]] 100 mg PO q12h'''''<br> OR <br> ▸ '''''[[Linezolid]] 600 mg PO q12h '''''
| style="padding: 5px 5px; background: #DCDCDC;" | '''≥ 10 mm  '''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Recent arrivals (less than 5 years) from high-prevalent countries
*Injection drug users
*Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.)
*Mycobacteriology lab personnel
*Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc)
*Children less than 4 years of age, or children and adolescents exposed to adults in high-risk categories
|-
|-
|}
| style="padding: 5px 5px; background: #DCDCDC;" | '''≥ 15 mm '''
|}
| style="padding: 5px 5px; background: #F5F5F5;" |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table07" style="background: #FFFFFF;"
*Persons with no known risk factors for TB
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #A1BCDD; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Non-Purulent Cellulitis}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Cephalexin]] 25 mg/kg/day PO divided q6h x 5-10 days'''''<br> OR <br> ▸ '''''[[Dicloxacillin]] 25 mg/kg/day PO divided q6h x 5-10 days'''''<br> OR <br>▸ '''''[[Clindamycin]] 10-13 mg/kg IV q6-8h  (max:40 mg/kg/day)'''''<br> OR <br> ▸ '''''[[TMP-SMX]] 4-6 mg/kg PO q12h (TMP component)'''''<br> OR <br> ▸'''''[[Doxycycline]]¶ 2 mg/kg PO q12h† '''''<br> OR <br> ▸ '''''[[Linezolid]] 10 mg/kg PO q8h (max: 600mg/dose)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL><sup>¶</sup> Not recommended for children < 8 years of age <br><sup>†</sup> For children ≤45 kg.  Children >45 kg receive adult dosing.  </SMALL>
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table08" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #A1BCDD; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Purulent Cellulitis}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Linezolid]] 600 mg PO q12h'''''<br> OR <br>  ▸ '''''[[Clindamycin]] 300 - 450 mg PO q8h'''''<BR> OR <BR>  ▸ '''''[[Minocycline]] 200 mg PO 1 dose, then 100 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[Doxycycline]] 100 mg PO q12h'''''<BR> OR <BR> ▸ '''''[[TMP-SMX]] 80-160 mg/400-800 mg  PO q12h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table09" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #A1BCDD; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Purulent Cellulitis}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Linezolid]] 10 mg/kg PO q8h (max: 600mg/dose)'''''<br> OR <br>  ▸ '''''[[Clindamycin]] 10-13 mg/kg IV q6-8h  (max:40 mg/kg/day)'''''<BR> OR <BR> ▸ '''''[[Minocycline]] 4 mg/kg PO 1 dose, then2 mg/kg/dose PO q12h '''''<BR> OR <BR> ▸ '''''[[Doxycycline]]¶ 2 mg/kg PO q12h†'''''<BR> OR <BR> ▸ '''''[[TMP-SMX]] 4-6 mg/kg PO q12h (TMP component)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL><sup>¶</sup> Not recommended for children < 8 years of age <br><sup>†</sup> For children ≤45 kg.  Children >45 kg receive adult dosing.  </SMALL>
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table10" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #A1BCDD; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Complicated Cellulitis}}
|-
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Parental Regimen}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]]  15-20 mg/kg IV q8-12h'''''<BR> OR <BR>▸ '''''[[Linezolid]] 600 mg IV q12h'''''<BR> OR <BR>  ▸ '''''[[Daptomycin]] 4mg/kg IV q24h''''' <BR> OR <BR>  ▸ '''''[[Telavancin]] 10mg/kg IV q24h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |  ▸ '''''[[Clindamycin]] 600 mg IV q8h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table10" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Oral Regimen}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Linezolid]] 600 mg PO q12h'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |  ▸ '''''[[Clindamycin]]'' 600 mg PO q8h'''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL> <sup>†</sup> Complicated cellulitis refers to a deeper soft-tissue infections and the association with necrotizing fasciitis, septic arthritis, or osteomyelitis</SMALL>
|-
|}
|}
 
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #A1BCDD; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Complicated Cellulitis}}
|-
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Parental Regimen}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Vancomycin]]  15 mg/kg IV q6h'''''<BR> OR <BR>▸ '''''[[Linezolid]] 10 mg/kg IV q8h (max: 600mg/dose)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left |  ▸ '''''[[Clindamycin]] 10-13 mg/kg IV q6-8h  (max:40 mg/kg/day)'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table11" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Oral Regimen}}
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Linezolid]] 10 mg/kg PO q8h (max: 600mg/dose)''''' <br> OR <br> ▸ '''''[[Clindamycin]] 10-13 mg/kg PO q6-8h  (max:40 mg/kg/day)'''''
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5" align=left | <SMALL> <sup>†</sup> Complicated cellulitis refers to a deeper soft-tissue infections and the association with necrotizing fasciitis, septic arthritis, or osteomyelitis</SMALL>
|-
|-
|}
|}
|}
|}
'''Note:'''
* Treatment of cellulitis in neonates usually requires hospitalization and parenteral therapy.  Oral therapy is given for completion of the treatment when the patogen is unknown.
* Optimal dose should be based on determination of serum concentrations.
* The above antibiotic regimen is '''NOT''' for initial empirical treatment of infections involving the face.
* Dose alteration for renal insufficiency may be needed in case of [[cephalosporins]].
* [[Clindamycin]] is an alternate therapy for patients at risk of severe hypersensitivity reaction to [[penicillins]] and [[cephalosporins]].
* [[Doxycycline]] is '''NOT''' recommended for children <8 years of age.
* Studies have shown an increase in treatment failure with [[TMP-SMX]] compared to other agents for [[cellulitis]] in children, reflecting [[TMP-SMX]] less action against [[Group A streptococcus]].<ref name="pmid19470525">{{cite journal| author=Elliott DJ, Zaoutis TE, Troxel AB, Loh A, Keren R| title=Empiric antimicrobial therapy for pediatric skin and soft-tissue infections in the era of methicillin-resistant Staphylococcus aureus. | journal=Pediatrics | year= 2009 | volume= 123 | issue= 6 | pages= e959-66 | pmid=19470525 | doi=10.1542/peds.2008-2428 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19470525  }} </ref>
==References==
{{Reflist|2}}

Latest revision as of 13:10, 4 September 2014

Tuberculin Rection Considered a Positive Result in:
≥ 5 mm
  • HIV-positive person
  • Recent contacts of TB case
  • Persons with nodular or fibrotic changes on CXR consistent with old healed TB
  • Patients with organ transplants and other immunosuppressed patients
≥ 10 mm
  • Recent arrivals (less than 5 years) from high-prevalent countries
  • Injection drug users
  • Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.)
  • Mycobacteriology lab personnel
  • Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight, etc)
  • Children less than 4 years of age, or children and adolescents exposed to adults in high-risk categories
≥ 15 mm
  • Persons with no known risk factors for TB
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