• Summary
  Click here to print a Quick Reference Guide
• Background
• Clinical Diagnosis
• Severity Assessment
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)
• Duration of Treatment
• Switch to oral agent(s)
• Treatment Failure
• Referral Criteria

Quick Links

• Table 1. Empirical inpatient intravenous antimicrobial regimens.
• Table 2. Empirical community intravenous antimicrobial regimens
• Table 3. Empirical oral antimicrobial regimens
• Table 4. Recommended directed antimicrobial regimens.

Diagnosis 

History

• Adult patients (>16) with new onset, spreading area of red, hot, painful skin
• Assess risk factors for adverse outcome/poor response to therapy (Box 1)
• Assess risk factors for unusual/problematic pathogens (Box 2)
• This guideline does not apply to infections of eyes, mouth/oral cavity or diabetic foot infection or infections associated with intra-abdominal infection.

Examination

• Carry out severity assessment – follow algorithm
• If there is skin necrosis, purpura, blisters, loss of sensation, severe pain or features of systemic sepsis – consider necrotising soft tissue infection, see Non-antimicrobial treatment
• Bilateral/symmetrical inflammation of lower limb skin is not usually caused by infection
• Alternative diagnoses to consider: varicose eczema (Stasis Dermatitis), erythema nodosum, inflammatory reactions e.g. insect bites, deep vein thrombosis, pyoderma gangrenosum, septic arthritis.

Investigations

• Blood cultures prior to starting antibiotics in any patient likely to receive intravenous antibiotics or with features of systemic infection
• Aspirates of fluid filled lesions (blisters, pustules, collections) for microbiological investigation.
• Wound swabs from surgical incisions, abscesses or ulcerated lesions if involved in skin infection, for microbiological investigation.
• FBC, CRP, U&E, LFTs (pre-op work-up or if intravenous antimicrobials may be required).

Non-antimicrobial treatment

• If necrotising soft tissue infection suspected, refer to in-house surgical team immediately - follow algorithm
• Draw around the edge of the abnormal skin/erythema with a permanent marker and write date and time on patient's skin
• Treat as per severe sepsis protocol if appropriate (link)
• Drain any collections of pus in an appropriate environment.
• Provide analgesia (disproportionate pain raises the possibility of necrotising fasciitis)
• Elevate the affected part, if practical

Antimicrobial treatment

Use severity assessment (algorithm) to guide treatment pathway:

• Empirical inpatient intravenous antimicrobial regimens for: non-surgery related skin and soft tissue infection (Part A) and surgical site infection (Part B). (Table 1).
• Empirical community intravenous antimicrobial regimens (Table 2).
• Empirical oral antimicrobial regimens (Table 3).
• Once organism confirmed, See table 4 for Organism-specific (directed) antimicrobial regimens

Referrals

• PLASTICS
  Hand/upper limb abscesses, necrotising soft tissue infection (fasciitis) at LGI site.
• ORTHOPAEDICS
  Abscess of Lower limb, foot (non diabetic) and involving a joint.
• GENERAL SURGERY
  Abscess of trunk, groin (Non-IVDU and no vessel involvement).
  Breast abscess out of hours (in hours, direct referral to breast team).
  Necrotising soft tissue infection (fasciitis) at SJUH site.
• VASCULAR
  Groin abscess in IVDU if vessel involvement.
  Diabetic feet with osteomyelitis/gas on plain films - cellulitis as per Diabetic feet guidelines.
• ENT
  Abscess of ears.
• MAX FAX
  Abscess of head or neck or facial cellulitis.
• GYNAECOLOGY
  Labial/Bartholin's abscess.

• Relapsing/recurrent infection discuss with Microbiology or Infectious Diseases
• Orbital cellulitis (see separate guideline) – ophthalmology
• Surgical site infection – refer to team that operated (link to appendix 2)

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Cellulitis is an acute spreading infection of the skin which may extend to involve the subcutaneous (soft) tissues. Skin and soft tissue infections include cellulitis associated with ulcers, traumatic wounds, surgical wounds and necrotising soft tissue infections.  Infections range in severity from the mild lesions that resolve spontaneously to severe life-threatening infection, such as necrotising fasciitis (see below).

The most common causes are Group A streptococci (Streptococcus pyogenes) and Staphylococcus aureus but other pathogens can be involved in particular clinical situations. For example, cellulitis caused by Group B, C or G streptococci are more common in diabetic patients or those with previous radiotherapy or surgery for cancer.¹ Anaerobes including Clostridium species can cause soft tissue infections in dirty wounds or in intravenous drug users.

The aetiology of surgical wound infections varies with type and site of surgery e.g. for pelvic-abdominal surgery it often includes Gram-negative bacilli (e.g. coliforms like Escherichia coli) and anaerobes which has important implications for empirical therapy.

Other less common organisms may be associated with specific risk factors or environmental exposure such as Pasteurella multocida infection following cat bites or Capnocyophaga canimorsus infection following dog bites and Vibrio vulnificus infection following sea water exposure, Aeromonas infection following fresh water exposure and Mycobacterium marinum infection in aquarium keepers. It is important to ensure such risk factors are elicited because it may affect empirical treatment contact microbiology for advice.

Necrotising soft tissue infection and fasciitis
Necrotising fasciitis is a life and limb-threatening surgical emergency, with a high mortality rate. It is a rapidly progressive soft-tissue infection, primarily involving the fascia but also adjacent tissues, leading to necrosis. Patients with necrotising fasciitis require immediate resuscitation and aggressive surgical debridement. True necrotising fasciitis is uncommon.

There is a spectrum of necrotising soft tissue infections, such as necrotising myositis or necrotising vasculitis, which may have an identical presentation and clinical course with features of pain, erythema, swelling, and systemic inflammatory response. Toxins released by the causative organism(s), in addition to pro-inflammatory mediators, allow rapid progression of the infection along tissue planes. Perforating blood vessels that supply the skin and subcutaneous tissues from deeper layers (‘perforators’) thrombose, leading to necrosis of the tissue involved.

Although clinical examination often provides a diagnosis, surgery may be necessary to confirm this, by visualising the fascial layer and obtaining tissue for microbiological and histological analysis. Necrotising fasciitis involving the perineum and external genitalia is called Fournier’s gangrene.

“Type 1” necrotising fasciitis is a necrotising soft tissue infection caused by mixtures of bacteria (polymicrobial) usually including both Gram-positive and Gram-negative bacteria including anaerobes. These mixed infections often occur in areas of the body usually colonised by faecal flora, or affect the abdominal wall or affect patients with leg ulcers and poor general health. Fournier’s gangrene is a form of type 1 necrotising fasciitis that affects the male genitals and perineum. It is more common in diabetics, alcoholics the malnourished and immunosuppressed.

“Type 2” necrotising fasciitis refers to necrotising soft tissue infections caused by single organisms (monomicrobial). Group A streptococci are the most common cause while Staphylococcus aureus accounts for a small number of cases. A primary portal of entry is not usually apparent and the legs are most commonly affected.

Cellulitis associated with septic arthritis should be managed according to the Guidelines for management of septic arthritis of native joints in adults.

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Recommendations:

• Assess local symptoms/signs. Symptoms of cellulitis usually begin with local tenderness, pain and redness of the skin, which may develop and intensify rapidly. Affected skin is tender to touch.
• Assess systemic symptoms/signs of infection such as general malaise, fever, sweats and chills, measure the National Early Warning System (NEWS) score
• Identify any history of previous surgery or trauma to the skin (e.g. laceration, puncture wound, insect or animal bite) or other lesions (e.g. tinea pedis, furuncle, ulcer) that might predispose to the development of cellulitis. NB. these are not always apparent.
• Assess for risk factors associated with treatment failure or adverse outcome according to Box 1.
• Misdiagnosis is common, in patients who are systemically well where the diagnosis is unclear, consider dermatology referral or watchful waiting.
  [Evidence level D]

Assess risk factors for specific pathogens that will affect empirical therapy according to Box 2.
Evidence level C

Evidence review/justification
There are no pathognomonic signs nor reliable diagnostic test for cellulitis. The involved area of skin is usually red, hot, swollen and tender. The borders are not usually elevated or sharply demarcated but can be in streptococcal infection that is confined to the dermis (a condition known as erysipelas). Bilateral leg cellulitis, whilst not impossible, is very rare. Varicose eczema is a much more likely cause of bilateral inflammation of the lower legs.

Misdiagnosis is common and a frequent cause of unnecessary antibiotics and admission to hospital.³ Other conditions that can present with inflamed skin include: varicose eczema (Stasis Dermatitis), erythema nodosum, inflammatory reactions e.g. insect bites, deep vein thrombosis, pyoderma gangrenosum, septic arthritis

Regional lymphadenopathy, often associated with lymphangitis, is common. Small patches of overlying skin may blister or undergo necrosis.

Local abscesses can occur so assess for fluctuance.

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The management of cellulitis depends on the severity of illness which should be assessed according to both physiological measurement and localised signs:

Recommendations

• Measure the National Early Warning System (NEWS) score.
  Evidence level C
• Assess for localised signs of severe infection including necrotising fasciitis:
  1. patient is experiencing pain that appears disproportionate to the severity of the cellulitis (e.g. unable bear weight on an affected leg)
  2. crepitus is present
  3. haemorrhagic blisters present
  4. extensive limb involvement or rapid progression of cellulitis Evidence level C

Evidence review/justification

Note that the NEWS score is just a guide; it has not been formally evaluated as predictor in skin and soft tissue infection. If a patient does not have a high NEWS score but appears ill, seek senior advice. Interpretation may be difficult in older patients, seek advice from the elderly care team if in doubt.

A Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score was developed to help distinguish between necrotising fasciitis and severe cellulitis or other soft tissue infections.⁴ It relies on a series of biochemical parameters to calculate a likelihood of a patient suffering from necrotising fasciitis (see below). However, it does NOT RULE OUT necrotising fasciitis, with a sensitivity of just 43% in a recent UK evaluation. Therefore, if there is clinical suspicion of necrotising fasciitis, refer to the in-house surgical team immediately for surgical exploration and debridement (see pathway on following page).

LRINEC comprises:
CRP >150mg/L: 4 points,
WCC <15 x106/mm²: 0 points, 15-25 x106/mm²: 1 point, >25 x106/mm²: 2 points.
Haemoglobin >13.5g/dL: 0 points, 11-13.5g/dL: 1 point, <11g/dL: 2 points.
Sodium <135mmol/L: 2 points, Creatinine >141umol/L: 2 points, Glucose >10mmol/L: 1 point

A score greater than 6 indicates that necrotising fasciitis was likely in the original work, with variable performance in subsequent analyses but a recent systematic review found it was a good predictor (receiver-operator characteristic [ROC] curve of 0.927.)^4-7

During guideline review there was no consensus on the value of using the LRINEC in clinical practice, so it is included for information only.

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Recommendations:

• Two sets of Blood cultures should be taken at different times in all patients with severe sepsis or systemic signs of infection (rigors, chills) or who are likely to be given intravenous antimicrobials. Evidence level D
• Blood culture should be taken before starting antimicrobials. Evidence level C
• FBC should be measured at baseline in patients requiring intravenous antimicrobial therapy and repeated according to clinical need.
  Evidence level D
• CRP should be measured at baseline in patients requiring intravenous antimicrobial therapy and repeated according to clinical need. Evidence level D
• U&E and LFTs should be measured at baseline in patients requiring intravenous antimicrobials or surgery and repeated according to clinical need. Evidence level D
• Needle aspirates of fluid filled lesions such as blisters or pustules and wound swabs from abscesses or ulcerated lesions if involved in cellulitis should be sent for culture. Evidence level C
• Routine needle aspiration of the cellulitic skin edge is not recommended. Evidence level B
• Deep tissue samples and pus samples (not swabs) should be sent from all patients with necrotising fasciitis.
  Evidence level C
• X-rays of the affected area are recommended when a metallic foreign body is suspected.²
  Evidence level C
• Doppler vascular examination should be undertaken in patients with lower limb cellulitis when a deep venous thrombosis is possible.²
  Evidence level C

Evidence review/justification.

Blood Cultures are positive in only 2-5% of cases of erysipelas cellulitis and have not been deemed to be cost effective if used in all patients^8,9 hence Blood cultures should be restricted to those with more severe infection according to criteria above.

NB In groin-injecting intravenous drug users Blood cultures should not be taken via a groin sinus. Blood cultures should not be taken by the patient.

C-reactive protein (CRP) is raised in more severe cellulitis; it is part of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score and can be a useful adjunct to clinical observation in assessing response to therapy.

Renal & liver function may influence choice and dose of antimicrobials as well as fluid balance, nutritional support etc.

Needle aspiration from the centre or advancing edge of a cellulitic lesion with culture of the aspirate has a poor success rate in determining the pathogen (10-30%)¹⁰ and cannot be recommended as a routine.¹¹ It should be considered when unusual pathogens are suspected or when initial antimicrobial therapy has failed.

Ultrasound scanning or magnetic resonance imaging may be required to identify drainable collections or evidence of necrotising infection or radiolucent foreign bodies.²
Evidence level C

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General Principles
The need for admission, the need for various investigations, the choice of antimicrobial therapy and the route of administration antimicrobials should be influenced by the severity of infection, the presence of risk factors for an adverse outcome and risk factors for specific pathogens. An algorithm to guide the appropriate treatment pathway is included. As with all guidelines, this is no substitute for clinical judgment and if there are concerns about the appropriateness of a suggested pathway these should be discussed with a senior colleague.

If the national early warning score (NEWS) is ≥5, patients require hospitalisation, management according to severe sepsis guidelines and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1).
Evidence level D

Patients with local signs of severe infection including necrotising infection require admission, urgent surgical assessment because they may need debridement of the affected area and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1).
Evidence level C

Patients with NEWS score 2-4 and/or risk factors for a poor outcome (Box 1) will initially require admission and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1).
Evidence level D

Patients with risk factors for a poor outcome (Box 1) and a NEWS score 0-1 or systemic symptoms of infection may initially require admission and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1) or, selected cases may be treated in the community according to empirical community intravenous antimicrobial regimens (Table 2), where this service is available.
Evidence level D

Patients with NEWS score 0-1, no systemic symptoms of infection and non-severe local infection can usually be managed with oral antimicrobials on an outpatient basis according to empirical oral antimicrobial regimens (Table 3)
Evidence level C

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Recommendations:

• Draw around the edge of the abnormal skin/erythema with a permanent marker and write date and time on patient's skin. Evidence level D.
• For non-severe surgical site infection, remove sutures at affected site and dress. Evidence level C
• Drain collections of pus/debride necrotic tissue. Evidence level C
• Ensure adequate analgesia, N.B. disproportionate pain should raise the possibility of deep soft tissue infection.
• Elevate the affected part, if practical. Evidence level D
• If NEWS is ≥5 or 3 in one parameter, patients require assessment and management according to sepsis guidelines and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1).
  Evidence level D
• Patients with local signs of severe infection including necrotising infection require admission, urgent assessment by the in-house surgical team because they may need debridement of the affected area and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1).
  Evidence level C
• Patients with NEWS score 2-4 and/or risk factors for a poor outcome (Box 1) will initially require admission and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1).
  Evidence level D
• Patients with risk factors for a poor outcome (Box 1) and a NEWS score 0-1 or systemic symptoms of infection may initially require admission and treatment according to empirical inpatient intravenous antimicrobial regimens (Table 1) or, selected cases may be treated in the community according to empirical community intravenous/oral antimicrobial regimens (Table 2), where this service is available.
  Evidence level D
• Patients with NEWS score 0-1, no systemic symptoms of infection and non-severe local infection can usually be managed with oral antimicrobials on an outpatient basis according to empirical oral antimicrobial regimens (Table 3)
  Evidence level C

Evidence review/justification

General Principles
The need for admission, the need for various investigations, the choice of antimicrobial therapy and the route of administration antimicrobials should be influenced by the severity of infection, the presence of risk factors for an adverse outcome and risk factors for specific pathogens. An algorithm (see Appendix 1) to guide the appropriate treatment pathway is included. As with all guidelines, this is no substitute for clinical judgment and if there are concerns about the appropriateness of a suggested pathway these should be discussed with a senior colleague.

Hyperbaric oxygen therapy has been used as a component of therapy for necrotising fasciitis but remains controversial. Facilities are not available in Leeds and early surgery is the priority and hyperbaric oxygen if considered necessary will be coordinated through plastic surgery.

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NB. Antimicrobials should not be started until after blood cultures have been taken.

Recommendation: use algorithm (Appendix 1) to assess severity and the need for empirical intravenous or oral therapy.

Recommendation: commence empirical treatment of non-surgery related infections according to Table 1, 2, or 3 part A, for surgical site infection use Table 1, 2, or 3 part B.

Evidence review/justification
All antibiotics carry risks, including the regimens recommended herein. It is important to review patients who are being treated with antibiotics on a daily basis to monitor response to therapy and for signs of toxicity. The empirical regimens recommended in this guideline should be prescribed for the shortest time possible to reduce the risk of adverse effects. In addition to routine daily review, a day three review should take place to plan modifications to therapy and total duration, based on available information.

If a patient was initially thought to have necrotising fasciitis but this diagnosis is excluded, consider “de-escalating antibiotic to appropriate cellulitis or SSI regimen.

Flucloxacillin will adequately cover the most common causes of cellulitis (Staphylococcus aureus and streptococci) in most clinical situations and is the “gold standard” against which new agents are compared, except when MRSA infection is suspected. When MRSA is confirmed or suspected, Linezolid or glycopeptide (e.g. Teicoplanin ) is considered the “gold standard”; a recent randomized open label study compared Vancomycin with Linezolid therapy for complicated skin and soft tissue infections: 91.5% of patients with cellulitis were cured in both treatment arms.¹² Open trials of Teicoplanin for SSTI reported rates ranging between 92%¹³ and 96.8%¹⁴ at a low dose of 3mg/kg Teicoplanin . Local evidence of treatment failures prompted use of a weight-based Teicoplanin dosing regimen (unpublished data). Vancomycin is being largely replaced by Teicoplanin because of repeated errors with vancomycin dosing and concerns about toxicity with larger doses. A recent meta-analysis did not find evidence of a difference in outcomes for cellulitis treated with either penicillins or cephalosporins and macrolides and lincosamides (Clindamycin ).¹⁵

For type 2 necrotising fasciitis (caused by group A streptococci) the addition of Clindamycin to a cell-wall acting agent has some theoretical benefit, but clinical evidence of effectiveness comes from just three cases of necrotising fasciitis included in a retrospective observation study of invasive group A streptococcal infection in children.¹⁶Clindamycin resistance is not uncommon in streptococci causing this condition. Therefore, high dose intravenous penicillin with Clindamycin is recommended, once a microbiological diagnosis is confirmed.¹

Exposure to specific environments or conditions puts patients at risk of infection with some less common pathogens that may not respond to empirical Flucloxacillin – see Box-2

Evidence update

Although systematic review of the treatment of uncomplicated skin and soft tissue abscesses (SSTAs) after incision and drainage found no evidence of a benefit for the addition of antibiotics for uncomplicated infection,¹⁷ a placebo controlled trial found evidence of improved outcomes with the addition of Clindamycin or Co-trimoxazole , but the benefit was restricted to those with S. aureus infection.¹⁸

A meta-analysis of trials of recently concluded that treatment with a macrolide or lincosamide for cellulitis or erysipelas has a similar efficacy and incidence of adverse effects as treatment with a beta-lactam.¹⁹ A RCT that investigated the addition of Co-trimoxazole to cephalexin did not demonstrate any benefit,²⁰ while another RCT found no difference between oral Clindamycin and Co-trimoxazole .²¹

Tedizolid is an oxazolidinone (same class as Linezolid ) which showed non-inferiority to Linezolid in a head-to-head randomised, double-blind, phase 3, non-inferiority trial of treatment for acute bacterial skin and skin-structure infections (ABSSSI).²² And treatment duration as 6 days in the tedizolid vs 10 days in the Linezolid arm. Tedizolid may be recommended on microbiology advice as an alternative to Linezolid .

A network meta-analysis of randomised controlled trials concluded that tedizolid was superior to vancomycin but no different from other comparator agents in the treatment of MRSA SSTI.²³ Another meta-analysis of randomised controlled trials of treatment for ABSSSI found no difference between vancomycin, Daptomycin , Linezolid , and novel antimicrobial agents including oritavancin, when assessing the early clinical response endpoint.²⁴

For MRSA surgical site infection, a systematic review concluded that “Linezolid is superior to vancomycin in the eradication of MRSA on the basis of evidence from one small trial that was at high risk of bias,”²⁵ similarly a Cochrane review found that Linezolid was superior to vancomycin but concluded the risk of bias was high.²⁶

The efficacy of Daptomycin versus other antibiotics for skin and soft-tissue infections has been assessed in a meta-analysis of randomised controlled trials, which concluded it was at least as effective and may be superior to vancomycin.²⁷

Oritavancin is a lipoglycopeptide antibiotic (related to glycopeptides) with activity against gram-positive bacteria, it is approved for use in the European Union but on LTHT formulary at present. A single 1200-mg dose of oritavancin was noninferior to 7-10 days of vancomycin in treating ABSSSIs caused by gram-positive pathogens, and was well tolerated in two similar RCTs.^28,29

Dalbavancin is also a lipoglycopeptide with a long half-life.³⁰ Although usually used as two doses a week apart, a single 1500-mg infusion of dalbavancin was recently found to be non-inferior to a 2-dose regimen in a RCT for ABSSSI.

*Adjust doses according to renal function. Where combinations of risk factors exist discuss with Microbiology or Infectious Diseases.

*Adjust doses according to renal function. Where combinations of risk factors exist discuss with Microbiology or Infectious Diseases.

*Adjust doses according to renal function. $ Only use Clindamycin if patient is under 65 years of age and is not known to have had Clostridium difficile infection previously.

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Antimicrobials should be modified according to culture and sensitivity results, ensuring the selected antibiotic is active against the causative organism and taking into account severity and response to therapy of case.

A, Evidence level A. *Adjust doses according to renal function; **in necrotising fasciitis; $ Only use Clindamycin if patient is under 65 years of age and is not known to have had Clostridium difficile infection previously. #if in pure culture.

##The Flucloxacillin dose for directed S. aureus therapy is lower than the empirical regimens. Higher doses are used in empirical regimens partly because of theoretical concerns about reduced susceptibility of streptococci to Flucloxacillin and partly to ensure high tissue levels early in therapy.

NB. Doses of antimicrobials or choice of antimicrobial agent may need amending on advice from microbiology or Infectious Diseases.

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Recommendations:

• The duration of antimicrobial therapy for cellulitis is guided by the clinical response. Antibiotics can be stopped when there has been clinical resolution of the cellulitis. This resolution normally takes between 1-2 weeks, although resolution may happen before or after this time period. (NB there may be residual skin discolouration in the area of cellulitis, “resolution” means pain, tenderness and other signs of acute inflammation have got better)
  Evidence level D
• Immunocompromised patients and those with lymphoedema may need more prolonged antimicrobial therapy.²

Justification/evidence review

The duration of therapy required for cellulitis has not been well studied but antimicrobials can generally be stopped after 1-2 weeks treatment when symptoms of infection have resolved and there has been marked improvement in signs of inflammation.² For example, a recent randomized open label study compared Vancomycin with Linezolid therapy for complicated skin and soft tissue infections: 91.5% of patients with cellulitis were cured in both treatment arms with a mean treatment duration of approximately 11 days.¹²

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Randomised trials and observational studies suggest that this can be done safely after 3-4 days, provided that fever, erythema and induration are resolving, white blood cell count and CRP are improving, systemic signs of infection are resolving and any co-morbidities are stabilised. Please see oral switch guidance.

Empirical oral regimens (Table 3) can be used to guide choice or oral switch when the pathogen is not known; oral options are also given in Table 4.

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Appendix 1 Summary Treatment Algorithm

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Appendix 2 CDU Treatment Algorithm

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Infections not responding to first or second choice therapy or these agents are contraindicated. Discuss with Infectious Diseases or Microbiology.

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• For cases of suspected Necrotising Fasciitis at the SJUH site initial referral should be to the General Surgical team
• For cases of Suspected Necrotising Fasciitis at the LGI site initial referral should be to the Plastic Surgery Team.
• Patients with relapsing/recurrent infection to Infectious Diseases
• Patients with blistering (including haemorrhagic) and ulcers to Dermatology

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