Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
CLINICAL CONDITION
Impetigo
Signs and symptoms:
 erythematous papules
 vesicles and pustules
 honey-colored crusts on an
erythematous base
Investigations:
 Gram stain and culture of
the pus or exudates
from skin lesions
Erysipelas
Signs and symptoms:
 Acute onset of symptoms
e.g. cutaneous redness,
warmth, tenderness
 Systemic symptoms e.g.
fever
Investigations:
 Cultures of blood, pus, or
bullae in patients with
systemic toxicity
USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE DURATION
(suitable in serious
penicillin allergy)
 Bullous and non-bullous impetigo can be Topical Fusidic acid 6-8 hourly Topical Fusidic acid 6-8 7 days
treated with oral or topical antimicrobials, but OR hourly
oral therapy is recommended for patients with Flucloxacillin 1g 6 hourly PO OR
numerous lesions or in outbreaks affecting
several people to help decrease transmission Add penicillin V 500mg 6 hourly Clindamycin 450mg 6 hourly
of infection. PO if streptococcus suspected PO
 Hygiene measures are important to aid
healing and stop the infection spreading to
other sites on the body and to other people;
advise patient appropriately.
 Management of the underlying cause (if
applicable) is recommended e.g. atopic
eczema, scabies, or head lice.
 Elevate affected extremity. Benzylpenicillin 2.4g Clindamycin 900mg 8 hourly 5-7 days
 Identify and manage any underlying risk 6 hourly IV IV depending on
factors such as eczema, tinea pedis, clinical response;
lymphoedema, leg ulceration, varicella and If no response within 48hrs or If MRSA positive add: if >7 days,
bites. acute deterioration add: Vancomycin IV as per dosing discuss with
Clindamycin 900mg 8 hourly IV guideline microbiology.
If MRSA positive add:
Vancomycin IV as per dosing
guideline
Oral step down:
Oral step down: Clindamycin 450mg 6 hourly
Amoxicillin 1g 8 hourly PO PO
If using vancomycin, consider If using vancomycin,
doxycycline 100mg 12 hourly PO consider doxycycline 100mg
or clindamycin 450mg 6 hourly 12 hourly PO or clindamycin
PO 450mg 6 hourly PO
1

CLINICAL CONDITION
Bites
(Dog, cat and human)
Signs and symptoms:
 Bite injury which is either
infected or at risk of
becoming infected.
Investigations:
 Xray in clenched fist/crush
injuries to exclude the
presence of teeth or dental
fragments, rule out bone
damage etc.
 If infected, send pus or a
deep wound swab for
culture, before cleaning
the wound
 Blood cultures where
indicated
 Surgical evaluation where
indicated
Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE DURATION
(suitable in serious
penicillin allergy)
Pre-emptive 3-5
 80% of cat bites and 5% of dog bites become infected. Co-amoxiclav 625mg Dog and Cat: days
 Cleanse wound thoroughly. Assess tetanus and rabies 8 hourly PO Doxycycline 100mg 12
risk; for tetanus prone wound, give human tetanus or hourly PO Treatment: 7
immunoglobulin with absorbed diphtheria (low dose) 1.2g 8 hourly IV Plus days
vaccine if necessary, according to immunization history. depending on severity Metronidazole 400mg 8
 Assess HIV, hepatitis B & C risk in the case of human hourly PO
bites. Oral step down:
 Cat bite wounds tend to penetrate deeply, with higher Co-amoxiclav 625mg 8 Human:
risk of associated osteomyelitis, tenosynovitis, and hourly PO Clarithromycin 500mg 12
septic arthritis. hourly PO
 Pre-emptive antibiotic therapy recommended for: Plus
o All human bite wounds <72 hrs old Metronidazole 400mg 8
o All cat bites hourly PO
o Animal bites to hand, foot, or face.
o Puncture wounds or
o Wounds requiring surgical debridement
o Wounds involving joints, tendons, ligaments, or (for dog, cat or human
suspected fractures bites)
o Animal bites < 48hrs where the risk of infection
is high Clindamycin 900mg 8
o Immuno-compromised, diabetic, elderly or hourly IV
asplenic patients. Plus
 Patients require review at 24 and 48hrs with primary Ciprofloxacin
care if minor wound or ED if more significant. 400mg 12 hourly IV
depending on severity.
Oral step down:
Clindamycin 450mg 6
hourly PO
Plus
Ciprofloxacin 400mg 12
hourly PO
2
 Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
CLINICAL USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE DURATION
CONDITION (suitable in penicillin
allergy/ MRSA)

Cellulitis Be wary of over diagnosing cellulitis. Consider possibility of Class I: Class I penicillin allergic Class I:
varicose eczema especially when erythema is bilateral. Flucloxacillin 1g 6 hourly PO or MRSA: 5 days
Signs and Doxycycline 100mg 12
symptoms:  Contact microbiology immediately if: Class II: hourly PO Class II:
 cutaneous o Rapidly spreading cellulitis (Group A Strep) Flucloxacillin 2g 6 hourly IV 5 days
redness, o Panton-Valentine Leukocidin (PVL) positive S. aureus +/- Class II penicillin allergic
warmth, strains suspected; generally affects previously healthy young Benzylpenicillin 2.4g or MRSA:
tenderness children and young adults. Risk factors include recurrent 6 hourly IV depending on Clindamycin 900mg 8
 Systemic abscess/SSTI and close contact/crowding. severity. hourly IV
symptoms e.g. o Necrotising fasciitis, Fournier’s or gas gangrene
fever  Elevate affected extremity. Oral step down: Oral step down:
 Identify and manage any underlying risk factors (e.g. eczema, Flucloxacillin 1g 6 hourly PO Doxycycline 100mg 12
Investigations: tinea pedis, lymphoedema, leg ulceration, varicella and bites) or hourly PO
 Take blood co-morbidities (such as diabetes mellitus or alcohol misuse) that Where patient suitable for Or
culture and may cause the cellulitis to spread rapidly, or delay healing. home IV treatment: Clindamycin 450mg 6
wound swab or  Class 1: no signs of systemic toxicity, and no significant co- hourly PO
pus for culture. morbidity. Ceftriaxone 1g 24 hourly IV
 Class 2: systemically well, but with a co-morbidity e.g. PVD,
If patient’s BMI is greater
chronic venous insufficiency or morbid obesity which may
than 30 the first dose of
complicate or delay resolution of their infection OR systemically
Ceftriaxone should be 2g,
unwell.
then 1g 24 hourly thereafter.
 Class 3-4: have severe sepsis syndrome with organ failure or
severe life threatening infection e.g. necrotising fasciitis (see
separate section).
 If known MRSA positive, check sensitivities if they are
available

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CLINICAL CONDITION
Cellulitis Class III
Signs and symptoms:
Five clinical features suggest the
presence of a deep and severe infection
of skin and its deeper tissue:
o severe, constant pain
o bullous lesions
o gas in the soft tissues
o systemic toxicity
o rapid spread centrally along fascial
planes.
Investigations:
 Take blood culture and send wound
swab, debrided tissue/ pus for
culture to microbiology.
 CT/MRI when indicated.
 In IV drug users consider anthrax
and potential for abscesses.
Contact microbiology for treatment
options.
Cellulitis Class IV/ Severe Soft Tissue
Infection such as:
 Necrotizing fasciitis
 Fournier’s gangrene
 Gas gangrene
 Evidence of toxic shock
Signs and symptoms:
As for Class III
Investigations:
As for Class III
Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
USEFUL INFORMATION RECOMMENDATIONS ALTERNATIVE DURATION
(suitable in serious penicillin
allergy)
o Daptomycin: If creatinine No MRSA: No MRSA: 5-7 days
kinase elevated before Flucloxacillin 2g 6 hourly IV Clindamycin 900mg 8 hourly IV
treatment contact microbiology Plus
for advice. Benzylpenicillin 2.4g If known MRSA:
o Monitor creatinine kinase 6 hourly IV depending on severity. Daptomycin 6mg/kg 24 hourly IV
before treatment and then
weekly (more frequently if Review antibiotics based on
receiving another drug known If known MRSA: cultures
to cause myopathy-preferably Daptomycin 6mg/kg 24 hourly IV
avoid concomitant use).
o If >83kg confirm dose with Oral step down: Oral step down:
pharmacy or microbiology Flucloxacillin 1g 6 hourly PO Clindamycin 450mg 6 hourly PO
between 9am and 5pm day 1 Oral step down for known
or 2 of treatment. Oral step down for known MRSA: MRSA:
o If known MRSA positive, Doxycycline 100mg 12 hourly PO Doxycycline 100mg 12 hourly PO
check sensitivities if they
are available
 These are acute, rapidly Piperacillin/tazobactam 4.5g 6 hourly Teicoplanin 10mg/kg 12 hourly x Severe
developing infections of deep IV 3 doses, then 10mg/kg 24 hourly cellulitis: 7
fascia which are life threatening. Plus Plus days
 Urgent surgical and microbiology Clindamycin 1.2g 6 hourly IV. Clindamycin 1.2g 6 hourly IV
input is required. If known MRSA add: Plus Necrotizing
 Treatment includes early surgical Daptomycin 6mg/kg 24 hourly IV Ciprofloxacin 600mg 12 hourly IV fasciitis,Fou
debridement and high dose Plus rnier’s
antibiotic therapy directed at the Contact microbiology if necrotising Metronidazole 500mg 8 hourly IV gangrene,G
pathogens. fasciitis or toxic shock syndrome. as
 If necrotising fasciitis or Fournier’s Review antibiotics based on gangrene,
gangrene suspected, isolate cultures Evidence of
patient with appropriate toxic shock:
contact/droplet precautions and seek advice
discuss with IPCT. from micro
 Daptomycin: As above
4
 Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATION ALTERNATIVE DURATION
(suitable in serious
penicillin allergy)
7 days
Preseptal cellulitis  Preseptal cellulitis: Flucloxacillin 2g 6 hourly IV Clindamycin 900mg 8
o No proptosis Plus hourly IV Treatment
Signs and symptoms: o No impairment of ocular motility Benzylpenicillin 2.4g should be
 eyelid swelling with o Normal optic nerve function 6 hourly IV continued until
or without erythema  If concerns of progression to orbital cellulitis, or not improving, treat the erythema
 ocular pain as orbital cellulitis and contact microbiology. Oral step down: Oral step down: and swelling
Flucloxacillin 1g 6 hourly Clindamycin 450mg 6 have resolved
Investigations: PO hourly PO or nearly
 Blood cultures Or resolved
 Consider CT Doxycycline 100mg 12
hourly PO

Vancomycin as per
Orbital cellulitis  Ophthalmologist, ENT and microbiology referral required. Cefotaxime 2g 6 hourly IV prescribing chart 7 days
 Most patients with uncomplicated orbital cellulitis can be treated Plus Plus
Signs and symptoms: with antibiotics alone. Vancomycin IV Ciprofloxacin 400mg 12 Treatment
as above +  Complications include subperiosteal abscess, orbital abscess, Plus hourly IV should be
 ophthalmoplegia visual loss, and intracranial extension. Metronidazole 500mg 8 Plus continued until
 proptosis  The main indications for surgery are a poor response to antibiotic hourly IV Metronidazole 500mg 8 all signs
 Conjunctival treatment, worsening visual acuity or pupillary changes, evidence hourly IV resolved.
swelling of an abscess (especially a large abscess (>10 mm in diameter) or
 Fever one that fails to respond promptly to antibiotic treatment).
 In some cases, drainage of affected sinuses is also required to
Investigations: control the infection.
 Blood cultures  The results of cultures and susceptibility testing from samples
 CT/MRI obtained during surgery can be used to tailor therapy.

5
 Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
CLINICAL CONDITION USEFUL INFORMATION RECOMMENDATION ALTERNATIVE DURATION
(suitable in serious
penicillin allergy

Infected Leg Ulcers  Take care when diagnosing infection on top of chronic venous Non-severe: Flucloxacillin Non-severe: 5-7 days
insufficiency. Manage associated oedema, pain and dermatitis as 1g 6 hourly PO Doxycycline 100mg 12
Signs and symptoms: well as infection. Clinically non-infected ulcers should not be hourly PO May be
 Enlarging ulcer. cultured. Severe: Flucloxacillin 2g 6 Severe: Clindamycin extended if
 Increased exudate.  Leg ulcers occasionally become infected, but are invariably hourly IV 900mg 8 hourly IV slow response;
 Increased pain. colonised by two or more different bacterial species. The +/- contact
 Pyrexia. predominant pathogens are S.aureus and beta-haemolytic Benzylpenicillin 2.4g 6 microbiology
 Foul odour. streptococci. hourly IV depending on
 Cellulitis  Organisms which commonly COLONISE (but rarely infect) ulcers severity
include: coliforms (especially Proteus species), Pseudomonas
Investigations: aeruginosa and enterococci. Oral step down: Oral step down:
 specimens obtained  For Diabetic Foot Infections see relevant guidelines Flucloxacillin 1g 6 hourly Doxycycline 100mg 12
by curettage. PO hourly PO
MRSA:

Teicoplanin 10mg/kg 12 hourly x 3 doses, then

10mg/kg 24 hourly

Oral step down:

Doxycycline 100mg PO 12 hourly

Infected insect/ tick  Most local reactions to insect/tick bites or stings can be managed Doxycycline 100mg 12 hourly PO Infected
bites or stings symptomatically; only treat with antibiotics if infected. insect bite:
 If a tick is still attached, remove it. 7 days
Signs and symptoms:  Tick bites: Consider micro/ID consultation and advise review by a
 local reactions doctor for consideration of antibiotics if they develop any Erythema
 papular urticarial symptoms of Lyme disease. migrans
 systemic allergic  For people who do not have an erythema migrans rash but have rash/Lyme
reaction symptoms suggestive of Lyme disease and a recent history of a disease:
 Erythema migrans tick bite or possible exposure to ticks, test for antibodies to Borrelia 21 days
rash burgdorferi.

6

CLINICAL CONDITION
Superficial abscesses,
boils and carbuncles
Signs and symptoms:
 Painful, tender, and
fluctuant red nodules,
often surmounted by a
pustule and encircled
by a rim of
erythematous swelling.
Investigations:
 Gram stain and culture
of pus from carbuncles
and abscesses are
recommended
Surgical wound
infections
Signs and symptoms:
 pain, swelling,
erythema, and purulent
drainage
Investigations:
 Send blood and culture
of the exudate if patient
is febrile.
Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
USEFUL INFORMATION RECOMMENDATION ALTERNATIVE DURATION
(suitable in serious penicillin
allergy)
Continue
 Treat with Incision and drainage as soon as possible. Flucloxacillin 1g 6 hourly Clindamycin 450mg 6 hourly antibiotics
 The decision to administer antibiotics as an adjunct to incision PO PO until
and drainage should be made based on if: drained.
o Severe or rapidly progressive infections
o The presence of extensive associated cellulitis
o Signs and symptoms of systemic illness
o Associated septic phlebitis
o Diabetes or other immune suppression
o Advanced age
o Location of the abscess in an area where complete
drainage is difficult (e.g. face, genitalia)
o Lack of response to incision and drainage alone
 A recurrent abscess at a site of previous infection should
prompt a search for local causes such as a pilonidal cyst,
hidradenitis suppurativa, or foreign material.
In deep seated infections, source control is critical. Oral Superficial infections: Superficial infections: Treat 5 days post
antibiotics without source control is rarely successful. Treat as per cellulitis as per cellulitis guidelines source
 Wound infections associated with cellulitis alone (i.e., no guidelines control
fluctuance) can be treated with a course of antibiotics without
open drainage. Deeper infections:
 Suture removal plus incision and drainage should be performed Deeper infections: Co-trimoxazole 1.44g 12
for surgical site infections Piperacillin/tazobactam hourly IV
 Adjunctive systemic antimicrobial therapy is not routinely 4.5g 8 hourly IV Plus
indicated, but in conjunction with incision and drainage may be +/- Metronidazole 500mg 8 hourly
beneficial for surgical site infections associated with a Gentamicin IV as per IV
significant systemic response, such as erythema and induration prescription chart
extending >5 cm from the wound edge, temperature 38.5°C, Oral step down:
heart rate >110 beats/minute, or white blood cell (WBC) count Oral step down: Trimethoprim 200mg 12 hourly
>12 Co-amoxiclav 625mg 8 PO
hourly PO Plus
Metronidazole 400mg 8 hourly
PO
7
 Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
CLINICAL USEFUL INFORMATION RECOMMENDATION ALTERNATIVE DURATION
CONDITION (suitable in serious penicillin allergy)

Burn wound  Treatment not recommended for Piperacillin/Tazobactam 4.5g 8 hourly Non-severe penicillin allergy: 7-14 days
infections colonisation, only if burn wound IV IV Teicoplanin as prescription chart
cellulitis or sepsis. Plus
Investigations:
 Discuss with microbiology when swab If MRSA add: Ceftazidime 2g 8 hourly IV
 Blood cultures Teicoplanin IV as prescription chart Plus
results available.
when indicated Metronidazole 500mg 8 hourly IV
 Swabs Oral step down:
Co-amoxiclav 625mg 8 hourly PO Oral step down as in severe

Severe penicillin allergy:

IV Teicoplanin as prescription chart
Plus
Ciprofloxacin 600mg 12 hourly IV
Plus
Metronidazole 500mg 8 hourly IV

Oral step down:

Clindamycin 450mg 6 hourly PO
Plus
Ciprofloxacin 400mg 12 hourly PO
Puncture wound  A careful history is required to Non-severe: Non-severe:
Or manage the patient and to identify risk Co-amoxiclav 625mg 8 hourly PO Co-trimoxazole 960mg PO 12 hourly Prophylaxis: 3-
Contaminated factors for complications of the Severe: Plus 5 days
wound puncture injury. Co-amoxiclav 1.2g 8 hourly IV Metronidazole 400mg PO 8 hourly
 Cleanse thoroughly and evaluate Oral step down: Treatment of
Investigations: wound for the presence of foreign Co-amoxiclav 625mg 8 hourly PO Severe: contaminated
 Surgical bodies. Co-trimoxazole 1.44g IV 12 hourly wound:
specimens for  Surgical debridement or abscess If plantar puncture wound, ear Plus 7-14 days
culture drainage is an important component cartilage wound, farmyard injury or Metronidazole 500mg IV 8 hourly.
of treatment of infected puncture not settling within 48hrs: Oral step down:
wounds. Trimethoprim 200mg 12 hourly PO
 For tetanus prone wound, give human Piperacillin/Tazobactam 4.5g 8 hourly Plus
tetanus immunoglobulin with IV Metronidazole 400mg 8 hourly PO
absorbed diphtheria (low dose) and Oral step down:
tetanus vaccine, according to Clindamycin 450mg 6 hourly PO
immunization history. Plus
8
 Following puncture injury antibiotic
prophylaxis can be administered in
high risk patients e.g. Forefoot injury,
Wearing shoes at the time of the
injury, Diabetes mellitus.
Ciprofloxacin 400mg 12 hourly PO If plantar puncture wound, ear cartilage
wound, farmyard injury or not settling
within 48hrs:
Teicoplanin IV as per prescription chart
Plus
Ciprofloxacin 600mg 12 hourly IV
Plus
Metronidazole 500mg 8 hourly IV
Oral step down:
Clindamycin 450mg 6 hourly PO
Plus
Ciprofloxacin 400mg 12 hourly PO
9
 Antibiotic guidelines for SKIN AND SOFT TISSUE INFECTIONS
CLINICAL USEFUL INFORMATION RECOMMENDATION ALTERNATIVE DURATION
CONDITION (suitable in serious
penicillin allergy)
Marine Infection  Many more potential pathogens compared to non- Cephalexin 500 mg 6 hourly Clindamycin 300mg 6 hourly 10-14 days
marine injury including Aeromonas, Edwardsiella tarda, PO PO
Erysipelothrix rhusiopathiae, Vibrio vulnificus, OR OR For Mycobacterium
Mycobacterium marinum Cefazolin 1g 8 hourly IV Clindamycin 600mg 8 hourly marinum
Plus IV d/w ID/Respiratory
 Empiric antibiotic coverage does not include coverage ●Levofloxacin 750 mg once Plus
for M. marinum infection, since the presentation is daily PO/IV ●Levofloxacin 750 mg once
subacute and without associated systemic toxicity. Plus daily PO/IV
•Metronidazole 500 mg 6 Plus
 A specimen (e.g. lesion aspirate, biopsy) should be hourly PO/IV if exposure to •Doxycycline 100 mg 12
obtained and the microbiology laboratory notified that sewage-contaminated water or hourly PO for coverage of
M. marinum is suspected so that appropriate culture if soil-contaminated wound) Vibrio species if seawater
conditions will be included. If acid-fast staining is OR exposure
positive or if the exposure history and physical •Doxycycline 100 mg 12 hourly
examination findings suggest M. marinum infection PO for coverage of Vibrio
(e.g. laceration from an aquarium), then we suggest species if seawater exposure
that specific treatment for M. marinum infection should
be initiated.
Oral step down: Oral step down:
 For tetanus prone wound, give human tetanus Discuss with microbiology Discuss with microbiology
immunoglobulin with absorbed diphtheria (low dose)
and tetanus vaccine, according to immunization
history.

Associated See Surgical Prophylaxis guidelines

underlying/open
fracture

10
 CLINICAL GUIDELINES ID TAG
Title: Antibiotic Guidelines for Skin and Soft tissue Infection
Dr M Brown, Consultant Microbiologist
Author: Dr S Hedderwick, Consultant Microbiologist
Dr G Conlon-Bingham, Antimicrobial Pharmacist
Speciality / Division: Microbiology, Pharmacy, MUSC
Directorate: Acute
Date Uploaded: 6th March 2020
Review Date
March 2021
Clinical Guideline ID
CG0477[4]

References:
1. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of
America. June 2014.
2. NICE 2019. Clinical Guideline 141. Cellulitis and Erysipelas: antimicrobial prescribing.
3. NICE 2018. Clinical Knowledge Summary. Impetigo.
4. Diagnosis and Treatment of Impetigo. Am Fam Physician. 2007 Mar 15;75(6):859-864.
5. NICE 2018. Clinical Knowledge Summary Bites: Human and Animal.
6. NICE 2015. Leg ulcer - Scenario: Infected venous leg ulcer.
7. NICE 2018. Lyme disease
8. NICE 2011. Insect bites and stings-Scenario: Infection.
9. www.uptodate.com. Accessed August 2018.

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