REVIEW

CURRENT
OPINION The optimal duration of treatment for skin
and soft tissue infections and acute bacterial
skin and skin structure infections
Silvia Corcione and Francesco Giuseppe De Rosa

Purpose of review
To summarize the current finding on SSTIs/ABSSSIs treatment duration.
Recent findings
In 2013, the FDA approved the definition of acute bacterial skin and skin structure infections (ABSSSIs).
From a clinical point of view, the new definition may present some advantages: the definition of the
severity of the disease, the measurement of reduction in lesion size, and effectiveness of treatment primary
endpoint at 48–72 h after treatment initiation. New therapeutic options with improved efficacy, safety,
and/or pharmacodynamics are available for ABSSSIs and so far, several questions still need to be
addressed for the management of these infections, including treatment duration.
Summary
There is a wide variation of duration of antimicrobial treatment in skin and soft tissue infections. Plenty of
published data available suggest that we should focus on the early response to shorten duration of
treatment, and that the antimicrobial stewardship perspective is extremely helpful in underscoring the need
for composite outcomes in clinical practice, as multiple tools are available to increase cost-efficacy,
including reduction of treatment changes, early oral switch, early discharge (even from the Emergency
Department), outpatient antimicrobial treatment, long-acting antibiotics, and all together, de-escalation
treatment strategies.
Keywords
acute bacterial skin and skin structure infections, de-escalation, duration of treatment, skin and soft tissue
infections, stewardship

INTRODUCTION lesion size of at least 75 cm2 (measured by the area of

For the last 25years, complicated skin and skin redness, edema, or induration) and include celluli-
structure infections (cSSSIs) and more recently acute tis, wound infection, and abscesses with surround-
&

bacterial skin and skin structure infections (ABSSSIs)
have globally placed an increasing burden on
healthcare systems [1,2]. ABSSSIs are the most
frequently diagnosed skin infections worldwide,
encountered in both community and hospital set-
tings: an observational retrospective cohort study
conducted from 2005 to 2010 utilizing administra-
tive claims data from the United States Health Core
Integrated Research Database showed that the
incidence of skin and soft tissue infections (SSTIs)
remains twice of that of urinary tract infections
(UTIs) and 10-fold of that of pneumonia [3]. ABSSSIs
can present with a broad spectrum of disease severi-
ties and include cellulitis, erysipelas, wound infec-
tions, and major cutaneous abscess [4]. In 2013,
the Food and Drug Administration (FDA) defined
ABSSSIs as bacterial infections of the skin with a
ing cellulitis [5 ]. From a clinical point of view, the
new ABSSSIs definition may offer some advantages
in clinical practice: the definition of the severity of
the disease, the measurement of reduction in lesion
size, and effectiveness of treatment primary end-
point at 48–72 h after antibiotic treatment. New
therapeutic options with improved efficacy, safety,
and/or pharmacodynamics are needed for ABSSSIs
and so far, several questions still need to be
Department of Medical Sciences, University of Turin, Turin, Italy
Correspondence to Professor Francesco Giuseppe De Rosa, MD,
Department of Medical Sciences, University of Turin, Italy.
E-mail: francescogiuseppe.derosa@unito.it
Curr Opin Infect Dis 2018, 31:155–162
DOI:10.1097/QCO.0000000000000440

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Skin and soft tissue infections
KEY POINTS
 There is a wide variation of antibiotic treatment course
duration in patients with SSTIs; both escalation and
de-escalation treatment strategies are widely adopted.
 The definition of ABSSSIs helps to define an early
clinical response. Although early clinical response may
be associated with shorter duration of treatment, there
is no demonstration that delayed response should be
associated with prolonged courses of antibiotics.
 Unfortunately, in clinical practice, most patients are
given multiple changes of antibiotics, which are often
empiric rather than rational.
addressed in the management of these infections,
including duration of treatment.
GENERAL CONSIDERATIONS ON
TREATMENT
Numerous treatment options for ABSSSIs are avail-
able and include beta lactams, quinolones, trimetro-
prim/sulphamethoxazole (TMP-SMX), daptomycin,
linezolid, tigecycline, teicoplanin, and vancomycin,
with the addition of new antibacterials such as
dalbavacin, tedizolid, and ceftaroline.
The optimal treatment duration is not known as
many confounding factors may be present, such as
comorbidities, cause/etiology, appropriateness of
drug or dosages. The Infectious Diseases Society of
America (IDSA) guideline suggests 7–14 days of
therapy, with individualization based on clinical
&&
response [6 ]. In clinical practice, however, studies
have demonstrated frequent use of antibiotics, with
multiple treatment changes, with broad spectrum
antimicrobial activity and further treatment given
&
at discharge [7 ,8]. Emphasis has been given to the
early response with the new definition of ABSSSIs
but the practical consequences on the rate of anti-
biotic changes have not been studied yet. The anti-
bacterial effects of new antibiotics are being
investigated at an early time point (48–72 h after
antibiotic administration) with the aim of assessing
a clinical response assuming that an objective mea-
surement of reduction in lesion size would confirm
the rapid action and effectiveness of treatment. It is
also anticipated that a favorable early response
would translate into late clinical cure after the
end of therapy (EOT) and allow more rapid wound
&
healing [5 ,9].
Most of the available studies were retrospective,
most conclusions are descriptive; patients are man-
aged in medical or surgical wards, immunosuppres-
sion is common, risk factors for antibiotic resistance
156 www.co-infectiousdiseases.com
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are numerous, the Gram-negative cause is growing
in healthcare-associated infections. Multiple antibi-
otic changes are often made and both escalation and
de-escalation strategies are used. New antibiotics are
available, and whenever used according to general
antimicrobial stewardship practices, they may result
in cost-savings.
Epidemiological studies are clear in demonstrat-
ing antibiotic changes, failure of de-escalation, and
frequent switch at discharge instead of treatment
&
interruption [7 ,8]. Early predictors of clinical
response are often unclear at the bedside, confound-
ing factors are frequently found in terms of severity
of disease or comorbidities and the dynamics of the
response should be better investigated in clinical
trials. In addition, treatment duration is greatly
influenced by the correct measures of early debride-
ment and drainages of purulent fluid collections or
abscesses, whilst the lack of correct source control
may erroneously lead to prolonged and unnecessary
antibiotic treatment.
DRAINAGE
Irrespective of antimicrobial therapy, the guidelines
recommend adequate source control for infection,
such as draining of abscesses and debridement of
nonviable tissues. In patients with ABSSSIs, the sur-
gical intervention and the source control, including
drainage of infected fluids, debridement of infected
deeper tissues and removal of infected devices or
foreign bodies, should be evaluated and performed
before treatment administration [10]. Incision and
drainage are indicated for most purulent methicil-
lin-resistant Staphylococcus aureus (MRSA) infec-
tions: a recent published study systematically
evaluated whether or not antibacterials provide
added benefit to infection and drainage alone for
purulent MRSA ABSSSIs: 11 studies were included in
the analysis, suggesting that anti-MRSA antibacte-
rials provide added benefit to incision and drainage
alone for purulent MRSA [11].
FRAILTY AND COMORBIDITIES
The increase in life expectancy has led to a growing
number of elderly patients with multiple chronic
comorbidities, with frequent hospitalization for
acute exacerbation of underlying diseases. Although
frailty has been considered as synonymous with
disability, comorbidity, or advanced old age, it is
recently recognized as a biological syndrome.
The REACH study showed that length of hospi-
tal stay was longer in patients with comorbidities
compared with those without comorbidities, and
in patients with MRSA compared with those with
Volume 31  Number 2  April 2018

methicillin-susceptible Staphylococcus aureus (MSSA)
infections. At multivariate analysis, comorbidities,
recurrent infections, diabetes mellitus, recent sur-
gery, and age at least 65 years were factors indepen-
dently associated with longer hospital stay [12].
Predisposing factors for ABSSSIs include disrup-
tion of the skin barrier as a result of trauma (e.g.
penetrating wounds, abrasions, or injection drug
use), or chronic cutaneous lesions, including
chronic inflammation (e.g. eczema or radiation
therapy), pre-existing skin infection (e.g. impetigo
or tinea pedis), varicella, and edema because of
venous insufficiency.
Amongst risk factors that are also frequent in
frail patients and may predispose to ABSSSIs, there
are smoking, decreased mobility, drug-induced dis-
orders, atherosclerosis, diabetes mellitus, malnutri-
tion, implanted devices, and congestive heart
failure. Additional issues include atypical signs
and symptoms chronic care facilities stay, risk of
colonization by MRSA or, possibly, gastrointestinal
multidrug resistant (MDR) colonization in patients
bed-ridden with pressure sores. In a retrospective
cohort study comparing the prevalence of antibiotic
resistance and clinical outcomes in older patients
admitted with acute infections from care homes
versus the community, the incidence of resistant
bacteria is higher in nursing home patients com-
pared with those reported in the control group
(70 versus 36%, P ¼ 0.026), isolation of any resistant
organism and receipt of initial inadequate antibiotic
therapy were both factors independently associated
with mortality [13,14].
ADMISSION AND DISCHARGE: DATA
FROM STUDIES
Although a clear distinction can be made between a
patient presenting with necrotizing fasciitis and that
of a stable patient with cellulitis, the vast majority of
ABSSSIs fall within a gray area between these disease
entities, with unclear decision about admission or
Table 1. Possible strategies to define treatment duration
Treatment MRSA
duration Practical features risk
Less than 7 days No relevant comorbidities; No
superficial infections;
ABSSSIs treated with
tedizolid
At least 7 days Necrotizing infections; Yes
implanted prosthesis;
immunocompromised;
elderly; diabetes
ABSSSIs, acute bacterial skin and soft tissue infections; MRSA, methicillin-resistant Staphylococcus aureus; OPAT, outpatient parenteral antimicrobial therapy.
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Duration of treatment for skin infections Corcione and Rosa
discharge directly from the emergency department
(Table 1). The decision as whether or not to admit a
patient with ABSSSIs from the emergency depart-
ment continues to be heavily based upon clinical
presentation (cellulitis with or without abscess;
wound infection; >75 cm2 surface area involve-
ment) and perceived need for intravenous anti-
biotics, whilst real data from the REACH study
highlighted that frail patients with comorbidities
were usually admitted because of fear for treatment
failure [12,15]. In a multicenter prospective study
including adults with a mean age of 38.7 years, the
reasons for hospitalization were the need for intra-
venous antibiotics in 85.1% and an underlying
disease in 11.7%. Other factors included fever,
erythema more than 10 cm, treatment failure,
comorbidity, and age more than 65 years [15].
CAUSE AND LENGTH OF TREATMENT
Although diagnosis is based on clinical presenta-
tion, the bacterial cause of ABSSSIs is confirmed in
over 60% of cases, and the evidence suggests the
predominance of Gram-positive bacteria. The most
common pathogens usually associated with ABSSSIs
are Gram-positive bacteria, such as S. aureus and
Streptococcus pyogenes; an increasing prevalence
of drug-resistant organisms, especially MRSA, has
become a leading cause of ABSSSIs in the USA,
and presents a challenge for treatment worldwide
[16]. Data from the European Antimicrobial Resis-
tance Surveillance (EARS) Network suggests that
MRSA accounts for 16.7% of all S. aureus isolates
in patients with community-acquired SSTIs; how-
ever, a large intercountry variation is evident across
Europe, with percentages ranging from 0 to 64.5%,
and MRSA percentages are generally lower in north-
ern Europe and higher in the southern and south-
eastern regions [17].
Among patients needing hospitalization, MRSA
appears as a leading pathogen, especially in culture-
confirmed surgical-site infections [16]. Evidence
Early assessment Escalation versus Early discharge/
of outcome de-escalation switch
48 h Possible escalation Switch to an oral
strategy in nonresponders administration
48–72 h De-escalation always to be OPAT
considered with clinical Long-acting drugs
response or with early
response
www.co-infectiousdiseases.com 157
Skin and soft tissue infections
suggests that elderly patients who have had a prior
exposure to a healthcare facility or hospital, or a
prior antibiotic course or intravenous catheter
remain at a higher risk of being colonized or infected
with hospital-acquired MRSA [16]. Since 2000, the
prevalence of community-acquired MRSA (CA-
MRSA) in patients without the common risk factors
for MRSA infection has increased tremendously, and
this genotypic profile is considered one of the most
common causes of ABSSSIs in the outpatient setting
in the United States Patients. With the evolution
of CA-MRSA-based infection, the management of
ABSSSIs has become more challenging for clinicians
[4].
Although S. aureus and streptococci are the pre-
dominant pathogens, enterococci and Gram-nega-
tive bacteria can also be involved in ABSSSIs.
Enterococcus spp. represent a substantial proportion
of pathogens causing ABSSSIs, particularly after
intra-abdominal surgery [18]. Risk factors for entero-
coccal infections include prolonged hospitalization,
advanced age, severity of underlying illness, antibi-
otic exposure, and interhospital transfer.
Gram-negative pathogens, such as Enterobacter-
iaceae and Pseudomonas aeruginosa, are isolated less
frequently than Gram-positive organisms from
patients with ABSSSIs, except in special settings such
as burn patients, polymicrobial infections involving
genital area, after urinary tract surgery, or in patients
residing in long-term care facilities who are fre-
quently colonized by MDR or potentially MDR
Gram-positive or Gram-negative pathogens [14].
Treatment duration is prolonged because of
complications of ABSSSIs, including bacteremia
(18.4%), osteomyelitis (7.2%), or necrotizing infec-
tions (1.1%). Eradication of the persisting pathogen
in bacteremia requires prolonged antibiotic treat-
ment (14–21 days), and bactericidal antibiotics such
Table 2. Clinical features for escalation and de-escalation
Reasons for escalation
Type of infections: deep soft tissue involvement, necrotizing infections;
implanted devices
Delayed source control or drainage; lack of response
comorbidities
Age at least 75 years
Diabetes
Chemotherapy
Immunosuppression
MRSA risk; Gram-negative cause
Recurrent ABSSSIs; concomitant BSI
Persistent fever or local and/or systemic symptoms
Inadequate initial therapy
ABSSSIs, acute bacterial skin and soft tissue infections; BSI, blood stream infections; MRSA, methicillin-resistant Staphylococcus aureus.
158 www.co-infectiousdiseases.com
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as vancomycin or daptomycin, generally recom-
mended for MRSA, although beta-lactams are effec-
tive against MSSA. In an open-label, multicentre,
randomized phase IIIb study conducted in hospital-
ized patients aged at least 65 years with ABSSSIs and
treated with daptomycin as first-line treatment, the
duration of treatment was between 5 and 14 days for
ABSSSIs without bacteremia and between 10 and
28 days for ABSSSIs with bacteremia [19]. Osteo-
myelitis as a complication of SSTIs occurs more
frequently in diabetic inpatients (13.3%) than in
nondiabetics (5.2%). Relatively to uninfected surgi-
cal controls, patients with ABSSSIs because of MRSA
have an increased risk of hospital readmission
within 90 days [odds ratio (OR) 35.0], increased risk
of mortality within 90 days (OR 7.27, P < 0.001),
and may require up to a further 23 days in hospital
(OR 4.36).
EARLY RESPONSE, OUTPATIENT
PARENTERAL ANTIBIOTIC THERAPY,
DE-ESCALATION, ORAL SWITCH,
AND DISCHARGE
There are multiple examples of a stewardship
approach of SSTIs and ABSSSIs and excellent reviews
on the topic, that also include short duration of
antibiotic treatment, S. aureus and MRSA causes,
nursing home residency, risk factors for MDR bacte-
ria, dynamics of early response, de-escalation and
escalation treatment strategies, discharge (even
directly from the emergency room), and outpatient
& && &
parenteral antibiotic therapy (OPAT) [7 ,20 ,21 ,22]
(Table 2).
Clinicians have a responsibility for appropriate
de-escalation of antimicrobial therapy in the treat-
ment of severe SSTIs, once culture results will be
available. Pathogen-directed antimicrobial therapy
Reasons for de-escalation
Type of infections: superficial infections
Source control effective/performed; early response
No relevant comorbidities
No MRSA risk or identification
Clinical response; negative biomarkers
Possible switch to oral therapy after early response
Volume 31  Number 2  April 2018

then is initiated, with de-escalation from the initial
broad-spectrum empiric antimicrobial regimen,
with an attempt to decrease to monotherapy if at
all possible. De-escalation of antimicrobial therapy
should occur as early as possible, but is only possible
if appropriate microbiologic specimens are obtained
at the time of SSTIs source control.
In patients who have presumed CA-MRSA SSTIs,
it has been recommended that uncomplicated SSTIs
in healthy individuals may be treated empirically
with oral clindamycin, TMP/SMX, or tetracyclines,
although specific data supporting the efficacy of
these treatments in large multicenter prospective
randomized clinical trials are lacking [23].
De-escalation and oral treatment may be given
to facilitate early discharge of patients provided that
pharmacological and nonpharmacological factors
of early response are assessed. In a recent study,
the concordance of clinical and biochemical data
were the strongest at days 2 and 3 of treatment;
importantly, 90% of patients escalated at day 2 were
(perhaps too early) classified as nonresponders, even
if there were no inappropriate treatments, strongly
suggesting that such strategy was often premature.
Moreover, nonpharmacological factors (female sex,
cardiovascular disease, higher body mass index,
shorter duration of symptoms, and cellulitis) had
a major impact on early response dynamics and
nonresponse at day 3 was predictive of treatment
duration more than 14 days but not of clinical
failure [22].
De-escalation is linked with the early discharge
strategy and the following criteria were proposed:
the presence of normal blood pressure, stable men-
tal status, stable comorbid illness and stable social
situations, absence of fever for 24 consecutive hours,
the ability to take oral medications, clinical
improvements (cessation of purulent drainage or
improved edema, induration, and erythema area)
and normal white blood count, which helps the
physician to switch from intravenous to oral ther-
apy [24]. The early switch strategy most commonly
applies to MRSA infections. In a retrospective Euro-
pean MRSA cSSTIs study from 12 countries and
hospitalized patients discharged alive, the most fre-
quent initial MRSA-active antibiotics were vanco-
mycin in half of the cases, followed by linezolid
and clindamycin, which were given at discharge
to shorten the length of stay [25].
Early discharge and OPAT are also linked and
intravenous treatments more commonly given are
based on ceftriaxone and teicoplanin [26]. In the
first study, patients received treatment for a mean of
5.32 days, 98% improved and OPAT saved the inpa-
tient facility 665 bed days. In the second study,
‘‘OPAT failure’’ was defined as hospitalization
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Duration of treatment for skin infections Corcione and Rosa
following initiation of OPAT and the success was
87%; a longer duration of intravenous therapy was
associated with MRSA, older age, vascular disease, a
diagnosis of bursitis, and treatment with teicoplanin.
In a pediatric study from Australia, the majority
(66%) of patients were given OPAT directly from the
Emergency Department who had SSTIs [22].
These studies showed the high efficacy of OPAT,
generally well tolerated and effective also directly
from the Emergency Department, but highlighted
the special need of specific stewardship approaches,
identifying patients with more complex manage-
ment pathways and poorer outcomes. We believe
that these studies on OPAT management may be
especially useful to understand that there is no need
of multiple treatment changes in most patients,
provided they are stable and follow-up is easily
performed.
In a network meta-analysis comparing the effi-
cacy and safety of intravenous antibiotics (dapto-
mycin, dalbavancin, linezolid, and tigecycline) used
in adult ABSSSIs, using vancomycin as comparator,
the likelihood of clinical and microbiological suc-
cess with dalbavancin was statistically similar to the
comparators studied but the drug had a significantly
lower likelihood of experiencing an adverse effect
than linezolid, a significantly lower likelihood of
experiencing adverse events than vancomycin and
daptomycin, and a significantly lower risk of all-
cause mortality than vancomycin, linezolid, and
tigecycline [27]. Furthermore, a 6-day course of
tedizolid was equal to a 10-day course of linezolid
&&
in ABSSSIs [28 ].
CONCLUSION
The duration of treatment in patients with SSTIs is a
complex issue and so far, lacking well designed
studies, it may range from 5 to 14 days depending
on necrotizing or nonnecrotizing infections, cause,
likelihood of multidrug resistance, clinical and lab-
oratory dynamic of early response as well as non-
pharmacological factors such as obesity. There is
a strong need of a sound stewardship approach
that avoids too many treatment changes, includes
specific considerations of MRSA risks, and clear
definition of escalation or de-escalation strategies.
Although short duration of antibiotic treatment is
frequently suggested by most guidelines, real-life
data report prolonged duration of treatment and
often guidelines are not kept in due consideration
&&
[6 ]. After the careful analysis of the available lit-
erature, special considerations for a prolonged treat-
ment should be given to nursing home patients,
health-care-associated infections and S. aureus SSTIs
with more than 7 days duration of signs and
www.co-infectiousdiseases.com 159
Skin and soft tissue infections

Table 3. Synthesis of evidence on treatment duration

Duration of treatment
Type of infection (days; range) Antibiotics References

Erysipelas 8–13 Levofloxacin; penicillin Bergkvist et al. [34]

Bernard et al. [35]
Cellulitis 10–14 Cefazolin; cephalexin; if MRSA risk/identification: Dall et al. [36]
clindamycin, TMP/SMZ; linezolid, Pallin et al. [37]
tedizolid intravenous agents Aboltins et al. [38]
Skin and soft tissue 4–28 Tigecycline; vancomycin with aztreonam; linezolid Breedt et al. [39 ]
&

infections (SSTIs) Dodds and Hawke [40]

ABSSSIs/cSSTIs Single dose – 14 Tigecycline versus vancomycin with aztreonam Chuang et al. [41]
Linezolid versus vancomycin Weigelt et al. [42]
Dodds and Hawke [40]

Linezolid versus oxacillin Stevens et al. [43]

Tedizolid versus linezolid Moran et al. [28 ]
&&

Prokocimer et al. [44]

Clindamycin versus trimethoprim/sulfamethoxazole Miller et al. [45]
Oritavancin versus vancomycin Corey et al. [46]
Dalbavancin versus vancomycin Boucher et al. [47]
Ceftaroline versus vancomycin with aztreonam Friedland et al. [48]
Dalbavancin versus linezolid Jauregui et al. [49]
Daptomycin versus antistaphylococcal penicillin/ Arbeit et al. [50]
vancomycin
Daptomycin versus vancomycin Quist et al. [51]

&
Adapted from Wintenberger et al. [30 ]. ABSSSIs, acute bacterial skin and soft structure infections; cSSTIs, complicated skin and soft tissue infections.

symptoms. By a stewardship perspective, there are
multiple possibilities of resource optimization in
patients with MRSA infection. Although the in-
hospital mortality was 8% and the mean hospital
stay was 26.3 days, mainly in medical wards, 56%
of initial treatment included old beta-lactams and
almost 40% of patients were prescribed a further
cycle of antibiotic treatment at discharge (linezolid,
&
9%) [7 ].
The new drugs have been reviewed in a system-
atic search linezolid (in Gram-positive and MRSA
SSTIs) and telavancin (in MRSA SSTIs) were more
effective. Telavancin was associated with more severe
adverse events and tigecycline had an official warn-
ing for all-cause mortality, not justified owing to the
heterogeneity of data included in the meta-analysis
& &
[7 ,29 ]. By an antimicrobial stewardship point of
view, there is a special need of individualized treat-
ment for patients with a variety of syndromes in
patients often elderly and immunosuppressed.
Unfortunately, treatment duration according to dif-
ferent guidelines may be in the range of one to two, as
reported by the Recommendation Group of the
French Infectious Diseases Society (SPILF; Table 3)
&
[30 ]. In a study in patients from nursing homes,
evaluated with the McGeer and the Loeb minimum
criteria, the duration of antibiotic treatment was
9.6  5.6 days (median 8.5 days, range 3–45]; the
clinical practice was different from the guidelines
and, unfortunately, doxycycline was most often
administered [31]. The stewardship approach has
been evaluated in very good pediatric studies, by
using quality improvement protocols, building
awareness of evidence, changing the culture of pre-
scribing and monitoring of prescribing with plan-do-
study-act cycles [14]. In one study, the proportion of
children discharged with short courses of antibiotics
increased from a baseline median of 23–74% whilst
no changes were observed in the proportion of chil-
dren admitted for treatment failure [32]. In a survey of
84 hospitals from 19 European Countries on avail-
ability of guidelines and their source, complete guide-
lines were reported by 20% of hospitals and the
majority (71%) used a range of different sources
[33]. In SSTIs, cephalosporin and antistaphylococcal
penicillins were recommended in 43 and 36%,
respectively. Overall, it seems that a considerable
improvement in the quality of guidelines and their
evidence base is required, linking empirical therapy
to resistance rates; the duration of treatment should
also be better clarified and special tools to reduce
duration through de-escalation, early switch or

160 www.co-infectiousdiseases.com Volume 31  Number 2  April 2018

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discharge, implementing OPAT whenever indicated,
are needed [33]. Moreover, there are plenty of oppor-
tunities to be explored in clinical trials, including
early de-escalation for patients with severe disease,
comorbidities and devices, at primary risk for MRSA
infection. There are plenty of questions to be
addressed in patients with SSTIs or ABSSSIs such as
the exact role of MRSA infections; the empiric use of
anti-MRSA agents; the knowledge of CA-MRSA and
MRSA epidemiology in the community; the dynamic
of early clinical and laboratory response; the use of
OPAT, perhaps directly from the Emergency Depart-
ment; the use of long-acting agents, with discharge
or without hospital. Overall, there is a strong need
for further, well designed studies evaluating the
effectiveness of shorter and effective treatment, with
de-escalation rather than escalation approach, eval-
uating the clinical cure as primary outcome and of
course the early response dynamic as well as other
descriptive data as a composite outcome.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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Volume 31  Number 2  April 2018