Skin and soft tissue

NHS Dumfries & Galloway Antimicrobial Handbook
NHS Dumfries and Galloway

Review previous microbiology results: If resistant target organisms previously isolated (e.g. MRSA, ESBL, known resistance to empirical antibiotic choices), discuss antibiotic choice with Paediatric and/or Microbiology Consultant.

User guide: for further advice regarding antimicrobial prescribing good practice, oral switch, penicillin allergy, dosing, and safety considerations: HERE

Cellulitis, Erysipelas, Severe Impetigo and Infected wounds (including eczema, burns)

First line 

PO/IV flucloxacillin
add IV gentamicin if severe sepsis / incomplete Hib immunisation

TOTAL duration (IV + PO)  5 to 7 days**
Penicillin allergy

PO azithromycin*

TOTAL duration  3 days **

or if severe sepsis / oral route not available

PO/IV clindamycin
add IV gentamicin if severe sepsis / incomplete Hib immunisation

TOTAL duration (IV + PO)  5 to 7 days**
Comments
  • Take account of severity, site of infection, risk of uncommon pathogens, any microbiological results and MRSA status.
  • Modify therapy according to culture results and clinical response.
  • Infection around eyes / nose are more concerning due to risk of serious intracranial complications.
    • Refer to "Peri-orbital cellulitis / Orbital cellulitis" section.
  • * PO clarithromycin (5 to 7 days) is an alternative
  • ** A longer course may be required, but skin takes time to return to normal and full resolution 5 to 7 days after starting treatment is not expected.

Human / Animal Bite

First line All bites

PO co-amoxiclav

If deep/septic: IV co-amoxiclav

Pencillin allergy Human bites

PO clarithromycin
and PO metronidazole

If deep/septic: discuss with Microbiology

Penicillin allergy Animal bites

PO co-trimoxazole
and PO metronidazole

If deep/septic: discuss with Microbiology

TOTAL duration (IV + PO)
  • Prophylaxis: 3 days
    • give to all moderate/severe bites, especially if oedema, crush, puncture wounds, facial, genital, hand or foot bites, or immunocompromised hosts
    • give to all cat bites
  • Infected: 5-7 days
  • Deep/septic: Depends on clinical response, surgical intervention and culture results. Discuss with Orthopaedics / Microbiology

All bites: consider tetanus prophylaxis
Human bites: consider blood borne virus transmission
Animal bites: consider rabies if animal bite acquired in endemic area. Public Health Scotland Guidance is available: HERE

Peri-orbital cellulitis / Orbital cellulitis

Peri-orbital cellulitis (mild / uncomplicated)
First line

PO co-amoxiclav

Total duration 5 - 7 days
Penicillin allergy

PO azithromycin

TOTAL duration  3 days

or

PO clarithromycin

TOTAL duration  5 - 7 days
Orbital Cellulitis or Peri-orbital cellulitis (severe)
First line

IV cefOTAXime
and IV flucloxacillin

If no improvement after 24 - 36 hours:
add IV metronidazole

Oral switch: co-amoxiclav

Penicillin allergy

IV clindamycin
and IV gentamicin 

Oral switch: clindamycin

TOTAL duration (IV + PO)
  • Continue until clinical resolution. At least 10 days, but up to 2-4 weeks may be required depending on disease severity.

Necrotising fasciitis

This is a medical emergency.
Involve appropriate surgical team early; debridement and source control is essential.
Consider IV immunoglobulin if confirmed (or strongly suspected) staphylococcal/streptococcal toxic shock syndrome AND failure to achieve rapid improvement with antibiotic therapy and other supportive measures AND life-threatening. NHS Scotland guidelines: HERE.

First line

IV piperacillin/tazobactam
and IV clindamycin
add IV gentamicin if severe sepsis

Penicillin allergy

IV vancomycin
and IV clindamycin
and IV gentamicin 

Gentamicin must be included in septic and non-septic patients with a penicillin allergy, in order to provide appropriate Gram negative cover.

TOTAL duration (IV + PO)
  • Depends on clinical response, surgical findings and culture results. Discuss with Microbiology Consultant and/or Surgical Consultant.

Editorial Information

Last reviewed: 20/02/2024

Next review date: 20/02/2026

Author(s): Dr Jon van Aartsen (Consultant Microbiologist), Dr Jed Bamber (Consultant Paediatrician).

Version: v1.0

Approved By: AMT (20.02.2024) and ADTC (28.02.2024)

Reviewer name(s): Dr Jed Bamber (Consultant Paediatrician), AMS Team.