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Idsa cellulitis guidelines 2020

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The American Society of Infectious Diseases (IDSA) has assembled a team of national experts to update the 2005 guidelines on the treatment of skin and soft tissue infections (SSTIs). The team's recommendations were developed in accordance with the recently published IDSA guidelines for the treatment of methicillin-
resistant Staphylococcus aureus infections. This guide focuses on the diagnosis and proper treatment of various SSTIs, ranging from minor superficial infections to life-threatening infections such as necrotizing fasciitis. In addition, due to the growing number of immunocompromised hosts worldwide, the guidelines
address the wide range of SSTIs that occur in this population. These guidelines emphasize the importance of clinical skills in the rapid diagnosis of SSTIs, pathogen detection and timely use of effective treatments. Gram spot and culture of gnome or exudates from skin lesions impetigo and ectims are recommended to
help determine whether Staphylococcus aureus and/or β-hemolytic streptococcus is the cause (strong, moderate), but treatment without these studies is reasonable in typical cases (strong, moderate). Bullous and nebulal impetigo can be treated with oral or topical antimicrobials, but oral therapy is recommended for
patients with multiple lesions or outbreaks affecting several people to help reduce transmission. Treatment of ectima should be an oral antimicrobial. Treatment of bullous and nebulary impetigo should be either with mupirocin or with retapaamulin twice a day (bid) for 5 days (strong, high). Oral therapy of ectima or
impetigo should be a 7-day regimen with an agent active against S. aureus if cultures give streptococcus alone (when oral penicillin is a recommended agent) (strong, high). Since S. aureus isolates from impetigo and ecthimas, methicillin is usually susceptible, dicloxacillin or cephalexin is recommended. If MRSA is
suspected or confirmed, doxycycline, clindamycin or sulfamethoxazole-trimethopry (SMX-TMP) (strong, moderate) is recommended. Systemic antimicrobials should be used for infections during outbreaks of post-streptococcal glomeronephritis to help eliminate jade strains of S. pyogenes from the community (strong,
moderate). II. What is the appropriate evaluation and treatment of plyed SSTIs (skin abscesses, furuncles, carbuncles, and inflamed epidermoid cysts)? Gram's recommendations and the culture of thion from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases
(strong, moderate). Gram spot and culture of gnome from inflamed epidermoid cysts is not recommended (strong, moderate). The incision and recommended for the treatment of inflamed epidermoid cysts, carbuncles, abscesses and large boils, soft (Figure 1) (strong, (strong, решение о введении антибиотиков,
направленных против S. aureus в качестве дополнения к разрезу и дренажу, должно приниматься на основе наличия или отсутствия синдрома системного воспалительного ответа (SIRS), такого как температура >38 градусов   по Цельсию или 24 вдоха в минуту, тахикардия >90 ударов в минуту или количество белых кровяных телец >12 000 или
или SSTI Vancomycin 30 mg/kg/d in 2 divided doses IV 40 mg/kg/d in 4 separated doses IV For patients with penicillin allergy; parenteral drug of choice to treat infections caused by MRSA Linezolid 600 mg every 12 h IV or 600 mg rate po 10 mg/kg every 12 hours IV or on for children zlt;12 in bacteriostatic;
Limited clinical experience No cross-resistance to other classes of antibiotics; expensive clindamycin 600 mg every 8 h IV or 300-450 mg qid po 25-40 mg/kg/d in 3 separated doses IV or 30-40 mg/kg/d in 3 divided doses of po Bacteriostatic; the potential for cross-resistance and resistance in strains resistant to
erythromycin; insouceable resistance in MRSA. An important option for children is Daptomycin 4 mg/kg every 24 h IV N/A bactericidal; Possible myopathy Ceftaroline 600 mg bet IV N/A Bactericide doxycycline, minocycline 100 mg rate po Not recommended for age qlt;8 yd bacteriostatic; Limited recent clinical experience
Trimethoprim-sulfamethoxazole 1-2 two-strength tablets rate po 8-12 mg/kg/d (based on the trimethoprim component) in 4 separated doses of IV or 2 divided doses of po Bactericidal; limited published efficacy data Non-purulent SSTI (cellulitis) Adult dosage Pediatric dosage antimicrobial agents for patients with severe
penicillin hypersensitivity N/A Streptococcal skin infections Penicillin 2–4 million units every 4–6 h IVClindamycin 600–900 mg every 8 h IVNafcillin 1–2 g every 4–6 h IVCefazolin 1 g every 8 h IVPenicillin VK 250–500 mg every 6 h poCephalexin 500 mg every 6 h po Penicillin 60–100 000 units/kg/dose every 6 h10–13
mg/kg dose every 8 h IV50 mg/kg/dose every 6 h33 mg/kg/dose every 8 h IV Clindamycin, vancomycin, linezolid, daptomycin, or telavancin. Resistance to clindamycin is 1%, but may increase in Asia N/A III. What is the appropriate treatment for recurrent skin abscesses? Recommendations of periodic abscess in place
of a previous infection should prompt the search for local causes such as cyst pylonidale, hidradenite suppurativa, or foreign material (strong, moderate). Recurrent abscesses should be drained and cultured in the early stages of infection (strong, moderate). After receiving the cultures of recurrent abscess, treat a 5- to
10-day course of antibiotic active against a pathogen isolated (weak, low). Consider a 5-day decolonization regimen twice a day of intranasal mupirocin, daily gorgexidine washes, and daily decontamination of personal items such as towels, sheets, and clothing for recurrent S. aureus infection (weak, low). Adult patients
should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood (strong, moderate). IV. What is appropriate for the evaluation and treatment of erysipelas and cellulite? Recommendations of Blood Culture or Cocerenous Aspirates, Biopsies tampons are not usually recommended (strong,
(strong, Blood is recommended (strong, moderate), as well as crops and microscopic examination to cutaneous aspirates, biopsies, or tampons should be considered in patients with malignancies for chemotherapy, neutropenia, severe cellular-mediated immunodeficiency, immersion injuries, and animal bites (weak,
moderate). Typical cases of cellulite without systemic signs of infection should be obtained by antimicrobial drug that is active against streptococcus (soft; Figure 1) (strong, moderate). In cellulite with systemic signs of infection (moderate non-purple; Figure 1), systemic antibiotics are shown. Many clinicians may include
coating against methicillin-susceptible S. aureus (MSSA) (weak, low). For patients whose cellulite is associated with penetrating trauma, evidence of MRSA infection elsewhere, colonization of the nose with MRSA, injectable drug use, or SIRS (severe non-cancer; Figure 1), vancomycin or other antimicrobial effective
against MRSA and streptococcus is recommended (strong, moderate). In patients with severe injuries, as defined in question 13 (severe non-purple; Figure 1), antimicrobial coverage of a wide range of action (weak, moderate). Vancomycin plus either piperacillin-tazobactam or imipenem/merpenem is recommended as a
reasonable empirical regimen for severe infections (strong, moderate). The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved during this time period (strong, high). It is recommended to exalt the affected area and treat predisposing factors such
as swelling or related skin disorders (strong, moderate). In cellulite of the lower extremities, clinicians should carefully study interdigitial spaces, as the treatment of cleavage, scaling or maceration can eradicate colonization with pathogens and reduce the incidence of recurrent infection (strong, moderate). Outpatient
therapy is recommended for patients who do not have SIRS, altered mental state, or hemodynamic instability (mild non-purple; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern about a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a heavy
patient with weakened immunity, or if outpatient treatment fails (moderate or severe non-purulative; Figure 1) (strong, moderate). Should anti-inflammatory drugs be used in addition to treating cellulite with antibiotics? The recommendations of Systemic Corticosteroids (e.g. prednizone 40 mg daily for 7 days) can be
considered in nondiabetic adult patients with cellulite (weak, moderate). VI. What is it like assessment and management of patients with recurrent cellulite? Recommendations to identify and treat predisposing conditions such as swelling, obesity, eczema, venous insufficiency, and predisposing network abnormalities
(strong, moderate). Such practices should be as part of routine patient care and, of course, during the acute stage of cellulite (strong, moderate). Administration prophylactic antibiotics, such as oral penicillin or erythromycin tracing for 4-52 weeks, or intramuscular benzatin penicillin every 2-4 weeks, should be considered
in patients who have 3-4 episodes of cellulite per year despite attempts to treat or control predisposing factors (weak, moderate). This program should continue as long as predisposing factors (strong, moderate) persist. VII. What is the site's preferred surgical infection management? Recommendations for removing
stitches plus incision and drainage should be met for surgical site infections (strong, low). Adjunct-intensive systemic antimicrobial therapy is not usually indicated, but in combination with incision and drainage can be beneficial for surgical infections of the site, Associated with a significant systemic response (Figure 2),
such as erythema and induction, extending to the edge of the wound, the temperature of the zgt;38.5 degrees Celsius, the pulse of the zgt;110 beats per minute, or the white blood cells (WBC) count of zgt;12,000/L (weak, low). A short course of systemic antimicrobial therapy is indicated in patients with surgical
infections after clean operations on the torso, head and neck or limbs, which also have systemic signs of infection (strong, low). In the first generation of cephalosporin or antistaphylococcal penicillin for MSSA, or vancomycin, linezolyde, daptomycin, tlavancin, or ceftarolin, where mrsA risk factors are high (nasal
colonization, prior to MRSA infection, recent hospitalization, recent antibiotics), is recommended (strong, low). See also tables 2 and 3.Agents are active against gram-negative bacteria and anaerobics such as cephalosporin or fluoroquinolone in combination with metronidazole, recommended for infections after
operations on the axillary, gastrointestinal, perineum or female genital tract (strong, low). See also table 3.Table 3.Antibiotics for the treatment of surgical infections and ureter surgery of the intestinal or genitourinary tract . Single-degree schemes ticarcillin-clavulanaat 3.1 g every 6 h IV Piperacillin-tazobaktam 3,375 g
every 6 h or 4.5 g every 8 h IV Imphene-cylastatin 500 mg every 6 hours IV Meropenham 1 g every 8 h IV Ertapenem 1 g every 24 h IV Combined Circuit Ceftriaxone 1 g every 24 h and metronidazole 500 mg every 8 h IV Ciprofloxacin 400 mg IV every 12 hours or 750 mg for every 12 h metro ninidazole 500 mg every 8
h IV Levofloxacin 750 mg IV every 24 hours and metronidazole 500 mg every 8 h IV Ampicillin-sulbaktam 3 g every 6 hours and gentamicin or tobramycin 5 mg/kg every 24 h IV Surgery of the torso or limb away from the washed or perineum Oxacillin or nafcillin 2 g every 6 h IV Cefazolin 0.5-1 g every 8 h IV cephalexin
500 every 6 h po SMX-TMP 160-800 mg po every 6 6 15 mg/kg every 12 h IV Surgery of the washstand or perine metronidazoles 500 mg every 8 h IV plus ciprofloxacin 400 mg IV every 12 h or 750 mg for every 12 h IV by levofloxacin 750 mg every 24 h IV po Ceftxone 1 g every 24 h VIII. What is the preferred
evaluation and treatment of necrotizing fasciitis, including Gangrene Fournier? Recommendations Fast Surgical Consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis or gas gangrene (severe unpurulened; Figure 1) (strong, low).
Empiric antibiotic treatment should be extensive (e.g. vancomycin or lynzolim plus piperacillin-tazobactam or carbapenem; or plus ceftriaxone and metronidazole), as etiology can be polymicrobial (mixed aerobic-anaerobic microbes) or monomicrob (group of streptococcus, community MRSA) (strong). See also Table
4.Penicillin plus Clindamycin recommended for the treatment of the documented group streptococcal necrotizing fasciitis (strong, low). See figures 1, 2 and table 4.Table 4.Treatment of necrotizing skin infections, fascia and muscle type infections. Antimicrobial first-line agent. Adult dosage. Pediatric dosage for neonatal
period. Antimicrobial agent for patients with severe penicillin hypersensitivity. Mixed infections Piperacillin-tazobactamplusvancomycin 3.37 g every 6-8 h IV30 mg/kg/d in 2 divided doses 60-75 mg/kg/dose of piperacillin component every 6 h IV10-13 mg/dose every 8 h IVdamycin or metronizozo with amineglycoside or
fluoroquinol Imipenm-cylastatin 1 g every 6-8 h IV N/A Meropenem 1 g every 8 h IV 20 mg/kg/dose every 8 h IV Ertapenem 1 g daily IV 15 mg/kg/every dose 12 h IV for children 3 mo-3 mo-312 y Cefotaximeplusmetidazoleorclindamycin 2 g every 6 h IV500 mg every 6 h IV600-900 mg every 8 h IV 50 mg/kg/dose every 6
h IV7.5 mg/dose every 6 h IV10-13 mg/13 mg/dose every 8 h IV N/A Streptococcus Penicillinplusclindamycin 2-4 million units every 4-6 h IV (adult)600-900 mg every 8 h IV 60,000-100,000 units/kg/dose every 6 h IV10-13 mg/dose every 8 h IV Vancomycin , linezoid, hinupristine/dalfopristin, daptomycin Staphylococcus
nafcillin 1-2 g every 4 h IV 50 mg/kg/dose every 6 h IV vancomycin, linezolyde, Hinupristins/dalfopristin, daptomycin Oxacillin 1-2 g every 4 h IV 50 mg/kg/dose every 6 h IV Cefazolin 1 g every 8 h IV 33 mg/kg/dose every 8 h IV Vancomycin (for resistant strain 30 mg/kg/d in 2 divided doses IV 15 mg/kg/dose every 6 h IV
Clindamycin 600-900 mg every 8 h IV 10-13 mg/kg/dose every 8 h IV bacteriotic; potential cross-resistance and resistance in erythromycin-resistant strains; disapproving resistance in MRSAb Clostridium species Clindamycinplus 600-900 600-900 every 8 h IV2-4 million units every 4-6 h IV (adult) 10-13 mg/kg/dose
every 8 h IV60 000-100 00 units/kg/dose every 6 h IV N/A Aeromonas hydrophile Doxycyclineplusciprofloxacinorceftriaxone 100 mg every 12 hIV500 mg every 12 hIV1 to 2 g every 24 h IV Is not recommended for children but, possibly N/A Vibrio vulnificus Doxycyclinepluscexoneorfotaxime 100 mg every 12 hIV1 g qid IV
is not recommended for children, but, N/A IX may need to be used in life-threatening situations. The recommendation of magnetic resonance imaging (MRI) is the recommended modality of imaging to diagnose piomyositis. Computed tomography (CT) and ultrasound examinations (strong, moderate) are also useful.
Blood cultures and abscess material must be obtained (strong, moderate). Vancomycin is recommended for initial empirical therapy. An agent active against enteric gram-negative bacillus should be added to infection in patients with weakened immunity or after an open muscle injury (strong, moderate). Cefazoline or
antistaphylococcus penicillin (e.g. nafcillin or oxacillin) is recommended for the treatment of piomyosisitis caused by MSSA (strong, moderate). Cm. Table 2.Early drainage of the ding material should be performed (strong, high). Re-examinations of images should be performed in a patient with permanent bacteriology to
identify inseparable pockets of infection (strong, low). Antibiotics should be administered intravenously initially, but once the patient is clinically improved, oral antibiotics are suitable for patients whose bacteremia is cleared quickly and there is no evidence of endocarditis or metastatic abscess. Two to three weeks of
therapy (strong, low) is recommended. X. What is the appropriate approach to assessing and treating clostidiaal gas gangrene or myonecrosis? Recommendations Urgent surgical examination of the alleged area of gas gangrene and surgical spraying of the tissues involved must be performed (severe non-purple; Figure
1) (strong, moderate). In the absence of a definitive etiological diagnosis, it is recommended to treat a wide range of vancomycin plus either piperacillin/tazobactam, ampicillin/sulbactam, or carbapenem antimicrobial (strong, low). Final antimicrobial therapy with penicillin and clindamycin (Figure 1) is recommended for the
treatment of clostidialic myonecrosis (strong, low). Hyperbaric oxygen therapy (HBO) is not recommended as it has not been proven to be beneficial to the patient and may delay resuscitation and surgical debridation (strong, low). XI. What is the role of pre-emptive antimicrobial therapy to prevent infection from bites Or
cats? Recommendations of pre-emptive early antimicrobial therapy for 3-5 days are recommended for patients who (a) are weakened by immunity; Are are (c) Have progressive liver disease; (d) Have a pre-existing or seding of the affected area; (e) Have moderate to severe injuries, especially an arm or face; or (f) have
injuries that may have penetrated periosteum or joint capsule (strong, low). Post-exposure rabies prevention may be shown; it is recommended that consultations be held with local health officials to determine whether vaccination (strong, low) should be initiated. XII. What is the treatment of infected animals bite-related
wounds? Recommendation Antimicrobial or agents active against aerobic and anaerobic bacteria such as amoxicillin-claulana (table 5) should be used (strong, moderate). Table 5. Recommended therapy for infections after animal or human antimicrobial agent bites by bite type. Type of therapy. Oral. Intravenous.
Comments. Animal bite Amoxicillin-claulanath 875/125 mg bet ... Some gram-negative rods are resistant; misses MRSA Ampicillin-sulbactam ... 1.5-3.0 g every 6-8 h Some gram-negative rods are resistant; misses MRSA Piperacillin-tazobaktam ... 3.37g every 6-8 h Misses MRSA Carbapenems See individual
information. Misses MRSA Doxycycline 100 mg bet 100 mg every 12 hours Excellent activity against Pasteurella multocida; some streptococcus resistant penicillin plus dicloxacillin 500 mg qid/500 mg qid ... SMX-TMP 160-800 mg rate 5-10 mg/kg/day component TMP Good activity against aerobics; Poor activity against
anaerobics Metronidazole 250-500 mg tid 500 mg every 8 hours Good activity against anaerobics; No activity against aerobics Clindamycin 300 mg tid 600 mg every 6-8 h Good activity against staphylococcus, streptococcus and anaerobics; misses P. multocida second generation cephalosporin Good activity against P.
multocida; misses anaerobes Cefuroxime 500 mg bet 1 g every 12 h Cefoxitin ... 1 g every 6-8 h third generation cephalosporin Ceftriaxone ... 1 g every 12 h Cefotaxime ... 1-2 g every 6-8 h Fluoroquinolones Good activity against P. multocida; misses MRSA and some anaerobic ciprofloxacin 500-750 mg rate 400 mg
every 12 h Levofloxacin 750 mg daily 750 mg daily Moxifloxacin 400 mg daily 400 mg daily Monotherapy; good for anaerobs also human bite Amoxicillin-claulanata 875/125 mg bet ... Some gram-negative rods are resistant; misses MRSA Ampicillin-sulbactam ... 1.5-3.0 g every 6 h Some gram-negative rods are resistant;
Skips MRSA Carbapenemy Misses MRSA Doxycycline 100 mg Bet... Good activity against species of Eikenella, staphylococcus and anaerobics; some streptococcus resistant XIII. Should tetanus be introduced toxoid for animal bites? The tetanus toxoid recommendation should be patients without toxic vaccination for 10
years. Tetanus Tetanus Tetanus and tetanus (Tdap) is preferable to tetanus and diphtheria (Td) if the first was not previously given (strong, low). 14. In Which Primary Wound Closure Patients Suitable for Animal Bites Wounds? The recommendation of primary wound closure is not recommended for wounds, except for
those on the face that must be managed with abundant irrigation, careful scattering, and pre-emptive antibiotics (strong, low). Other wounds can be approximate (weak, low). XV. What is proper treatment for cutaneous anthrax? The recommendation of Oral Penicillin V 500 mg 4 times a day (zid) for 7-10 days is the
recommended treatment of naturally acquired coquenous anthrax (strong, high). Ciprofloxacin 500 mg per mouth (at) rate or levofloxacin 500 mg intravenously (IV)/po every 24 hours × 60 days is recommended for bioterrorism cases due to the suspected effects of aerosol (strong, low). 16. What is the appropriate
approach to the evaluation and treatment of bacillary angiomatose and cat scratch? Recommendations of azithromycin are recommended for cat scratch disease (strong, moderate) according to the following dosing protocol: Patients of qgt;45 kg: 500 mg per day 1 followed by 250 mg for 4 additional days (strong,
moderate). Patients: 10 mg/kg per day 1 and 5 mg/kg for another 4 days (strong, moderate). Erythromycin 500 mg acid or doxycycline 100 mg bet for 2 weeks to 2 months is recommended for the treatment of bacillary angiomatosis (strong, moderate). What is the preferred treatment for Erysipeloid? Recommendation
penicillin (500 mg acid) or amoxicillin (500 mg 3 times a day )tid) for 7-10 days is recommended for the treatment of eryzipeloids (strong, high). What is the proper treatment of glanders? The recommendation of Ceftazidime, gentamicin, imipenem, doxycycline, or ciprofloxacin is recommended based on in vitro
susceptibility (strong, low). What is the appropriate diagnosis and treatment of bubonic plague? The recommendation of bubonic plague should be diagnosed with Gram stain and culture of aspirated material from the suprapurative lymph node (strong, moderate). Streptomycin (15 mg/kg intramuscularly IM every 12
hours) or doxycycline (100 mg bid po) is recommended for the treatment of bubonic plague (strong, low). Gentamicin can be replaced with streptomycin (weak, low). XX. What is suitable for diagnosing and treating tolaremia? Recommendations of serological tests are the preferred method of diagnosing tularemia (weak,
low). Streptomycin (15 mg/kg every 12 hours im) or gentamicin (1.5 mg/kg every 8 hours IV) is recommended for the treatment of severe cases of trilaremia (strong, low). Tetracycline (500 mg kid) or doxycycline (100 mg po rate) is recommended for the treatment of mild cases of tularemia (strong, low). Report to a
microbiological laboratory if there is a suspicion that tularemia (strong, 21: What is the appropriate approach to assessing SSTIs in Patients? Recommendations In addition to infection, differential diagnosis of skin lesions should include drug eruption, skin penetration with underlying malignancy, chemotherapy or
radiation-induced reactions, Sweet Syndrome, erythema multiform, leukotoclastic vasculitis, and graft against host disease among allogeneic transplant recipients (strong, high). Differential diagnosis of skin lesions infection should include bacterial, fungal, viral and parasitic agents (strong, high). A biopsy or the desire of
lesions to obtain material for histological and microbiological evaluation should always be implemented as an early diagnostic step (strong, high). What is the appropriate approach to SSTIs in patients with fever and neutropenia? Recommendations determine whether the current representation of fever and neutropenia is
the patient's initial episode of fever and neutropenia, or persistent unexplained fevers of their initial episode (after 4-7 days) or a subsequent episode of fever and neutropenia (relapse) (strong, low). Aggressively identify the etiology of SSTI by aspiration and/or biopsy damage to the skin and soft tissues and present them
for thorough cytological/histological evaluations, microbial staining, and cultures (strong, low). Risk-stratification of patients with fever and neutropenia depending on susceptibility to infection: High-risk patients are those with expected long-term (7 days) and deep neutropenia (absolute number of neutrophils of 100 cells
/LC) or with the Multinational Association of Supportive Care (MASCC) score of 21; Low-risk patients are those with expected brief (lt;7 days) periods of neutropenia and multiple comorbidities (strong, low) or with a MASCC score ≥21 (strong, moderate). Determine the extent of infection through a thorough physical
examination, blood culture, chest X-rays and additional imaging (including chest CT), as evidenced by clinical signs and symptoms (strong, low). XXIII. What is appropriate antibiotic therapy for patients with SSTIs during the initial episode of fever and neutropenia? Recommendations for hospitalization and empirical
antibacterial therapy with vancomycin plus antipsenomal antibiotics such as cephepime, carbapenem (imipenem-cylastatin or meropene or doripenem) or piperacillin-tazobaktam (strong, high) are recommended. Documented clinical and microbiological SSTIs should be treated on the basis of the antimicrobial
susceptibility of isolated organisms (strong, high). It is recommended that the duration of treatment of most bacterial SSTIs should be 7-14 days (strong, moderate). Surgery recommended for drainage abscess tissues after bone marrow restoration or for progressive polymicro microbial necrotizing fasciitis or myonecrosis
(strong, low). Adjunct-colony-stimulating factor therapy (granulocyte-stimulating factor of the colony (G-CSF), macrophag granulocyte granulocytes GM-CSF factor or granulocyte transfusion is generally not recommended (weak, moderate). Acyclovir should be administered to patients suspected or confirmed to have a
cokenous or common chickencap virus (herpes simplex virus (herpes simplex virus (HSV) or wind cup virus (strong, moderate). XXIV. What is appropriate antimicrobial therapy for patients with SSTIs during persistent or recurring episodes of fever and neutropenia? Recommendations of yeast and form remain the main
cause of infection associated with persistent and recurrent fever and neutropenia; therefore, empirical antifungal therapy (table 6) should be added to the antibacterial regimen (strong, high). The empirical introduction of vancomycin or other agents with gram-positive activity (linezolyde, daptomycin, or ceftarolin, table 7)
should be added if not yet administered (strong, high). Candida species SSTIs should be treated with echinocandome or if Candida parapsyosis has been isolated, the lipid formula amfotheric B (strong, high) with friconazole as an acceptable alternative (strong, moderate). Treatment should be carried out within 2 weeks
after the registration of blood flow infection or resolution of skin lesions (strong, moderate). Aspergillus SSTIs should be treated with voricozole (strong, high), or, lipid compositions of amphotericin B, posaconazole, or echinocand for 6-12 weeks (strong, low). Mikora/Rizopa infections should be treated with the lipid

formula amphotericin B (strong, moderate) or poconazole (strong, low) (table 6). The addition of echinocandin can be considered on the basis of synergy in muri models of mouscormicosis and observational clinical data (weak, low). Fusarium types of infections should be treated with a high dose of IV voriconazole or
posaconazole (strong, low). Start treatment of antibiotic-resistant bacterial organisms (table 7), in patients currently on antibiotics (strong, moderate). Intravenous acyclovir should be added to the patient's antimicrobial regimen for suspected or confirmed kuyan or spread HSV infections or HPV (strong, moderate). Blood
cultures should be obtained and skin lesions in this population of patients should be aggressively evaluated by culture aspiration, biopsy, or surgical excision, as they can be caused by resistant microbes, yeast or mold (strong, moderate). The sensitivity of single-nasal fungal antigenic test (1.3-β-d-glucan or
galactomanan tests) is low, especially in patients receiving antifungal agents, and the benefits of laboratory tests for fungal antigen or DNA detection remain inconsistent (strong, moderate). The polymerase of the chain reaction (PCR) in the peripheral blood for HSV and HGH may be helpful in diagnosing a common
infection in patients with skin lesions (weak, moderate). Table 6.Standard doses of antifungal agents antifungal antifungal antifungal . Oral dose. IV Dose . Comments. Foconazole 100-400 mg every 24 h 800 mg load dose, then 400 mg daily Candida krusei and Candida glabrata resistant Voriconazolea 400 mg rate × 2
doses, then 200 mg every 12 h 6 mg/kg IV every 12 hours for 2 doses, and then 4 mg/kg IV every 12 h Accumulation of cyclodextrin vehicle with IV formulation with renal failure Posaconazole 400 mg rates with nutrition N /A Covers Mucorales Lipid complex amphotericin B N/A 5 mg/A kg/kg d Not active against fusaria
liposomal amphotericin B N/A 3-5 mg/kg/d Not active against fusaria Table 7.Standard doses of antimicrobials are active against multi-drug-resistant antimicrobials. IV Dose . Comments. Vancomycin 30-60 mg/kg/d in 2-4 divided doses Target serum concentration of trough 15-20 microgram/ml in severe infections of
daptomycin 4-6 mg/kg/d Covers VRE, strains not subject to vancomycin can be cross-resistant to daptomycin Linezolid 600 mg every 12 h 100% of the oral cavity; so oral doses are the same as IV doses. Covers VRE and MRSA Colistin 5 mg/kg, then 2.5 mg/kg every 12 hours of nephrotoxic; does not apply to gram-
positive or anaerobics, Proteya, Serratia, Burkholderia XXV. What is the appropriate approach to assessing SSTIs in patients with cellular immunodeficiency? Recommendations Consider immediate consultation with a dermatologist familiar with the cellular manifestations of infection in patients with cellular immune
defects (e.g., patients with lymphoma, lymphocytic leukemia, organ transplant recipients, or those who receive immunosuppressive drugs such as antitumor necrosis or certain monocludic antibodies). Consider biopsy and surgical debrication in the early stages of treatment of these patients (weak, low). Empirical
antibiotics, antifungal and/or antiviral drugs should be considered in life-threatening situations (weak, moderate). The use of specific agents should be addressed with the participation of the main group, dermatology, infectious diseases and other advisory groups (strong, moderate). INTRODUCTION This practice guide
contains recommendations for diagnosing and managing skin and soft tissue infections (SSTIs) of otherwise healthy hosts and compromised hosts of all age groups. These recommendations are of new importance due to the sharp increase in the frequency and severity of infections and the emergence of resistance to
many antimicrobials commonly used to treat SSTIs in the past. For example, between 2000 and 2004, the total number of hospitalizations for these infections increased by 29%. In addition, 6.3 million doctor's office visits per year are related to SSTIs. Similarly, between 1993 and 2005, the number of annual visits to
emergency departments for SSTIs 1.2 million to 3.4 million patients. Some of these increased frequencies are associated with community-related methicillin-resistant Staphylococcus aureus (MRSA). These infections have different etiology that are partly dependent on different epidemiological conditions. As a result,
obtaining a thorough history, which includes information about the patient's immune status, geographic location, travel history, recent trauma or surgery, previous antimicrobial therapy, lifestyle, hobbies, exposure or animal bites, is important in developing an adequate differential diagnosis and an appropriate index of
suspicion for specific etiological agents. Recognition of the results of physical examination and understanding of the anatomical relationship of the skin and soft tissues are crucial for establishing the correct diagnosis. In some cases, this information is insufficient and tissue biopsy or aspiration may be required. In
addition, radiographic procedures may be crucial in a small subset of patients to determine the level of infection and the presence of gas, abscess or necrotizing process. Finally, surgical research or debridation is an important diagnostic as well as therapeutic procedure in patients with necrotizing infections or
myonecrosis and may be important for individual immunocompromised hosts. The clinical evaluation of patients with SSTI is aimed at determining the cause and severity of infection and should take into account specific pathogens and local models of antibiotic resistance. Many different microbes can cause soft tissue
infections, and although specific bacteria can cause a certain type of infection, significant overlaps in clinical presentation occur. The keys to diagnosis and algorithmic approaches to diagnosis are detailed in the text to follow. Specific recommendations for therapy are given, each with a rating that indicates strength and
evidence for recommendations in line with the Infectious Diseases Society of America (IDSA)/U.S. Public Health System Classification System to evaluate recommendations in clinical guidelines (table 1). Answers to the following 24 clinical questions: What is appropriate for evaluating and treating impetigo and ectima?
What is the appropriate evaluation and treatment of skin abscesses, boils, carbuncles and inflamed epidermoid cysts? What is the appropriate treatment for recurrent skin abscesses? What is suitable for evaluating and treating erysipelas and cellulite? Should corticosteroids be used in addition to treating cellulite with
antibiotics? What is the preferred assessment and management of patients with recurrent cellulite? What is the preferred treatment for surgical site infections? What is the preferred assessment and treatment of necrotizing fasciitis, including Gangrene Fournier? What is the appropriate approach to the management of
piomyositis? What's the proper to assess and treat clostidial gas gangrene or or Is the role of pre-emptive antimicrobial therapy to prevent infection from dog or cat bites? What is the treatment for wounds associated with the bites of infected animals? Should tetanus be administered toxoid for wounds from animal bites?
In which patients primary wound closure is suitable for animal bite wounds? What is the appropriate treatment for anthrax? What is the appropriate approach for evaluating and treating bacillary angiomatose and cat scratch? What is the preferred treatment for erysipeloide? What is proper treatment of glands? What is the
appropriate diagnosis and treatment of bubonic plague? What is appropriate for the diagnosis and treatment of tolaremia? What is the appropriate approach to assessing SSTIs in immunocompromised patients? What is the appropriate approach to assessing SSTIs in patients with fever and neutropenia? What is the
appropriate antibiotic therapy for patients with SSTIs during the initial episode of fever and neutropenia? What is the appropriate antimicrobial therapy for patients with STDs during persistent or recurring episodes of fever and neutropenia? What is the appropriate approach to assessing SSTIs in patients with cellular
immunodeficiency? PRACTICE GUIDELINES are systematically designed by applications to assist practitioners and patients in making decisions about appropriate care for specific clinical circumstances. The attributes of high-quality guidelines include validity, reliability, reproducibility, clinical applicability, clinical
flexibility, clarity, interdisciplinary process, evidence review and documentation. METHODOLOGY Group Composition Group of 10 Interdisciplinary Experts in SSTIs Management In Children and Adults was convened in 2009. Efforts have been made to include people from different geographical areas, paediatric and
adult practitioners, as well as a wide range of specialties. The group consisted of 10 IDSA members. The mission included 8 adult infectious disease doctors, one pediatric infectious disease doctor and one general surgeon. The team members were selected based on their clinical and research examination on various
SSTIs, including infections in compromised hosts, necrotizing fasciitis, gas gangrene, cellulite, and to cutaneous abscesses and infections after surgery and animal and human bites. Finally, some members were selected based on their experience for specific microbes such as staphylococcus, streptococcus, Clostridium
species and anaerobics. Two members were selected to ensure that the IDSA/MRSA Guidelines were met. The literature review and analysis of the Recommendations contained in this guide were developed after a review of studies published in English, although foreign language articles were included in some of the
Cochrane reviews summarized in the guide. The research was identified through LISTA (EBSCO) and PubMed are looking for unlimited dates using theme titles. Examples of keywords used to search for literature were: skin abscess (recurrent and recurrent), dog bites, skin infections and soft tissues, cellulite,
erycisipelas, site surgical infections, wounds, staphylococcus, streptococcus, cat bites, tetanus, wound bite (care and closure), irrigation, amoxicillin, amoxicillin clavanath, cefuroxic, levofroxacin, moxifloxacin, sulfamethoxal-trimethos. The Process Review To Evaluate Evidence, the team followed a process agreed with
other IDSA guidelines. The evidence-based evaluation process was based on the IDSA Handbook for the Development of Clinical Practice Guidelines and concerned the systematic weighing of the quality of the evidence and the evaluation of the assessment using the Recommendation, Development and Evaluation
Assessment System (GRADE) (table 1) (table 1-4, 9, 10). GRADE is a newly created system for assessing the quality of evidence and the strength of health recommendations. The members of the group were divided into pairs consisting of primary and secondary authors. Each author was asked to review the literature,
evaluate the evidence and determine the strength of the recommendations, along with a summary of the evidence supporting each recommendation. The panel reviewed all the recommendations, their strength and the quality of the evidence. Disagreements have been discussed and resolved, and all members of the
group agree with the final recommendations. Consensus development based on evidence The Panel held twice for face-to-face meetings and held teleconferences in 6 cases to complete the management's work. The purpose of the teleconference was to discuss clinical issues to be addressed, to assign topics to
consider and write the original draft, and to discuss recommendations. The group as a whole reviewed all the separate sections. This guidance has been reviewed and approved by the IDSA Standards and Practice Committee (SPGC) and the Board of Directors and approved by the Society for Pediatric Infectious
Diseases (PIDS). The Guidelines and Conflicts of Interest Panel complied with IDSA's conflict of interest policy, which requires disclosure of any financial or other interests that may be construed as representing an actual, potential or obvious conflict. Members of the Panel were presented with an IDSA statement of
conflict of interest and were asked to identify links with companies in developing products that may be affected by the adoption of this guide. Information on employment, advice, stock ownership, fees, research funding, expert testimony and membership in company advisory committees was requested. Decisions on
whether a person's role should be restricted as a result Potential conflicts of interest are listed in the Confessions section. The review dates of the year, the panel chairman, the SPGC Communications Advisor, and the chairman of the SPGC will determine the need to revise the guidelines based on the study of current
literature. If necessary, the entire group will meet again to discuss possible changes. If necessary, the panel will recommend reviewing the guidelines to the SPGC and IDSA board and other collaborating organizations for review and approval. WHAT is suitable for assessing and treating impetigo and extrathima? Gram
stain recommendations and culture of gnome or exudates from skin lesions impetigo and ectims are recommended to help determine whether Staphylococcus aureus and/or β-hemolytic streptococcus is the cause (strong, moderate), but treatment without these studies is reasonable in typical cases (strong, moderate).
Bullous and nebulal impetigo can be treated with oral or topical antimicrobials, but oral therapy is recommended for patients with multiple lesions or outbreaks affecting several people to help reduce transmission. Treatment of ectima should be an oral antimicrobial. Treatment of bullous and nebulary impetigo should be
either topical mupirocin or retapaamulin twice a day (bid) for 5 days (strong, high). Oral therapy of ectima or impetigo should be a 7-day regimen with an agent active against S. aureus if cultures give streptococcus alone (when oral penicillin is a recommended agent) (strong, high). Since S. aureus isolates from impetigo
and ecthimas, methicillin is usually susceptible, dicloxacillin or cephalexin is recommended. If MRSA is suspected or confirmed, doxycycline, clindamycin or sulfamethoxazole-trimethopry (SMX-TMP) (strong, moderate) is recommended. Systemic antimicrobials should be used for infections during outbreaks of post-
streptococcal glomerulonephritis to help eliminate jaded strains of streptococcal piogen from the community (strong, moderate). Evidence Summary Impetigo can be either bullish or non-ish. Bullous impetigo is caused by strains of S. aureus, which produce a toxin that breaks down the dermal epidermal compound to
form brittle, thin-roofed vesicopustules. These damages can rupture, creating cortical, erythema erosion, often surrounded by collared roof residues. Nebululic impetigo can occur from infections β hemolytic streptococcus or S. aureus, or both in combination. Impetigo begins as erythemato papules, which quickly develop
into bubbles and pustules that break, with a dried discharge forming a honey-colored crust on an erythema-based basis. Ectima is a deeper infection than and S. aureus and/or streptococcus may be the cause. Defeats begin as bubbles that burst, causing Erythemato ulcers with adeptic crusts, often with surrounding
erythema swelling. Unlike impetigo, the ectim heals with scars. Cultures of fluid vesicles, ulcers, erosion or ulcers establish the cause. If crops do not give streptococcus alone, antimicrobial therapy should be active against both S. aureus and streptococcus. Oral penicillins resistant penicillin or first-generation
cephalosporins are generally effective, as most staphylococcal isolates from impetigo and ectims methicillin are susceptible. Alternatives to penicillin allergic patients or infections with MRSA include doxycycline, clindamycin, or SMX-TMP. When streptococcus in itself is the cause, penicillin is the drug of choice, with
macrolide or clindamycin as an alternative to penicillin allergic patients. Topical treatment with mupirocin or retapaamulin is as effective as oral antimicrobials for impetigo. Clinical experience shows that systemic therapy is preferred for patients with multiple lesions or in outbreaks affecting multiple people to help reduce
transmission (table 2). What is the appropriate assessment and treatment of pingable SSTIs (skin abscesses, furuncles, carbuncles, and inflammation of epidermoid cysts) ? (Figure 1) Gram's recommendations are slick and the culture of gue from carbuncles and abscesses is recommended, but treatment without these
studies is reasonable in typical cases (strong, moderate). Gram spot and culture of gnome from inflamed epidermoid cysts is not recommended (strong, moderate). Incision and drainage is recommended for the treatment of inflamed epidermoid cysts, carbuncles, abscesses and large boils (strong, high). The decision to
administer antibiotics against S. aureus as a supplement to incision and drainage should be made on the basis of the presence or absence of systemic inflammatory response syndrome (SIRS), such as temperature of zgt;38, t11;36 degrees, tachypnea,gt;degrees of zlt;400 cells/zL (moderate; Figure 1) (strong, low). An
antibiotic active against MRSA is recommended for patients with carbuncles or abscesses who have markedly impaired host defenses and in patients with SIRS (Figure 1, Table 2) (strong, low). Evidence Summary Cutaneous Abscesses Cutaneous abscesses are collections of pus within the dermis and deeper skin
tissues. They are usually painful, tender, and fluctuant red nodules, often surmounted by a pustule and encircled by a rim of erythematous swelling. Cutaneous abscesses can be polymicrobial, containing regional skin flora or organisms from the adjacent mucous membranes, but S. aureus alone causes a large
percentage of skin abscesses, with a substantial number due to MRSA strains [16–18]. Epidermoid (or epidermal inclusion) cysts, often cells/μl= figure= 1)= (strong,= low).= an= antibiotic= active= against= mrsa= is= recommended= for= patients= with= carbuncles= or= abscesses= who= have= markedly= impaired=
host= defenses= and= in= patients= with= sirs= (figure= 1,= table= 2)= (strong,= low).= evidence= summary= cutaneous= abscesses= cutaneous= abscesses= are= collections= of= pus= within= the= dermis= and= deeper= skin= tissues.= they= are= usually= painful,= tender,= and= fluctuant= red= nodules,= often=
surmounted= by= a= pustule= and= encircled= by= a= rim= of= erythematous= swelling.= cutaneous= abscesses= can= be= polymicrobial,= containing= regional= skin= flora= or= organisms= from= the= adjacent= mucous= membranes,= but= s.= aureus= alone= causes= a= large= percentage= of= skin= abscesses,=
with= a= substantial= number= due= to= mrsa= strains= [16–18].epidermoid= (or= epidermal= inclusion)= cysts,= often=> по
Цельсию или 24 вдоха в минуту, тахикардия >90 ударов в минуту или количество белых кровяных телец >12 000 или или Labeled sebaceous cysts usually contain skin flora in a cheesy keratin material. When inflammation and sullenness occur, they are a reaction to the rupture of
the cyst wall and the extrusion of its contents in the dermis, rather than the actual infectious process. Incision, the evacuation of gnome and debris, as well as the sensing of the cavity for the decay of loculations provides effective treatment of skin abscesses and inflamed epidermoid cysts. A randomized study comparing
the incision and drainage of maple abscesses with ultrasonicly controlled aspiration of needle abscesses, found that aspiration was successful in only 25% of cases overall and 10% with MRSA infections. Accordingly, this form of treatment is not recommended. The simple coating of the surgical area with a dry bandage
is usually the easiest and most effective treatment for the wound .21, 22. Some doctors cover the wound with stitches or pack it with gauze or other absorbent material. One small study, however, found that the packaging caused more pain and did not improve healing compared to simply covering the cut area with sterile
gauze. Adding systemic antibiotics for incision and drainage of cokenous abscesses does not improve treatment rates (17, 21, 22, 24, 25), even in those associated with MRSA, but have a modest effect on the recurrence time of other abscesses (17, 25). However, systemic antibiotics should be given to patients with
severe host protection disorders or signs or symptoms of systemic infection (Figure 1, Table 2). In addition, multiple abscesses, age extremes and lack of response only to incision and drainage are additional conditions in which systemic antimicrobial therapy should be considered. Furuncles and Carbuncles Furuncles (or
boils) are hair follicle infections, usually caused by S. aureus, in which the suppuracia extends through the dermis into the subcutaneous tissue where a small abscess is formed. They differ from folliculitis, in which inflammation is more superficial and the epiphany is limited to epidermis. Clinically, furuncles inflammatory
nodules with excessive pustules through which hair emerges. Infection involving several adjacent follicles produces a carbuncle, a charcoal inflammatory mass with a flowing from several follicular holes. Carbuncles develop most often on the back of the neck, especially in people with diabetes. They tend to be larger and
deeper than boils. Furuncles often rupture and drain spontaneously or after treatment with moist heat. Most large boils and all carbuncles must be treated with incision and drainage. Systemic antimicrobials are generally not needed if fever or other evidence of systemic infection is present (Figure 1). What is the
appropriate treatment for recurrent skin abscesses? Recommendations A an abscess at the site of a previous infection should be prompted to search for local causes such as cyst pylonidale, hidradenite suppurativa, or foreign material (strong, moderate). Recurrent abscesses should be drained and cultured in the early
stages of infection (strong, moderate). The culture of recurrent abscess and treatment from a 5- to 10-day course of antibiotics are active against a pathogen isolated (weak, low). Consider a 5-day decolonization regimen twice a day of intranasal mupirocin, daily gorgexidine washes, and daily decontamination of personal
items such as towels, sheets, and clothing for recurrent S. aureus infection (weak, low). Adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood (strong, moderate). Evidence Summary of a recurrent abscess at the previous site of infection may be caused by local factors
such as foreign material, hidradinitis suppurativa, or pylonidal cyst (26, 27), whose eradication may be curative. Incision and drainage should be performed for periodic abscesses. The benefits of additional antimicrobial therapy in preventing relapses are unknown. Older randomized trials have shown that twice a day
intranasal mupirocin for 5 days each month (28) or a 3-month program of oral clindamycin 150 mg per day (29) reduce the rate of further infections. Whether such schemes are effective in the current era of community MRSA is unclear. In one randomized trial, twice-daily use of nasal mupirocin for 5 days among military
personnel who wore MRSA in the nose did not reduce the frequency of subsequent skin infections (30, 31). Cleaning the body three times a week is chlorhexidine-soaked tissue after the shower is also considered ineffective. 5-day decolonization with two-day intranasal mupirocin and daily bathing with chlorhexidine (32)
or diluted bleach (1/4-1/2 cups of bleach per full bath) to prevent relapses may be considered, but evidence of efficacy is rare. One uncontrolled study reported an end to the epidemic of boils in the village with the help of mupirocin, an antibacterial hand detergent and daily washing of towels, sheets, crests and razors. A
recent study in children found the use of preventive measures for the patient and contacts households resulted in significantly fewer relapses in the patient than using measures in the patient only . Since patients with neutrophil dysfunction develop recurrent abscesses in early childhood, patients who develop abscesses
in adulthood do not need to assess the function of neutrophil. RECOMMENDATIONS ON ERYSIPELAM AND CELLULITE IV. What is suitable for the evaluation and treatment of erycipelas and cellulite? Recommendations of Blood Culture or Cocerenous Aspirates, or tampons are not usually recommended (strong,
moderate). Blood cultures are recommended moderate), and coceenous and microscopic examination of coquenous aspirates, biopsies or tampons should be considered in patients with malignancies during chemotherapy, neutropenia, severe cellular immunodeficiency, immersion injuries and animal bites (weak,
moderate). Typical cases of cellulite without systemic signs of infection should be obtained by antimicrobial drug that is active against streptococcus (soft; Figure 1) (strong, moderate). In cellulite with systemic signs of infection (moderate non-purple SSTI; Figure 1) systemic antibiotics are shown. Many doctors may
include coverage against MSSA (weak, low). For patients whose cellulite is associated with penetrating trauma, evidence of MRSA infection elsewhere, nasal colonization with MRSA, injectable drug use, purulent drainage, or SIRS (severe non-drug), vancomycin or other antimicrobial effective against MRSA and
streptococcus is recommended (strong, moderate). In patients with severe compromised drugs (as defined in question 13) it is possible to consider a wide range of antimicrobials (weak, moderate). Vancomycin plus either piperacillin-tazobactam or imipenem-merpene is recommended as a reasonable empirical regimen
for severe infection (strong, moderate). The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved during this time period (strong, high). It is recommended to exalt the affected area and treat predisposing factors such as swelling or related skin
disorders (strong, moderate). In the lower limb of cellulite, clinicians should carefully examine the interdigitial nasal space because the treatment of cleavage, scaling or maceration can eradicate colonization with pathogens and reduce the incidence of recurrent infection (strong, moderate). Outpatient therapy is
recommended for patients who do not have SIRS, altered mental state, or hemodynamic instability (mild non-purple; Figure 1) (strong, moderate). Hospitalization is recommended if there is concern about a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a heavy patient with
weakened immunity, or if outpatient treatment fails (moderate or severe non-purulative; Figure 1) (strong, moderate). Evidence Summary cellulite and erysipelas refer to diffuse, superficial, spreading skin infections. The term cellulite is not suitable for the kidonic inflammation associated with collections of hgly, such as
septic bursitis, boils, or skin abscesses. For example, when skin redness, heat, tenderness and swelling surround a suprapodative focus, such as an infected bursa, the appropriate terminology is bursitis with ambient inflammation rather than septic bursitis with surrounding cellulite. This distinction is clinically important for
primary treatment treatment is an antimicrobial therapy, while for pingable collections the main component of management is gnoc insulting, while antimicrobial therapy is either not needed or plays a supporting role (Figure 1 and Table 2). The term erysipelas has 3 different meanings: (1) for some, erysipelas is an
infection limited to upper dermis, including superficial lymphatic, while cellulite includes deeper dermis and subcutaneous fat, and the survey erysipelas putatively has more clearly defined boundaries of inflammation than cellulite; (2) For many, erysipelas was used to refer to cellulite involving only the face; and (3) for
others, especially in European countries, cellulite and erysipela are synonymous. These infections cause rapidly spreading areas of erythema, swelling, tenderness and heat, sometimes accompanied by lymphangit and inflammation of regional lymph nodes. The surface of the skin may resemble an orange peel (peau
d'orange) due to the superficial skin swelling of the surrounding hair follicles and causing the skin dimples, because the follicles remain tied to the main dermis. Bubbles, bulls and cokenous hemorrhage can develop in the form of petehia or echimos. Systemic manifestations are usually mild, but fever, tachycardia,
confusion, hypotension, and white bloodocytosis are sometimes present and may occur a few hours before skin abnormalities appear. These infections occur when microbes disrupt the skin surface, especially in patients with fragile skin or reduced local host protection against conditions such as obesity, previous skin
injuries (including surgery), previous episodes of cellulite, and swelling from venous insufficiency or lymphedema (36, 37). The origin of the disturbed skin surface may be obvious, such as injuries, ulcers, and pre-existing skin inflammations, but often breaks in the skin are small and clinically unapprehied. These infections
are most common on the lower legs. Blood cultures are generally positive ≤5% of cases. Yields of inflamed skin crops range from ≤5% to about 40%. Differences in diagnostic sensitivity and specificity are due to the diversity of patient populations studied, cellulite definitions, inclusion or exclusion of cases with
accompanying abscesses, and the determination of whether isolates are pathogens or contaminants. Cultures punch biopsy samples give the body in 20%-30% of cases (39, 47), but the concentration of bacteria in tissues is usually quite low. Combined data from exemplary cultures, serological studies (41, 48-51) and
other methods (e.g. immunohystochemical staining to detect antigens in skin biopsies (51, 52)) indicate that the vast majority of these infections are the result of often Group A, as well as from other groups such as B, C, F, F, G. The source of these pathogens is often unclear, but in many cases of cellulite feet,
responsible streptococcus are found in macerated, scaly, or fissile interdigitial leg space (53, 54). This observation highlights the importance of detecting and treating tinea pedis, erythrazma, and other causes of nasal network abnormalities. Sometimes the reservoir of streptococcus is an canal or vagina, especially for
group B streptococcal cellulite in patients with previous gynecological cancer, treated with surgery and radiation therapy. Staphylococcus aureus is less likely to cause cellulite, but cases associated with this organism are usually associated with an open wound or previous penetrating injury, including the site of illegal
drug injections. Some other organisms may cause cellulite, but usually only in special circumstances such as animal bites, freshwater or marine immersion damage, neutropenia, or severe cellular-mediated immunodeficiency. Cultures of blood, tissue aspirates or skin biopsy are not necessary for typical cases of cellulite.
Blood cultures should be obtained and skin biopsy cultures or aspirate are considered for patients with malignancies, severe systemic features (such as high fever and hypotension), and unusual predisposing factors such as immersion injuries, animal bites, neutropenia, and severe cells mediated immunodeficiency.
Therapy of typical cellulite cases should include an antibiotic active against streptococcus (table 2). A large percentage of patients may receive oral medications from the outset for typical cellulite, and suitable antibiotics for most patients include penicillin, amoxicillin, amoxicillin-claulanate, dicloxacillin, cephaloxamine, or
clindamycin. In cases of uncomplicated cellulite, a 5-day course of antimicrobial therapy is as effective as a 10-day course if clinical improvement occurred by 5 days. In a retrospective study of cellulite and abscesses requiring hospitalization, the average duration of treatment was 2 weeks, and only about a third of
patients received specific treatment of gram-positive pathogens. Two-thirds received treatment in a very wide range, and the failure rate of 12% did not differ regardless of the range of treatment. In some patients, coceenosis inflammation and systemic features worsen after the onset of therapy, probably because the
sudden destruction of pathogens releases powerful enzymes that increase local inflammation. MRSA is an unusual cause of typical cellulite. A prospective study of patients with cellulite in a high-frequency medical center of other MRSA-associated SSTIs showed that treatment with β-lactams, such as cephalusolin or
oxacillin, was successful in 96% of patients, suggesting that cellulite due to MRSA is a rarity and treatment of this organism as Unnecessary. However, the coverage FOR MRSA may be cellulite is associated with penetrating trauma, especially as a result of illicit drug use, ply drainage or simultaneous evidence of MRSA
infection elsewhere. MrsA treatment options in these circumstances (table 2) include intravenous drugs (vancomycin, daptomycin, linezorid, or telavancin) or oral therapy with doxycycline, clindamycin or SMX-TMP. If coverage for both streptococcus and MRSA is desirable for oral therapy, options include clindamycin
alone or a combination of either SMX-TMP or doxycycline with β lactam (e.g. penicillin, cephalexin, or amoxicillin). The activity of doxycycline and SMX-TMP against β-hemolytic streptococcus is not known, and in the absence of abscess, ulcers or plying drainage, β-lactam monotherapy is recommended. This is further
evidenced by a recent double-blind study showing that the SMX-TMP plus cephalexin combination was no more effective than cephalexin alone in pure cellulite. The rise of the affected area accelerates the improvement, contributing to the gravitational drainage of swelling and inflammatory substances. Patients should
also receive therapy for any predisposing conditions such as shingles pedis, trauma, or venous eczema (stagnation of dermatitis). Should anti-inflammatory drugs be used in addition to treating cellulite with antibiotics? The recommendations of Systemic Corticosteroids (e.g. prednizone 40 mg daily for 7 days) can be
considered in nondiabetic adult patients with cellulite (weak, moderate). Evidence Summary Treatment of Inflammation in These Infections by combining antimicrobial therapy with either a nonsteroidal anti-inflammatory agent (ibuprofen 400 mg 4 times a day qid for 5 days) or systemic corticosteroid significantly
accelerates clinical improvement compared to antimicrobial therapy alone .60, 61 . A randomized, double-blind, placebo-controlled study involving 108 adult nondiabetic patients found that an 8-day course of oral corticosteroids combined with antimicrobial therapy resulted in a significantly faster clinical resolution of
cellulite (primarily legs) than antimicrobial therapy alone. The long-term follow-up axis of these patients showed no difference in relapse or relapse (61, 62). The benefits of systemic corticosteroids in this situation are consistent with their effectiveness and safety as an additional treatment for other infections. The doctor
should make sure that deeper infections such as necrotizing fasciitis are not present. Most patients can receive treatment without hospitalization (63, 64). Hospitalization is indicated on suspicion of necrotizing infection or for patients with severe systemic features such as fever, delirium or hypotension. Other signs include
a bad reaction to outpatient severe immunocompromise and problems with patient adherence to treatment. WHAT'S WHAT Preferred assessment and management of patients with recurrent cellulite? Recommendations to identify and treat predisposing conditions such as swelling, obesity, eczema, venous insufficiency,
and predisposing network abnormalities (strong, moderate). These practices should be performed as part of routine patient care and, of course, during the acute stage of cellulite (strong, moderate). Administration prophylactic antibiotics, such as oral penicillin or erythromycin tracing for 4-52 weeks, or intramuscular
benzatin penicillin every 2-4 weeks, should be considered in patients who have 3-4 episodes of cellulite per year despite attempts to treat or control predisposing factors (weak, moderate). This program should continue as long as predisposing factors (strong, moderate) persist. Evidence Summary Patients with a previous
bout of cellulite, especially involving the legs, have annual relapse rates of about 8%-20% (65-67). The infection usually occurs in the same area as the previous episode. Swelling, especially lymphedema and other local risk factors such as venous insufficiency, previous trauma (including surgery) in the area, and tinea
pedis or other leg network abnormalities (65-71), increase the recurrence rate. Other predisposing conditions include obesity, tobacco use, cancer history and homelessness (66, 67, 71). Eliminating these factors may reduce the recurrence rate, but evidence of such benefits is rare. For patients with relapses, despite
such efforts, antimicrobial prevention can reduce the frequency of future episodes. Two randomized trials using twice-daily oral penicillin or erythromycin showed a significant reduction in relapses among antibiotic recipients compared to control (72, 73). An observational study of monthly intramuscular injections of 1.2
million units of benzatine penicillin showed that this regimen was only useful in a subgroup of patients who did not have identifiable predisposing factors for relapse. In a study of patients with recurrent cellulite involving hand lymphedema caused by breast cancer treatment, 2.4 million units of two-week intramuscular
benzatin penicillin seemed to reduce the frequency of episodes, but there was no control group. The duration of therapy is uncertain and infections can be repeated after the prevention stops. For example, a recent double-blind comparative study showed that phenoxymethyl-penicillin, given as 250 mg twice a day for 12
months, increased relapse time to 626 days compared to 532 days in the control group and reduced the recurrence rate from 37% to 22%. WHAT is the preferred management of surgical Site? Recommendations Removing the seam plus incision and drainage should be performed for surgical site infections site low).
Adjunct-intensive systemic antimicrobial therapy is not usually indicated, but in combination with incision and drainage can be beneficial for surgical site infections, Associated with a significant systemic response (Figure 2), such as erythema and induction, stretching to 5 cm from the edge of the wound, temperature of
zgt;38.5 degrees Celsius, heart rate of zgt;110 beats per minute, or white blood cells (WBC) count to qgt;12,000/L (weak, low). A short course of systemic antimicrobial therapy is indicated in patients with surgical infections after clean operations on the torso, head and neck or limbs, which also have systemic signs of
infection (strong, low). The first generation of cephalosporin or antistaphylococcal penicillin for methicillin-susceptible Staphylococcus aureus (MSSA) or vancomycin, linezorid, daptomacin, tlavancin, or ceftarolin, where risk factors for MRSA are high (nasal colonization, prior to MRSA infection, recent hospitalization,
recent antibiotics) Agents active against gram-negative bacteria and anaerobics such as cephalosporin or fluoroquinolone in combination with metronidazole are recommended for infections after operations on the underarm, gastrointestinal (GI) tract, intermediate or female genital tract (table 2) (strong, low). Evidence
Summary of Wound Infections, or Surgical Infection Site (SSIs) are the most common adverse event affecting hospitalized surgical patients. Data from the National Nosocomial Infection Surveillance System (NNIS) show that the average incidence of SSI is 2.6%, which is 38% of nosocomial infections in surgical patients.
The frequency of SSI is clearly associated with the category of operations, with net operations and low-risk operations (NNIS) having the lowest incidence, and contaminated operations and high-risk operations with higher infection rates. Unfortunately, there are no studies that objectively compared SSI treatments. SSI is
divided into categories of surface SSI incision, deep SSI and organ/space SSI. Surface incisional SSIs only include subcutaneous space, between the skin and the main muscular fascia, occur within 30 days of surgery, and is documented with at least one of the following: (1) gnome cut drainage, (2) positive culture of
asepticly obtained fluid or tissue from a superficial wound, (3) local signs and symptoms of pain or tenderness, swelling, and erectitis after incision opened by the surgeon (if the culture is negative), or (4) the diagnosis of SSI based on their experience and doctor. A deep incision infection involves deeper soft tissue (e.g.
fascia and muscle) and occurs within 30 days of surgery or within 1 year if the prosthesis has been inserted and has the same findings as described for SSI incisions. The organ/space SSI has temporary limitations and evidence of infection as a deep incision of SSI, and this can include any part of the anatomy (organs
or spaces) other than the initial surgical incision. Examples will include postoperative peritonitis, empyea, or joint space infection. Any deep SSI that does not resolve the expected manner after treatment should be investigated as a possible superficial manifestation of a deeper organ/space infection. Diagnosis and
treatment of organ space infections in the abdominal cavity are discussed in other guidelines. Tedizolid and dalbavancin are also effective treatments for SSTI including those caused by MRSA and can be approved by the U.S. Food and Drug Administration (FDA) in June 2014.Local signs of pain, swelling, erythema, and
gnome drainage provide the most reliable information in the diagnosis of SSI. In patients with pathological obesity or in patients with deep, multi-layered wounds such as thoracotomium, external signs of SSI may be delayed. While many patients with SSI will develop fever, this usually does not occur immediately after
surgery, and in fact, most postoperative fevers are not related to SSI. Flat, erythematic skin changes can occur around or near a surgical incision during the first week without swelling or drainage wounds. Most decide without any treatment. The cause is unknown, but may refer to the sensitivity of tape or other local insult
tissues not involving bacteria. Numerous experimental studies and clinical trials show that antibiotics started immediately after surgery or continue for long periods after the procedure do not prevent or treat this inflammation or infection. Thus, the suspicion of a possible SSI does not justify the use of antibiotics without a
definitive diagnosis and the establishment of other therapeutic measures such as wound discovery (Figure 2). SSIs rarely occur within the first 48 hours after surgery, and fever during this period usually occurs from noncommunicable or unknown causes. SSIs that occur in this period are almost always due to S.
pyogenes or Clostridium species. After 48 hours, SSI is a more common source of fever, and a thorough examination of the wound is indicated; 4 days after surgery, fever can equally be caused by SSI or other infection or other unknown sources. Later infections are less likely, but surveillance standards require 30 days
of monitoring operations without the placement of prosthetic material and for 1 year for operations in which the prosthesis was inserted. Accordingly, fever or systemic signs during the first few postoperative days should be accompanied by a direct examination of the wound to rule out streptococcal or clostridial infection
(see section on necrotization of soft tissue infections and clostridial myonocross), but should not otherwise cause further manipulation of the wound. Patient Patients early infection due to streptococcus or clostridium have drainage wounds with responsible organisms present on the Gram stain (Figure 2). White blood cells
may not be evident in drainage in most clostridial and some early streptococcal infections. Another rare cause of early fever and systemic signs after surgery is staphylococcal syndrome of toxic shock (89, 90). In these cases, the wound is often deceptively benign in appearance. Erytroderm occurs early and
desquamation occurs late. Fever, hypotension, abnormal studies of liver and renal blood, and diarrhea are early findings. The appropriate treatment is to open the incision, perform the culture, and start anti-staphylococcus treatment. The most important therapy for SSI is to open the incision, evacuate the infected
material and continue dressing until the wound heals with secondary intent. Most textbooks of surgery, infectious diseases or even surgical infectious diseases discuss epidemiology, prevention and surveillance for ICU in detail, but not their treatment. Two of them contain simple, unaccounted-for recommendations for
opening an infected wound without antibiotics. Thus, it's a total of 5 cm of erythema and induration, and if the patient has a minimal systemic signs of infection. (38.5)C, and the t99-z12,000 cells. the cesses are found to be little or no benefit for antibiotics when they're combined with drainage. The single's published trial
of the antibiotic administration for ssi' specifically found no clinical benefit. Bacteremia, and then prophylactic' antibiotics are not recommended.patients' with a temperature at 38.5 degrees Celsius or heart rhythm of qgt;110 beats per minute or eritem , go beyond the edge of the wound at zgt;5 cm may require a short
course (e.g. 24-48 hours) of antibiotics, as well as opening the seam line (Figure 2). The choice of antibiotics is usually empirical, but can be supported by The Gram Spot, the culture of wound content (table 2), and the location of surgery. For example, SSI after gastrointestinal or female genital surgery has a high
probability of mixed gram-positive and gram-negative flora with both the faculty and the anaerobic organism. Antibiotics deemed suitable for treating intra-abdominal infection are appropriate. If the operation was a clean procedure that did not penetrate the intestinal or sexual tracts, the most common organisms are S.
aureus streptococcal species. If the facility in which the surgery was performed has a significant proportion of infections with MRSA or the patient has had prior to MRSA infection, nasal colonization or earlier on antibiotics, the initial antibiotic should include vancomycin, linezorid, daptomycin, daptomycin, daptomycin, or
ceftarolin to cover MRSA, as well as one of the following for gram-negative and anaerobic coating: (1) piperacillin-tazobactam, (2) carbapenem, or (3) ceftriaxone and metronidazole (table 3). Infections after surgery on the wash also have a significant recovery of gram-negative organisms, and infections in the
intermediate part have a higher incidence of gram-negative organisms and anaerobics (100, 103, 104); the choice of antibiotics should ensure coverage of these organisms (table 3). Figure 2 presents a schematic algorithm for approaching patients with suspected SSIs and includes specific recommendations for
antibiotics. Infections developing after surgical procedures associated with non-sterile areas such as the colon, vaginal, bile or respiratory mucosa may be caused by a combination of aerobic and anaerobic bacteria (18, 87, 88, 101). These infections can progress rapidly and include deeper structures than just skin such
as fascia, fat or muscle (tables 3 and 4). What is the preferred evaluation and treatment of necrotizing fasciitis, including Fournier Gangrene? Recommendations Fast Surgical Consultation is recommended for patients with aggressive infections associated with signs of systemic toxicity or suspicion of necrotizing fasciitis
or gas gangrene (severe unpurulened; Figure 1) (strong, low). Empirical antibiotic treatment should be extensive (e.g. vancomycin or linzolyde plus piperacillin-tazobactam or plus carbapenem, or plus ceftriaxone and metronidazole), as etiology can be polymicrobic (mixed aerobic-anaerobic microbes) or monomicrob
(group Streptococcus, community acquired MRSA) Penicillin plus clindamycin is recommended for the treatment of a documented group of streptococcal necrotizing fasciitis (strong, low). The summary of evidence of necrotizing SSTIs differs from milder, superficial infections by clinical presentation, coexisting systemic
manifestations and treatment strategies (table 4). These deep infections are associated with fascial and/or muscle compartments and are potentially devastating due to major tissue destruction and death. They usually develop from an initial break in the skin associated with injury or surgery. They can be monomicrobic,
usually from streptococcus or less commonly acquired by MRSA, Aeromonas hydrophiles, or Vibrio vulnificus, or polymicrobial, involving mixed aerobatic bacterial flora. Although many specific variations of necrotizing soft tissue infections have been described on the basis of etiology, microbiology and the specific
anatomical location of infection, the initial approach to diagnosis, antimicrobial treatment and surgery for all forms and is more important than determining a particular option. At the beginning of the course, distinguishing between cellulite, which should only to treat antimicrobials and necrotizing infection that requires
surgery is crucial but can be difficult. Necrotizing fasciitis necrotizing fasciitis is an aggressive subcutaneous infection that is tracked along a superficial fascia that includes all tissue between the skin and the main muscles .106, 107. The term fasciitis sometimes leads to the mistaken impression that muscular fascia or
aparerosis is involved, but in fact it is the superficial fascia that is most commonly involved. Clinical features Expansion from skin lesions are observed in most cases. Initial lesion can be trivial, such as minor abrasions, an insect bite, an injection site (as in addicts), or boiling, and a small minority of patients have no
visible skin damage. The initial presentation of cellulite, which can move quickly or slowly. As it progresses, there is systemic toxicity, often including high temperatures, disorientation, and lethargy. Examination of the local area usually reveals skin inflammation, swelling and discoloration or gangrene and anesthesia. A
distinctive clinical feature is the wooden-hard induration of subcutaneous tissues. With cellulite, the subcutaneous tissues are palpable and give way; The fasciitis of the main tissues are solid, and the fascial planes and muscle groups cannot be discernible by palpation. A wide erythema tract sometimes manifests itself
along the route of infection, as it progresses proximally in the limb. If there is an open wound, sensing the edge with a blunt instrument allows a ready autopsy of surface fascial planes far beyond the edge of the wound. Bacteriology In monomicrobial form common pathogens are S. pyogenes, S. aureus, V. vulnificus, A.
hydrophila and anaerobic streptococcus (Peptostreptococcus). Staphylococcus infection and hemolytic streptococcus can occur simultaneously. Most infections are found in communities and are present in the extremities, with about two thirds of infections occurring in the lower extremities. There are often predisposing
conditions such as diabetes, athesticerotherotic vascular disease, venous insufficiency with swelling, venous stagnation or vascular failure, ulcers, or drug injections. Cases of necrotizing fasciitis arising after a wind or trivial injury, such as minor scratches or insect bites, usually occur due to S. pyogenes or, much less
frequently, acquired by the MRSA community. Mortality in patients with streptococcal necrotizing fasciitis, hypotension and organ failure is high, from 30% to 70% (109, 110). Nearly 50% of patients with necrotizing fasciitis caused by S. pyogenes do not have an entry portal, but develop a deep infection in the exact