SKIN AND SOFT TISSUE INFECTIONS

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Localised Impetigo

Common organisms:

Staphylococcus aureus

Streptococcus pyogenes

Cloxacillin 500-1000mg PO q6h for 5-7 days

OR

Cephalexin 250-500mg PO q6h for 5-7 days

OR

Cefadroxil 500mg PO q12h for 7 days

Topical 2% Fusidic acid q8-12h for 5 days (Outpatient use only)

Generalised Impetigo/ Ecthyma

Cephalexin 250-500mg PO q6h

OR

Cefadroxil 500mg PO q12h

Amoxicillin-clavulanate 625mg PO q8h

Duration : 5-7 days.

Penicillin allergy: Erythromycin ethylsuccinate 800mg PO q12h

Other alternative/ in case of  CA- MRSA:  

Clindamycin 600mg PO q8h

OR

Trimethoprim-sulfamethoxazole 160/800mg PO q12h

Ecthyma gangrenosum Pseudomonas spp.

Ciprofloxacin 500mg PO q12h

OR

Piperacillin-tazobactam 4.5gm IV q6-8h

Ceftazidime 2gm IV q8h

OR

Cefepime 2gm IV q8h

Consider adding aminoglycoside in selected cases such as in immunocompromised, neutropenic and septic shock patients.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Furuncles

Cloxacillin 500mg PO q6h for 5-7 days

Amoxicillin-clavulanate 625mg PO q8h for 5-6 days

Carbuncles

Common organism:

Staphylococcus aureus

Cloxacillin 1-2gm IV q6h

Cefazolin 1gm IV q8h

OR

Amoxicillin-clavulanate 1.2gm IV q8h

Surgical drainage is the mainstay of treatment.

Duration : 7-10 days.

Erysipelas

Common organism:

Streptococcus pyogenes

Phenoxymethylpenicillin 500mg PO q6h

OR

Amoxicillin 500mg PO q8h

Cephalexin 500mg PO q6h

Duration : 7-10 days.

If severe:

Benzylpenicillin 2-4MU IV q4-6h

If severe:

Cefazolin 1gm IV q8h

OR

Cefuroxime 750mg IV q8h

MRSA:

*Vancomycin 15-20mg/kg q8-12h; not to exceed 2gm/dose

Diabetic Foot Infections

Refer to section Surgical Infection – Diabetic Foot Infections

Gas Gangrene / Myonecrosis / Necrotizing Fasciitis

Refer to section Surgical Infection – Bone and Joint Infections

Yaws

Treponema pertenue

Benzathine penicillin G 1.2MU IM single dose

Doxycycline 100mg PO q12h for 15 days

OR

Azithromycin 30mg/kg (max 2gm) single dose

Penicillin allergy:

Tetracycline 500mg PO q6h for 15 days

OR

Erythromycin ethylsuccinate 800mg PO q12h for 15 days

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Mild:

Common organisms:

Staphylococcus aureus

Streptococcus pyogenes

Cephalexin 500mg PO q6h

Amoxicillin-clavulanate 625mg PO q8h

OR

Cefuroxime 250-500mg PO q12h

Duration: 5-10 days Change to oral once condition improves.

Gram negative coverage may be necessary in the following circumstances:

• Potential relation of the cellulitis to a decubitus ulcer.
• Crepitant cellulitis Prominent skin necrosis/ gangrene.
• Location: Perioral, Perirectal cellulitis.

Clinical Condition:

• Septicaemic shock Suspecting necrotizing fasciitis.
• Immunocompromised patients.
• Specific exposures*

Moderate:

Common organisms:

Staphylococcus aureus

Streptococcus pyogenes

Cloxacillin 1-2gm IV q6h

Cefazolin 1-2gm IV q8h

Severe:

Common organisms:

Staphylococcus aureus

Streptococcus pyogenes

Ampicillin-sulbactam 3gm IV q6-8h

PLUS*

Clindamycin 600mg IV q6h

(Deescalate once cultures are available/Necrotizing fasciitis ruled out)

Piperacillin-tazobactam 4.5gm IV q6-8h

PLUS*

Clindamycin 600mg IV q6h

(Deescalate once cultures are available/Necrotizing fasciitis ruled out)

Consider alternative organisms in the following circumstances:

*** Consider adding 3^rd Generation Cephalosporin in severe infection.

Dog/cat bite:

Common organisms:

Pasteurella multocida

Capnocytophaga canimorsus

Amoxicillin-clavulanate 625mg PO q8h

Cat scratch disease

Bartonella henselae

Azithromycin 500mg PO on Day 1, then 250mg PO q24h for 4 days

Human bite:

Common organisms:

Eikenella corrodens

anaerobes

Staphylococcus aureus

Amoxicillin-clavulanate 625mg PO q8h

Salt water exposure:

Common organism:

Vibrio sp.

Doxycycline 200mg stat then 100mg PO q12h

PLUS

***Ceftriaxone 2gm IV q24h

Fresh or brackish water exposure:

Common organisms:

Aeromonas spp.,

Plesiomonas spp.

Ciprofloxacin 400mg IV q12h

OR

Ciprofloxacin 750mg PO q12h

Neutropenic patients:

Common organisms: Pseudomonas aeruginosa, other Gram-negative bacteria

Piperacillin-tazobactam 4.5gm IV q6-8h

Ceftazidime 2gm IV q8h

OR

Cefepime 2gm IV q8h

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

MRSA

Vancomycin 15-20mg/kg IV q8-12h

In severe infections:

To load with Vancomycin 25-30mg/kg IV, followed by 15-20mg/kg (actual body weight) IV q8-12h; not exceeding 2gm /dose

Linezolid 600mg IV/PO q12h

****Consider CA-MRSA if:

Outbreaks of known CA-MRSA

If non-resolving cellulitis.

**** If CA-MRSA suspected

Clindamycin 300-450mg IV/PO q8h

OR

Doxycycline 100mg PO q12h

OR

Trimethoprim-sulfamethoxazole 160/800mg PO q12h

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Common organisms:

Staphylococcus aureus,

Coagulase negative Staphylococcus sp.,

Gram negative rods

Early stage phlebitis:

Remove the intravenous cannula

Peripheral intravenous catheters with associated pain, induration, erythema, or exudate should be removed.

Medium and advanced stage phlebitis or thrombophlebitis:

Remove the intravenous cannula and take blood culture

Can consider empirical treatment if persistent fever:

Cephalexin 500mg PO q6h

OR

Cloxacillin 1-2gm IV q6h

Infection/Condition and Likely Organism

Suggested Treatment

Preferred

Alternative

Bed Sore/Pressure Sore/Decubitus Ulcer

Local treatment is preferred.

If there is surrounding cellulitis/signs of bacteremia/ fasciitis/ surrounding intramuscular abscess/ osteomyelitic changes (OM) changes: Ampicillin-sulbactam 3gm IV q6-8h

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Refer to National Tuberculosis Management Guidelines 2019

Hansen’s Disease (Leprosy) in HIV infected

Same as in non HIV infected patients

Non-Tuberculous Mycobacterial Infections

Mycobacterium marinum

Clarithromycin 500mg PO q12h

PLUS

Minocycline/Doxycycline 100mg PO q12h

Duration: At least 2 months of treatment until clearance

Rifampicin 600mg PO q24h

PLUS

Ethambutol 15mg/kg PO q24h for 4-6 months, and continue for at least 1 month after lesions have been cleared

OR

Monotherapy Doxycycline 100mg PO q12h for 1-2 months after lesion clearance (3-4 months)

Often resistant to Isoniazid

Mycobacterium kansasii

Isoniazid 300mg PO q24h

PLUS

Rifampicin 600mg PO q24h

PLUS

Ethambutol 15mg/kg PO q24h for 18 months

Mycobacterium ulcerans (Buruli ulcer)

Rifampicin 10mg/kg PO

q24h

PLUS

Streptomycin 15mg/kg IM q24h for 8 weeks

Rifampicin 10mg/kg PO q24h

PLUS

Streptomycin 15mg/kg IM q24h for 4 weeks

Followed by:

Rifampicin 10mg/kg PO q24h

PLUS

Clarithromycin 7.5mg/kg PO q12h

Wide surgical excision and debridement are important.

Duration:

For 4-6 months, and continue for at least 1 month after lesions have been cleared.

Mycobacterium fortuitum

Combination therapy (2 of the following):

Clarithromycin 500mg PO q12h

OR

Doxycycline/Minocycline 100mg PO q12h

OR

Ciprofloxacin 500-750mg PO q12h

PLUS*

*Amikacin 15mg/kg IV q24h

*Amikacin: Started for severe infection until clinical improvement (together with 2 oral agents), then continue with just 2 oral agents.

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Tinea capitis

Trichophyton

Microsporum

Griseofulvin 500mg PO q12h for 6 to 12 weeks or longer till fungal cultures are negative

OR

Terbinafine 250mg PO q24h for 6-8 weeks

PLUS

2.5% Selenium sulphide shampoo

OR

2% Ketoconazole shampoo, 2-3 times per week for 2 weeks

Itraconazole 200mg PO q24h

Duration is based on mycological agent: Trichophyton sp : 2-4 weeks

Microsporum sp : 8-12 weeks

Other recommendations:

• For kerion, Griseofulvin should be considered as first line unless Trichophyton has been cultured as the pathogen.
• Duration of treatment may be longer. Contacts of patient may be treated with 2% ketoconazole shampoo 2-3 times per week for 2 weeks
• Surgical excision is to be avoided.
• Topical therapy alone is not recommended for the management of tinea capitis.
• Consider adding oral prednisolone in selected cases.

Tinea barbae

Same as treatment of Tinea capitis

Tinea corporis/ Tinea cruris/Tinea faciei

Trichophyton

 Mircosporum

Epidermophyton

Mild infection:

Topical imidazoles or allylamines cream/lotion:

e.g.: Terbinafine/Butenafine/ Sertaconazole/ Luliconazole

Duration: till clinical clearance with additional 2 weeks

Recommendations:

• In patients with renal or hepatic impairment, caution should be exercised while prescribing systemic antifungals.
• Terbinafine clearance significantly reduced in patient with renal impairment. Other systemic antifungals are preferred in these patients.
• Topical Nystatin should not be used in dermatophytosis as they are not effective against dermatophytes.

Extensive infections or Tinea incognito (Steroid modified) Above

PLUS

Terbinafine 250mg PO q24h for 2 weeks

OR

Itraconazole 200mg PO q24h for 2 weeks

OR

Griseofulvin 500mg PO q12h or q24h for 4-6 weeks

Tinea manuum/ Tinea pedis

Trichophyton, Microsporum,

Epidermophyton

Terbinafine 250mg PO q24h for 2-4 weeks

OR

Itraconazole 200mg PO q24h for 2-4 weeks

OR

Griseofulvin 500mg PO q12h or q24h for 6-12 weeks

Along with TOPICAL Antifungals

Fluconazole 150mg/week PO for 4 weeks

Recommendations:

Topical keratolytic agents can be used in conjunction with antifungals for hyperkeratotic type of tinea pedis/manuum. KMnO₄ in 1:10,000 dilution wet dressings, applied for 20 min 2-3 times/day, may be helpful if vesiculation or maceration is present. Systemic antifungals can be prescribed as first line treatment in severe moccasin-type tinea pedis or severe recurrent tinea with blisters.

Tinea unguim
Trichophyton, Microsporum,
Epidermophyton

Amorolfine 5% Nail
Lacquer weekly
application
Duration:
For 6 months (fingernails)
For 12 months (toenails)
OR*

Pulse Itraconazole 200mg
PO q12h for 1 week per
month
Duration:
For 2 months (fingernails)
For 3 months (toenails)

OR

Terbinafine 250mg PO
q24h
Duration:
For 6 weeks (fingernails)
For 12 weeks (toenails)

Griseofulvin 500mg PO
q12h
Duration:
For 6 months (fingernails)
For 12 months (toenails)

Amorolfine 5% Lacquer is
not indicated for children
less than 12 years old.

Patients with
contraindications
to systemic agents
may consider topical
antifungal agents.

*Topical can be used in
combination with oral
therapy.

Diagnosis of
onychomycosis should
be confirmed with KOH
preparation, culture,
or PAS stain. Empirical
treatment is not
recommended.

First line: Topical
treatment only

Selenium Sulphide 2%
shampoo
Apply to affected areas 5
minutes before bathing
OR
2% Ketoconazole
shampoo apply to
affected areas 5 minutes
before bathing

For face:
Ketoconazole 200mg 2
tabs stat
Or
Itraconazole 200mg q12h
for 5-7 days

Recommendations:
Ketoconazole shampoo
or Selenium sulphide
shampoo can be used
once every two to four
weeks for approximately
six months in order to try
and prevent recurrence

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Candida albicans

Mild cutaneous candidiasis: Topical Imidazole q12h till clear e.g.,

Miconazole 2% cream,

Clotrimazole 1% cream,

Sertaconazole 1% cream

Treatment of sexual partner is advisable in case of recurrent infection.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (e.g.: Cola drinks). Avoid PPIs and H2 blockers.

Extensive cutaneous candidiasis:

*Itraconazole 200mg PO q24h for 1 week

Vulvovaginitis/ Balanoposthitis:

Fluconazole 150mg stat dose

Fluconazole 100mg PO q24h for 1 week (in severe and immunocompromised patients)

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Subcutaneous Fungal infections

Lymphocutaneous and Cutaneous Sporotrichosis

*Itraconazole 200mg PO q12h until all lesions have resolved (usually for a total of 2-6 months)

For patients not able to tolerate Itraconazole:

Terbinafine 250mg PO q12h

OR

Fluconazole 400-800mg q24h

In some immunocompromised condition such as AIDS, longer treatment may be necessary. Refer to Opportunistic Infections in HIV Patients.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (e.g.: Cola drinks). Avoid PPIs and H2 blockers.

**Avoid azole in pregnancy.

Systemic sporotrichosis (pulmonary, osteoarticular, meningeal, or disseminated sporotrichosis)

Amphotericin B deoxycholate 0.7-1mg/kg q24h for 2 weeks

Followed by, *Itraconazole 200mg PO q12-24h for 12 months

Sporotrichosis in Pregnancy**

Terbinafine 250mg PO q24h

Amphotericin B deoxycholate 0.7-1mg/kg q24h

Cutaneous fungal infection in immunocompromised patients

Refer to treatment of disseminated fungal infection in immunocompromised/HIV patients Opportunistic Infections in HIV patients

Skin biopsy for histopathologic examination (HPE) and culture are advised before commencing treatment.

Aspergillus spp., Scedosporium Apiospermum, and Fusarium sp Infection

Voriconazole 6mg/kg IV q12h for 2 doses, followed by 4mg/kg IV q12h

Amphotericin B (deoxycholate) 0.7-1mg/kg q24h

OR

Amphotericin B (lipid formulation) 3-5mg/kg q24h

Cryptococcal infections

Mild

Life threatening

Fluconazole 100-400mg PO q24h

Refer to Treatment of disseminated fungal infection in immunocompromised/HIV patients Opportunistic Infections in HIV patients

Penicilliosis and life threatening acute severe disseminated Histoplasmosis

Refer to Treatment of disseminated fungal infection in immune compromised/HIV patients

Opportunistic Infections in HIV patients

Infection/Condition and Likely Organism

Suggested Treatment

Comments

Preferred

Alternative

Herpes Simplex Infections

Mild infection:

Acyclovir 400mg PO q8h for 5 days

Valacyclovir 1gm PO q12h

Severe life threatening: Acyclovir 5-10mg/kg IV q8h for 5 days or until able to take orally, then change to oral

Genitalia:

Refer to National STI guidelines

Chickenpox (Varicella zoster)

Immunocompetent

Acyclovir 800mg PO 5 times daily for 7 days

Valacyclovir 1gm PO q8h

Advisable to start treatment early within 48 hours.

Immunocompromised

Acyclovir 10mg/kg IV q8h for 7 days (change to oral once there is an improvement)

Herpes zoster

Please refer to varicella zoster treatment above

Topical antiviral treatment is not recommended for Herpes Zoster.

Systemic antiviral treatment is recommended for all immunocompromised patient or for immunocompetent patients with following criteria:

• >50 years of age
• Have moderate or severe pain
• Have moderate or severe rash
• Have non-truncal involvement

Advisable to start treatment early within 48-72 hours.

Infection/Condition and Likely Organism

Suggested Treatment

Preferred

Alternative

Scabies

Sarcoptes scabiei

Permethrin 5% lotion/ cream apply and leave  overnight, clean next day, family treatment, wash clothes

PLUS

Antihistamines

Repeat application after 1 week

Tab. *Ivermectin 6mg 2 tabs stat, repeat after 1 week

*Not recommended for children <12 years or <15kg

In pregnancy/ Immunocompromised:

Permethrin 5% lotion/ cream apply and leave for 8 hours

Repeat application after 1 week

Head Lice

Pediculus humanus capitis

Permethrin 1% lotion apply to scalp for 10 min and wash off

OR

Malathion 1% shampoo

Repeat application after 1 week

Body Lice/Pubic Lice

Pediculus humanus

Malathion lotion 0.5% for 8-12 hours and wash off

OR

Permethrin 1% cream apply to affected area for 10 min and wash off