Introduction

Journal of Drugs in Dermatology, Nov-Dec, 2005

The most common skin and skin structure infections (SSSIs) seen by dermatologists are cellulitis, impetigo, and folliculitis. Without prompt antibiotic treatment, these types of infection can lead to skin and skin structure destruction and scarring and eventually to systemic sequelae such as nephritis, carditis, arthritis, septicemia, and death. (1) Among pediatric clinic consultations, up to 17% of dermatologic complaints result from bacterial skin infections. (2)

To treat patients with uncomplicated (u) SSSIs, dermatologists typically initiate empiric antibiotic therapy against the most probable pathogens, Staphylococcus aureus and Streptococcus pyogenes. Dermatologists must also decide whether to use incision and drainage, whether to obtain a culture, which antibiotic(s) to prescribe, and whether to refer a patient to an infectious disease specialist. They must also consider the risk for community-acquired methicillinresistant S. aureus (MRSA), the risk for complications, and comorbidities. (1) Empiric treatment should take all of the above into account, as well as the possibilities of infection by Gram-negative organisms and potential cross reactivity in penicillin-allergic patients.

To guide primary care physicians in the initial empiric antibiotic treatment of uSSSIs, a panel of dermatology experts convened in a roundtable discussion to develop an algorithm based on the most recent evidence-based data. (1) The algorithm offers guidance in the differential diagnosis of uSSSI and complicated SSSI (cSSSI), initial empiric therapy, and treatment of high-risk patients. The algorithm recommends the use of cephalosporins, penicillinase-resistant penicillins, and [beta]-lactam/[beta]-lactamase inhibitor combinations for initial empiric therapy. Specifically, an extended-spectrum cephalosporin such as cefdinir provides excellent coverage of infections by Gram-positive and common Gram-negative organisms and may be used in patients who have a history of penicillin allergy.

Dermatologists soon found that the specific use of this algorithm was somewhat limited in a variety of clinical situations that frequently occur. A new treatment algorithm was therefore developed and used as the basis for the treatment of a variety of clinical concerns.

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A panel of 7 dermatology experts in the treatment of uSSSIs participated in a symposium held in Chicago at the American Academy of Dermatology meeting of July 20-24, 2005. These experts discussed modifications of the current algorithm and the use of the new algorithm (Dirk M. Elston, MD); pharmacokinetic and pharmacodynamic effects, antimicrobial resistance, and MRSA (Thomas R. Fritsche, MD, PhD); updates on treating uSSSIs (Theodore Rosen, MD); preventing and treating perioperative infections (Mary E. Maloney, MD); prophylaxis for and treatment of uSSSIs in laser and cosmetic surgery (Mark S. Nestor, MD, PhD); treatment of uSSSIs in the diabetic patient (Phoebe Rich, MD); and treatment of uSSSIs in pediatric and adolescents (Lawrence A. Schachner, MD).

The content of this supplement is based on the presentations of these experts and the new algorithm.

References

1. Scher RK, Elston DM, Hedrick JA, Joseph WS, Maurer T, Murakawa GJ. Treatment options in the management of uncomplicated skin and skin structure infections. Cutis. 2005;75(1 Suppl):3-23.

2. Schaper NC, Apelqvist J, Bakker K. The international consensus and practical guidelines on the management and prevention of the diabetic foot. Curr Diab Rep.2003;3:475-479.