›Penicillin VK PO
›500 mg PO every 6 hours
›If pure streptococcal etiology and no penicillin allergy
›MRSA coverage when indicated
›TMP-SMX DS PO
›One double-strength tablet PO every 12 hours
›Indicated for purulent drainage, IVDU, prior MRSA infection
›Monitor creatinine and potassium
›Doxycycline PO
›100 mg PO every 12 hours
›Alternative to TMP-SMX for MRSA coverage
›Avoid in pregnancy
›Penicillin allergy alternatives
›Clindamycin PO
›300 to 450 mg PO every 6 to 8 hours
›Provides streptococcal and MRSA coverage
›Counsel on C. difficile risk
IV antibiotics (moderate to severe, inpatient)
›Standard IV regimens
›Cefazolin IV
›1 to 2 g IV every 8 hours
›First-line for non-purulent infection requiring admission
›Renal dose adjustment when creatinine clearance < 35 ml/min
›Ceftriaxone IV
›1 to 2 g IV every 24 hours
›Alternative once-daily dosing for inpatient care
›Less renally adjusted than cefazolin
›Ampicillin-sulbactam IV
›3 g IV every 6 hours
›Broader anaerobic and gram-negative coverage
›Renal dose adjustment required
›MRSA coverage IV
›Vancomycin IV
›15 to 20 mg/kg IV every 8 to 12 hours
›AUC-guided monitoring per institutional protocol
›Target AUC/MIC 400 to 600 for MRSA
›Daptomycin IV
›4 to 6 mg/kg IV every 24 hours
›Alternative for vancomycin intolerance
›Not effective for pulmonary infection if concurrent
›Severe or immunocompromised hosts
›Piperacillin-tazobactam IV
›4.5 g IV every 6 hours
›Extended infusion over 4 hours per local protocol
›Covers gram-negatives including Pseudomonas
›Add vancomycin if MRSA risk concurrent
›Combination therapy for polymicrobial or unclear source
›De-escalate when cultures return
Treatment for specific pathogens
›Streptococcal toxic shock concern
›Penicillin G IV plus clindamycin IV
›Penicillin G 2 to 4 million units IV every 4 to 6 hours
›Clindamycin 600 to 900 mg IV every 8 hours
›Clindamycin inhibits exotoxin production (Eagle effect mechanism)
›IVIG consideration in refractory streptococcal toxic shock
›1 to 2 g/kg IV single dose
›Class IIb recommendation
›Nodular lymphangitis (sporotrichoid pattern)
›Itraconazole PO for sporotrichosis
›200 mg PO daily for 3 to 6 months
›Monitor liver function tests
›Clarithromycin PO for M. marinum
›500 mg PO every 12 hours
›Ethambutol 15 mg/kg PO daily may be added
›Duration 3 to 6 months guided by clinical response
›Specific therapy guided by culture and susceptibility for all atypicals
Duration and reassessment
›Antibiotic duration
›Uncomplicated lymphangitis
›5 days minimum per IDSA guidelines
›Extend if not improving clinically at 5 days
›IDSA Class I recommendation for minimum 5-day course
›Clinical response dictates extension
›Reassess at 48 to 72 hours
›Response assessment
›Streaking progression monitoring
›Advance in streaking at 24 hours does not necessarily indicate failure
›Reassess at 48 hours before declaring treatment failure
›If no improvement at 48 to 72 hours
›Broaden antibiotic coverage
›Consider MRSA or atypical organism
›Imaging to exclude abscess or deep infection