Skin and Soft Tissue Infections (SSTI) Antibiotic

Skin and Soft Tissue Infections (SSTI) Antibiotic Guidelines (Adult)

Reference Number: 144TD(C)25(B3) Version Number: 6 Issue Date: 29/08/2019 Page 1 of 20

It is your responsibility to check on the intranet that this printed copy is the latest version


Lead Author: Sue Wei Chong; Antimicrobial Pharmacist

Additional author(s) Antibiotic Steering Group

Original document written by Christine Khan

Division/ Department:: NCA Diagnostics and Pharmacy Group

Applies to: Salford Royal Care Organisation

Approving Committee Medicines Management Group

Date approved: 19/8/2019

Expiry date: August 2022

Contents

Contents

1. Overview (What is this guideline about?) ....................................................................... 3

2. Scope (Where will this document be used?) .................................................................. 3

3. Background (Why is this document important?) ............................................................. 3

4. What is new in this version? ............................................................................................ 4

5. Policy/Guideline ............................................................................................................... 4

5.1 Clinical assessment ......................................................................................................... 4

5.2. Microbiological investigations .......................................................................................... 5

5.3. Empiric treatment of SSTI ............................................................................................... 6

5.4 MRSA ............................................................................................................................ 10

5.5 Other considerations of SSTI ........................................................................................ 10

5.6 Management of cellulitis at home with intravenous antibiotics ...................................... 10

5.7 Post-operative wound infections .................................................................................... 11

5.8 Prophylaxis and treatment of mammalian bites ............................................................. 11

5.9 Antibiotic prophylaxis for wounds in the Emergency department .................................. 12

5.10 Treatment of Septic Bursitis .......................................................................................... 13

5.11 Treatment of Peritoneal Dialysis Exit Site Infections ..................................................... 14

6. Roles and responsibilities .............................................................................................. 15

7. Monitoring document effectiveness ............................................................................... 15

8. Abbreviations and definitions ........................................................................................ 16

9. References .................................................................................................................... 16

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)

Pennine Acute Hospitals NHS Trust (PAT)




10. Appendices ................................................................................................................... 17

Appendix 1 – Fluoroquinolones adverse effects ..................................................................... 17

11. Document Control Information....................................................................................... 18

12. Equality Impact Assessment (EqIA) screening tool ....................................................... 19




1. Overview (What is this guideline about?)

This guideline provides recommendations on the management of skin and soft tissue infection in adults and empirical antimicrobial choices.

2. Scope (Where will this document be used?)

This policy applies to all clinical staff involved the prescribing of antimicrobials.

Associated Documents

144TD(C)25(A5) - Issue No 3.1 - Antimicrobial Stewardship Policy

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/topics-

prescriptions/antibiotic/antibiotic-prescribing-principles/144tdc25a5/

163TD(C)(33) – Issue No. 14 - Medicines Policy

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-

clinical/gen/163tdc33/?locale=en

144TD(C)25(B2) – Issue No. 5 - Diabetic Foot Infections - Antibiotic Guidelines

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-

department-clinical/ag/144tdc25b2/

3. Background (Why is this document important?)

Antimicrobial agents are among the most commonly prescribed drugs and account for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to individual patients are compromised by the development of bacterial drug resistance. Resistance is a natural and inevitable result of exposing bacteria to antimicrobials.

Good antimicrobial prescribing will help to reduce the rate at which antibiotic resistance emerges and spreads. It will also minimise the many side effects associated with antibiotic prescribing, such as Clostridium difficile infection. It should be borne in mind that antibiotics are not needed for simple coughs and colds. In some clinical situations, where infection is one of several possibilities and the patient is not showing signs of systemic sepsis, a wait and see approach to antibiotic prescribing is often justified while relevant cultures are performed.

This document provides treatment guidelines for the most common situations in which antibiotic treatment is required. The products and regimens listed here have been selected by the Trust's Medicines Management Group on the basis of published evidence. Doses assume a weight of 60-80kg with normal renal and hepatic function. Adjustments may be needed for the treatment of some patients.

This document provides treatment guidelines for the appropriate use of antibiotics. The recommendations that follow are for empirical therapy and do not cover all clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20% of cases. Alternative recommendations will be made by the microbiologist in consultation with the clinical team.

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/topics-prescriptions/antibiotic/antibiotic-prescribing-principles/144tdc25a5/

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/topics-prescriptions/antibiotic/antibiotic-prescribing-principles/144tdc25a5/

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-clinical/gen/163tdc33/?locale=en

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-clinical/gen/163tdc33/?locale=en

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25b2/





This document refers to the treatment of adult patients (unless otherwise stated). Please refer to up to date BNF/SPC for a full list of cautions, contra-indications, interactions and adverse effects of individual drugs

4. What is new in this version?

Severe sepsis changed to septic shock as severe sepsis no longer exists as a definition

Recommendation added to take blood cultures for line infection.

5. Policy/Guideline

Microbiology of SSTI The most common infecting organisms causing skin & soft tissue infection (SSTI) are (in decreasing order of frequency): Staphylococcus aureus, other Gram positive cocci, Gram negative bacilli and anaerobes. If the causative organism(s) is (are) identified, therapy may be modified after discussion with a microbiologist. A number of different bacteria can cause necrotising fasciitis. Where a single agent is involved, this is typically a community-acquired Group A streptococcus (S. pyogenes). Polymicrobial necrotising infection typically has a mixture of anaerobic and aerobic bacteria and may follow penetrating abdominal trauma, be associated with IV drug use or arise from a perianal or Bartholin’s abscess. 5.1 Clinical assessment

Assessment must be made to classify the severity of infection as a useful guide to admission and treatment decisions. The system below has been adapted from the CREST guidelines, 2005. The treatment of Diabetic Foot Infections is covered in a separate policy, Antibiotic Guidelines- Diabetic Foot Infections. Patient should also be assessed for risk factors for specific pathogens such as:

Animal or human bite

Exposure to sea or fresh water (discuss treatment options with microbiology) In addition, it is important to recognize features suggesting either necrotizing fasciitis or PVL-associated Staphylococcal infection.






5.2. Microbiological investigations Microbiological sampling not routinely required for Class I infections unless recent antimicrobial therapy or previous antibiotic-resistant organisms. Cultures should be taken from any skin break/ulceration or blister fluid for Class II, III and IV infections. Blood cultures should be taken for a line infection and for any Class III or IV infections Recommendations for Sample collection Collect swab specimens before antimicrobial therapy where possible. Specimens should be transported and processed as soon as possible. The volume of the specimen influences the transport time that is acceptable. Large volumes of purulent material maintain the viability of anaerobes for longer. The recovery of anaerobes is compromised if the transport time exceeds 3 hr. If processing is delayed, refrigeration is preferable to storage at ambient temperature. Delays of over 48hr are undesirable for best result outcome Pus swabs; Pus when present, is preferable to a swab, particularly from deep seated infection sites. Ideally, a minimum volume of 1mL of pus should be sent. However, pus swabs are acceptable when pus is not readily available or if the area to be sampled is superficial. When using swabs, please sample the deepest part of the wound, or a representative part of the lesion. Swabbing dry crusted areas is unlikely to yield the causative pathogen. Ulcers: If specimens are taken from ulcers, the debris on the ulcer should be removed and the ulcer should be cleaned with saline. A biopsy or, preferably, a needle aspiration of the edge of the wound should then be taken. A less invasive irrigation-aspiration method may be preferred. Place the tip of a small needleless syringe under the ulcer margin and irrigate gently with at least 1 mL sterile 0.9% NaCl without preservative. After massaging the ulcer margin, repeat the irrigation with a further 1 mL sterile saline. Massage the ulcer margin again, aspirate approximately 0.25 mL of the fluid and transfer to a sterile container. Swabs should be placed in bacterial transport media. If a delay in transporting to the laboratory is anticipated, please store at 4oc.




5.3. Empiric treatment of SSTI

Classification First Line Penicillin Allergic MRSA suspected Additional comments

Class I: No signs of systemic toxicity No uncontrolled co-morbidities Can usually be managed with oral antimicrobials on an outpatient basis

Flucloxacillin 1g PO QDS (for patients <80kg 500mg PO QDS may be adequate )

clarithromycin 500mg BD PO

doxycycline 100mg BD PO

Typical Duration 5 days

Class II: Systemically ill or Systemically well but with a co-morbidity such as peripheral vascular disease, chronic venous insufficiency or morbid obesity which may complicate or delay resolution of their infection.

Flucloxacillin 1g IV QDS - for patients > 80kg use 2g IV QDS - maximum 1g IV QDS if eGFR <15

clarithromycin 500mg IV BD

Vancomycin IV

A short course of IV therapy is usually necessary. Consider referral for Home IV therapy. See Management of cellulitis at home with intravenous antibiotics below.

Continuation treatment as Class I infection, typical duration: 7-14 days. Max. oral dose of flucloxacillin is 1g QDS.

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25h3/




Class III: Infection in a patient with evidence of systemic inflammatory response syndrome. Clinically recognised by 2 or more of:

• Temperature >38.3oC or <36oC

• Heart rate >90/min

• Resp rate >20/min or PaCO2 <4.3kPa

• WBC >12,000 or <4000/mm3

or may have unstable co-morbidities that may interfere with a response to therapy or have a limb threatening infection due to vascular compromise

Flucloxacillin 2g IV QDS - maximum 1g IV QDS if eGFR <15 If patient is immunocompromised or has had a treatment failure with first line regimes: Piperacillin-tazobactam IV 4.5g TDS Continuation therapy should be based on culture results. If MRSA negative and no positive culture results: co-amoxiclav 625mg tds, typical duration 7-14 days.

Vancomycin IV If patient is immunocompromised or has had a treatment failure with first line regimes: Add oral ciprofloxacin 500mg BD Continuation therapy should be based on culture results.

Vancomycin IV If patient is immunocompromised or has had a treatment failure with first line regimes: Add oral ciprofloxacin 500mg BD Continuation therapy should be based on culture results.

Continuation treatment as Class I infection, typical duration: 7-14 days






Class IV: Septic shock (Sepsis plus hypotension {SBP<90 or MAP<70} or signs of organ dysfunction). If refractory hypotension, rash or diarrhoea is present, consider toxic shock syndrome – discuss antibiotic treatment with a microbiologist.

Piperacillin-tazobactam IV 4.5g TDS plus Vancomycin IV

vancomycin IV plus oral ciprofloxacin 500mg BD plus oral metronidazole 400mg TDS

As per first line or penicillin allergic

Oral continuation therapy should be based on culture results. If MRSA negative and no positive culture results: co-amoxiclav 625mg tds, typical duration 14 days.

Necrotising fasciitis: Necrotising fasciitis affects the soft tissue and fascia. Infection usually extends from an area of damaged skin or a surgical wound. Signs may include

severe pain which is out of proportion to cutaneous signs

wooden-hard feel to subcutaneous tissues

subcutaneous extension of inflammation >

Vancomycin IV plus clindamycin IV 900mg TDS plus meropenem 1g IV TDS Seek urgent surgical and microbiology advice

If penicillin allergic with history of anaphylaxis, vancomycin IV plus clindamycin IV 900mg TDS plus ciprofloxacin 400mg IV BD

As per first line or penicillin allergic

Rationalised therapy for Group A Streptococcus infection:

benzyl penicillin IV plus clindamycin IV/oral

Consider IV immunoglobulin therapy if not responding








cutaneous dark violet skin

discolouration or necrosis

cutaneous blistering or bullous lesions

Systemic toxicity +/- altered mental state

Suspected severe PVL-associated S. aureus infection: Panton-Valentine Leukocidin (PVL)-associated infection should be suspected if a patient has a necrotising SSTI, recurrent furunculosis or abscesses, or there is clustering of SSTIs within a household or social group

Linezolid (only on Microbiology approval) IV or oral 600 mg BD plus clindamycin 900mg IV TDS

Add oral rifampicin 600mg BD in extreme cases or if not responding to therapy

As per first line As per first line Flucloxacillin or Clindamycin alone are adequate for moderate SSTI due to PVL MSSA




5.4 MRSA For microbiologically confirmed MRSA infection, treat according to reported susceptibility test results with one of the following regimens

a) vancomycin IV (where infection is severe) b) Daptomycin IV (Microbiology approval required) c) linezolid IV or oral for severe cellulitis where vancomycin is contraindicated (Microbiology

approval required) d) clindamycin IV or oral (where MRSA is susceptible to erythromycin) e) doxycycline in mild/moderate infection (where MRSA is susceptible to tetracycline)

5.5 Other considerations of SSTI

The differential diagnosis of cellulitis includes venous thrombosis and varicose eczema (for which antibiotics are not indicated).

Superficial swabs are easily contaminated by colonising bacteria, which may include both

skin and faecal organisms. They are poorly predictive of the pathogenic organisms causing the underlying infection. Swab results should therefore be interpreted with caution.

Good skin and wound care is important in promoting healing of skin and infected

wounds. Emollients, topical antiseptics and specialist dressings may be indicated. Take advice from senior nursing staff, tissue viability specialists and podiatrists, where appropriate.

Consider underlying risk factors (such as diabetes, immune deficiency, leg ulcers,

lymphoedema, leg oedema, venous insufficiency, and obesity) and manage these appropriately. Diabetic patients with foot ulcers must be referred to the Podiatry service.

Consider the possibility of underlying osteomyelitis: investigate and treat appropriately.

Consider whether a soft tissue collection is present and needs incision and drainage.

Bacterial soft tissue infection may arise secondary to fungal nail or interdigital skin

infections: investigate and treat if indicated.

5.6 Management of cellulitis at home with intravenous antibiotics

Patients admitted via the Emergency department or the Emergency Assessment Unit (EAU) with cellulitis may be considered for Home/Outpatient IV Therapy (HOPT). This part of the service is provided by the Rapid Response Team (212 4226). The criteria for this service are outlined below. Please contact Rapid Response team for full details.





INCLUSION CRITERIA EXCLUSION CRITERIA

Cellulitis with associated lymphangitis +/- lymphadenopathy

Cellulitis which has not improved with oral antibiotics or cellulitis with pyrexia

Salford resident or Salford GP

At least 18 years of age

Access to a telephone

Suitable home environment

Any other acute medical problem requiring admission

Evidence of septic shock (e.g. hypotension, new onset confusion)

Cellulitis associated with suspected underlying bone or joint involvement

Facial or ophthalmic cellulitis

Breast cellulitis

Significant mental health or substance misuse issues

5.7 Post-operative wound infections

A surgical wound infection is likely to be present if two out of the following are present, • Temperature above 380C • Pus at the operative site • Spreading cellulitis around the wound. Antibiotic management as per ‘Empiric treatment of SSTI’ above unless the wound is likely to be contaminated by faecal flora e.g. perianal wound or stoma site infection in which case use co-amoxiclav IV/oral in place of flucloxacillin.

5.8 Prophylaxis and treatment of mammalian bites

Mammalian bites are typically colonised by pathogens found in the oral cavities of the offending animal. These are a mixture of aerobic and anaerobic micro-organisms including; Streptococci, Staphylococci, Moraxella, Neisseria. Fusobacterium, Bacteroides, Porphyromonas, and Prevotella spp. Pasteurella multocida is a Gram-negative pathogen particularly prevalent in dog (57%) and cat (75%) bites. In cases of human bite wounds and clenched fist wounds, where HIV and Hepatitis B status is unknown, please treat patients in line with the Trust’s PEP policy. Prophylaxis of mammalian bites is indicated in the following circumstances;

All cat bites, animal bites to the hand, foot and face; puncture wounds; wounds requiring surgical debridement; wounds involving joints, tendons, ligaments or suspected fracture

Clenched-fist wounds (wound inflicted from a punch coming in contact with teeth) Wounds that have undergone primary closure People who are at risk of serious wound infection e.g. diabetic, cirrhotic, asplenic or

immunocompromised patients People with a prosthetic valve or prosthetic joint

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-clinical/gen/ecdu109/?locale=en




NB: All patients with mammalian bites (especially dog bites) inflicted outside of the UK and Ireland should be considered for rabies vaccination, as should bites inflicted by bats from within UK and Irish borders. Prophylaxis of infection: Co-amoxiclav 625mg tds for 5 days. If penicillin allergic; Doxycycline 100mg bd PO and metronidazole 400mg tds PO for 5 days. Antibiotics are not usually required in newly presenting patients if the wound is greater than two days old and there is no sign of infection. Treatment of infection (wounds >2days old showing signs of infection): Mild inflammation Co-amoxiclav 625mg tds for 7-14 days. If penicillin allergic; Doxycycline 100mg bd PO and metronidazole 400mg tds PO for 7-14 days. Moderate to severe inflammation: Co-amoxiclav 1.2g tds IV Continuation treatment as for mild infection, typical duration: 7-14 days If penicillin allergic; Please consult microbiology for recommendation. Swabs should be taken from newly presenting wounds greater than two days old, that are exhibiting signs of infection, prior to commencing antibiotic therapy to assist with rationalising treatment once cultures and sensitivities are available.

5.9 Antibiotic prophylaxis for wounds in the Emergency department

All wounds should be irrigated copiously with sterile saline, and grossly visible debris should be removed. Lacerations: For simple lacerations with no current signs of infection, antibiotic prophylaxis is NOT recommended. Proper wound preparation is the essential measure for preventing wound infection after suturing simple lacerations. Advise the patient to seek medical attention if they develop signs of infection. Patients with more complex lacerations that require more than just simple cleaning and who require referral to other specialities may require antibiotic prophylaxis. This should be discussed with the specialists on an individual patient basis.




Puncture wounds: Do NOT routinely offer antibiotic prophylaxis for puncture wounds. Offer antibiotic prophylaxis for patients at high risk for subsequent infection: contaminated puncture wounds (especially with organic matter), diabetes mellitus, immunodeficiency, a retained organic foreign body, or injuries through an intact shoe. All patients with puncture wounds should be followed closely for evidence of infection, regardless of whether or not they receive prophylactic antibiotics. Prophylaxis regimes: First line: Flucloxacillin 500mg QDS PO (for patients >80kg use 1g QDS PO)

Penicillin allergy: Clarithromycin 500mg BD for 3 days Contamination with organic matter e.g. soil: Co-amoxiclav 625mg TDS Duration of Prophylaxis: Antibiotic prophylaxis should not be prescribed for longer than 72 hours. Tetanus immunisation: Check the patient’s tetanus immunization status and administer a booster dose of tetanus vaccine if needed.

5.10 Treatment of Septic Bursitis

Treatment of septic bursitis requires appropriate antibiotics, optimally guided by identification of the organism and antibiotic sensitivity testing. Draining of the infected bursa fluid is also indicated in the management of infected bursae. Initial antibiotic selection is guided by knowledge of common pathogens. In 80% of cases this is Staphylococcus aureus or other Gram-positive organisms. Rationalisation of therapy should be conducted if cultures and sensitivities indicate an atypical pathogen. Treatment choice: Mild inflammation: Flucloxacillin 500mg qds PO (for patients >80kg use 1g qds PO) If penicillin allergic, clarithromycin 500mg bd PO If MRSA is suspected: doxycycline 100mg bd PO Typical duration: 14 days




Moderate/Severe inflammation: Flucloxacillin 1g qds IV (for patients >80kg use 2g qds IV) If penicillin allergic or MRSA is suspected: Vancomycin IV.

5.11 Treatment of Peritoneal Dialysis Exit Site Infections

Purulent drainage from the catheter exit site indicates the presence of infection. Erythema may or may not represent infection. An exit site infection is defined by the presence of purulent drainage, with or without erythema of the skin at the catheter-epidermal interface. Pericatheter erythema without purulent drainage is sometimes an early indication of an infection. In recently inserted catheters or following trauma, erythema may represent a skin reaction. Clinical judgement must be exercised to decide where antibiotic therapy should be commenced. Note, a positive culture on routine screening indicates colonisation rather than infection. Eradication of MSSA or MRSA using mupirocin nasal ointment in combination with enhanced exit site antiseptic cleaning is required. Patients presenting with discharge from the exit site and possible exit site infection should have the exit site swabbed and sent to microbiology for culture and sensitivity. Sensitivities should be reported in 48-72 hours. Most exit site infections are due to Gram positive (e.g. S. aureus) bacteria. Gram negative infections (e.g. P. aeruginosa, E. coli) are less common. Tunnel infections usually present as erythema, oedema or intense tenderness over the subcutaneous pathway. In the majority of cases this will be concurrent with an exit site infection. Staphylococcus aureus and Pseudomonas aeruginosa exit site infections in particular are often associated with tunnel infections. Initial treatment should be given to cover Staphylococcus aureus: [If the patient has a history of Pseudomonas aeruginosa infections therapy should be given to cover this pathogen in addition]. Flucloxacillin 500mg qds PO (for patients >80kg use 1g qds PO) If penicillin allergic, clarithromycin 500mg bd PO Treatment should be reviewed weekly and continued for 14-28 days (until signs of infection have resolved and the exit site appears normal) Patients with signs of systemic illness (SIRS criteria present) and patients with cellulitis extending more than 2cm from the catheter exit site will require individualisation of antibiotic therapy and should be discussed with a senior renal physician and a microbiologist.

Antimicrobial therapy must be reviewed when cultures & sensitivity results are available: Add rifampicin 300mg bd if rifampicin-susceptible S. aureus is isolated.





Pseudomonas aeruginosa infections are especially difficult to treat and may require prolonged therapy with 2 antibiotics – following discussion with a microbiologist. First line treatment is ciprofloxacin 250-500mg bd for 21 days. Ciprofloxacin should be given at 10am and 10pm to avoid concomitant administration with phosphate binders. Ciprofloxacin doses should be separated from binders by a minimum of 2 hours. For resistant organisms or non-responding infections, seek advice from a consultant nephrologist and a microbiologist: Consideration may need to be given to

IV antimicrobial therapy Removal of PD catheter

Antibiotic therapy should be continued until the exit site appears entirely normal – minimum of two weeks for S. aureus and three weeks for P. aeruginosa. Early catheter removal and replacement should be considered for P.aeruginosa or tunnel infections. Renal Community Team The renal community team must be informed of all patients with exit site infections on diagnosis. Follow up will be determined by the patient’s location.

6. Roles and responsibilities

All clinical staff involved in the prescribing of antimicrobials to adhere to this policy including full documentation on EPMAR as detailed.

7. Monitoring document effectiveness

Key standards:

Indication should be documented. The rationale for any deviation from the Trust’s Antibiotic Policy should be documented in a separate clinical note.

Review the patient’s allergy status prior to prescribing antibiotics.

The initial prescription for antibiotics should have the total intended course length from the outset.

Prescriptions for IV antibiotics should have be reviewed every 24hrs for suitability to switch to oral antibiotics

Relevant culture results should be used to guide treatment where applicable.




Audits of compliance with the guideline will be conducted on a regular basis as part of the Antibiotic Point Prevalence study. Compliance with guidelines is also one of the elements of the Antibiotic prescribing bundle which is audited monthly

8. Abbreviations and definitions

BNF – British National Formulary EPMAR – Electronic prescribing medication administration record

IV - Intravenous

MHRA - Medicines and Healthcare products Regulatory Agency

MRSA – Methicillin-resistant Staphylococcus Aureus

PO – oral

PVL - Panton-Valentine Leukocidin

SPC – Summary of Product Characteristics SSTI – Skin and soft tissue infections

9. References

Li Philip Kam-Tao et al Peritoneal Dialysis-Related Infections Recommendations: 2010 Update Peritoneal Dialysis International 2010 vol 30 pp393-423 Clinical Resource Efficiency Support Team. 2005. Guidelines on the Management of Cellulitis in adults. Belfast: CREST Infectious Disease Society of America. 2005. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections. Clinical Infectious Diseases; 41:1373–406 Medeiros IM, Saconato H. Antibiotic prophylaxis for mammalian bites. Cochrane Database of Systematic Reviews, 2001; Issue 2. Art. No.: CD001738. DOI: 10.1002/14651858.CD001738. Brakenbury PH, Muwanga C. A comparative double blind study of amoxycillin/clavulanate vs placebo in the prevention of infection after animal bites. Arch Emerg Med., 1989; 6(4): 251. Morgan M, Palmer J. Dog bites. BMJ, 2007; 334 (7590): 413. Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Patchen Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann, Sheldon L. Kaplan, Jose G. Montoya, James C. Wade; Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clin Infect Dis 2014; 59 (2): e10-e52. doi: 10.1093/cid/ciu296 Daniel J Sexton, Dlinor L Baron.H Soft tissue infections due to dog and cat bites. UpToDate. [online] Available: https://www.uptodate.com/contents/soft-tissue-infections-due-to-dog-and-cat bites?source=see_link&sectionName=Prophylaxis&anchor=H8 Chudnofsky CR, Sebastian S. Special wounds. Nail bed, plantar puncture, and cartilage. Emerg Med Clin North Am., 1992; 10(4): 801-22.




Larry M Baddour, Aaron MP Ed: Daniel J Sexton, MD Allyson Bloom, MD Infectious complications of puncture wounds. UpToDate. [Online] Available: https://www.uptodate.com/contents/infectious-complications-of-puncture-wounds?source=machineLearning&search=puncture%20wounds&selectedTitle=1~118&sectionRank=1&anchor=H505135224#H505135224 Fisher MC, Goldsmith JF, Gilligan PH. Sneakers as a source of Pseudomonas aeruginosa in children with osteomyelitis following puncture wounds. J Pediatrics. 1985; 106(4):607. NICE CKS Lacerations July 2015 NICE CKS (online) Available: https://cks.nice.org.uk/lacerations#!management

10. Appendices

Appendix 1 – Fluoroquinolones adverse effects

*Fluoroquinolones warning

Please note that serious adverse events affecting musculoskeletal and nervous systems have

been reported very rarely with fluoroquinolone antibiotics (ciprofloxacin, levofloxacin,

moxifloxacin, ofloxacin). Fluoroquinolone treatment should be discontinued at the first signs of a

serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness,

joint pain, joint swelling, peripheral neuropathy, and central nervous system effects. Prescribe

with special caution for people older than 60 years, with renal impairment, or solid-organ

transplants as they are at a higher risk of tendon injury. The MHRA recommends avoiding use

of a corticosteroid with a fluoroquinolone since co-administration could exacerbate

fluoroquinolone-induced tendinitis and tendon rupture

Fluoroquinolones may be associated with a small increased risk of aortic aneurysm and

dissection, particularly in older patients. They should only be used after careful benefit-risk

assessment and after consideration of other therapeutic options in patients with, or at risk for,

aortic aneurysm and dissection.

For further information see November 2018 & March 2019 MHRA alerts.

https://www.uptodate.com/contents/infectious-complications-of-puncture-wounds?source=machineLearning&search=puncture%20wounds&selectedTitle=1~118&sectionRank=1&anchor=H505135224#H505135224






11. Document Control Information

All sections must be completed by the author prior to submission for approval

Lead Author: Sue Wei Chong; Antimicrobial Pharmacist

Lead author contact details:

[email protected] 01612 065819

Consultation List the persons or groups who have contributed to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

Antibiotic Steering Group SCO June 2019

Microbiologists SCO June 2019

Endorsement List the persons or groups who have seen given their support to this guideline. (please state which Care Organisation)

Name of person or group

Role / Department / Committee (Care Org)

Date

Dr Alex Peel Antibiotic Steering Group Chair SCO June 2019 May 2017 Aug 2015

Dr Paul Chadwick Medicines Management Group Chair

SCO June 2017 Oct 2011

Dr John MacDonald Medicines Management Group Chair

SCO Dec 2015 Feb 2014

Dr Paul Chadwick Antibiotic Steering Group Chair SCO Jan 2014 May 2011

Keywords / phrases: Antibiotics, Infection, Cellulitis, wound infection, mammalian bites, animal bite, human bites

Communication plan:

The guideline will form part of the Trust Antibiotic Policy and thus can be accessed via the Antibiotic and Infection Control hotlinks area on the front page of Synapse. In addition, adherence to the policy will be encouraged through FY1 and FY2 teaching sessions.

Document review arrangements:

This document will be reviewed by the author, or a nominated person, at least once every three years or earlier should a change in legislation, best practice or other change in circumstance dictate.

This section will be completed following committee approval

Guideline Approval: Name of Approving Committee: Medicines Management Group

Chairperson: Dr Richard Cooper

Approval date: 19/8/2019

Formal Committee decision

mailto:[email protected]




12. Equality Impact Assessment (EqIA) screening tool

Legislation requires that our documents consider the potential to affect groups differently, and eliminate or minimise this where possible. This process helps to reduce health inequalities by identifying where steps can be taken to ensure the same access, experience and outcomes are achieved across all groups of people. This may require you to do things differently for some groups to reduce any potential differences.

1a) Have you undertaken any consultation/

involvement with service users, staff or other

groups in relation to this document?

Yes/No

Please state:

1b) Have any amendments been made as a

result?

Yes/No

Please Comment:

2) Does this guideline have the potential to affect any of the groups below differently or

negatively? This may be linked to access, how the process/procedure is experienced, and/or

intended outcomes. Prompts for consideration are provided, but are not an exhaustive list.

Protected Group Yes No Unsure Reasons for decision

Age (e.g. are specific age groups excluded? Would the same

process affect age groups in different ways?) X

Sex (e.g. is gender neutral language used in the way the

guideline or information leaflet is written?) X

Race (e.g. any specific needs identified for certain groups such

as dress, diet, individual care needs? Are interpretation and translation services required and do staff know how to book these?)

X

Religion & Belief (e.g. Jehovah Witness stance on blood

transfusions; dietary needs that may conflict with medication offered.)

X

Sexual orientation (e.g. is inclusive language used? Are

there different access/prevalence rates?) X

Pregnancy & Maternity (e.g. are procedures suitable for

pregnant and/or breastfeeding women?) X

Marital status/civil partnership (e.g. would there be any

difference because the individual is/is not married/in a civil partnership?)

X

Gender Reassignment (e.g. are there particular tests related

to gender? Is confidentiality of the patient or staff member maintained?)

X

Human Rights (e.g. does it uphold the principles of Fairness,

Respect, Equality, Dignity and Autonomy?) X

Carers (e.g. is sufficient notice built in so can take time off work

to attend appointment?) X

Socio/economic (e.g. would there be any requirement or

expectation that may not be able to be met by those on low or limited income, such as costs incurred?)

X

Disability (e.g. are information/questionnaires/consent forms

available in different formats upon request? Are waiting areas suitable?) Includes hearing and/or visual impairments, physical

x




disability, neurodevelopmental impairments e.g. autism, mental health conditions, and long term conditions e.g. cancer.

Are there any adjustments that need to be made to ensure that people with disabilities have the same access to and outcomes from the service or employment activities as those without disabilities? (e.g. allow extra time for appointments, allow advocates to be

present in the room, having access to visual aids, removing requirement to wait in unsuitable environments, etc.)

x

3) Where you have identified that there are potential differences, what steps have you taken to mitigate these? Not applicable

4) Where you have identified adjustments would need to be made for those with disabilities, what action has been taken? Not applicable

5) Where the policy, procedure, guidelines, patient information leaflet or project impacts on patients how have you ensured that you have met the Accessible Information Standard – please state below: Not applicable ……………………………………………………………………………………………………………… EDI Team/Champion only: does the above ensure compliance with Accessible Information Standard

o Yes

o No

If no what additional mitigation is required:

Will this guideline require a full impact assessment? No Please state your rationale for the decision: : Update to existing version of guideline and none of the changes made are identified as likely to affect equality or diversity outcomes (a full impact assessment will be required if you are unsure of the potential to affect a group differently, or

if you believe there is a potential for it to affect a group differently and do not know how to mitigate

against this - Please contact the Inclusion and Equality team for advice on [email protected]) Author: S W Chong Date: 8/8/19 Sign off from Equality Champion: Date:

mailto:[email protected]