PHILIPPINE DERMATOLOGICAL SOCIETY

COMMON BACTERIAL INFECTIONS(2004)

Philippine Dermatological Society

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Rm. 1015 Front Tower, Cathedral Heights Complex, St. Lukes Medical Center, E. Rodriguez Sr. Ave, Quezon CityEmail: pds@pacific.net.ph Website: http://www.pds.org.ph Tel/Fax No.: 727-7309 Fax No.: 932-9269

Francisca C. Roa, MDEvangeline B. Handog MDMa. Lorna F. Frez, MDMa. Teresita Gabriel MD

Benjamin Bince, MDMarcellano Cruz MDMa. Juiet Macarayo MDArnelfa Paliza MDGeorgina Pastorfide MDCarmela Veronica Reyes MDLilian Villafuerte MD

Amelia V. Tianco, MD

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Treatment Guideline on Common Bacterial Infections

impetigo

Impetigo contagiosa is the most common superficial bacterial infection produced by Streptococci, Staphy-lococci, or a combination of both bacteria.

More common in children but may occur in any age.

Bullous and non-bullous impetigo represent two clini-cal forms.

Presents as thin-roofed bullae or ruptured vesicles which expose a red, moist base covered by honey-yellow crusts, with "stuck-on appearance".

Prevention

• Benzoyl peroxide wash (soap bar)/ or any antibacterial soap

• Check family members for signs of impetigo

• 20-25% of individuals are nasal carriers

Author: Ma. Teresita G. Gabriel, M.D.

Treatment

For limited, localized infections:

• Mupirocin 2% or fusidic acid ointment or cream is used 3x a day for 7-10 days.

For widespread infections:

• Oral antibiotics are administered. A penicillinase re-sistant antibiotic such as cloxacillin 250 mg, cefalexin 250 mg 4x a day or sodium fusidate 250-500 mg BID is prescribed. See table for other drugs.

ecthyma

Ecthyma is a deeper bacterial infection characterized by an ulcerative staphylococcal or streptococcal pyoderma, nearly always of the shins or dorsal feet.

Ecthyma is characterized by a saucer-shaped ulcer with a raw base and elevated edges. Lesions usually heal with scarring.

Treatment

• Cleansing with soap and water, followed by applica-tion of mupirocin, bacitracin, or fusidic acid, thrice a day.

• Cloxacillin or a first-generation cephalosporin must be given orally or parenterally.

folliculitis

Folliculitis, a staphylococcal infection, is an inflamma-tion of the hair follicle characterized by papules, pustule, erosion or crust.

Distribution is variable, often the scalp, arms, legs, axil-lae and trunk are involved. It occurs as dome-shaped pustules with small erythematous halos arise in the center of the follicle.

S. aureus is the most common infecting organism.

Treatment

• Heat, friction and occlusion should be minimized.

• Antibacterial soap, warm compresses, and topical antibiotics are used

• Mupirocin or fusidic acid is effective in limited, su-perficial involvement.

Organism Drug of Choice alternative Group Penicillin Erythromycin A Strep Benzathine PCN Cefalexin < 6 years old 600,000 units, IM > 7 years old 1.2M units Staphylococcus Dicloxacillin Cefalexin aureus 40-50mg/kg/day (child) Amoxicillin 20 mg/kg/day GAS & Erythromycin Clarithromycin S. aureus 40 mg/kg/day Azithromycin (children) Clindamycin 15 mg/kg/day (children) MRSA Minocycline Cotrimoxazole (Methicillin- Sodium Fusidate Ciprofloxacin Resistant 250-500mg/tab, Staphylococcus BID or TID aureus) for 7-14 days

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than 2 years old.

• Hib serves as chemoprophylaxis of household mem- bers in patients less than 4 years old who are unim- munized.

erysipelas

Erysipelas is an acute inflammatory form of cellulitis with prominent lymphatic involvement

Characterized by more superficial and has margins that are more clearly demarcated from normal skin.

Prodromal symptoms consists of malaise, chills, fever and occasionally, anorexia and vomiting.

Treatment

• Penicillin V orally (20 to 50 mg 4x a day) is the drug of choice. Erythromycin can also be used.

• Azithromycin 500 mg on day 1 and 250 mg on days 2 to 5, or clarithromycin 250 to 500 mg every 12 hours for 7 to 14 days are alternatives for patients who can-not take penicillin.

paronychia

Paronychia is a condition wherein there is an inflamma-tory reaction involving the folds of the skin surrounding the fingernail.

Paronychia is characterized by acute or chronic puru-lent, tender, and painful swellings of the tissues around the nail.

Causative bacteria are usually Staph. aureus, Streptococ-cus pyogenes, Pseudomonas, Proteus sp or anaerobes.

Treatment

• Protection against trauma. Cover with a bandage or dressing.

• Incision and drainage should be done on acutely in- flamed pyogenic abscesses.

• For acute suppurative paronychia due to S. aureus, a semisynthetic penicillin or a first-generation ce-pha- losporin maybe given orally. Sodium fusidate tablet 250-500 mg BID or TID is also effective.

leg ulcers

Leg ulcer is a chronic, nonhealing lesion located on the medial aspect of the leg associated with chronic venous insufficiency (F>M), chronic arterial insufficiency, pe-

• Oral antistaphylococcal antibiotics (oxacillin, cloxacillin, cefuroxime, Na fusidate are indicated for extensive cases.)

furuncles & Carbuncles

A furuncle (boil) is a walled-off, deep, painful, fluctuant mass enclosing a collection of pus, often involving from staphylococcal folliculitis.

A carbuncle is an extremely painful, deep, intercon-nected aggregate of infected follicles (coalescing furuncles).

Treatment

• Warm, moist compresses are applied 15 to 30 minutes several times a day.

• Drainage is the primary management for fluctuant lesions.

• Nasal carriage of Staph. aureus is eradicated by mupi-rocin 2% cream or fusidic acid cream applied to the anterior nares BID for 5 days. For persistent coloniza-tion, rifampin 600 mg once a day and cloxacillin 500 mg 4x a day, for 7 to 10 days is prescribed.

• Oral anti-staphylococcal antibiotics.

Cellulitis

Cellulitis is an infection of the dermis and subcutane-ous tissue characterized by red, hot, tender-to-painful plaque with an indefinite border may cover a small or wide area

In adults and children most often caused by Group A Streptococcus (β-hemolytic) and Staphylococcus aureus.

Facial, periorbital, head & neck involvement in children less than 2 years old is most commonly caused by H. influenza.

Treatment

• Warm compresses to relieve pain.

• Elevation of the leg hastens recovery.

• Analgesics

• Empiric treatment with antibiotics aimed at Staphy- lococcal and Streptococcal organisms is appropri-ate.

• Ampicillin for children because it has coverage for H.influenza.

• Hib immunization in children has dramatically re- duced the incidence of cellulitis in children less

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methicillin-resistant strains) and Streptococcus.

2. Low resistance rates

3. Low sensitizing potential

3. No cross sensitivity with other antibiotics

4. Excellent permeability

protective device for wound healing

Protect the wound from further damage, such as contact with dirt, soil or insects, by applying protective gauze or dressing. Dressings may also help reduce odor and help absorption of moisture especially in highly exuda-tive wounds. Wound dressings are also beneficial in improving the appearance of wound site and may even help promote the functional use of the affected part.

As a further precaution, dressings must be changed frequently and disposed immediately.

ripheral sensory neuropathy or DM. It is more common in the late middle and old age

Risk factors: circulatory problems, minor injury, mal-nutrition, sedentary lifestyle

Ulcer formation occurs suddenly after slight trauma.

The ulcers have sharp, or sloping border and are deep or superficial.

Patients may have secondary eczematous dermatitis (stasis dermatitis).

There is a significant long-term morbidity.Leg ulcers often do not heal unless underlying problem is cor-rected

Treatment

• Control of venous insufficiency.

• Crusts and exudates are surgically debrided.

• The application of occlusive film promotes rapid healing by suppressing crust formation and enhancing epidermal migration.

• Metronidazole gel applied before dressing helps decrease odor.

• Continuous wet saline compresses promotes granula-tion tissue

• Give oral antibiotics to control secondary infection.

erythrasma

Erythrasma is a chronic, bacterial infection caused by Corynebacterium minutissimum. It affects the intertrigi-nous areas of the toes, groins and axillae.

Present as sharply marginated, brownish-red, scaling patches on affected areas.

Predisposing factors include diabetes, warm, humid climate and prolonged occlusion of the skin.

Treatment

• Wash with benzoyl peroxide (bar or wash) or any antibacterial soap

• Benzoyl peroxide (2.5%) gel daily for 7 days or topi-cal erythromycin solution BID for 7 days. Topical azoles are also effective.

• Systemic antibiotic therapy using erythromycin QID for 7 days is prescribed in resistant cases.

Characteristics of an ideal antibacterial agent

1. Should have activity against Staph. aureus (including 105

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Philusa

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Drugs Mentioned in the Treatment GuidelineThis index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems.

CephalosporinsCefaclor Ceclobid Ceclor/Ceclor CD Clorotir Pharex Cefaclor RiteMED Cefaclor XelentCefalexin Aseflex Biogenerics Cefalexin Bloflex Cefalexin-Vamsler Cefalin Capsule Cefalin Drops/Suspension Ceporex Cidoxine Cromlex Difagen Drugmaker's Biotech Cefalexin Eliphorin Europharma Cefalexin Exel Fensid Fevenil Forexine Genflex Gesenal Harvexyl Keflex Lefex Lexibase Lexum Lyceplix Medoxine Oneflex Oranil Pectril Pharex Cefalexin RiteMED Cefalexin Selzef Servispor VCP Cefalexin Xinflex ZeporinCefatrizine ZanitrinCefazolin Biogenerics Cefazolin Faxilen Lupex StancefCefotiam CeradolanCefpodoxime proxetil Banan

Cefprozil ProcefCefradine Sediner Velodyne VelosefCefradroxil DuracefCefuroxime Biogenerics Cefuroxime Kefox Lifurox Profurex RiteMED Cefuroxime Romicef Shincef Zegen Zinacef Zinnatpenicillins Amoxicillin Aldemox Amoxil Amoxsteryl Amoxtrex Amusa Apamax/Apamax Forte Athenalyn Axmel Bacihexal Biogenerics Amoxicillin Cartrimox Cilfam Clearamox Curamox Daisamox DLI-Amoxicillin Drugmaker's Biotech Amoxicillin Eleomox Emilex Glamox Globamox Globapen Harvimox Himox IHC-Amoxicillin Intermox Jamox/Jamox Forte Littmox Macropage Medimoxil Megamox Montecil Moxigen Moxillin

Oramox/Oramox Forte Pediamox Pharex Amoxicillin Pharmamox Polymox Promox RiteMED Amoxicillin Semoxillin Servimox Shinamox Sumoxil Teramoxyl ZymoxylAmpicillin Ampicin Ampimycin Ampin Amplivacil Apamacin Bactimed Biogenerics Ampicillin Celidam Cloxamicin DLI Ampicillin Drugmaker's Biotech Ampicillin Eurotrexil Excillin Genaxcin Pensyclox Pensyn Polypen Saloxin Shinapen Unasyn IM/IV YSS AmpicillinBenzylpenicillin RiteMED Benzylpenicillin

Potassium UL Benzylpenicillin Potassium YSS Benzylpenicillin SodiumCloxacillin Biogenerics Cloxacillin Cloxamicin Cloxigen Drugmaker's Biotech Cloxacil-

lin Encloxil Europharma Cloxacillin IHC-Cloxacillin Interclox Myrex Cloxacillin Oxaclen Patriflex Pharex Cloxacillin Prostaphlin-A RiteMED Cloxacillin

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Co-Amoxiclav Amoclav Augmentin NatravoxOxacillin Prostaphlin Wydox YSS Oxacillin SodiumPhenoxymethylpenicillin K Centrapen Megapen Sumapen UL Phenoxymethyl Penicillin KPen G benzathine Penadur L-AlincosaminesClindamycin Biogenerics Clindamycin Clindal Dalacin C HCl/ Dalacin

Palmitate/ Dalacin C Phosphate

Inprosyn-HPMacrolidesAzithromycin ZithromaxClarithromycin Klaricid/Klaricid OD OnexidErythromycin Am-Europharma Erythromycin Ditron

Drugmaker's Biotech Erythromycin

Erasymin Erosuccin Ery-Max Erycar Erycin Erythrocin/Erythrocin DS Erythrolan Ethiocin Faulding/DBL Erythromycin

Lactobionate Gentrocin Ilosone Pharex Erythromycin RiteMED Erythromycin Romaxin Sefavex ServitrocinQuinolonesCiprofloxacin Ciprobay Cipromet Cirok Iprolan Pharex Ciprofloxacin Xipro Zyfloxsulfonamide Combinations

Cotrimoxazole Am-Europharma Cotrimoxazole Bacidal Bactille Forte Bactille-TS Bactrim Bacxal Biogenerics Cotrimoxazole Cotrexel Cotribase Cotrimoxazole-Vamsler DLI-Cotrimoxazole Doctrimox Drugmaker's Biotech

Cotrimoxazole Fedimed Genoxzole/Genoxzole Forte Genzaprim/Genzaprim Forte Globaxol Gutrisul Intrafort Kathrex Lagatrim Forte Macromed Microbid/ Microbid DS Onetrim Pharex Cotrimoxazole Procor RiteMED Cotrimoxazole Septrin Servitrim Synerzole Thoprim Trihexal Trim-S Trimephar Trizole SuspensiontetracyclinesMinocycline MinocinTetracycline RiteMED Tetracycline Tetracycline-B UnimycinOther anti-infectivesRifampin (Rifampicin) Am-Europharma Rifampicin Biogenerics Rifampicin Carfamin Crisarfam Dipicin Drugmaker's Biotech

Rifampicin Fevram Koccifam Lypro-Cap Medifam Natricin Forte Odifam Pharex Rifampicin

PMI Rifampicin Pyrina Ramicin Refam Rexilan Ricyn Rifadin Rifamax Rimactane Rimactazid 225/Rimactazid

300/ Rimactazid 450/Rimactazid 600

Rimaped RiteMED Rifampicin TubercoxSodium fusidate Fucidintopical therapyBenzoyl peroxide Benoxyl 5 Benzac AC Gel/Wash Benzac W Gel/Wash Brevoxyl PanoxylFramycetin sulfate Sofra-TulleFusidic acid/Sodium fusidate Fucidin Cream/OintmentGentamicin sulfate Bactiderm Ointment Garamycin 1% Cream/ OintmentMupirocin BactrobanMetronidazole RobazSodium fusidate Fucidin Intertulle Fusoderm 2% OintmentVaccineHib Act-Hib Hiberixbandages/Dressings 3M Active Strips Band-Aid Leukoplast Mediplast Elastic Bandage Mediplast Gauze Bandage Mediplast Gauze Pads Medigauze Elastic Bandage Medigauze Gauze Bandage Micropore First Aid Tape