50대/환자
4일 동안 지속된 근육통으로 내원
머리 염색 후 두피로 가려워 심하게 긁었다.
38.1도 발열
P/E Skin erythema, warmth, tenderness, scalp and forehead
Impression R/O Cellulitis, scalp and forehead
참고 : 이전 블로그
https://blog.naver.com/sjloveu2/220722411515
항생제는 beta-hemolytic streptococci와 methicillin-susceptible Staphylococcus aureus (MSSA)를 대상으로 하며 IV cefazolin과 PO cephalexin입니다.
Patients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or exudate and no associated abscess) should be managed with empiric therapy for infection due to beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA). Common options are cefazolin for intravenous therapy and cephalexin for oral therapy; options and doses are summarized in the algorithm (algorithm 1).
Clinical approach to management of nonpurulent cellulitis in adults
This algorithm outlines our approach to initial empiric antibiotic therapy of patients with cellulitis or erysipelas without an abscess or purulent drainage. It includes various appropriate antibiotic options depending on the patient presentation. The choice among them further depends on factors such as patient allergies or medication intolerance, expected toxicities or drug interactions, physician familiarity with the different antibiotics, expected local rates of resistance, cost, and convenience of administration.
MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible S. aureus; IV: intravenously.
* The decision to administer antimicrobial therapy parenterally should be individualized based on clinical presentation and patient characteristics. Parenteral antimicrobial therapy is generally appropriate when severe illness or any of these features is present. Comorbidities that increase the risk of severe or complicated infection, such as the presence of an immunocompromising condition (eg, neutropenia, recent organ transplant, advanced HIV infection, B cell or T cell deficiency, or use of immunosuppressive agents), should lower the threshold for parenteral therapy.
¶ Five days of antibiotic therapy is generally sufficient; extension up to 14 days may be warranted for slow response to therapy.
Δ Intravenous antibiotic dosing as follows (if two doses are listed for a given agent, the higher one is for patients with higher weights [eg, >120 kg] or more severe illness):
Cefazolin 1 to 2 g IV every 8 hours.
Ceftriaxone 1 to 2 g IV every 24 hours.
Ciprofloxacin 400 mg IV every 12 hours.
Clindamycin 600 to 900 mg IV every 8 hours.
Daptomycin 4 to 6 mg/kg IV every 24 hours.
Flucloxacillin 2 g IV every 6 hours.
Nafcillin 2 g IV every 4 hours.
Oxacillin 2 g IV every 4 hours.
Vancomycin 15 to 20 mg/kg/dose IV every 8 to 12 hours (not to exceed 2 g per dose).
A one-time 25 mg/kg loading dose is appropriate for severely ill patients.
A target trough level of 15 to 20 mcg/mL is appropriate in patients with severe and deep-seated infections.
A target trough of 10 to 15 mcg/mL is appropriate for non-severe infections.
◊ Oral antibiotic dosing as follows (if two doses are listed for a given agent, the higher one is for patients with higher weights [eg, >120 kg] or more severe illness):
Amoxicillin 875 mg orally twice daily.
Cefadroxil 1 g orally daily.
Cephalexin 500 mg orally four times daily.
Clindamycin 300 to 450 mg orally four times daily.
Dicloxacillin 500 mg orally four times daily.
Doxycycline 100 mg orally twice daily.
Flucloxacillin 500 mg orally four times daily.
Minocycline 200 mg orally once, then 100 mg orally every 12 hours.
Penicillin V potassium 500 mg orally every 6 hours.
Trimethoprim-sulfamethoxazole 1 to 2 double-strength tablets orally every 12 hours.
§ Penicillin and amoxicillin are preferred for erysipelas. For patients with a penicillin allergy, cephalexin (depending on the allergy), clindamycin, and trimethoprim-sulfamethoxazole are alternatives. Linezolid is another alternative but should be reserved for circumstances in which the other options cannot be used.
¥ Risk factors for MRSA include:
Recent (eg, within the prior one to two months) hospitalization or surgery.
Residence in a long-term care facility.
Hemodialysis.
HIV infection.
‡ For oral treatment of beta-hemolytic Streptococcus and MRSA, we generally favor trimethoprim-sulfamethoxazole, doxycycline, or minocycline because of the greater associated risk of Clostridioides (formerly Clostridium) difficile infection with clindamycin. However, doxycycline and minocycline do not have good antistreptococcal activity and so are administered with amoxicillin. Other active options include linezolid, tedizolid, and delafloxacin, but these should be reserved for circumstances in which the other options cannot be used.
† Vancomycin is the preferred parenteral anti-MRSA option. Daptomycin is an acceptable alternative agent for patients who have prior infection or colonization with a MRSA isolate with a minimum inhibitory concentration ≥2, do not respond to vancomycin, have prior treatment failure with vancomycin, or do not tolerate vancomycin. Additional alternative anti-MRSA agents include ceftaroline, linezolid, tedizolid, delafloxacin, omadacycline, telavancin, dalbavancin, and oritavancin; use of these agents is limited by high cost and, in some cases, availability. Refer to the UpToDate topic on the treatment of skin and soft tissue infection due to MRSA for further discussion of the approach to antibiotic selection.
REF. UpToDate 2019.06.21
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