Rapidly progressive skin / soft tissue infections

[Clin Infect Dis 2014;59:e10-52]

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Predisposing factors
  • trauma/surgery

  • immunosuppression/malignancy

  • diabetes

  • chronic renal/hepatic disease

  • chicken pox

  • IVDU

Clinical Findings


  • pain out of proportion to appearance

  • edema or tenderness beyond the cutaneous erythema

  • cellulitis

  • fever

  • tachycardia

  • induration (hard, wooden feel of subcutaneous tissue)

  • areas of anaesthesia in affected skin


  • severe pain

  • skin discoloration/necrosis (purple or black)

  • blistering

  • hemorrhagic bullae

  • crepitus

  • "dishwater" gray drainage

  • systemic inflammatory response syndrome (SIRS)/sepsis

  • multi-organ failure/shock



- Surgical debridement and irrigation are essential. Send specimens for culture. For culture-directed therapy, see Culture-Directed Infections: Skin & Soft Tissue.

- Infectious Diseases consult strongly recommended.

- Duration of therapy (IV/PO) dependent on clinical picture.

Rapidly progressive skin/soft tissue infections

- On initial presentation it may be difficult to determine etiologic agent(s).

Usual Pathogens

S. pyogenes (Group A Strep)
Mixed aerobic/anaerobic organisms
S. agalactiae (Group B Strep)
Group C,G Streptococci
S. pneumoniae
S. aureus/MRSA
Clostridium spp
Vibrio vulnificus (salt water exposure)
Aeromonas hydrophila (fresh water exposure)
Enterobacterales (chronic hepatic/renal disease)
P. aeruginosa (neutropenia, burns, IVDU)


Empiric Therapy Dose Duration
Ceftriaxone 100mg/kg IV q24h minimum 10 days
Clindamycin 40mg/kg/d IV div q8h  

Polymicrobial or MRSA suspected

Empiric Therapy Dose Duration
Piperacillin-tazobactam 300mg piperacillin/kg/d IV div q6-8h minimum 10 days
[Vancomycin 60mg/kg/d IV div q6h  
Linezolid] < 5 y.o.: 30mg/kg/d IV/PO div q8h  
  > 5 y.o.: 20mg/kg/d IV/PO div q12h