Mare Nostrum

Skin & Soft Tissue Infection (SSTI)

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Skin & Soft Tissue Infection (SSTI)

🃏 Order set for Skin Signs in Systemic Disease

  • SSTI classification:
    • Non-purulent: Erysipelas (superficial dermis, well-demarcated), Cellulitis (deeper dermis, indistinct border), Necrotizing fasciitis
    • Purulent: Abscess, Furuncle, Carbuncle
  • Severity (IDSA 2014): Mild = outpatient PO; Moderate = IV ATB; Severe = ICU/surgical
  • Necrotizing fasciitis อย่าขาด: เจ็บสัดส่วนเหนือปริมาณที่เห็น, skin discoloration (grayish/bluish), gas ใน tissue (CT/X-ray), rapid progression, LRINEC score ≦6 = high risk
  • Organisms: Non-purulent = Group A Strep (ส่วนใหญ่), Purulent = MRSA CA (community-acquired), DM/immunocomp = Gram-negative, polymicrobial (NF type 1)
  • Risk factors for MRSA: previous MRSA, recent hospitalization, contact sports, incarceration, IV drug use
  • Diabetes — poor wound healing + risk polymicrobial + Gram-negative; foot ulcer = special consideration

🕐 One-Day Orders

🔬 Investigation

  • Mark skin border ด้วยปากกา + timestamp — ติดตาม progression
  • CBC — leukocytosis (>15,000 = moderate-severe)
  • CRP / ESR — inflammatory marker
  • BUN, Cr, electrolytes — sepsis, DM, renal function
  • DTX / FBS ถ้า DM — ควบคุมน้ำตาล
  • Blood culture x2 ถ้ามี fever/chills/hemodynamic instability
  • Wound swab / pus C/S ถ้ามี purulent discharge/abscess
  • X-ray บริเวณ ถ้า suspected NF — subcutaneous gas (NF pattern)
  • CT scan ถ้า deep space infection, NF suspect, gas in fascia

💊 Medication

  • [Mild — Non-purulent cellulitis, outpatient:] Cefalexin 500 mg q6h x 5 วัน
  • [Moderate — IV ATB for admit:]
    • Non-purulent: Cloxacillin 2 g IV q6h (MSSA) หรือ Cefazolin 2 g IV q8h (Group A Strep และ MSSA)
    • Purulent/MRSA risk: Vancomycin 25 mg/kg IV loading → AUC-guided
    • DM/Immunocompromised: Ampicillin-Sulbactam 3 g IV q6h (polymicrobial coverage)
  • [Purulent abscess]: ผ่า-ระบาย (Incision & Drainage) — adequate drainage = definitive สำหรับ uncomplicated abscess (ATB may not be needed if <2 cm, immunocompetent)
  • [Necrotizing Fasciitis]: ผ่าตัด debridement อย่างเร็ว (surgical emergency!) + Piperacillin-Tazobactam 4.5 g IV q6h + Clindamycin 900 mg IV q8h (anti-toxin effect on Strep) + Vancomycin ถ้า MRSA risk

🔁 Continuous Orders

🔬 Investigation

  • ติดตาม border mark ทุก 8–12 ชม. — ถ้า spread เพิ่ม หรือ ไม่ respond ATB = reassess, consider NF
  • CBC, CRP ทุก 48–72 ชม. — response to ATB
  • ติดตาม wound C/S result — de-escalate

💊 Medication

  • De-escalate ATB ตาม culture และ clinical response (48–72 ชม.)
  • IV→PO switch ถ้า improving: Cloxacillin → Cefalexin; Vancomycin → TMP-SMX หรือ Doxycycline (MRSA CA)
  • ระยะเวลา ATB: non-purulent cellulitis 5 วัน; moderate cellulitis 5–7 วัน; ถ้า NF = หลัง adequate debridement + clinical improvement 10–14 วัน
  • [DM wound care]: daily dressing, debridement, ควบคุม glucose, wound care specialist referral

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