San Francisco Department of Public Health
Outpatient Treatment Guidelines for Skin & Soft Tissue Infections in the era of increasing Community-Associated MRSA
1. For simple, drainable abscess(es) not involving deeper structures, incision & drainage (I&D) is
the treatment of choice alone. Antibiotics are not necessary or recommended if the following criteria are met:
i. Adequate I & D can be performed, or appropriate referral can be made for procedure
ii. No systemic signs (afebrile, otherwise stable and a candidate for outpatient therapy)
If these criteria are met, I & D is preferable to antibiotics.
2. There is no evidence that mildly immunosuppressive underlying conditions such as diabetes
mellitus or HIV would change this recommendation.
3. Send wound culture (ideally obtained from I & D) if:
i. Patient doesn’t meet the criteria above and will need antibiotics
ii. Patient has recurrent skin and soft tissue infections
See following algorithm for additional guidance:
Cellulitis without drainage, (+/- surrounding minor folliculitis cellulitis) Incise & drain abscess If unsure if adequately
• No antibiotics are drained: recommended IF: Rx Abx to cover for MRSA & GAS for 5-7 days:
• Clindamycin or
o TMP-SMZ or
one day) and
MRSA sensitivities in Kings County do not support the empiric use of Clindamycin.
• No systemic signs (afebrile, otherwise stable and a candidate for outpatient therapy)
2If patient has risk factors for healthcare-associated MRSA (hospitalized or had surgery, dialysis, or residency
in a long-term care facility in the past year, or an indwelling catheter or percutaneous medical device at the time of culture), clindamycin is NOT recommended.
3Doxycycline is an acceptable alternative to TMP-SMZ if patient has allergy or contraindications to TMP-
San Francisco Department of Public Health
Other miscellaneous guidance:
• Impetigo may still be treated empirically with antibiotics to cover Group A Streptococcus (GAS)
and Methicillin-sensitive Staphylococcus aureus (MSSA) such as cephalexin or dicloxacillin.
• Once culture results are available, if MSSA is recovered, a beta-lactam antibiotic such as
cephalexin or dicloxacillin is preferable.
• These infections can be extremely painful and recommendation or prescription of pain relief
• Criteria to consider hospital admission:
o Systemically ill (fevers, chills) o Failed outpatient therapy o Parenteral therapy indicated secondary to severely immunosuppressive conditions (e.g.
o There is insufficient data to recommend the routine use of intranasal mupirocin or any
specific decolonization or eradication regimens. Various studied regimens have not been proven effective in preventing re-infection or primary or secondary transmission in the community. Consider consultation with an Infectious Disease specialist for recommendations for specific circumstances such as patients with recurrent SSTIs.
ANTIBIOTICS Adult Dose Pediatric Advantages Disadvantages Clindamycin
• Excellent tissue & • Taste (suspension)
Trimethoprim- 2 DS po BID Sulfamethoxazole (TMP/SMZ) Doxycycline
• MSSA & MRSA • Not for use in <8 yo
Amoxicillin
Acknowledgements: Thank you to the following contributors to these guidelines:
• Erica Pan, MD, MPH, Communicable Disease Control & Prevention Section, SFDPH
• Henry Chambers, MD, Chief, Division of Infectious Diseases, SFGH
• Lisa Winston, MD, Hospital Epidemiologist, SFGH
• David Young, MD, Professor of Surgery (Plastics), UCSF & Director, ISIS Clinic, SFGH
• Daniel Deck, PharmD, Infectious Diseases Clinical Pharmacist, SFGH
• Adam Hersh, MD, PhD, Pediatric Infectious Disease Fellow, UCSF • Jeff Klausner, MD, Director, STD Section, SFDPH