Outpatient Treatment of Antibiotic-Resistant Soft Tissue Infections

Initial Management Approach

The Infectious Diseases Society of America recommends incision and drainage as the primary treatment for abscesses, with oral TMP-SMX, doxycycline, or clindamycin as first-line antibiotic options for 5-10 days 1, 2
Incision and drainage is the cornerstone of therapy for purulent infections, and may be adequate alone for simple abscesses without systemic features 1
Antibiotics should be added when there are multiple sites of infection, rapid progression with associated cellulitis, signs of systemic illness, comorbidities, extremes of age, or abscesses in difficult-to-drain locations 1

The American College of Physicians recommends TMP-SMX dosing at 1-2 double-strength tablets twice daily, with a duration of 5-10 days for uncomplicated infections 1, 2
Doxycycline dosing is recommended at 100 mg twice daily, with a duration of 5-10 days 1, 2
Clindamycin dosing is recommended at 300-450 mg three times daily, with a duration of 5-10 days 1, 2

The Infectious Diseases Society of America recommends empiric coverage for beta-hemolytic streptococci for nonpurulent cellulitis, using beta-lactam antibiotics as first-line treatment 1

The standard duration of treatment is 5-10 days for uncomplicated outpatient infections 2
Clinical response should be evident within 48-72 hours, and if no improvement is seen, reassessment and consideration of alternative diagnoses or resistant organisms is necessary 1, 3

For pediatric patients, TMP-SMX dosing is recommended at 4-6 mg/kg/dose twice daily, doxycycline dosing is recommended at 2 mg/kg/dose twice daily, and clindamycin dosing is recommended at 10-13 mg/kg/dose three times daily 1, 2, 3
For pregnant patients, clindamycin is preferred if antibiotic treatment is necessary, and TMP-SMX and tetracyclines should be avoided 1, 4

The Infectious Diseases Society of America recommends both TMP-SMX (160-320/800-1600 mg PO q12h) and doxycycline (100 mg PO q12h) as equivalent first-line options for outpatient treatment of purulent skin and soft tissue infections, with treatment duration of 5-10 days 5, 6, 7, 8

If antibiotics are indicated for a skin abscess, the American College of Clinical Pharmacy suggests proceeding with antibiotic selection, and switching from Bactrim DS to doxycycline monotherapy may be a preferred approach if the UTI treatment course is nearly complete 5
The Infectious Diseases Society of America implies that continuing Bactrim DS and adding doxycycline may be an alternative approach only if the UTI requires completion of the full TMP-SMX course and the abscess requires immediate additional coverage 5