Soft tissue injury, significant contamination or established infection
For skin and soft tissue wounds that have developed secondary infection.
- Thorough cleaning and/or surgical debridement may be indicated.
- Give antibiotics for 5 days, depending on clinical presentation
- Tetanus risk assessment should be performed. See also Tetanus prone wounds.
- Where infection has involved sea water or fresh water, consider Aeromonas spp. or Vibrio spp. infection.
- Take a swab if discharge from wound and send to microbiology. Re-assess wound after 24 - 48 hours if no improvement.
Contaminated injury
For skin and soft tissue wounds that are significantly contaminated but not actively infected
- Thorough cleaning and/or surgical debridement is indicated.
- Tetanus risk assessment should be performed. See also Tetanus prone wounds.
- Consider antibiotics for 3 days where heavy contamination has occurred, especially with soil, mud, faeces, or dirty water.
- Consider antibiotics for 5 days where a foreign body has been removed from a contaminated wound.
- Offer a 5 day treatment course for patients with a human or animal bite if there are symptoms and signs of infection see Bites, human + animal
- Where a foreign body cannot be removed, contact Micro/ID.
Use IV treatment only where there are signs of severe infection e.g. sepsis.
Preferred
amoxicillin 1g po tds (or 1g iv tds) PLUS metronidazole 400mg po tds (or 500mg iv tds if NBM) PLUS gentamicin 5mg/kg* (Gentamicin is for a maximum of 3 days)
*Take a gentamicin level at 6-14 hours after first dose to calculate dosing interval, usually 24 hourly, 36 hourly or 48 hourly. See gentamicin monograph for dosing (including renal dosing) and monitoring.
Alternative
Consider penicillin allergy assessment and delabelling
For penicillin allergy (non-severe):
cefalexin 1g po tds PLUS metronidazole 400mg po tds (or 500mg iv tds if NBM)
OR
cefazolin 2g iv tds PLUS metronidazole 400mg po tds (or 500mg iv tds if NBM)
For penicillin allergy (severe) or MRSA positive patients:
co-trimoxazole 960mg po bd (or 960mg iv bd) PLUS metronidazole 400mg po tds (or 500mg iv tds if NBM)
OR
doxycycline 100mg po bd PLUS metronidazole 400mg po tds (or 500mg iv tds if NBM)
For wounds with exposure to fresh- or sea- water: ADD doxycycline 100mg po bd (if not already prescribed)
If severely unwell, discuss with Micro/ID to consider treatment with a fluoroquinolone.