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IDSA GUIDELINES

Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections
Dennis L. Stevens,1,3 Alan L. Bisno,5 Henry F. Chambers,6,7 E. Dale Everett,13 Patchen Dellinger,2 Ellie J. C. Goldstein,8,9 Sherwood L. Gorbach,14 Jan V. Hirschmann,3,4 Edward L. Kaplan,15,16 Jose G. Montoya,10,11,12 and James C. Wade17
1 Infectious Diseases Section, Veterans AffairsMedical Center, Boise, Idaho; 2Department of Surgery, 3University of Washington School of Medicine, and 4Seattle Veterans Affairs Medical Center, Seattle, Washington; 5University of Miami Miller School of Medicine, Miami, Florida; 6 Infectious Diseases, San Francisco General Hospital, and 7University of California–San Francisco, San Francisco, 8R. M. Alden Research Laboratory, Santa Monica,9University of California, Los Angeles School of Medicine, Los Angeles, and 10Department of Medicine and 11Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, and 12Research Institute, Palo Alto Medical Foundation, Palo Alto, California; 13University of Missouri Health Science Center, University of Missouri, Columbia; 14Tufts University School of Medicine,Boston, Massachusetts; 15University of Minnesota Medical School and 16Division of Epidemiology, University of Minnesota School of Public Health, Minneapolis, Minnesota; and 17Division of Neoplastic Diseases and Related Disorders, Medical College of Wisconsin, Milwaukee, Wisconsin

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EXECUTIVE SUMMARY Soft-tissue infections are common,generally of mild to modest severity, and are easily treated with a variety of agents. An etiologic diagnosis of simple cellulitis is frequently difficult and generally unnecessary for patients with mild signs and symptoms of illness. Clinical assessment of the severity of infection is crucial, and several classification schemes and algorithms have been proposed to guide the clinician [1]. However,most clinical assessments have been developed from either retrospective studies or from an author’s own “clinical experience,” illustrating the need for prospective studies with defined measurements of severity coupled to management issues and outcomes. Until then, it is the recommendation of this committee that patients with soft-tissue infection accompanied by signs and symptoms of systemictoxicity (e.g., fever or hypothermia, tachycardia [heart rate, 1100 beats/min], and hypotension [systolic blood pressure, !90 mm Hg or 20 mm Hg below baseline]) have blood drawn to determine the following laboratory parame-

Received 13 July 2005; accepted 14 July 2005; electronically published 14 October 2005. These guidelines were developed and issued on behalf of the Infectious Diseases Society ofAmerica. Reprints or correspondence: Dr. Dennis L. Stevens, Infectious Disease Section, VAMC, 500 West Fort St. (Bldg. 45), Boise, ID 83702 (dlsteven@mindspring.com). Clinical Infectious Diseases 2005; 41:1373–406 2005 by the Infectious Diseases Society of America. All rights reserved. 1058-4838/2005/4110-0001$15.00

ters: results of blood culture and drug susceptibility tests, complete bloodcell count with differential, and creatinine, bicarbonate, creatine phosphokinase, and Creactive protein levels. In patients with hypotension and/or an elevated creatinine level, low serum bicarbonate level, elevated creatine phosphokinase level (2– 3 times the upper limit of normal), marked left shift, or a C-reactive protein level 113 mg/L, hospitalization should be considered and a definitiveetiologic diagnosis pursued aggressively by means of procedures such as Gram stain and culture of needle aspiration or punch biopsy specimens, as well as requests for a surgical consultation for inspection, exploration, and/or drainage. Other clues to potentially severe deep soft-tissue infection include the following: (1) pain disproportionate to the physical findings, (2) violaceous bullae, (3)...