12 CellulitisErysipelas MPED 20160606

B1

Cellulitis/Erysipelas (1 of 10)

No

Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.

1Patient presents w/ signs & symptoms

suggestive of cellulitis

2DIAGNOSIS

Is cellulitis confi rmed?

ALTERNATIVE DIAGNOSIS

CLASSIFY LESION

PURULENT CELLULITIS MRSA

NONPURULENT CELLULITIS

ERYSIPELAS

A Non-pharmacological therapy• Patient education

B Pharmacological therapyOral Antibiotics• Clindamycin• Co-trimoxazole • Linezolid• Tetracyclines

- Doxycycline - Minocycline

IV Antibiotics• Vancomycin plus

- Cefotaxime or- Gentamicin

C Surgical therapy• Incision & drainage


B Pharmacological therapyOral Antibiotics• Amoxicillin • Erythromycin • PenicillinIV Antibiotics• Cefazolin• Ceftriaxone

TREATMENTSee next page

Yes

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CONTINUE THERAPY

Yes

NONPURULENT CELLULITIS


B Pharmacological therapyOral Antibiotics• Dicloxacillin• Cefalexin• Clindamycin• Penicillin IV Antibiotics• Cefazolin• Clindamycin• Oxacillin• Penicillin


B Pharmacological therapyOral Antibiotics• Amoxicillin plus

- Co-trimoxazole or - Tetracyclines (Doxycycline/Minocycline) or

• Clindamycin• LinezolidIV Antibiotics• Cephalosporins

- Cefazolin - Ceftriaxone - Cefotaxime

• Clindamycin• Co-trimoxazole• Gentamicin• Linezolid• Vancomycin plus Piperacillin/

Tazobactam

Beta-hemolytic Streptococci& MRSA

Beta-hemolytic Streptococci& MSSA


1 CELLULITIS/ERYSIPELAS

• An acute spreading skin infection that may go deep, involving the subcutaneous tissues• Typically occurs in areas where the skin integrity has been compromised• May also result from blood-borne spread of infection to the skin & subcutaneous tissues• Commonly caused by beta-hemolytic streptococci & Staphylococcus aureus in adults, & Haemophilus infl uenzae

type B in patients <3 yr - Infection due to streptococci is rapidly spreading because of streptokinase while that of staphylococci is localized

- Consider Methicillin-resistant S aureus (MRSA) in patients w/ recurrent cellulitis, or refractory to treatment Erysipelas• A type of cellulitis w/ sharply demarcated margins involving the epidermis & superfi cial lymphatics• Onset of symptoms is acute whereas cellulitis has an indolent course• More commonly caused by beta-hemolytic streptococciSigns & Symptoms• Rapidly spreading area of acute infl ammation of the dermis & subcutaneous tissue• Lymphangitis & infl ammation of the regional lymph nodes may occur• Area is usually tender, erythematous & warm to the touch• Patient may have malaise, fever & chillsPredisposing Factors• Obesity• Diabetes mellitus & malignancy• Immunocompromise• Previous cutaneous damage• Edema from venous insuffi ciency or lymphatic obstruction

NoImprovement of symptoms?

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2 DIAGNOSIS

• Diagnosis is usually made by clinical presentation w/ or w/o Gram stain & culture• Clinical response is usually evident w/in 24-48 hr• Disease progression despite receipt of oral antibiotics suggests infection w/ resistant microbes, an underlying

condition or presence of a deeper, more serious infection• In patients who become increasingly ill or experience increasing toxicity, an aggressive evaluation should be

initiated, & antibiotic treatment modifi ed on the basis of Gram stain results, culture results & antimicrobial susceptibilities of organisms obtained from surgical specimens

Clinical PresentationUncomplicated cellulitis• Area involved is erythematous, warm to the touch, swollen & is distinguished from erysipelas by non-elevated,

ill-defi ned margins• Primarily involves the subcutaneous tissues & dermis• Erysipelas is more common among infants & young children• Local tenderness & regional adenopathy are usually present• Constitutional signs & symptoms are usually present (eg fever, chills & malaise)• Etiology: Beta-hemolytic streptococcal etiology in 90% of infections but S aureus is diffi cult to exclude esp if

mixed infection occursComplicated cellulitis• Cellulitis in DM patients• Facial cellulitis, as meningitis may occur• Presence of comorbidities (eg peripheral vascular disease, chronic venous insuffi ciency, morbid obesity)• Presence of signifi cant systemic symptoms (eg irritability, tachycardia, tachypnea, hypotension)• Signs of potentially severe deep soft-tissue infection (eg violaceous bullae, cutaneous hemorrhage, skin sloughing,

gas in the tissue)• Etiology: Group A streptococci, Staphylococcus aureus, H infl uenzae B, Enterobacteriaceae & anaerobesPurulent Cellulitis• Presence of purulent exudate or drainage w/o a drainable abscessNonpurulent Cellulitis• Absence of purulent exudate or drainage & no abscessRecurrent Cellulitis• Cellulitis occurring 3-4 times/yr even w/ pharmacological prophylaxis & control of predisposing factorsLab TestsGram stain, Culture & Sensitivity• Cellulitis in a neonate should prompt a full sepsis evaluation• Etiology of cellulitis remains unidentifi ed in most patients & empiric treatment may be based on clinical

presentation• Lesion culture

- Cultures of aspirate, biopsy & swabs identify causative organism in ~25% of cases - If a specimen can be taken from the site of origin of the cellulitis, +ve culture can be obtained in about 1/3 of patients

- Essential only for those w/ history of malignancy, systemic complications (ie pyrexia, hypotension), predisposing factors (ie immersion injury, animal bites, neutropenia)

• Blood cultures (BC) - Useful only in patients w/ signifi cant leukocytosis, neutropenia, acute onset & high fever, animal bites, immersion injuries, in immunocompromised or in a toxic-appearing patient

• Lumbar puncture should be done if H infl uenzae facial cellulitis is suspected, or if there are signs of systemic toxicity

Imaging Studies• Unnecessary in most cases • CT or MRI for suspected necrotizing fasciitis• Radiographic exams may be used to rule out osteomyelitis© M

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A NON-PHARMACOLOGICAL THERAPYPatient Education• Advise on good personal hygiene & wound care

- Cover draining wounds w/ clean bandage - Regularly bathe & wash hands after coming in contact w/ a wound - Avoid sharing or reusing items that came in contact w/ infected skin - Inspect interdigital toe spaces regularly esp if w/ lower extremity cellulitis

• Immobilization & elevation of aff ected limb - Eff ects: May help to decrease swelling & pain esp if used early in the course of treatment

• Dressings - Cool sterile saline dressing may be applied - Eff ects: Removes purulent exudate from ulcers or infected abrasions, may help to decrease local pain

• Compression Stockings - May help w/ edema

B PHARMACOLOGICAL THERAPYChoice of Route of Administration for Empiric TreatmentOral Antibiotics• If lymphadenopathy, fever & other constitutional signs are not present (eg WBC <15,000), then may typically

treat patient w/ oral antibiotics on an outpatient basisParenteral Antibiotics• If symptoms do not improve or if disease progresses signifi cantly w/in the fi rst 24-48 hr, parenteral therapy

may be needed• If lymphadenopathy, fever or constitutional signs are present• Neonates should be admitted & given initial parenteral therapy if w/ moderate to severe presentation• Considered in patients w/ comorbidities (eg DM, peripheral vascular diseases)Choice of Antibiotic• Tailored according to known pathogen, comorbid condition, & special situations like water (salt or freshwater)

exposure or animal bites - Treatment should also address underlying predisposing conditions

• Empiric therapy may be started pending culture results - For patients w/ purulent cellulitis, treatment is directed towards MRSA since it is the dominant pathogen in this type of cellulitis; therapy for beta-hemolytic streptococci is likely not needed

- For patients w/ nonpurulent cellulitis, treatment is directed towards Methicillin-sensitive S aureus (MSSA) & beta-hemolytic streptococci - Empiric therapy for MRSA may be needed if patient has signs of systemic infection, is unresponsive to initial therapy, has recurrent infection, or has a previous episode of or is at high risk for MRSA infection

Penicillins (beta-lactamase resistant)• Recommended therapy for patients w/ erysipelas, moderate nonpurulent & purulent cellulitis, & MRSA

infection• Recommended antibiotics against mild nonpurulent cellulitis caused by group A Streptococcus or S aureus

- Some authorities recommend antistaphylococcal penicillin alone while others advocate antistaphylococcal penicillin + Penicillin or Amoxicillin

- Combination may increase adverse eff ects• Recommended for initial treatment of neonates w/ moderate to severe cellulitis• Also recommended for recurrent cellulitisPenicillin G (IV)• Used for erysipelas & moderate nonpurulent uncomplicated cellulitis• Treatment option for patients w/ recurrent cellulitis• Observe patient for localized S aureus infectionCephalosporins (1st Generation)• If staphylococcal infection is suspected• Usually suffi cient for mild nonpurulent uncomplicated cellulitis


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B PHARMACOLOGICAL THERAPY (CONT’D)Cephalosporins (2nd & 3rd Generation) (Parenteral)• Usually used empirically in DM patients who have early mild cellulitis• Treatment alternative for patients w/ moderate nonpurulent cellulitisAminopenicillin/Beta-Lactamase Inhibitors• Considered 2nd-line alternative by some authorities• Eff ective & esp useful in the presence of bone or joint infectionMacrolides• Eg Erythromycin, Roxithromycin• May be used if patient is allergic to Penicillin• Macrolide resistance among Group A Streptococci has increased & has become a concern in some

countries• Erythromycin is the main macrolide used unless Erythromycin resistance is widespread in the community• Also used for prophylactic treatment against recurrent cellulitis• Studies showed that the effi cacy of Roxithromycin for erysipelas was comparable to that of BenzylpenicillinOther Antibiotics• Clindamycin

- Used in patients allergic to Penicillin & cephalosporins - Alternative therapy for patients w/ nonpurulent or purulent cellulitis caused by MSSA or MRSA infection

• Co-trimoxazole - Used for nonpurulent cellulitis & moderate purulent cellulitis - Has very good activity against community-acquired MRSA but not to streptococci

• Linezolid - Used in patients allergic to Penicillin & for complicated cellulitis & erysipelas

• Vancomycin - Treatment option for patients allergic to Penicillin - Combination w/ Piperacillin/Tazobactam or Imipenem/Meropenem is recommended for patients w/ severe nonpurulent cellulitis

- Combination w/ Cefotaxime or Gentamicin is recommended as 1st-line parenteral treatment for neonates w/ MRSA infections

- Also used for patients w/ penetrating trauma, nasal colonization w/ MRSA, & IV drug useQuinolones• Eg Ciprofl oxacin, Levofl oxacin, Moxifl oxacin, Ofl oxacin• � ose that have enhanced activity against Gram-positive bacteria have been shown to be eff ective• Used for cellulitis caused by Vibrio vulnifi cus • Not recommended for patients living in MRSA-prevalent regionsTetracyclines• Eg Doxycycline, Minocycline• May be considered for moderate-severe purulent cellulitis, MSSA, & MRSA infectionsLength of � erapy• It is typically recommended that once erythema, warmth & edema have subsided signifi cantly, patient may

be treated for an additional 10 days w/ oral antibiotics• Antibiotic therapy for neonates is usually administered for 7-10 days; 5-10 days for patients >1 mth• Treatment duration may be extended for severe cases Prophylaxis• Preventive measures may be helpful in reducing recurrent skin infections

- Staphylococcal infection: Oral Clindamycin - Beta-hemolytic streptococcal infection: Penicillin or Erythromycin for 4-52 wk or Benzathine Penicillin IM injections every 2-4 wk

C SURGICAL THERAPYIncision & Drainage • Recommended 1st-line intervention in patients w/ mild-severe purulent cellulitis

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All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.

Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.

Specifi c prescribing information may be found in the latest MIMS.

Dosage Guidelines

AMINOGLYCOSIDEDrug Dosage Remarks

Amikacin Newborns:Initial dose: 10 mg/kg IM/IVMaintenance dose: 7.5 mg/kg IM/IV 12 hrlyChildn & infants: 15 mg/kg/day IM/IV inj of 2-3 min or infusion over 30-60 min, given in 2-3 divided doses x 7-10 daysMax dose: 1.5 g/day

Adverse Reactions• GI eff ects (N/V, anorexia, diarrhea); CNS eff ects

(ototoxicity, dizziness, vertigo, convulsions, mental depression, hallucinations); GU eff ects (acute renal failure, interstitial nephritis, acute tubular necrosis); Other eff ects (skin rash, electrolyte imbalance, inc serum bilirubin & aminotransferases, inj site atrophy or fat necrosis)

• Potentially fatal: nephrotoxicity, ototoxicity, neuromuscular blockade, resp paralysis

Special Instructions• Contraindicated in patients w/ hepatic impairment,

perforated ear drum• Use w/ caution in patients w/ renal impairment,

cystic fi brosis, obesity, myasthenia gravis, parkinsonism, at high risk for ototoxicity & nephrotoxicity, & patients taking neuromuscular blocking agents

Gentamicin 2-2.5 mg/kg IV 8 hrly

ANTIBACTERIAL COMBINATIONDrug Dosage Remarks

Co-trimoxazole (Sulfamethoxazole (SMX) & Trimethoprim (TMP))

8-12 mg/kg/day PO divided 12 hrly based on TMP8-12 mg/kg/day IV divided 6 hrly based on TMP

Adverse Reactions• GI eff ects (N/V, anorexia, diarrhea);

Hypersensitivity reactions (fever, rashes, pruritus, photosensitivity reactions, exfoliative dermatitis, erythema nodosum)

• Rare: Hypersensitivity reactions (toxic epidermal necrolysis, Stevens-Johnson syndrome); Renal eff ects (interstitial nephritis, tubular necrosis, renal failure, crystalluria); Hematologic eff ects (agranulo-cytosis, aplastic anemia, thrombocytopenia, leucopenia, hypoprothrombinemia, eosinophilia); Hepatic eff ects (elevated liver enzymes, cholestatic jaundice)

Special Instructions• Adequate fl uid intake should be maintained during

treatment• Contraindicated in patients w/ hypersensitivity to

any of its components, serious hematologic disorders, infants <2 mth old

• Use w/ caution in patients w/ renal or hepatic impairment, folate defi ciency, allergy, asthma, SLE, G6PD defi ciency, AIDS© MIM

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Dosage Guidelines

CEPHALOSPORINS (ORAL/PARENTERAL)Drug Dosage Remarks

Cephalosporins (1st Generation) (Oral) Cefadroxil 30 mg/kg/day PO divided 12 hrly Adverse Reactions

• Hypersensitivity reactions (skin rashes, urticaria, eosinophilia, fever, reactions resembling serum sickness & anaphylaxis)

• Rare: Hepatic eff ects (transient increases in liver enzyme values, hepatitis, cholestatic jaundice); GI eff ects (N/V, diarrhea); Hematologic eff ects (hemolytic anemia, neutropenia, thrombocytopenia, agranulocytosis, bleeding); Other eff ect (convulsions w/ high doses)

Special Instructions• Contraindicated in

patients w/ known hypersensitivity to cephalosporins

• Given w/ caution to patients w/ a history of allergy (esp to penicillins), renal impairment

• Renal & hematological status should be monitored esp during prolonged & high-dose therapy

Cefalexin(Cephalexin)

25-50 mg/kg/day PO divided 6 hrlyMax dose: 4 g/day

Cefradine(Cephradine)

50-100 mg/kg/day PO divided 6 hrlyMax dose: 4 g/day

Cephalosporins (1st Generation) (Parenteral)Cefaclor 20 mg/kg/day PO in 3 divided doses

Max dose: 1 g/day Cefazolin 25-50 mg/kg/day PO/IV divided 6-8 hrly

Max dose: 100 mg/kg/dayCefradine 50-100 mg/kg/day PO divided 6 hrly

Max dose: 4 g/day Cephalosporins (2nd Generation) (Parenteral) Cefmetazole 25-150 mg/kg/day IV divided 6-8 hrly Cefuroxime 30-100 mg/kg/day PO divided 6-12 hrly

Max dose: 500 mg/day Cephalosporins (3rd Generation) (Parenteral)Cefoperazone Neonates <8 days: 50-200 mg/kg/day IV 12 hrly

Childn & infants: 50-200 mg/kg/day IV in 2 divided doses 8-12 hrlyMax dose: 12 g/day

Cefotaxime 0-1 wk: 50 mg/kg IV 12 hrly1-4 wk: 50 mg/kg IV 8 hrly>4 wk: 50-180 mg/kg/day IM/IV divided 4-6 hrly

Ceftazidime <2 mth: 25-60 mg/kg/day IV/IM in 2 divided dosesChildn & infants >2 mth: 30-100 mg/kg/day IV/IM in 2-3 divided doses

Ceftriaxone <12 yr: 50-75 mg/kg/day IV divided 12 hrly>12 yr: 1-2 g IV 24 hrlyMax dose: 4 g/day

Other Cephalosporin (Parenteral) Ceftaroline 600 mg IV 12 hrly© M

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Dosage Guidelines

MACROLIDESDrug Dosage Remarks

Azithromycin >6 mth: 10 mg/kg PO 24 hrly x 3 days15-25 kg: 200 mg PO 24 hrly x 3 days26-35 kg: 300 mg PO 24 hrly x 3 days36-45 kg: 400 mg PO 24 hrly x 3 days

Adverse Reactions• GI eff ects (abdominal discomfort & cramp,

N/V, diarrhea, pseudomembranous colitis); Hypersensitivity reactions (pruritus, urticaria, skin rash, anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis); CNS eff ects (confusion, hallucinations, seizures, vertigo, sensorineural deafness, tinnitus)

Special Instructions• Contraindicated in patients w/ known

hypersensitivity to macrolides, history of cholestatic jaundice/hepatic dysfunction associated w/ prior use of Azithromycin

• Avoid in patients previously w/ jaundice & hepatic or renal impairment, myasthenia gravis, arrhythmia, inc risk for torsades de pointes, low K or Mg blood levels

Clarithromycin 7.5 mg/kg PO 12 hrly for 5-10 daysMax dose: 500 mg/day

Erythromycin 30-50 mg/kg/day PO divided 6 hrly25-50 mg/kg/day IV divided 6 hrly

Roxithromycin 5-8 mg/kg/day PO divided 12 hrly for 7-10 daysMax dose: 300 mg/day

OTHER ANTIBIOTICSDrug Dosage Remarks

Clindamycin 10-20 mg/kg/day PO divided 8 hrly25–40 mg/kg/day IV divided 8 hrly

Adverse Reactions• GI eff ects (severe antibiotic-related pseudomembranous

colitis, N/V, abdominal pain or cramps); Hypersensitivity reactions (rashes, urticaria)

• Rare: Hypersensitivity reactions (anaphylaxis, erythema multiforme, exfoliative & vesiculobullous dermatitis); Hepatic eff ects (overt jaundice & hepatic damage); Hematologic eff ects (leucopenia, eosinophilia, agranulocytosis, thrombocytopenia);

Special Instructions• Contraindicated in patients w/ known hypersensitivity to any

drug in this class• Use w/ caution in patients w/ gastrointestinal disease,

hepatic or renal impairment, a history of colitis or atopy• Periodic tests of liver & kidney function & blood counts have

been recommended in infants

Lincomycin >1 mth: 30-60 mg/kg/day PO divided 6-8 hrly

Linezolid 10 mg/kg PO/ IV 12 hrly

Sodium fusidate 250 mg PO 12 hrly

Rifampicin 20 mg/kg/day PO once daily

Vancomycin 40 mg/kg/day IV divided 6 hrly

OTHER BETA-LACTAMSDrug Dosage Remarks

CarbapenemImipenem/Cilastatin

≥3 mth, <40 kg: 15-25 mg/kg IV 6 hrlyMax dose: 2 g/day≥40 kg: 1-2 g/day IV in 3-4 divided dosesMax dose: 4 g/day or 50 mg/kg/day

Adverse Reactions• GI eff ects (N/V, diarrhea, tongue discoloration, altered taste);

Dermatologic eff ects (rashes, urticaria, exfoliative dermatitis); Other eff ect (fever, inj site reactions, thrombophlebitis)

• Potentially fatal: Stevens-Johnson syndrome, toxic epidermal necrolysis

Special Instructions• Use w/ caution in patients w/ renal or hepatic

impairment, epilepsy, childn <3 mth© M

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Dosage Guidelines

PENICILLINSDrug Dosage Remarks

Bacampicillin >25 kg: 12.5-25 mg/kg PO 6 hrly Adverse Reactions• Hypersensitivity reactions

(skin rashes, anaphylaxis); GI eff ects (diarrhea, nausea, pseudomembranous colitis)

• Rare: Hematologic eff ects (hemolytic anemia, neutropenia, prolonged bleeding time, defective platelet function); CNS eff ects (convulsions, encephalopathy); Other eff ect (electrolyte disturbances)

Special Instructions• Contraindicated in

patients w/ known hypersensitivity to penicillins

• Given w/ caution to patients w/ a known history of allergy, renal impairment

• Renal, hepatic & hematological status should be monitored during prolonged & high-dose therapy

Benzylpenicillin sodium (Penicillin G, Penicillin G Na)

30,000 IU/kg body wt/day in 2-3 divided doses

Phenoxymethyl-penicillin (Penicillin V, Penicillin V K)

50 mg/kg/day PO divided 6 hrly

Aminopenicillins w/ or w/o Beta-lactamase InhibitorsAmoxicillin/clavulanic acid (Co-amoxiclav) (Amoxicillin & Clavulanic acid), Amoxicillin/clavulanate)

20-40 mg/kg/day PO divided 8 hrly based on AmoxicillinMax dose: 2 g/day

Ampicillin/sulbactam [Sultamicillin (Ampicillin & Sulbactam), Sultamicillin: Pro-drug of Ampicillin/sulbactam, the 2 drugs are linked chemically w/ a double ester]

150 mg/kg/day IV/IM divided 6-12 hrly

Antistaphylococcal PenicillinsCloxacillin 25-50 mg/kg/day PO divided 6 hrlyDicloxacillin 25 mg/kg/day PO divided 6 hrlyFlucloxacillin <2 yr: 62.5 mg PO 6 hrly

2-10 yr: 125 mg PO 6 hrly>10 yr: 250 mg PO 6 hrly

Oxacillin <40 kg: 25-100 mg/kg/day IV divided 4-6 hrly

OTHER BETA-LACTAMS (CONT’D)Drug Dosage Remarks

MonobactamAztreonam >1 wk: 30 mg/kg

IV/IM 6-8 hrly>2 yr: 50 mg/kg IV/IM 6-8 hrly

Adverse Reactions• Hypersensitivity reactions (rash, pruritus, urticaria); GI eff ects

(abdominal pain, N/V, diarrhea, pseudomembranous colitis); Hematologic eff ects (leucopenia, reversible thrombocythemia, thrombocytopenia, eosinophilia, neutropenia); CNS eff ects (headache, paresthesia, convulsions); Other eff ect (deranged liver function)

Special Instructions• Contraindicated in patients w/ hypersensitivity to carbapenems,

cephalosporins, penicillins & other beta-lactam antibiotics & in MRSA infection

• Use w/ caution in patients w/ GI complaints• Monitor levels of transaminase & bilirubin in patients w/

hepatic disease

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Specifi c prescribing information may be found in the latest MIMS.Please see the end of this section for the reference list.

Dosage Guidelines

TOPICAL ANTIBIOTICDrug Dosage Remarks

Mupirocin Apply to aff ected area 8 hrly for 5-14 days

Adverse Reactions• Most preparations are well-tolerated• Discomfort or pruritus localized to area of applicationSpecial Instructions• Contraindicated in patients w/ known hypersensitivity• Use w/ caution in patients w/ moderate or severe renal

impairment

TETRACYCLINESDrug Dosage Remarks

Doxycycline Initial dose: 4 mg/kg/day PO divided 12 hrly for 1 dayMaintenance dose: 2 mg/kg PO once daily

Adverse Reactions• GI eff ects (N/V, diarrhea, esophageal ulceration, glossitis,

stomatitis, dysphagia); CNS eff ects (intracranial hypertension, headache, dizziness, tinnitus, visual disturbances, papilledema); Other eff ects (renal impairment, nail & teeth discoloration)

• Rare: GI eff ects (oral candidiasis, pruritus ani, enterocolitis, pseudomembranous colitis); Renal eff ects (acute renal failure, interstitial nephritis); Hypersensitivity reactions (rashes, fi xed drug eruptions, exfoliative dermatitis, toxic epidermal necrolysis, drug fever, pericarditis, angioedema, urticaria, asthma, anaphylaxis); Hematologic eff ects (agranulocytosis, aplastic anaemia, haemolytic anaemia, eosinophilia, neutropenia, thrombocytopenia, hypoprothrombinaemia)

Special Instructions• Not recommended for patients <8 yr• Oral tetracyclines must be taken w/ plenty of fl uid while in

an upright position, & well before going to bed• Contraindicated in patients w/ known hypersensitivity to

any drug in the group• Use w/ caution in patients w/ myasthenia gravis, SLE, renal

or hepatic impairment• � e eff ects on teeth should be considered & tetracyclines

only used when absolutely essential

Minocycline >13 yr:Initial dose: 4 mg/kg POMaintenance dose: 2 mg/kg/dose PO 12 hrly

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12 CellulitisErysipelas MPED 20160606

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