Patients at low risk of MRSA infection

For empirical therapy of post-traumatic wound infection associated with systemic features or involving deeper tissues, for patients at low risk of MRSA infection, use:

cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. cefazolin cefazolin cefazolin

Regimens with additional anaerobic activity are required for heavily contaminated severe injuries or if there has been significant tissue maceration. Use:

1amoxicillin+clavulanate intravenously amoxicillin + clavulanate amoxicillin+clavulanate amoxicillin+clavulanate

2+0.2 g formulation

adult, or child 40 kg or more: 2+0.2 g 8-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment

1+0.2 g formulation

adult, or child 40 kg or more: 1+0.2 g 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin+clavulanate intravenous dosage adjustment

child 1 month to younger than 3 months and less than 4 kg: 25+5 mg/kg 12-hourly

child 1 month to younger than 3 months and 4 kg or more: 25+5 mg/kg 8-hourly

child 3 months or older and less than 40 kg: 25+5 mg/kg up to 1+0.2 g 8-hourly. If the bone is infected, use a dose of 25+5 mg/kg up to 1+0.2 g 6-hourly

OR (as a two-drug regimen)

1cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment cefazolin cefazolin cefazolin

PLUS

metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. metronidazole metronidazole metronidazole

For penetrating injuries through footwear, treatment for Gram-negative bacteria (including Pseudomonas aeruginosa) is required. Use:

piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) intravenously, 6-hourly¹. For dosage adjustment in adults with kidney impairment, see piperacillin+tazobactam dosage adjustment. piperacillin + tazobactam piperacillin+tazobactam piperacillin+tazobactam

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin who have not sustained a penetrating injury through footwear, use cefazolin with or without metronidazole as above.

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin, the cefazolin containing regimens above can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin in whom cefazolin is not used, or for patients who have had a severe delayed³ hypersensitivity reaction to a penicillin; who have not sustained a penetrating injury through footwear, use:

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly⁴. clindamycin clindamycin clindamycin

For patients with hypersensitivity to penicillins who have sustained a penetrating injury through footwear, use:

ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly⁵. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment ciprofloxacin ciprofloxacin ciprofloxacin

PLUS

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly⁴. clindamycin clindamycin clindamycin

See General principles for duration of therapy, including switch to oral therapy.

¹ Administration of piperacillin+tazobactam over 3 hours may be preferred to ensure adequate drug exposure for Pseudomonas aeruginosa. Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return

⁴ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return

⁵ Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice.Return