Wounds not associated with significant trauma and not exposed to soil- or sewage-contaminated water
For empirical therapy for patients without significant trauma whose wounds have not been exposed to soil- or sewage-contaminated water, use:
flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment flucloxacillin flucloxacillin flucloxacillin
PLUS
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly1. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. ciprofloxacin ciprofloxacin ciprofloxacin
For patients at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin to the empirical regimen. Use:
vancomycin intravenously; see Intermittent vancomycin dosing in noncritically ill adults or Intermittent vancomycin dosing for young infants and children for initial dosing. vancomycin vancomycin vancomycin
In some regions, based on local susceptibility data, clindamycin is a suitable alternative to vancomycin (see dosage below).
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, 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
PLUS
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly1. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. ciprofloxacin ciprofloxacin ciprofloxacin
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin who are at increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin (see dosage above) to cefazolin and ciprofloxacin. In some regions, based on local susceptibility data, clindamycin is a suitable alternative to vancomycin (see dosage below).
For patients who have had a severe immediate2 hypersensitivity reaction to a penicillin, the cefazolin containing regimen above with or without vancomycin 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, use:
clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly clindamycin clindamycin clindamycin
PLUS
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly1. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. ciprofloxacin ciprofloxacin ciprofloxacin
For patients who have had a severe immediate 2 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 are at increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), replace clindamycin with vancomycin (see dosage above). In some regions, based on local susceptibility data, clindamycin is a suitable alternative to vancomycin.
Modify therapy based on the results of culture and susceptibility testing; see Aeromonas species, Vibrio species and Mycobacterium marinum.
If a pathogen is not identified, the duration of empirical therapy is determined by clinical response. Switch to oral therapy (as for localised infection) as soon as possible. A total duration of therapy (intravenous + oral) of 5 to 7 days is likely to be appropriate; however, a longer duration of therapy is needed for wounds involving the deeper tissues (such as bones, joints or tendons).