Wounds associated with significant trauma or exposed to soil- or sewage-contaminated water
For empirical therapy for patients whose wounds are associated with significant trauma (including shark and crocodile bites) or have been exposed to soil- or sewage-contaminated water (eg following a flood or natural disaster), use:
cefepime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefepime dosage adjustment cefepime cefepime cefepime
PLUS
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. metronidazole metronidazole metronidazole
For patients at increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), add vancomycin (see dosage below) to the above regimen. If local epidemiology suggests clindamycin is a suitable alternative to vancomycin, use cefepime plus clindamycin (see dosage below); it is not necessary to include metronidazole for additional anaerobic activity.
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use the appropriate cefepime-based regimen as above.
For patients who have had a severe immediate1 hypersensitivity reaction to a penicillin, the cefepime-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 immediate1 hypersensitivity reaction to a penicillin in whom cefepime is not used, or for patients who have had a severe delayed2 hypersensitivity reaction to a penicillin, use:
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly3. 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
For patients who have had a severe immediate1 hypersensitivity reaction to a penicillin in whom cefepime is not used, or for patients who have had a severe delayed2 hypersensitivity reaction to a penicillin; who are at increased risk of MRSA infection (see Risk factors for infection with methicillin-resistant Staphylococcus aureus), use:
ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) intravenously, 8-hourly3. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment ciprofloxacin ciprofloxacin ciprofloxacin
PLUS
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
PLUS
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. metronidazole metronidazole metronidazole
However, if local epidemiology suggests clindamycin is a suitable alternative to vancomycin, use ciprofloxacin plus clindamycin (see dosage above); it is not necessary to include metronidazole for additional anaerobic activity.
Modify therapy based on the results of culture and susceptibility testing; see Aeromonas species, Vibrio species and Mycobacterial infections / 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).