April 7, 2021

Optimization of Emergency Department Antimicrobials for Uncomplicated Skin and Soft Tissue Infection (SSTI)

By ejschwartz

Courtney Matthews, PharmD

Kellyn Engstrom, PharmD, MPH

SSTIs are commonly encountered in the Emergency Department and broad coverage is often started even in cases of uncomplicated disease. A recent study completed by the Veterans Affairs in 2020 with 1828 immunocompetent hospitalized patients analyzed the prescribing practices for uncomplicated SSTIs. Only 14% of these patients received guideline-compliant antimicrobial therapy for appropriate durations of therapy. Use of unnecessary agents with broad gram-negative spectrums of activity occurred in 45% of patients and unnecessary addition of empiric coverage targeting methicillin-resistant Staphylococcus aureus (MRSA) coverage was as high as 70%1.

For uncomplicated purulent cellulitis, Staphylococcus aureus is the most common pathogen and empiric therapy should be directed to this pathogen, particularly targeting MRSA until susceptibilities are known. If hospital admission is warranted, vancomycin monotherapy constitutes the optimal antimicrobial therapy. If the patient may be managed as an outpatient, given typical MRSA susceptibilities, either trimethoprim/sulfamethoxazole or doxycycline with or without cefadroxil should be prescribed.  Conversely for an uncomplicated non-purulent cellulitis, beta-hemolytic Streptococci are the most common pathogens. Therefore, these patients may be managed with cefazolin monotherapy as inpatients or cefadroxil monotherapy as outpatients.2,3 For further questions, please refer to the following algorithm adapted to help guide empiric antimicrobial therapy for uncomplicated SSTIs.

Please contact Kellyn Engstrom, PharmD, MPH (engstrom.kellyn@mayo.edu) or Courtney Matthews, PharmD (Matthews.courtney@mayo.edu) with any questions or comments.


  1. Sutton, J.D. Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation. Open Forum Infectious Disease. Volume 7, Issue 1, January 2020.
  2. Miller, L.G., et. Al. Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005-2010. BMC Infectious Disease. Volume 15, Issue 362, August 2015.
  3. Stevens, D.L. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Disease. Vol 59, July 2014.

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