Severity

Treatment options

Mild

– Cephalexin 500 mg PO qida,c

– Amoxicillin/clavulanate 875/125 mg PO bid

– Cloxacillin 250-500 mg PO every 6 h

– Alternatives with MRSA coverage: SMX-TMP 1-2 double-strength tablets PO bidb,c; doxycycline 100 mg PO bid; clindamycin 600 mg PO tidd

Moderate

– Cefazolin 1-2 g IV every 8 hc

– Ceftriaxone 1-2 g IV every 24 h

– Alternatives with MRSA coverage: vancomycin 15-20 mg/kg IV every 12 hc; clindamycin 600 mg IV every 8 hd

Severe

– Piperacillin/tazobactam 4.5 g IV every 8 h,c and

– Vancomycin 25-30 mg/kg IV once, then 15-20 mg/kg IV every 12 hc,e

– In case of suspected necrotizing fasciitis, add clindamycin 900 mg IV every 8 hf

If vancomycin cannot be used, consultation with infectious diseases is recommended before initiation of alternative agents, such as linezolid or daptomycin.

Antimicrobial therapy should be modified if there are risk factors for resistant organisms or concern for a polymicrobial infection.

a Larger adults may require higher doses.

b Variable streptococci coverage, would not be used as empiric monotherapy (limited data).

c In patients with normal renal function.

d Clindamycin may be considered if clindamycin local resistance is <10%-15% and/or there are other compelling indications. It should be avoided as a first-line option.

e Maximum, 2 g per dose.

f This is typically continued for 48-72 hours after the patient has been hemodynamically stable for 48-72 h.