Medication Summary
Drug therapy for staphylococcal scalded skin syndrome (SSSS) consists of parenteral antibiotics to cover S aureus, which is considered the primary source of the toxin-mediated syndrome.
Topical therapy with agents, such as fusidic acid and/or mupirocin, can be used as adjuncts to parenteral antibiotics, but they should not be used alone in true cases of staphylococcal scalded skin syndrome (SSSS).
Antibiotics
Class Summary
When the susceptibility of the organism is not yet known, the DOC is a penicillinase-resistant synthetic penicillin (eg, nafcillin). However, should the organism show susceptibility to penicillin G, then that drug should be chosen as the main course of therapy. A first-generation cephalosporin can be used as an alternative. In penicillin-allergic patients, macrolides or aminoglycosides may be substituted. Increasing rates of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections warrant consideration for vancomycin or linezolid therapy in patients who initially appear toxic or who fail to respond to nafcillin.
Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Septra DS, Sulfatrim)
Trimethoprim: Inhibits dihydrofolate reductase, thereby blocking production of tetrahydrofolic acid from dihydrofolic acid
Sulfamethoxazole: Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid
Nafcillin (Nalipen in Dextrose)
Treats infections caused by penicillinase-producing staphylococci, and thus is DOC for penicillin G-resistant staphylococcal infections. Do not use for treatment of penicillin G-susceptible staphylococci. Use parenteral therapy initially in severe infections, using very high doses for very severe infections.
Penicillin G procaine
Long-acting parenteral penicillin (IM only) indicated in treatment of moderately severe infections caused by penicillin G-sensitive microorganisms. Useful in treatment of moderately severe infections of skin and skin structures. In adults, administer by deep IM injection only into upper, outer quadrant of buttock. In infants and small children, midlateral aspect of thigh may be better site for administration.
Amoxicillin and clavulanate (Amoclan, Augmentin, Augmentin ES-600, Augmentin XR)
Drug combination that extends antibiotic spectrum of this penicillin to include bacteria normally resistant to beta-lactam antibiotics. Indicated for skin and skin-structure infections caused by beta-lactamase-producing strains of S aureus. In children >3 mo, base dose on amoxicillin content. Because of different amoxicillin-to-clavulanic acid ratios in 250-mg tablets (250/125) vs 250-mg chewable tablets (250/62.5), do not use 250-mg tablet until child weighs >40 kg.
Cefazolin
First-generation semisynthetic cephalosporin, which, by binding to one or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. Total daily dosages are same for IV/IM routes.
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls. Primarily active against skin flora. Typically used for skin-structure coverage and as prophylaxis in minor procedures.
Clindamycin (Cleocin)
Lincosamide useful as treatment against serious skin and soft-tissue infections caused by most staphylococci strains. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome, where it binds preferentially to 50S ribosomal subunit, inhibiting bacterial growth.
Gentamicin
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with both agent against gram-positive organisms and one that covers anaerobes.
Not antibiotic of first choice. Consider using only if penicillins or other less toxic drugs are contraindicated, when bacterial susceptibility tests and clinical judgment indicate its use, and in mixed infections caused by susceptible strains of staphylococci and gram-negative organisms.
Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution, as well as body space into which agent needs to distribute. Dose of gentamicin may be given IV/IM. Each regimen must be followed by at least trough level drawn on third or fourth dose, 0.5 h before dosing; may draw peak level 0.5 h after 30-min infusion.
Tobramycin
Used in skin, bone, and skin-structure infections caused by S aureus, Pseudomonas aeruginosa, Proteus species, Escherichia coli, Klebsiella species, and Enterobacter species. Indicated in serious staphylococcal infections when penicillin or other potentially less toxic drugs contraindicated and when bacterial susceptibility testing and clinical judgment indicate use. To prevent increased toxicity caused by excessive blood levels do not exceed 5 mg/kg/d, unless serum levels monitored.
Erythromycin (E.E.S., Ery-Tab, Eryped, Erythrocin, PCE)
Indicated for treatment of infections caused by susceptible strains including S aureus. Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl t-RNA from ribosomes. This inhibits bacterial growth.
Age, weight, and severity of infection determine proper dosage. When bid dosing desired, half of total daily dose may be taken q12h. For more severe infections, double dose.
Vancomycin
Indicated for patients who cannot receive or have failed to respond to penicillins and cephalosporins or have infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use creatinine clearance to adjust dose in patients diagnosed with renal impairment.
Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing gastrointestinal or genitourinary procedures.
Linezolid (Zyvox)
Binds to bacterial 23S rRNA of the 50S subunit to prevent protein translation; also elicits nonselective MAO inhibition.
Oxacillin (Bactocill)
Bactericidal antibiotic that inhibits cell wall synthesis by binding to one or more of the penicillin binding proteins. Used in the treatment of infections caused by penicillinase-producing staphylococci. May be used to initiate therapy when a staphylococcal infection is suspected.
Antibacterials, Topical
Class Summary
These agents are used to treat open excoriations and erosions and can be used as adjuncts to parenteral antibiotics, but they should not be used alone in true cases of staphylococcal scalded skin syndrome.
Mupirocin (Bactroban, Bactroban Nasal, Centany, Centamy AT)
Bactericidal; inhibits protein synthesis in susceptible bacteria by reversibly binding to bacterial isoleucine-tRNA ligase (isoleucyl-tRNA synthetase), the enzyme that catalyzes the formation of isoleucyl-tRNA from isoleucine and tRNA
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Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
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Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
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Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
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Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
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Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
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Staphylococcal scalded skin syndrome. Photograph by David Effron, MD, FACEP.
