Topical 2% fusidic acid q8-12h

OR

Topical 2% mupirocin q8h

(Outpatient use only)

--

General measures include warm compress, antiseptic washes, good skin hygiene and clean sharp razors when shaving.

Obtain a pus or swab for culture and sensitivity if accessible.

Topical antibiotic therapy is preferred for folliculitis that persists with general measures and involves a limited area of the skin.

Cloxacillin 500mg PO q6h

OR

Cephalexin 1000mg PO q12h 

--

Systemic antimicrobial therapy with S. aureus coverage is suggested for patients with deep or extensive folliculitis that fails to resolve or recurs after topical therapy.

Consider the etiology of the folliculitis and the severity and the distribution of the lesions.

Referral to a dermatologist if other etiologies are considered, especially when initial systemic treatment fails:

1.Gram-negative folliculitis (e.g. Enterobacter, Klebsiella, Escherichia, Serratia, Morganella, and Proteus species): primarily in patients on long-term antibiotic therapy, most often during treatment for acne.

2. Pseudomonal folliculitis: appears 8-48 hours after exposure to contaminated water (e.g. hot tub/spa) or wet suits.

3. Folliculitis caused by Malassezia furfur, Demodex mites or herpes simplex virus: seen in immunocompromised patients.

Cloxacillin 500mg PO q6h

Amoxicillin/clavulanate 625mg PO q8h

Duration: 5 days

If lesions spontaneously rupture and drain, systemic antimicrobials are usually unnecessary unless fever or evidence of systemic infection is present.

Cloxacillin 1-2g IV q6h

OR

Cefazolin 1g IV q8h

Amoxicillin/clavulanate 1.2g IV q8h

OR

Ampicillin/sulbactam 3g q6h

Surgical drainage is the mainstay of treatment.

Consider IV to PO switch if adequate surgical treatment and rapid clinical response.

Duration: 7-10 days

Topical 2% fusidic acid q8-12h

OR

Topical 2% mupirocin q8h

(Outpatient use only)

Cloxacillin 500mg PO q6h

OR

Cephalexin 500mg PO q12h 

Duration: 5 days

Antibiotic allergy:

Erythromycin ethylsuccinate 800mg PO q12h

Other alternative/in case of CA-MRSA:

Clindamycin 300mg PO q6h

OR

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

Refer to Appendix 3 for antibiotic allergy.

Phenoxymethylpenicillin 500mg PO q6h

OR

Amoxicillin 500mg PO q8h 

If severe:

Benzylpenicillin 2-4MU IV q4-6h

*CA-MRSA:

Clindamycin 300mg PO q6h

OR

Trimethoprim/sulfamethoxazole 160/800mg PO q12h 

Cephalexin 1000mg PO q12h

If severe:

Cefazolin 1g IV q8h

OR

Cefuroxime 750mg IV q8h

CA-MRSA:

**Vancomycin 15-20mg/kg q8-12h; not to exceed 2g/dose

Duration: 5 days

*CA-MRSA: IV Vancomycin is used if oral therapy is not feasible

**Refer to Appendix 1 for vancomycin loading dose.

Ciprofloxacin 500mg PO q12h

OR

*Piperacillin/tazobactam 4.5g IV q6 – 8h 

Ceftazidime 2g IV q8h

OR

Cefepime 2g IV q8h 

Duration: 7 days (based on clinical response)

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). 

Severe:

*Piperacillin/tazobactam 4.5g IV q6h-8h

(Deescalate once cultures are available/ Necrotizing fasciitis ruled out)

**Antibiotic Prophylaxis:

Phenoxymethylpenicillin (Penicillin V) 250mg PO q12h (500mg PO q12h if BMI ≥ 33)

Mild:

Amoxicillin/clavulanate 625mg PO q8h

OR

Ampicillin/sulbactam 375mg PO q12h

Moderate:

Ampicillin/sulbactam 3g IV q6h 

OR

Amoxicillin/clavulanate 1.2g IV q8h

OR

Cefazolin 1-2g IV q8h

Severe:

Ampicillin/sulbactam 3g IV q6h

OR

Amoxicillin/clavulanate 1.2g IV q8h

OR

Antibiotic allergy:

Clindamycin 600mg IV q6h 

(Deescalate once cultures are available/ Necrotizing fasciitis ruled out)

Antibiotic Prophylaxis:

Antibiotic allergy:

Clarithromycin 250mg PO q24h

OR

Erythromycin ethylsuccinate 400mg PO q12h

Duration: 5-10 days (longer duration may be required in case of no clinical improvement or if an underlying medication condition is present).

Consider IV to PO switch once patient's condition improves. Refer to Appendix 6.

Refer to Appendix 3 for antibiotic allergy.

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). 

**Antibiotic prophylaxis may be considered in patients with 3 to 4 episodes of recurrent cellulitis per year despite attempts to treat or control predisposing factors such as lymphoedema, obesity, eczema and venous insufficiency. Antibiotic prophylaxis should be continued for one year and to reassess the need for further prophylaxis if indicated thereafter.

Dog/cat/human/rodent/reptile bite:

Amoxicillin/clavulanate 625mg PO q8h

Monkey bite:

Amoxicillin/clavulanate 625mg PO q8h

PLUS

*Acyclovir 800 mg PO 5 times daily for 14 days 

--

Duration: 5 days

*Add acyclovir only when exposed to a macaque via bites and scratches, exposure to tissue culture material, exposure to tissue obtained during autopsies of monkeys, needlestick injuries, cage scratches, mucosal splash.

Azithromycin 500mg PO on Day 1, then 250mg PO q24h for 4 days

--

--

Doxycycline 200mg STAT, then 100mg PO q12h

MAY ADD

*Ceftriaxone 2g IV q24h 

--

*Consider adding third generation cephalosporins in severe infections. 

Trimethoprim/sulfamethoxazole 320/1600mg PO q12h

Ciprofloxacin 400mg IV q12h

OR 

Ciprofloxacin 750mg PO q12h

PLUS 

Cloxacillin 500mg PO q6h 

MAY ADD

*Metronidazole 400mg PO q8h

Oral therapy is encouraged if wounds are not associated with systemic features or involving deeper tissues.

Add metronidazole if wounds immersed in soil- or sewage-contaminated water.  

*Piperacillin/tazobactam 4.5g IV q6-8h

OR

Cefepime 2g IV q8h

--

*Piperacillin/tazobactam: if given as q8h, to be given as extended infusion (over 3 – 4 hours). 

Vancomycin 15-20mg/kg IV q8-12h

In severe infections:

To load with vancomycin 25-30mg/kg IV, followed by 15-20mg/kg (actual body weight) IV q8-12h; not exceeding 2g/dose

Linezolid 600mg IV/PO q12h

IV to PO switch is encouraged once clinically improves. Refer to Appendix 6.

Refer to Appendix 1 for vancomycin loading dose.

Clindamycin 300-600mg IV/PO q6-8h

OR

Doxycyline 100mg PO q12h

OR

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

--

Consider CA-MRSA if:

●   Outbreaks of known CA-MRSA

●   Non-resolving cellulitis

Grade 3-5:

Empirical treatment:

Cloxacillin 1g IV q6h

If blood culture negative and clinical improvement, to switch to oral:

Cloxacillin 500mg PO q6h 

OR

Cephalexin 1000mg PO q12h

Grade 3-5:

Cefazolin 2g IV q8h

Duration: 5 days (depending on clinical response)

Peripheral intravenous catheters with associated pain, induration, erythema, or exudate should be removed.

VISUAL INFUSION PHLEBITIS SCORE

Score 0:

Insertion site healthy, no signs of phlebitis

Score 1:

Presence of one of the following signs: Slight pain or slight redness at IV insertion site.

Score 2:

Presence of 2 of the following signs: 

Pain at IV site, redness or swelling. 

Score 3:

Presence of all of the following signs: 

Pain along the path of the cannula, redness around the insertion site and swelling. 

Score 4:

Presence of all of the following signs: 

Pain along the path of the cannula, redness around the insertion site, swelling, palpable venous cord. 

Score 5:

Presence of all of the following signs: 

Pain along the path of the cannula, redness around the insertion site, swelling, palpable venous cord, febrile. 

Local treatment (debridement and dressing) is preferred.

If there is surrounding cellulitis/signs of bacteremia/ fasciitis/ surrounding intramuscular abscess/ OM changes:

Ampicillin/sulbactam 3g IV q6h 

OR

Amoxicillin/clavulanate 1.2g IV q8h

--

--

Rifampicin 600mg PO once a month (supervised)

PLUS

Dapsone 100mg PO q24h

PLUS

Clofazimine 300mg PO once a month and 50mg PO q24h 

Duration:

Paucibacillary: 6 months

Multibacillary: 1 year

*Bacterial resistance or hypersensitivity to first line:

Can be substituted with one of the following:

Ofloxacin 400mg PO q24h

OR

Minocycline 100mg PO q24h

OR

Clarithromycin 500mg PO q24h

*Second line or drug-resistant regimen can only be initiated by a dermatologist.

Prophylaxis of leprosy with single dose rifampicin for contacts of leprosy patients after excluding leprosy and TB disease, and in the absence of other contraindication:

10-14 years old: 450 mg  

≥15 years old: 600 mg 

Clarithromycin 500mg PO q12h

PLUS

Rifampicin 600mg PO q24h

OR

Ethambutol 25mg/kg PO q24h 

--

Often resistant to isoniazid.

To change the treatment regime based on susceptibility results once available.

For deep tissue involvement, consider 3 drug combination therapy:

Clarithromycin 500mg PO q12h

PLUS

Rifampicin 600mg PO q24h

PLUS

Ethambutol 25mg/kg PO q24h

Duration: continue for another 1 to 2 months of treatment after clinical resolution.

Rifampicin 600mg PO q24h

PLUS

Ethambutol 15mg/kg PO q24h

PLUS

Isoniazid 300mg PO q24h

OR

Clarithromycin 500mg PO q12h

OR

Azithromycin 250mg PO q24h 

--

Duration: minimum of 12 months duration

Rifampicin 10mg/kg PO q24h

PLUS

Clarithromycin 7.5mg/kg PO q12h

Rifampicin 10mg/kg PO q24h

PLUS

Streptomycin 15mg/kg IM q24h for 4 weeks 

Followed by:

Rifampicin 10mg/kg PO q24h

PLUS

Clarithromycin 7.5mg/kg PO q12h

Wide surgical excision and debridement are important.

Duration

WHO category 1:

Pre-ulcerative lesions and skin lesions smaller than 5 cm, duration of antibiotic 4 weeks with simple excision or 8 weeks of antibiotic therapy only

WHO category 2:

Antibiotic at least 8 weeks with supportive care (E.g.: surgery)

WHO category 3:

Lesions > 15cm, antibiotic plus surgical debridement and reconstruction.  Duration of treatment depends on clinical response as complications are common (joint and bone involvement)

Surgical debridement plus 2 active agents depending on the severity of lesions.

Mild disease:

Clarithromycin 500mg PO q12h

OR

Azithromycin 250-500mg PO q24h

OR

Trimethoprim/sulfamethoxazole 160/800mg PO q12h

OR

Minocycline 100mg PO q12h

OR

Ciprofloxacin 750 mg PO q12h

MAY ADD

*Amikacin 15mg/kg IV q24h

Severe disease:

Initial induction with:

Amikacin 15mg/kg IV q24h

OR

Imipenem 1g IV q12h

PLUS

Clofazimine 100-200mg PO q24h

--

Duration: 4-6 months depending on clinical response.

*Amikacin:

Started for severe infection until clinical improvement (together with 2 oral agents), then continue with just 2 oral agents.

Serious skin and soft tissue infection, bone and disseminated disease, immunocompromised host: use 2 drug combination therapy (consider 3 drug for severe infection) for first 2-8 weeks.

To change the treatment regime based on susceptibility results once available.

To consider oral switch once there is clinical improvement, to complete the remaining duration.

Griseofulvin 500mg PO q12h for 6 to 12 weeks or longer until fungal cultures are negative

OR

Terbinafine 250mg PO q24h

PLUS

2.5% selenium sulphide shampoo 

OR 

2% ketoconazole shampoo,

2 – 3 times per week for 2 weeks 

*Itraconazole 5mg/kg PO q24h

OR

Fluconazole 6mg/kg PO q24h

Duration is based on mycological result/ type of treatment agent and clinical response. E.g.:

Trichophyton sp : 2-4 weeks

Microsporum sp : 8-12 weeks

Other recommendations:

• For kerion, griseofulvin should be considered as first line unless Tricophyton has been cultured as the pathogen. Duration of treatment may be longer.

• Contacts of patient may be treated with 2% ketoconazole shampoo 2 – 3 times per week for 2 weeks.

• Surgical excision is to be avoided.

• Topical therapy alone is not recommended for the management of tinea capitis.

• Consider adding oral prednisolone in selected cases.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or oranges drinks). Avoid PPIs and H2 blockers.

Mild infections:

Topical imidazoles or allylamines cream/lotion. E.g.:

Clotrimazole 1%

OR

Miconazole 2%

OR

Ketoconazole

OR

Terbinafine

Duration: Until clinical clearance with additional 2 weeks

Extensive infections:

Terbinafine 250mg PO q24h for 2 weeks

OR

*Itraconazole 200mg PO q24h for 2 weeks

OR

Griseofulvin 500mg PO q12h or q24h for 4-6 weeks

Extensive Infections:

Fluconazole 150-300mg per week PO for 3-4 weeks

Other recommendations:

• In patients with renal or hepatic impairment, caution should be exercised while prescribing systemic antifungals. 

• Terbinafine clearance is significantly reduced in patient with renal impairment. Other systemic antifungals are preferred in these patients.

• Topical nystatin should not be used in dermatophytosis as they are not effective against dermatophytes.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers. 

First line:

Topical antifungals as mentioned in tinea corporis for 4-8 weeks

Resistant cases:

Terbinafine 250mg PO q24h for 2-4 weeks

OR

*Itraconazole 200mg PO q24h for 2-4 weeks

OR

Griseofulvin 500mg PO q12h for 6-12 weeks 

Resistant cases:

Fluconazole 150mg/week PO for 4 weeks 

Other recommendations:

● Topical keratolytic agents can be used in conjunction with antifungals for hyperkeratotic type of tinea pedis/manuum.

● Potassium permanganate in 1:10,000 dilution wet dressings, applied for 20 min 2–3 times/day, may be helpful if vesiculation or maceration is present.

● Systemic antifungals can be prescribed as first line treatment in severe moccasin-type tinea pedis or severe recurrent tinea with blisters.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

*Amorolfine 5% Nail Lacquer once weekly application

Duration:

Fingernails: 6 months

Toenails: 12 months

OR

**Pulse itraconazole 200mg PO q12h for 1 week per month

Duration:

Fingernails: 2 months

Toenails: 3 months

OR

Terbinafine 250mg PO q24h

Duration:

Fingernails: 6 weeks

Toenails: 12 weeks

Griseofulvin 500mg PO q12h

Duration:

Fingernails: 6 months

Toenails: 12 months

OR

Fluconazole 150mg PO once weekly

Duration:

Fingernails:  ≥ 3 months

Toenails: 6-12 months

*Amorolfine 5% Nail Lacquer is not indicated for children less than 12 years old.

Patients with contraindications to systemic agents may consider topical antifungal agents.

Diagnosis of onychomycosis should be confirmed with a KOH preparation test, culture, or PAS Stain. Empirical treatment is not recommended.

**Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

First line: Topical treatment only

Selenium sulphide 2% shampoo;

Apply to affected areas 10 minutes before bathing, or

Dilute to 1:1 with water, apply and leave overnight (treat for 1-2 weeks)

OR

Ketoconazole 2% shampoo, apply to affected areas 10 minutes before bathing

For face:

Topical imidazole for 4-6 weeks. E.g.: Miconazole 2% cream, clotrimazole 1% cream

For recurrent or resistant cases:

*Itraconazole 200mg PO q24h for 1 week or 400mg single dose 

OR 

Fluconazole 300mg PO weekly dose for 2 weeks

Alternative for selenium sulphide and ketoconazole shampoo:

Sulfur preparation

OR

Salicylic solution

Recommendations:

Ketoconazole shampoo or selenium sulphide shampoo can be used once every two to four weeks for approximately six months in order to try and prevent recurrence.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (e.g.: Cola or orange drinks). Avoid PPIs and H2 blockers.

Mild cutaneous candidiasis:

Topical imidazole q12h until clear. E.g.:

Miconazole 2% cream

OR

Clotrimazole 1% cream

Extensive cutaneous candidiasis:

*Itraconazole 200mg PO q24h for 1 week

Extensive cutaneous candidiasis:

Fluconazole 100mg PO q24h for 1 week (in severe and immunocompromised patients)

Treatment of sexual partner is advisable in case of recurrent infection.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

*Itraconazole 200mg PO q12h until all lesions have resolved

(usually for a total of 3–6 months)

For patients not able to tolerate itraconazole:

 Terbinafine 500mg PO q12h

OR

Fluconazole 400mg q24h 

In some immunocompromised condition such as AIDS, longer treatment may be necessary. Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV Patients section.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

**Avoid azole in pregnancy  

Amphotericin B deoxycholate 0.7-1mg/kg IV q24h for 2 weeks

Followed by;

*Itraconazole 200mg PO q12-24h for at least of 12 months duration

**In pregnancy and breastfeeding:

Terbinafine 500mg PO q12h

**In pregnancy and breastfeeding:

Amphotericin B deoxycholate 0.7-1mg/kg IV q24h

In some immunocompromised condition such as AIDS, longer treatment may be necessary. Refer to Infections in Immunocompromised Patients - Opportunistic Infections in HIV Patients section.

*Itraconazole: Absorption depends on gut acidity. Take capsule with food and acidic beverage (E.g.: cola or orange drinks). Avoid PPIs and H2 blockers.

**Avoid azole in pregnancy. 

Voriconazole 6mg/kg IV q12h for 2 doses,

followed by 4mg/kg IV q12h

Amphotericin B (deoxycholate) 0.7–1mg/kg q24h

OR

Amphotericin B (lipid formulation) 3–5mg/kg q24h 

For Lomentospora prolificans, consider surgical debridement and reduction of immunosuppression.

Consider IV to PO switch once clinically improving and can tolerate orally.

Fluconazole 400mg PO q24 h

--

--

Acyclovir 400mg PO q8h 

*Valacyclovir 1g PO q12h

OR

*Famciclovir 500mg PO q12-24h

Duration: 7 days

*Not listed in MOH Drug Formulary

Immunocompromised:

Acyclovir 10mg/kg IV q8h for 7 days (change to oral once there is an improvement)

--

Advisable to start treatment early within 48 hours.

Refer to varicella zoster treatment.

--

Topical antiviral treatment is not recommended for herpes zoster.

Systemic antiviral treatment is recommended for all immunocompromised patients or for  immunocompetent patients with following criteria:

1. >50 years of age 

2. Moderate or severe pain 

3. Moderate or severe rash

4. Non-truncal involvement

Advisable to start treatment early within 48-72 hours.

Apply benzyl benzoate emulsion 25% (EBB) from neck down and leave for 24 hours for 2-3 days

OR

Apply permethrin 5% lotion/cream and leave for 8 hours

Repeat application after 1 week.

In pregnancy/Immunocompromised:

Apply permethrin 5% lotion/cream and leave for 8 hours.

Repeat application after 1 week.

--

Clothing and bedding of persons with scabies should be washed in hot water and dried. 

Apply permethrin 1% lotion to scalp for 10 minutes and wash off

OR

Apply malathion 1% shampoo and leave for 15 minutes and wash off

Repeat application after 1 week.

--

Use special fine-toothed nit comb to reduce risk of re-infestation.

Apply malathion lotion 0.5% for 8-12 hours and wash off

OR

Apply permethrin 1% cream to affected area for 10 minutes and wash off

--

--

Cloxacillin 1-2g IV q6h

OR

Cefazolin 1-2g IV q8h

Amoxicillin/clavulanate 625mg PO q8h

OR

Ampicillin/sulbactam 750mg PO q12h

Antibiotic allergy:

Clindamycin 600mg IV/PO q8h

Surgical drainage is the mainstay of management.

Duration: 10 to 14 days but shorter antibiotic duration (5 to 7 days) can be considered if adequate source control and local wound management has shown clinical improvement.

Refer to Appendix 3 for antibiotic allergy.

Cefazolin 1-2g IV q8h

Amoxicillin/clavulanate 1.2g IV q8h

Antibiotics may be necessary in certain high-risk groups:

• Inhalation injury

• Immunocompromised patients (E.g.: extreme age groups (elderly and children), diabetes mellitus, obesity, impaired immunity)

• Delay in burn wound excision

• Mechanical ventilation

• Total body surface area (TBSA) burn > 20%

Amoxicillin/clavulanate 1.2g IV q8h 

--

Surgical drainage +/- debridement is the mainstay of therapy.

Refer to Otorhinolaryngology Infections section for deep neck space abscess.

Amoxicillin/clavulanate 1.2g IV q8h

Ampicillin/sulbactam 3g IV q6h

Refer to Otorhinolaryngology Infections section for Malignant Otitis Externa.