SKINIPEDIA - Skin Diseases: Erysipelas (St. Anthony's Fire)
Skin Diseases and Conditions: Erysipelas (St. Anthony's Fire)
A Study by Loretta Davis, MD, Professor, Department of Internal Medicine, Division of Dermatology, Medical College of Georgia
Coauthor(s): John A Cole, MD, Resident Physician, Division of Dermatology, University of Florida Health Science Center, Gainesville; Keith Benbenisty, MD, Consulting Staff, Associates in Dermatology, MDs, PA
Medication
The objective of pharmacotherapy is to reduce morbidity and to prevent complications.
Antibiotics
Penicillin is the standard therapy for typical erysipelas, although coverage for S aureus should be considered in the appropriate setting.
Penicillin VK (Wycillin, PenVeeK)
Penicillin G procaine (Wycillin) and penicillin VK (PenVeeK) are currently recommended as first-line agents for the treatment of moderately severe infections of skin and skin structure. In adults, administer penicillin G procaine by deep IM injection only into upper, outer quadrant of buttock. In infants and small children, the midlateral aspect of the thigh may be a better site for administration.
Adult
Penicillin G procaine: 0.6-1.2 million U IM bid for 10 d
Penicillin VK: 250-500 mg PO qid for 10-14 d
Pediatric
Penicillin G procaine:
<30 kg: 300,000 U/d
>30 kg: Administer as in adults
Penicillin VK:
<12 years: 25-50 mg/kg/d PO divided tid/qid; not to exceed 3 g/d
>12 years: Administer as in adults
Increases risk of bleeding when administered concurrently with warfarin; ethacrynic acid, aspirin, indomethacin, and furosemide may compete with penicillin G for renal tubular secretion, increasing penicillin serum concentrations; probenecid can increase effects; coadministration of tetracyclines can decrease effects; may increase methotrexate toxicity; may decrease contraceptive efficacy; may interfere with immunological response to live typhoid vaccine; concurrent administration with aminoglycoside therapy may result in inactivation of aminoglycoside (amikacin appears to possess greatest stability in presence of penicillins; in treatment of severely ill patients requiring both penicillin and aminoglycoside therapy, amikacin is aminoglycoside of choice)
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Never use IV route to administer penicillin G procaine; administer >10 d to eliminate organism and to prevent such complications as endocarditis and rheumatic fever; serious adverse effect includes hemolytic anemia
Dicloxacillin (Dycill, Dynapen)
Treatment of infections caused by penicillinase-producing staphylococci. Penicillinase-resistant penicillin that will cover for S aureus.
Adult
125-500 mg PO qid for 10 d
Pediatric
<40 kg: 12.5 mg/kg/d PO q6h
>40 kg: 125 mg PO q6h
Probenecid may increase effect of penicillins; tetracyclines may decrease effect of penicillins with concurrent use; has been found to reduce anticoagulant effectiveness of warfarin.
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Renal impairment; cross-sensitivity to other penicillin derivatives; breastfeeding; caution in impaired renal function
Nafcillin (Unipen)
Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Because of thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to PO as clinically indicated.
Adult
1-2 g IV qid for 7 d
Infection due to S aureus, penicillinase-producing: 500 mg IV q4h; alternatively, 500 mg IM q4-6h
Severe infection: 1000 mg IV or IM q4h
Pediatric
0-4 kg: 10 mg/kg IM bid
4-40 kg: 25 mg/kg IM bid; alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses
Children: 50 mg/kg/d PO divided qid
Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives; concomitant penicillin and aminoglycoside therapy reported to result in inactivation of aminoglycoside both in vivo and in vitro; nafcillin appears to decrease cyclosporine serum concentrations or interfere with cyclosporine assay
Documented hypersensitivity; hypersensitivity to corn or corn products; dextrose solutions may precipitate an allergic reaction
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Renal impairment; cross-sensitivity to other penicillin derivatives; breastfeeding; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); adverse reactions include hypokalemia and interstitial nephritis; history of significant allergies or asthma; increased risk for allergic reaction; diarrhea subsequent to nafcillin may be indicative of overgrowth of Clostridium difficile resulting in pseudomembranous colitis
Reports of proteinuria associated with high doses of nafcillin indicate this pseudoproteinuria is result of interaction between nafcillin and/or metabolites and quantitative reagents used in TCA (trichloroacetic acid) and sulfosalicylic acid method of urine protein analysis (semiquantitative dipstick technique for estimation of urinary protein [primarily albumin] does not produce this interaction); antibiotics that possess bacterial activity against Salmonella typhi organisms may interfere with immunological response to live typhoid vaccine (allow 24 h or more to elapse between administration of last dose of antibiotic and live typhoid vaccine)
Erythromycin (E-mycin, E.E.S., Eryc)
Macrolide used for penicillin-allergic individuals. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half total daily dose may be taken q12h. For more severe infections, double the dose.
250-500 mg PO qid for 10 d
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection.
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; inhibition of cytochrome P450 3A enzymes by erythromycin (caution with other medications metabolized by these enzymes).
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; hepatotoxicity or skin rash may occur; caution in breastfeeding