SEIP–AEPAP–SEPEAP consensus document on the aetiology, diagnosis and treatment of bacterial skin infections in out-patients

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Conejo-Fernández, M.J. Martínez-Chamorro, J.A. Couceiro, F.A. Moraga-Llop, F. Baquero-Artigao, F. Alvez, A. Vera Casaño, R. Piñeiro-Pérez, S. Alfayate, M.J. Cilleruelo, C. Calvo" "autores" => array:11 [ 0 => array:3 [ "nombre" => "A.J." "apellidos" => "Conejo-Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "M.J." "apellidos" => "Martínez-Chamorro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "J.A." "apellidos" => "Couceiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "F.A." "apellidos" => "Moraga-Llop" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "F." 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"apellidos" => "Calvo" "email" => array:1 [ 0 => "ccalvorey@ono.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Sociedad Española de Infectología Pediátrica (SEIP), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Asociación Española de Pediatría de Atención Primaria (AEPaP), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Regional Universitario Carlos Haya, Málaga, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso SEIP-AEPAP-SEPEAP sobre la etiología, el diagnóstico y el tratamiento de las infecciones cutáneas bacterianas de manejo ambulatorio" ] ] "textoCompleto" => "IntroductionThe skin is the first barrier of the organism against external agents and skin infections, the most frequent reason for paediatric dermatology consultations. The main risk factors are deterioration of the integrity of the skin, poor hygiene, overcrowding, humidity and immunodeficiency.The most prevalent bacteria are Staphylococcus aureus (S. aureus) and Streptococcus pyogenes (S. pyogenes). Both can cause skin infections by direct inoculation, haematogenous dissemination and through the production of toxins,<a class="elsevierStyleCrossRef" href="#bib0205">1</a> as in Staphylococcal scalded skin syndrome by S. aureus and staphylococcus or streptococcus toxic shock syndrome.Based on the system of consensus documents, we will add the strength of the recommendation to our proposed measures, following the classification of the Infectious Diseases Society of America (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0210">2</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Antibiotic treatment of skin infectionsIn general, the antibiotic treatment of skin infections is empirical.<a class="elsevierStyleCrossRef" href="#bib0215">3</a> Blood or aspirate cultures, biopsies and swabs are only recommended under certain circumstances (chemotherapy, neutropoenia, serious immunodeficiency, immersion wounds, animal bites, infection of the general condition, suspicion of complications, extensive infection, suspicion of ecthyma gangrenosum, necrotising fasciitis, admitted patients) or in the event of poor response to treatment. Treatment should be based on clinical analysis, possible microorganism involved, site, extension and depth of the infection, and personal history.Asymptomatic skin infections involving the superficial layers of the skin are usually treated with antiseptics or topical antibiotics; those with the best coverage against common pathogens are mupirocin ointment and fusidic acid cream or ointment. In infections by methicillin-sensitive S. aureus with poor response to mupirocin, retapamulin ointment is a valid alternative in patients aged over 9 months.<a class="elsevierStyleCrossRef" href="#bib0220">4</a>Systemic antibiotic therapy is reserved for certain clinical forms (cellulitis), extensive forms, rapid progression or dissemination, serious cases or patients in generally poor condition (necrotising fasciitis), neonates, cellulitis-adenitis in patients under 3 months of age and in immunodepressed patients. Sometimes, incision and surgical drainage are essential.If there is suspicion of S. aureus, the antibiotic of choice is cloxacilin, although its pharmacological characteristics (administration every 6h, low bioavailability and bad taste) make amoxicillin–clavulanic acid and first-generation cephalosporin (cefadroxil or cefalexin) a reasonable alternative. In the event of contraindication for β-lactams, the drugs of choice are clindamycin (only available in 150 and 300mg capsules in Spain) and trimethoprim-sulfamethoxazole.If there is suspicion of S. pyogenes, the antibiotic of choice is penicillin or amoxicillin. In patients who are allergic to β-lactams, 16-atom macrolides can be used (josamycin or midecamicina), clindamycin or, in the event of non-anaphylactic reaction, first-generation cephalosporin.In infections where both bacteria may be implicated, treatment with amoxicillin–clavulanic acid or a first-generation cephalosporin is indicated.At the time of drafting this document, neither cefadroxil nor cefalexin, the only first-generation cephalosporin with oral presentation, are sold in Spain in suspension form, and only 500mg capsules are available. Under these circumstances, second-generation cephalosporin (cefuroxime, cefaclor), despite being slightly less active against gram-positive cocci than first-generation cephalosporin, is a valid alternative.Main infectious conditionsImpetigoThe onset of impetigo may occur at any age and is transmitted by autoinoculation, direct contact, or contaminated objects. It produces non-scarring epidermal lesions, well delimited, usually in exposed areas. It may be bullous or non-bullous. In the non-bullous form, caused by S. pyogenes, S. aureus (alone or in co-infection) and, occasionally, by group C and G streptococci, the lesions evolve from macula to papules, vesicles and pustules, which finally form a thick meliceric crust. In the bullous form, caused by S. aureus exfoliative toxins, the lesions evolve to vesicles and then to blisters with yellow more or less turbid and even purulent fluid, and finally form a fine crust. The main complication is local dissemination (cellulitis, lymphadenitis) or even systemic complications (pneumonia, osteoarthritis, sepsis).In non-complicated mild cases, topical disinfectants can be used, mupirocin or fusidic acid every 8h, or retapamulin every 12h, for 5–7 days. If the lesions are extensive or with systemic symptoms, oral antibiotic therapy with amoxicillin–clavulanic acid, a first- or second-generation cephalosporin, or cloxacilin is recommended.<a class="elsevierStyleCrossRef" href="#bib0225">5</a>Perianal bacterial dermatitisPerianal bacterial dermatitis consists of an erythema around the anus caused by S. pyogenes or less frequently by S. aureus, alone or associated with S. pyogenes.<a class="elsevierStyleCrossRef" href="#bib0230">6</a> Incidence peaks at 3–5 years of age, predominantly in males (70%), although prevalence is the same in both sexes if vulvovaginitis is included,<a class="elsevierStyleCrossRef" href="#bib0240">8</a> which together with balanoposthitis constitute what is known as perineal disease.It manifests as a non-elevated erythema, measuring 2–3cm, around the anus, with well-delimited edges, sometimes accompanied by pruritus, painful bowel movement, constipation, overflow incontinence, haematochezia and fissures.<a class="elsevierStyleCrossRef" href="#bib0245">9</a> Boys may present with balanoposthitis and girls with vulvovaginitis with secretion and dysuria.<a class="elsevierStyleCrossRef" href="#bib0250">10</a> There are usually no general symptoms, unlike cellulitis. In the acute phase (<6 weeks progression) the lesion is red, bright, humid and painful, and may present a whitish pseudo-membrane. Without treatment, lesions become chronic, with painful fissures, mucous secretion or psoriasis-like plates with yellowish periphery crust. When the cause is staphylococcus, there may be pustules and the erythema extends towards the adjacent skin.<a class="elsevierStyleCrossRef" href="#bib0230">6</a>Patients or members of the household may have presented acute pharyngoamigdalitis or a skin infection<a class="elsevierStyleCrossRef" href="#bib0235">7</a> in the previous 3 months or simultaneously with perianal dermatitis, or be pharyngeal or perianal carriers of S. pyogenes.<a class="elsevierStyleCrossRefs" href="#bib0235">7,8</a> Recurrence after treatment with penicillin or amoxicillin is frequent (up to 37%),<a class="elsevierStyleCrossRef" href="#bib0255">11</a> especially if there are non-diagnosed cases in relatives.It is believed that transmission is by contact, whether through autoinoculation (infection or pharyngeal or skin carrier) or interfamilial contagion, especially if bath water is shared<a class="elsevierStyleCrossRef" href="#bib0250">10</a> or if a relative has presented acute pharingoamigdalitis or perianal dermatitis.<a class="elsevierStyleCrossRef" href="#bib0235">7</a>Diagnosis is based on clinical analysis and confirmation is bacteriological. Samples from the perianal area must be gathered from all patients (A-II) and pharyngeal samples if there are symptoms (B-III), for a rapid antigen detection test for S. pyogenes (100% positive predictive value)<a class="elsevierStyleCrossRef" href="#bib0235">7</a> or a culture. If the result of the test is negative, it is recommended to prepare a culture due to the possibility of false negatives or S. aureus as a cause of the condition (A-II). Potential cases in persons cohabiting with the patient should be investigated and a rapid diagnostic test or a culture for symptomatic patients (B-III) carried out, since this is a frequent cause of recurrences within the family.Although good results have been reported with topical antibiotic therapy in monotherapy (B-II), the use of systemic antibiotics is recommended in all cases (A-II). If no rapid diagnostic test available or if it is positive, oral treatment with penicillin or amoxicillin for 10 days is recommended (B-II), which may be prolonged to 14–21 days based on clinical progress (C-III).<a class="elsevierStyleCrossRef" href="#bib0250">10</a> If there is no response after one cycle of amoxicillin, or if the diagnostic test was negative, and while waiting for the result of the culture, amoxicillin–clavulanic acid may be used (C-III).When choosing the initial antibiotic therapy, a familial history of streptococci or staphylococcus infection must be taken into consideration (C-II).For recurrent infection cefuroxime is recommended<a class="elsevierStyleCrossRef" href="#bib0255">11</a> for 7–10 days (C-II). The association of oral and topic treatment seems to decrease recurrences (A-II).<a class="elsevierStyleCrossRef" href="#bib0230">6</a>Infections of hair follicles: folliculitis, furuncle and carbuncleThe aetiological agent of hair follicle infection is S. aureus, followed by gram-negative bacilli. Predisposing factors include obesity, diabetes, hyperhidrosis, immunosuppression and atopical dermatitis.Clinically, patients present with lesions on hair-bearing sites on the face, neck, armpits or glutei, ranging from a papule-vesicle with a erythematosus base (folliculitis, which affects the superficial hair follicle), to tender erythematosus nodules (furuncle, extending to the deep dermis), to warm, tender, erythematous plaques (carbuncle, affecting the surrounding subcutaneous cellular tissue).The diagnosis is clinical and a microbiological study is only recommended for lesions that are atypical or respond poorly to treatment.<a class="elsevierStyleCrossRef" href="#bib0260">12</a>Treatment is initially topical with mupirocin or fusidic acid, and in recurrent or extensive forms not responding to topical treatment, a combination of amoxicillin–clavulanic acid, clindamycin, cefadroxil, cefalexin or cefuroxime. For furuncles and carbuncles, it is recommended to apply local heat and assess the possibility of making an incision and surgical drainage.Acute bacterial lymphangitisThis is defined as the inflammation of the lymphatic vessels of the subcutaneous tissue. The organisms most frequently involved are S. pyogenes, S. aureus and Pasteurella multocida (P. multocida) (the latter after an animal bite). There is usually systemic involvement, even before the distal oedema and linear cord to regional nodes are evident.Empirical treatment in mild to moderate forms is amoxicillin–clavulanic acid or a first- or second-generation cephalosporin.ErysipelasThis is a superficial infection affecting the superior dermis, the subcutaneous cellular tissue and sometimes the lymphatic system, in most cases caused by S. pyogenes or streptococci of groups B, C or G.<a class="elsevierStyleCrossRefs" href="#bib0205">1,13–18</a>The triggering factors include abrasions, ulcers, intertriginous fungal infections of the feet, venous or lymphatic obstruction and chronic oedema. In neonates, the infection may originate in the umbilical cord and extend to the abdominal wall.Onset is acute, characterised by an erythematosus plate with well-defined and slightly elevated edges. It is more frequent in lower limbs and face, and may be associated with regional lymphadenitis. There are usually general symptoms (fever, chills, discomfort), sometimes before cutaneous signs. Systemic complications are also possible (sepsis, streptococcal toxic-shock syndrome, endocarditis, etc.), although they are rare in otherwise healthy patients. When the infection is resolved it produces scaling and hyperpigmentation.The diagnosis is clinical (A-II); haemocultures and cultures of skin biopsies or aspirates have a low yield.Treatment consists of administration of oral penicillin or amoxicillin (A-III).<a class="elsevierStyleCrossRef" href="#bib0205">1</a> Patients with lesions of more than 5cm or generally poor condition, infants and immunodepressed patients may require hospitalisation and parenteral treatment (A-II). The care of wounds and their predisposing factors are also important aspects of the treatment (A-II).CellulitisThis is an acute infection affecting the dermis and subcutaneous cellular tissue. Predisposing factors include trauma, wounds and pre-existing infections. It appears as a warm, tender, poorly defined erythematous plaque, which sometimes causes phlyctena, petechial or local necrosis and may be accompanied by lymphadenitis and systemic symptoms.<a class="elsevierStyleCrossRef" href="#bib0285">17</a>The main cause is S. aureus and S. pyogenes. Other less frequent microorganisms are Streptococcus agalactiae and gram-negative bacilli in neonates and enterobacteria in immunosuppressed patients.Its location may provide an aetiological orientation: in the periauricular region and the sole of the foot with puncture wounds P. aeruginosa is more frequent, while in bites, P. multocida is common.The diagnosis is clinical, but a microbiological study is recommended in the cases discussed in the section on general treatment. An ultrasound scan may be useful to differentiate cellulitis from non-fluctuant abscesses.A systemic antibiotic treatment with good coverage against S. aureus and S. pyogenes must always be recommended. In mild cases and under strict surveillance, oral treatment with amoxicillin–clavulanic acid, cloxacilin, cefadroxil, cefalexin, cefuroxime or clindamycin may be considered.<a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> summarise of other infectious conditions of clinical relevance, and <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> details the recommended dosage of the most widely used anti-infective drugs.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Superinfection of bite or puncture woundsMost superinfections of the wounds produce clinical manifestations in the first 12h, generally erythema, pain or some other type of secretion through the wound. In human bites, fever above 38°C, abscess and lymphagitis are established criteria of superinfection, as well as the presence of at least 4 of the following: erythema extending more than 3cm from the edge of the wound, pain on palpation, inflammation, purulent drainage or leukocyte count of over 12,000cells/ml.In superinfections of puncture wounds in the foot, clinical symptoms usually begin during the first 5–7 days if the causative agent is Staphylococcus, and after 7 days if it is produced by Pseudomonas. It is important to note the infection of bones and deep tissues.<a class="elsevierStyleCrossRefs" href="#bib0315">23,24</a>In addition to local cleaning and debridement, prophylactic antibiotic treatment is recommended only in the cases listed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> (A-I) and according to the guidelines in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Standard prophylaxis should always be considered in the case of rabies, tetanus and other diseases transmitted through wounds.Community-acquired methicillin- resistant S. aureusEpidemiologyIn the United States, where up to 80% of staphylococci isolated in ambulatory patients are resistant to methicillin, Community-acquired methicillin- resistant S. aureus (CA-MRSA) represents a public health problem.<a class="elsevierStyleCrossRef" href="#bib0325">25</a> In Spain, some studies in paediatric populations report a frequency of resistance to methicillin in S. aureus of 9–14.8%,<a class="elsevierStyleCrossRefs" href="#bib0330">26–29</a> but there are no studies at the national level. The frequency in neonates was investigated in the Community of Madrid<a class="elsevierStyleCrossRef" href="#bib0350">30</a> from 2007 to 2009, and a prevalence of 3.3% was reported.The role of methicillin resistance as an indicator of seriousness is starting to be questioned, and more relevance is being given to other virus factors, such as Panton–Valentine leukocidin (PVL),<a class="elsevierStyleCrossRef" href="#bib0360">32</a> although most strains of PVL are also resistant to methicillin.<a class="elsevierStyleCrossRefs" href="#bib0355">31,33</a> Nosocomial MRSA is associated with certain multidrug-resistant genotypes, but this is not the case in CA-MRSA, which only rarely presents resistance to macrolides and lincosamides.<a class="elsevierStyleCrossRefs" href="#bib0335">27,31,33</a>Clinical symptoms and diagnosisAlthough they may cause pneumonia, sepsis and osteoarthritis, most CA-MRSA infections are limited to the skin and soft tissues.There are no clinical criteria to differentiate skin infections produced by methicillin-sensitive S. aureus from those caused by MRSA,<a class="elsevierStyleCrossRef" href="#bib0370">34</a> although in the latter, therapeutic failure and formation of abscesses and necrosis with black superficial crust similar to a spider bite are more frequent.<a class="elsevierStyleCrossRef" href="#bib0215">3</a> Given the implications for treatment, any non-fluctuant lesions suggestive of abscesses detected during physical examination should be studied under ultrasound examination (C-III). If possible, it is recommended to take samples for culture, determination of LPV and genetic profiling.TreatmentThe current low incidence of AC-MRSA in the paediatric population does not justify amending empirical antibiotic therapy guidelines. However, under certain circumstances changes must be considered, such as extensive cellulitis, abscesses or necrosis, the presence of recurrent abscesses in children or in other members of their household, poor response to conventional treatment, patients living in highly endemic areas (Asia, America or Eastern Europe) or living with known carriers (C-III).In minor, non-suppurating infections (impetigo, mild superinfection of wounds, etc.), topical treatment with mupirocin is usually sufficient<a class="elsevierStyleCrossRef" href="#bib0375">35</a> (A-III). In skin abscesses, incision and early surgical drainage are essential. This has been shown to be effective with otherwise healthy patients with non-complicated infections to achieve full healing with no adjuvant antibiotic therapy<a class="elsevierStyleCrossRefs" href="#bib0375">35–38</a> (A-II). Systemic antibiotic treatment is recommended in other localised infections, as adjuvant if drainage has been incomplete, if there is intense local infection (abscesses of more than 5cm) and in patients under 2 years of age or with other risk factors (immunosuppression, moderate-serious atopical dermatitis, etc.) (A-III).The drug of first choice is oral clindamycin, which also inhibits the production of LPV<a class="elsevierStyleCrossRef" href="#bib0375">35</a> (A-II). Trimethoprim–sulfamethoxazole is an effective alternative in areas where there is high resistance to clindamycin (A-II), in the event of intolerance, or when capsules are not suitable for the patient. Linezolid must be avoided in mild-moderate infections, because it is expensive, has potential adverse effects and leads to development of resistances. The presence of LPV does not require changes in the therapeutic approach although it is associated with a greater need for incision and surgical drainage.<a class="elsevierStyleCrossRefs" href="#bib0215">3,31</a>If empirical treatment is initiated with any of these drugs, changing to a betalactamic is recommended as soon as its sensitivity can be proved.Study and treatment of carriersIt is estimated that 19.3% of the Spanish population is colonised by S. aureus, of which only 1.3% are MRSA.<a class="elsevierStyleCrossRef" href="#bib0395">39</a> The most frequent areas of colonisation are the nostrils, but axilla inguinal and intestinal carriers have also been described.<a class="elsevierStyleCrossRef" href="#bib0400">40</a> Considering the low incidence of MRSA in paediatrics, the systematic study of persons living with the patient is not recommended, and should be limited to outbreaks in limited communities (families, institutions, etc.) and recurrent infections<a class="elsevierStyleCrossRef" href="#bib0215">3</a> (C-III). In these cases, decolonisation in the child and carriers living in their household should consist of nasal mupirocin every 12h and washing the body and hair with 4% chlorhexidine soap for 5–10 days (C-III). In the event of therapeutic failure with mupirocin, topical fusidic acid every 12h along with oral trimethoprim–sulfamethoxazole for 7 days should be used<a class="elsevierStyleCrossRefs" href="#bib0215">3,35</a> (C-III).PreventionThe main transmission pathway seems to be intimate skin-to-skin contact.<a class="elsevierStyleCrossRef" href="#bib0400">40</a> General prevention measures consist in minimising the risk of skin trauma (use of protection during sports activities, etc.) (C-III), keeping wounds clean and covered (A-III), frequent hand washing and body hygiene (A-III), avoiding sharing towels and clothes (A-III) and proper disposal of contaminated objects<a class="elsevierStyleCrossRefs" href="#bib0375">35,40</a> (C-III).Conflict of interestThe authors declare that there are no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres600541" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec614787" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres600542" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec614786" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Antibiotic treatment of skin infections" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Main infectious conditions" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Impetigo" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Perianal bacterial dermatitis" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Infections of hair follicles: folliculitis, furuncle and carbuncle" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Acute bacterial lymphangitis" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Erysipelas" ] 5 => array:2 [ "identificador" => "sec0090" "titulo" => "Cellulitis" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Superinfection of bite or puncture wounds" ] ] ] 7 => array:3 [ "identificador" => "sec0095" "titulo" => "Community-acquired methicillin- resistant S. aureus" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Epidemiology" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Clinical symptoms and diagnosis" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Treatment" ] 3 => array:2 [ "identificador" => "sec0075" "titulo" => "Study and treatment of carriers" ] 4 => array:2 [ "identificador" => "sec0080" "titulo" => "Prevention" ] ] ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-12-16" "fechaAceptado" => "2015-01-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec614787" "palabras" => array:4 [ 0 => "Bacterial skin infections" 1 => "Staphylococcus aureus" 2 => "Streptococcus pyogenes" 3 => "Treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec614786" "palabras" => array:4 [ 0 => "Infecciones cutáneas bacterianas" 1 => "Staphylococcus aureus" 2 => "Streptococcus pyogenes" 3 => "Tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Skin infections are a common cause for dermatological consultations in the paediatric setting. A review is presented of the clinical manifestations, diagnosis and treatment of the main bacterial skin infections, as well as the diagnosis and treatment of super-infected puncture and bite wounds. The most prevalent bacteria in skin infections are Staphylococcus aureus and Streptococcus pyogenes. Treatment is usually empirical, since microbiological studies are only recommended under certain circumstances or lack of improvement with common therapies. Superficial skin infections can be treated with local antiseptics or antibiotics (mupirocin or fusidic acid). Systemic treatment is usually reserved for patients with extensive or severe disease or with other risk factors. Systemic treatment depends on the suspected infecting bacteria, with penicillin, amoxicillin, amoxicillin–clavulanic acid and first- or second-generation cephalosporin being the most frequently used drugs. Due to the low incidence of community-acquired methicillin-resistant infection by S. aureus in Spain, the use of clindamycin or co-trimoxazole is only recommended after severe disease, relapses or a clear epidemiological background." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las infecciones cutáneas constituyen un motivo de consulta frecuente en dermatología pediátrica. Se revisan las manifestaciones clínicas, el diagnóstico y el tratamiento de los principales cuadros infecciosos bacterianos de la piel, así como de la sobreinfección de las heridas punzantes y por mordedura. Las bacterias más prevalentes en las infecciones cutáneas son Staphylococcus aureus (S. aureus) y Streptococcus pyogenes. El tratamiento es generalmente empírico y solo ante determinadas circunstancias o mala evolución clínica se recomienda el estudio microbiológico. Las infecciones cutáneas superficiales pueden tratarse con antisépticos y antibióticos tópicos (mupirocina o ácido fusídico). El tratamiento sistémico se reserva para formas extensas, graves o con otros factores de riesgo del huésped. En estos casos, el antibiótico de elección dependerá, entre otros factores, de los patógenos sospechados; los más utilizados son penicilina, amoxicilina, amoxicilina-ácido clavulánico y cefalosporinas de primera o segunda generación. Considerando la baja incidencia de S. aureus resistente a la meticilina de adquisición comunitaria en nuestro país, no se recomienda modificar el tratamiento empírico salvo en circunstancias de especial gravedad, recurrencia o antecedente epidemiológico, en cuyo caso el tratamiento recomendado es clindamicina o trimetoprima-sulfametoxazol." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Conejo-Fernández AJ, Martínez-Chamorro MJ, Couceiro JA, Moraga-Llop FA, Baquero-Artigao F, Alvez F, et al. Documento de consenso SEIP–AEPAP–SEPEAP sobre la etiología, el diagnóstico y el tratamiento de las infecciones cutáneas bacterianas de manejo ambulatorio. An Pediatr (Barc). 2016;84:121." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Taken from Khan et al.<a class="elsevierStyleCrossRef" href="#bib0210">2</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Strength of recommendation</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">A \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good evidence to support a recommendation for use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">B \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate evidence to support a recommendation for use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">C \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Poor evidence to support a recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">D \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate evidence to support a recommendation against use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">E \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Good evidence to support a recommendation against use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Quality of the evidence</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Evidence from at least one properly randomised, controlled trial \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Evidence from at least 1 well-designed clinical trial, without randomization; from cohort or case-controlled analytic studies (preferably from more than 1 centre); from multiple time series; or from dramatic results from uncontrolled experiments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Evidence from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982529.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Strength of recommendation and quality of evidence." ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Taken from Moraga-Llop and Tobeña Rue<a class="elsevierStyleCrossRef" href="#bib0290">18</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomical location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infection \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Scalp \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Abscesses in new borns \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Fingers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Paronychia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blistering distal dactylitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lower limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cellulitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Erysipelas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Folliculitis by P. aeruginosa (hot tubs, depilation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lymph nodes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adenophyllum \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sweat glands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Eccrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Periporitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Apocrine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hydrosadenitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Lips \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Angular cheilitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cheeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Erysipelas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bacterial cellulitis: pneumococci, Haemophilus influenzae type b \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Cellulitis-adenitis syndrome by S. agalactiae \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Umbilicus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Neonatal omphalitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Outer ear \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Auricular chondritis (piercing) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Eyelids \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Periorbital cellulitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Perineum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Perianal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Balanopreputial \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Perianal bacterial disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vulvovaginal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Sole of the foot \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Infection by P. aeruginosa (puncture wound, shoes) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pitted keratolysis (keratolysis plantare sulcatum) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Skin folds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Erythrasma by Corynebacterium minutissimumIntertrigo by S. pyogenes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982531.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical forms of most frequent bacterial skin infections according to their location of preference." ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aetiology \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Predisposing factors \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical analysis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Blistering distal dactylitis<a class="elsevierStyleCrossRefs" href="#bib0280">16–18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Soft part of the fingersInfrequent: other surfaces of palms and soles \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. pyogenesLess frequent: S. aureus, S. agalactiae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wounds, atopic dermatitis, humidity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blister with purulent fluid, slightly tender, with erythematous baseNo general symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: culture<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incision and drainage+amoxicillin–clavulanic acid 10 daysIf there is poor response cephalosporin, clindamycinMupirocin: optional (not in monotherapy) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ecthyma<a class="elsevierStyleCrossRefs" href="#bib0285">17–19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lower and upper limbs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. pyogenes, S. aureus copathogen? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pruritic lesions: bites, scabies, pediculosis; poor hygiene; malnutrition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ulcer with black crust that becomes chronic and heals leaving a scarComplications:cellulitis lymphagitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: Gram stain and culture of exudate or biopsy of deep tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Removal of crusts with moist dressingsTopical fusidic acid/mupirocin if the lesion is small (<2cm)Oral 1st generation cephalosporin/amoxicillin–clavulanic acid/macrolide 7 days<a class="elsevierStyleCrossRef" href="#bib0375">35</a>Consider admission \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Ecthyma gangrenosum<a class="elsevierStyleCrossRefs" href="#bib0285">17,18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Perineum, glutei, lower limbs, apocrine areas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">P. aeruginosaOther bacteria, fungi and virus (immunosuppressed) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Immunosuppression (serious neutropenia), healthy infants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Necrotic ulcer with black crust (bacterial vasculitis of small veins)Sepsis by P. aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: culture of the lesions, haemocultures, skin biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Early systemic treatment (intravenous) anti-Pseudomonas sp. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Erythrasma<a class="elsevierStyleCrossRef" href="#bib0290">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Humid body folds: interdigital spaces of feet, groins, armpits, infra-mammalian and interglutei areas \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corynebacterium minutissimun, mixed flora, S. pyogenes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heat, humidity, obesity, maceration of the skin, diabetes mellitus, bad hygiene \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Red/brown lesions with irregular well-defined, slightly scalingMild pruritus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalWood's lamp: reddish fluorescence<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>Confirmation: methylene/Gram blue staining<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Topical with erythromycin, clindamycin, mupirocin, imidazoles or Whitfield's solution<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> 2 times a dayExtensive or persistent cases:oral clarithromycin for 10–14 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Hidradenitis<a class="elsevierStyleCrossRefs" href="#bib0285">17,22</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Axilla, groins, perineum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus, Oropharyngeal anaerobes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heat, humidity, hormonal changes, poor hygiene \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Painful nodules causing abscesses leaving hypertrophic scars or fistulasVery frequent recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: culture<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Strict hygiene+topical antiseptics/antibiotics+early oral amoxicillin–clavulanic acid/clindamycin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Neonatal omphalitis<a class="elsevierStyleCrossRef" href="#bib0300">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Umbilicus or umbilical cord \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Gram-negative bacilliS. aureusS. pyogenesLess frequent:anaerobes, mixed infections \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Delivery at home or areas with poor health resources, improper care of cord prematurity, chorioamnionitis, premature rupture of membranes, etc. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Erythema, oedema and bad periumbilical odour, sometimes accompanied by secretion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: exudate culture<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mild:–chlorhexidine+mupirocinModerate–serious:–admission, intravenous antibiotic therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Acute paronychia<a class="elsevierStyleCrossRef" href="#bib0290">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nail folds \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus or mixed aerobe flora (S. pyogenes, Pseudomonas sp.) or anaerobe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Microtrauma, humidity, irritants (onychophagia, finger suction), contact dermatitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Warn fold, red, swollen, painful and frequently with pus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: culture<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superficial: warm, moist dressings, 2–3 times a dayDeep: incision and drainage+oral amoxicillin–clavulanic acid or cefadroxil 7 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Periporitis<a class="elsevierStyleCrossRefs" href="#bib0310">22,24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Occipital region, big folds, back and glutei \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Humidity, lack of hygiene, malnutrition, chronic diseases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mild form: miliaria pustulosaSerious form: nodules, abscesses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalConfirmation: culture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Avoid hyperhidrosisMild form: antiseptics (zinc sulfate)/mupirocinSerious form: incision and drainage+oral amoxicillin–clavulanic acid+topical mupirocin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Pitted keratolysis<a class="elsevierStyleCrossRef" href="#bib0305">21</a>Keratolysis plantare sulcatum<a class="elsevierStyleCrossRefs" href="#bib0280">16,24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Soles of the feetRare: palms of the hands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Corynebacterium sp.Others: Dermatophilus congolensis and Kytococcus sedentarius \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Humidity: hyperhidrosis, closed shoes, prolonged submersion in water \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Superficial depressions of the epidermis (pitted), sometimes with linear pattern (sulcatum), bad odour, sometimes burning, stinging \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalWood's lamp coral red fluorescence<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a>Confirmation: culture<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Treatment of hyperhidrosis+wash with antiseptic soap +topical erythromycin, clindamycin, fusidic acid or mupirocinImidazoles+topical urea or Whitfield solution<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a>2 times a day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cellulitis-adenitis syndrome<a class="elsevierStyleCrossRef" href="#bib0325">25</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Face and neck: cheeks, submandibular region \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">S. agalactiae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Colonisation of mucosa? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">New-borns (2–6 weeks)Facial/submandibular cellulitisFever, irritability, refusal to feedIpsilateral acute otitis mediaBacteraemia: sepsis/meningitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ClinicalAspirate cultureHaemocultureLumbar puncture: Gram staining, culture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Admission and intravenous treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982530.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Not necessary in typical cases." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Whitfield's solution: 6–12% benzoic acid and 3–6% Vaseline-based salicylic acid." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Not so useful due to high risk of contamination. Always assess clinical context." ] ] ] "descripcion" => array:1 [ "en" => "Other clinical forms of bacterial skin infections." ] ] 3 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drugs \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dosage \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum permissible dose \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Penicillin V \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25–50mg/kg/d every 6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cloxacilin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50mg/kg/d every 6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Amoxicillin (±clavulanic acid) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50–60mg/kg/d every 8–12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefadroxil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25–50mg/kg/d every 12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefalexin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20–25mg/kg/d every 6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2g \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefuroxime \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 months–5 years: 15mg/kg/d every 12h5–12 years: 125mg/12h>12 years: 250mg/12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cefaclor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20mg/kg/d every 8h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clarithromycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15mg/kg/d every 12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Josamycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30–50mg/kg/d every 12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Midecamicin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35–50mg/kg/d every 8–12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Clindamycin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10–30mg/kg/d every 6h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8g/d \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Trimethoprim–sulfamethoxazole (TMP–SMX) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6–12mg TMP/kg/d every 12h30–60mg SMX/kg/d every 12h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">TMP: 320mg/dSMX: 1600mg/d \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982532.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "General duration of the treatment: 7–10 days, except for perianal bacterial dermatitis treated with penicillin or amoxicillin (10–21 days) and erysipelas (10–14 days)." ] ] ] "descripcion" => array:1 [ "en" => "Posology of most used oral antibiotics in bacterial skin infections.<a class="elsevierStyleCrossRef" href="#tblfn0020">a</a>" ] ] 4 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Taken from Bangert et al.<a class="elsevierStyleCrossRef" href="#bib0325">25</a>." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cat and human bites \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dog bites with delay in assistance of >8h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dog bites in hands, feet and face \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Deep puncture wounds \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Wounds with crushing, oedema or requiring debridement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Wounds with infection of tendons, muscles or joints \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Wounds with underlying fractures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Puncture wounds in the sole of the foot with delay in assistance of >24h, with extensive involvement or devitalised tissue \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Underlying disease: immunodepression, risk of endocarditis, chronic pneumopathy, chronic hepatopathy, diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982533.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Indications of antibiotic prophylaxis in bites and puncture wounds.<a class="elsevierStyleCrossRef" href="#bib0325">25</a>" ] ] 5 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Taken from Álvez González.<a class="elsevierStyleCrossRef" href="#bib0315">23</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganisms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Allergy to penicillin. \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dog bite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pasteurella canisCapnocytophaga canimorsus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Amoxicillin–clavulanic acid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No anaphylaxis:– 2nd or 3rd generation cephalosporin+clindamycinAnaphylaxis:– Trimethoprim–sulfamethoxazole+clindamycin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Cat bite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pasteurella multocidaPasteurella septicaCorynebacteriumBartonella henselae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Dog and cat bites \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">StaphylococcusStreptococcusEnterococcusAnaerobes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Human bite \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Streptococcus anginosusStaphylococus aureusEikenella corrodensFusobacteriumPeptostreptococcusPrevotella \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Puncture wound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Staphylococus aureusBeta-haemolytic StreptococcusAnaerobesPseudomonas aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wound for <7 daysCefadroxilAmoxicillin–clavulanic acid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wound for <7 daysNo anaphylaxis:–cefadroxilAnaphylaxis:–clindamycin \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Wound on foot for >7 daysHospital admissionIntravenous antibiotic therapy antipseudomonic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab982534.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Infections secondary to bites and puncture wounds.<a class="elsevierStyleCrossRef" href="#bib0315">23</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:40 [ 0 => array:3 [ "identificador" => "bib0205" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.L. Stevens" 1 => "A.L. Bisno" 2 => "H.F. Chambers" 3 => "E. Patchen" 4 => "A.J. Goldstein" 5 => "S.L. Gorbach" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/cid/ciu444" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2014" "volumen" => "59" "paginaInicial" => "e10" "paginaFinal" => "e52" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24973422" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0210" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Quality and strength of evidence of the Infectious Diseases Society of America clinical practice guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.R. Khan" 1 => "S. Khan" 2 => "V. Zimmerman" 3 => "L.M. Baddour" 4 => "I.M. Tleyjeh" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1086/656735" "Revista" => array:6 [ "tituloSerie" => "Clin Infect Dis" "fecha" => "2010" "volumen" => "51" "paginaInicial" => "1147" "paginaFinal" => "1156" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20946067" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0215" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infecciones por Staphylococcus aureus resistente a meticilina adquirido en la comunidad en niños" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M.A. Frick" 1 => "F.A. Moraga-Llop" 2 => "R. Bartolomé" 3 => "N. Larrosa" 4 => "M. Campins" 5 => "Y. Roman" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.eimc.2010.01.007" "Revista" => array:6 [ "tituloSerie" => "Enferm Infecc Microbiol Clin" "fecha" => "2010" "volumen" => "28" "paginaInicial" => "675" "paginaFinal" => "679" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20678828" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0220" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Infecciones por estafilococo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. 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Spanish Association of Paediatrics

SEIP–AEPAP–SEPEAP consensus document on the aetiology, diagnosis and treatment of bacterial skin infections in out-patients

Documento de consenso SEIP-AEPAP-SEPEAP sobre la etiología, el diagnóstico y el tratamiento de las infecciones cutáneas bacterianas de manejo ambulatorio

A.J. Conejo-Fernándeza, M.J. Martínez-Chamorrob, J.A. Couceiroc, F.A. Moraga-Llopa, F. Baquero-Artigaoa, F. Alveza, A. Vera Casañod, R. Piñeiro-Péreza, S. Alfayatea, M.J. Cillerueloa, C. Calvoa,

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ccalvorey@ono.com

Corresponding author.

a Sociedad Española de Infectología Pediátrica (SEIP), Spain

b Asociación Española de Pediatría de Atención Primaria (AEPaP), Spain

c Sociedad Española de Pediatría Extrahospitalaria y Atención Primaria (SEPEAP), Spain

d Servicio de Dermatología, Hospital Regional Universitario Carlos Haya, Málaga, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The skin is the first barrier of the organism against external agents and skin infections&#44; the most frequent reason for paediatric dermatology consultations&#46; The main risk factors are deterioration of the integrity of the skin&#44; poor hygiene&#44; overcrowding&#44; humidity and immunodeficiency&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The most prevalent bacteria are <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41; and <span class="elsevierStyleItalic">Streptococcus pyogenes</span> &#40;<span class="elsevierStyleItalic">S&#46; pyogenes</span>&#41;&#46; Both can cause skin infections by direct inoculation&#44; haematogenous dissemination and through the production of toxins&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> as in <span class="elsevierStyleItalic">Staphylococcal</span> scalded skin syndrome by <span class="elsevierStyleItalic">S&#46; aureus</span> and staphylococcus or streptococcus toxic shock syndrome&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Based on the system of consensus documents&#44; we will add the strength of the recommendation to our proposed measures&#44; following the classification of the Infectious Diseases Society of America &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Antibiotic treatment of skin infections</span><p id="par0020" class="elsevierStylePara elsevierViewall">In general&#44; the antibiotic treatment of skin infections is empirical&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> Blood or aspirate cultures&#44; biopsies and swabs are only recommended under certain circumstances &#40;chemotherapy&#44; neutropoenia&#44; serious immunodeficiency&#44; immersion wounds&#44; animal bites&#44; infection of the general condition&#44; suspicion of complications&#44; extensive infection&#44; suspicion of ecthyma gangrenosum&#44; necrotising fasciitis&#44; admitted patients&#41; or in the event of poor response to treatment&#46; Treatment should be based on clinical analysis&#44; possible microorganism involved&#44; site&#44; extension and depth of the infection&#44; and personal history&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Asymptomatic skin infections involving the superficial layers of the skin are usually treated with antiseptics or topical antibiotics&#59; those with the best coverage against common pathogens are mupirocin ointment and fusidic acid cream or ointment&#46; In infections by methicillin-sensitive <span class="elsevierStyleItalic">S&#46; aureus</span> with poor response to mupirocin&#44; retapamulin ointment is a valid alternative in patients aged over 9 months&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Systemic antibiotic therapy is reserved for certain clinical forms &#40;cellulitis&#41;&#44; extensive forms&#44; rapid progression or dissemination&#44; serious cases or patients in generally poor condition &#40;necrotising fasciitis&#41;&#44; neonates&#44; cellulitis-adenitis in patients under 3 months of age and in immunodepressed patients&#46; Sometimes&#44; incision and surgical drainage are essential&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">If there is suspicion of <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; the antibiotic of choice is cloxacilin&#44; although its pharmacological characteristics &#40;administration every 6<span class="elsevierStyleHsp" style=""></span>h&#44; low bioavailability and bad taste&#41; make amoxicillin&#8211;clavulanic acid and first-generation cephalosporin &#40;cefadroxil or cefalexin&#41; a reasonable alternative&#46; In the event of contraindication for &#946;-lactams&#44; the drugs of choice are clindamycin &#40;only available in 150 and 300<span class="elsevierStyleHsp" style=""></span>mg capsules in Spain&#41; and trimethoprim-sulfamethoxazole&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">If there is suspicion of <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#44; the antibiotic of choice is penicillin or amoxicillin&#46; In patients who are allergic to &#946;-lactams&#44; 16-atom macrolides can be used &#40;josamycin or midecamicina&#41;&#44; clindamycin or&#44; in the event of non-anaphylactic reaction&#44; first-generation cephalosporin&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In infections where both bacteria may be implicated&#44; treatment with amoxicillin&#8211;clavulanic acid or a first-generation cephalosporin is indicated&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">At the time of drafting this document&#44; neither cefadroxil nor cefalexin&#44; the only first-generation cephalosporin with oral presentation&#44; are sold in Spain in suspension form&#44; and only 500<span class="elsevierStyleHsp" style=""></span>mg capsules are available&#46; Under these circumstances&#44; second-generation cephalosporin &#40;cefuroxime&#44; cefaclor&#41;&#44; despite being slightly less active against gram-positive cocci than first-generation cephalosporin&#44; is a valid alternative&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main infectious conditions</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Impetigo</span><p id="par0055" class="elsevierStylePara elsevierViewall">The onset of impetigo may occur at any age and is transmitted by autoinoculation&#44; direct contact&#44; or contaminated objects&#46; It produces non-scarring epidermal lesions&#44; well delimited&#44; usually in exposed areas&#46; It may be bullous or non-bullous&#46; In the non-bullous form&#44; caused by <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;alone or in co-infection&#41; and&#44; occasionally&#44; by group C and G streptococci&#44; the lesions evolve from macula to papules&#44; vesicles and pustules&#44; which finally form a thick meliceric crust&#46; In the bullous form&#44; caused by <span class="elsevierStyleItalic">S&#46; aureus</span> exfoliative toxins&#44; the lesions evolve to vesicles and then to blisters with yellow more or less turbid and even purulent fluid&#44; and finally form a fine crust&#46; The main complication is local dissemination &#40;cellulitis&#44; lymphadenitis&#41; or even systemic complications &#40;pneumonia&#44; osteoarthritis&#44; sepsis&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In non-complicated mild cases&#44; topical disinfectants can be used&#44; mupirocin or fusidic acid every 8<span class="elsevierStyleHsp" style=""></span>h&#44; or retapamulin every 12<span class="elsevierStyleHsp" style=""></span>h&#44; for 5&#8211;7 days&#46; If the lesions are extensive or with systemic symptoms&#44; oral antibiotic therapy with amoxicillin&#8211;clavulanic acid&#44; a first- or second-generation cephalosporin&#44; or cloxacilin is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Perianal bacterial dermatitis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Perianal bacterial dermatitis consists of an erythema around the anus caused by <span class="elsevierStyleItalic">S&#46; pyogenes</span> or less frequently by <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; alone or associated with <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a> Incidence peaks at 3&#8211;5 years of age&#44; predominantly in males &#40;70&#37;&#41;&#44; although prevalence is the same in both sexes if vulvovaginitis is included&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">8</span></a> which together with balanoposthitis constitute what is known as perineal disease&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It manifests as a non-elevated erythema&#44; measuring 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm&#44; around the anus&#44; with well-delimited edges&#44; sometimes accompanied by pruritus&#44; painful bowel movement&#44; constipation&#44; overflow incontinence&#44; haematochezia and fissures&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">9</span></a> Boys may present with balanoposthitis and girls with vulvovaginitis with secretion and dysuria&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> There are usually no general symptoms&#44; unlike cellulitis&#46; In the acute phase &#40;&#60;6 weeks progression&#41; the lesion is red&#44; bright&#44; humid and painful&#44; and may present a whitish pseudo-membrane&#46; Without treatment&#44; lesions become chronic&#44; with painful fissures&#44; mucous secretion or psoriasis-like plates with yellowish periphery crust&#46; When the cause is staphylococcus&#44; there may be pustules and the erythema extends towards the adjacent skin&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients or members of the household may have presented acute pharyngoamigdalitis or a skin infection<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> in the previous 3 months or simultaneously with perianal dermatitis&#44; or be pharyngeal or perianal carriers of <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">7&#44;8</span></a> Recurrence after treatment with penicillin or amoxicillin is frequent &#40;up to 37&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a> especially if there are non-diagnosed cases in relatives&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">It is believed that transmission is by contact&#44; whether through autoinoculation &#40;infection or pharyngeal or skin carrier&#41; or interfamilial contagion&#44; especially if bath water is shared<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> or if a relative has presented acute pharingoamigdalitis or perianal dermatitis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Diagnosis is based on clinical analysis and confirmation is bacteriological&#46; Samples from the perianal area must be gathered from all patients &#40;A-II&#41; and pharyngeal samples if there are symptoms &#40;B-III&#41;&#44; for a rapid antigen detection test for <span class="elsevierStyleItalic">S&#46; pyogenes</span> &#40;100&#37; positive predictive value&#41;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">7</span></a> or a culture&#46; If the result of the test is negative&#44; it is recommended to prepare a culture due to the possibility of false negatives or <span class="elsevierStyleItalic">S&#46; aureus</span> as a cause of the condition &#40;A-II&#41;&#46; Potential cases in persons cohabiting with the patient should be investigated and a rapid diagnostic test or a culture for symptomatic patients &#40;B-III&#41; carried out&#44; since this is a frequent cause of recurrences within the family&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Although good results have been reported with topical antibiotic therapy in monotherapy &#40;B-II&#41;&#44; the use of systemic antibiotics is recommended in all cases &#40;A-II&#41;&#46; If no rapid diagnostic test available or if it is positive&#44; oral treatment with penicillin or amoxicillin for 10 days is recommended &#40;B-II&#41;&#44; which may be prolonged to 14&#8211;21 days based on clinical progress &#40;C-III&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">10</span></a> If there is no response after one cycle of amoxicillin&#44; or if the diagnostic test was negative&#44; and while waiting for the result of the culture&#44; amoxicillin&#8211;clavulanic acid may be used &#40;C-III&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When choosing the initial antibiotic therapy&#44; a familial history of streptococci or staphylococcus infection must be taken into consideration &#40;C-II&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">For recurrent infection cefuroxime is recommended<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">11</span></a> for 7&#8211;10 days &#40;C-II&#41;&#46; The association of oral and topic treatment seems to decrease recurrences &#40;A-II&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">6</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Infections of hair follicles&#58; folliculitis&#44; furuncle and carbuncle</span><p id="par0105" class="elsevierStylePara elsevierViewall">The aetiological agent of hair follicle infection is <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; followed by gram-negative bacilli&#46; Predisposing factors include obesity&#44; diabetes&#44; hyperhidrosis&#44; immunosuppression and atopical dermatitis&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Clinically&#44; patients present with lesions on hair-bearing sites on the face&#44; neck&#44; armpits or glutei&#44; ranging from a papule-vesicle with a erythematosus base &#40;folliculitis&#44; which affects the superficial hair follicle&#41;&#44; to tender erythematosus nodules &#40;furuncle&#44; extending to the deep dermis&#41;&#44; to warm&#44; tender&#44; erythematous plaques &#40;carbuncle&#44; affecting the surrounding subcutaneous cellular tissue&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The diagnosis is clinical and a microbiological study is only recommended for lesions that are atypical or respond poorly to treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Treatment is initially topical with mupirocin or fusidic acid&#44; and in recurrent or extensive forms not responding to topical treatment&#44; a combination of amoxicillin&#8211;clavulanic acid&#44; clindamycin&#44; cefadroxil&#44; cefalexin or cefuroxime&#46; For furuncles and carbuncles&#44; it is recommended to apply local heat and assess the possibility of making an incision and surgical drainage&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Acute bacterial lymphangitis</span><p id="par0125" class="elsevierStylePara elsevierViewall">This is defined as the inflammation of the lymphatic vessels of the subcutaneous tissue&#46; The organisms most frequently involved are <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#44; <span class="elsevierStyleItalic">S&#46; aureus</span> and <span class="elsevierStyleItalic">Pasteurella multocida</span> &#40;<span class="elsevierStyleItalic">P&#46; multocida</span>&#41; &#40;the latter after an animal bite&#41;&#46; There is usually systemic involvement&#44; even before the distal oedema and linear cord to regional nodes are evident&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Empirical treatment in mild to moderate forms is amoxicillin&#8211;clavulanic acid or a first- or second-generation cephalosporin&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Erysipelas</span><p id="par0135" class="elsevierStylePara elsevierViewall">This is a superficial infection affecting the superior dermis&#44; the subcutaneous cellular tissue and sometimes the lymphatic system&#44; in most cases caused by <span class="elsevierStyleItalic">S&#46; pyogenes</span> or streptococci of groups B&#44; C or G&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">1&#44;13&#8211;18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The triggering factors include abrasions&#44; ulcers&#44; intertriginous fungal infections of the feet&#44; venous or lymphatic obstruction and chronic oedema&#46; In neonates&#44; the infection may originate in the umbilical cord and extend to the abdominal wall&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Onset is acute&#44; characterised by an erythematosus plate with well-defined and slightly elevated edges&#46; It is more frequent in lower limbs and face&#44; and may be associated with regional lymphadenitis&#46; There are usually general symptoms &#40;fever&#44; chills&#44; discomfort&#41;&#44; sometimes before cutaneous signs&#46; Systemic complications are also possible &#40;sepsis&#44; streptococcal toxic-shock syndrome&#44; endocarditis&#44; etc&#46;&#41;&#44; although they are rare in otherwise healthy patients&#46; When the infection is resolved it produces scaling and hyperpigmentation&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The diagnosis is clinical &#40;A-II&#41;&#59; haemocultures and cultures of skin biopsies or aspirates have a low yield&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Treatment consists of administration of oral penicillin or amoxicillin &#40;A-III&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">1</span></a> Patients with lesions of more than 5<span class="elsevierStyleHsp" style=""></span>cm or generally poor condition&#44; infants and immunodepressed patients may require hospitalisation and parenteral treatment &#40;A-II&#41;&#46; The care of wounds and their predisposing factors are also important aspects of the treatment &#40;A-II&#41;&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Cellulitis</span><p id="par0160" class="elsevierStylePara elsevierViewall">This is an acute infection affecting the dermis and subcutaneous cellular tissue&#46; Predisposing factors include trauma&#44; wounds and pre-existing infections&#46; It appears as a warm&#44; tender&#44; poorly defined erythematous plaque&#44; which sometimes causes phlyctena&#44; petechial or local necrosis and may be accompanied by lymphadenitis and systemic symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">17</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The main cause is <span class="elsevierStyleItalic">S&#46; aureus</span> and <span class="elsevierStyleItalic">S&#46; pyogenes</span>&#46; Other less frequent microorganisms are <span class="elsevierStyleItalic">Streptococcus agalactiae</span> and gram-negative bacilli in neonates and enterobacteria in <span class="elsevierStyleItalic">immunosuppressed</span> patients&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Its location may provide an aetiological orientation&#58; in the periauricular region and the sole of the foot with puncture wounds <span class="elsevierStyleItalic">P&#46; aeruginosa</span> is more frequent&#44; while in bites&#44; <span class="elsevierStyleItalic">P&#46; multocida</span> is common&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The diagnosis is clinical&#44; but a microbiological study is recommended in the cases discussed in the section on general treatment&#46; An ultrasound scan may be useful to differentiate cellulitis from non-fluctuant abscesses&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">A systemic antibiotic treatment with good coverage against <span class="elsevierStyleItalic">S&#46; aureus</span> and <span class="elsevierStyleItalic">S&#46; pyogenes</span> must always be recommended&#46; In mild cases and under strict surveillance&#44; oral treatment with amoxicillin&#8211;clavulanic acid&#44; cloxacilin&#44; cefadroxil&#44; cefalexin&#44; cefuroxime or clindamycin may be considered&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRefs" href="#tbl0010">Tables 2 and 3</a> summarise of other infectious conditions of clinical relevance&#44; and <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> details the recommended dosage of the most widely used anti-infective drugs&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Superinfection of bite or puncture wounds</span><p id="par0190" class="elsevierStylePara elsevierViewall">Most superinfections of the wounds produce clinical manifestations in the first 12<span class="elsevierStyleHsp" style=""></span>h&#44; generally erythema&#44; pain or some other type of secretion through the wound&#46; In human bites&#44; fever above 38<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; abscess and lymphagitis are established criteria of superinfection&#44; as well as the presence of at least 4 of the following&#58; erythema extending more than 3<span class="elsevierStyleHsp" style=""></span>cm from the edge of the wound&#44; pain on palpation&#44; inflammation&#44; purulent drainage or leukocyte count of over 12&#44;000<span class="elsevierStyleHsp" style=""></span>cells&#47;ml&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In superinfections of puncture wounds in the foot&#44; clinical symptoms usually begin during the first 5&#8211;7 days if the causative agent is <span class="elsevierStyleItalic">Staphylococcus</span>&#44; and after 7 days if it is produced by <span class="elsevierStyleItalic">Pseudomonas</span>&#46; It is important to note the infection of bones and deep tissues&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In addition to local cleaning and debridement&#44; prophylactic antibiotic treatment is recommended only in the cases listed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> &#40;A-I&#41; and according to the guidelines in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0205" class="elsevierStylePara elsevierViewall">Standard prophylaxis should always be considered in the case of rabies&#44; tetanus and other diseases transmitted through wounds&#46;</p></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Community-acquired methicillin- resistant <span class="elsevierStyleItalic">S&#46; aureus</span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Epidemiology</span><p id="par0210" class="elsevierStylePara elsevierViewall">In the United States&#44; where up to 80&#37; of staphylococci isolated in ambulatory patients are resistant to methicillin&#44; Community-acquired methicillin- resistant <span class="elsevierStyleItalic">S&#46; aureus</span> &#40;CA-MRSA&#41; represents a public health problem&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a> In Spain&#44; some studies in paediatric populations report a frequency of resistance to methicillin in <span class="elsevierStyleItalic">S&#46; aureus</span> of 9&#8211;14&#46;8&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">26&#8211;29</span></a> but there are no studies at the national level&#46; The frequency in neonates was investigated in the Community of Madrid<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">30</span></a> from 2007 to 2009&#44; and a prevalence of 3&#46;3&#37; was reported&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">The role of methicillin resistance as an indicator of seriousness is starting to be questioned&#44; and more relevance is being given to other virus factors&#44; such as Panton&#8211;Valentine leukocidin &#40;PVL&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">32</span></a> although most strains of PVL are also resistant to methicillin&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">31&#44;33</span></a> Nosocomial MRSA is associated with certain multidrug-resistant genotypes&#44; but this is not the case in CA-MRSA&#44; which only rarely presents resistance to macrolides and lincosamides&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">27&#44;31&#44;33</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Clinical symptoms and diagnosis</span><p id="par0220" class="elsevierStylePara elsevierViewall">Although they may cause pneumonia&#44; sepsis and osteoarthritis&#44; most CA-MRSA infections are limited to the skin and soft tissues&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">There are no clinical criteria to differentiate skin infections produced by methicillin-sensitive <span class="elsevierStyleItalic">S&#46; aureus</span> from those caused by MRSA&#44;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">34</span></a> although in the latter&#44; therapeutic failure and formation of abscesses and necrosis with black superficial crust similar to a spider bite are more frequent&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> Given the implications for treatment&#44; any non-fluctuant lesions suggestive of abscesses detected during physical examination should be studied under ultrasound examination &#40;C-III&#41;&#46; If possible&#44; it is recommended to take samples for culture&#44; determination of LPV and genetic profiling&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Treatment</span><p id="par0230" class="elsevierStylePara elsevierViewall">The current low incidence of AC-MRSA in the paediatric population does not justify amending empirical antibiotic therapy guidelines&#46; However&#44; under certain circumstances changes must be considered&#44; such as extensive cellulitis&#44; abscesses or necrosis&#44; the presence of recurrent abscesses in children or in other members of their household&#44; poor response to conventional treatment&#44; patients living in highly endemic areas &#40;Asia&#44; America or Eastern Europe&#41; or living with known carriers &#40;C-III&#41;&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In minor&#44; non-suppurating infections &#40;impetigo&#44; mild superinfection of wounds&#44; etc&#46;&#41;&#44; topical treatment with mupirocin is usually sufficient<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a> &#40;A-III&#41;&#46; In skin abscesses&#44; incision and early surgical drainage are essential&#46; This has been shown to be effective with otherwise healthy patients with non-complicated infections to achieve full healing with no adjuvant antibiotic therapy<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">35&#8211;38</span></a> &#40;A-II&#41;&#46; Systemic antibiotic treatment is recommended in other localised infections&#44; as adjuvant if drainage has been incomplete&#44; if there is intense local infection &#40;abscesses of more than 5<span class="elsevierStyleHsp" style=""></span>cm&#41; and in patients under 2 years of age or with other risk factors &#40;immunosuppression&#44; moderate-serious atopical dermatitis&#44; etc&#46;&#41; &#40;A-III&#41;&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The drug of first choice is oral clindamycin&#44; which also inhibits the production of LPV<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a> &#40;A-II&#41;&#46; Trimethoprim&#8211;sulfamethoxazole is an effective alternative in areas where there is high resistance to clindamycin &#40;A-II&#41;&#44; in the event of intolerance&#44; or when capsules are not suitable for the patient&#46; Linezolid must be avoided in mild-moderate infections&#44; because it is expensive&#44; has potential adverse effects and leads to development of resistances&#46; The presence of LPV does not require changes in the therapeutic approach although it is associated with a greater need for incision and surgical drainage&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;31</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">If empirical treatment is initiated with any of these drugs&#44; changing to a betalactamic is recommended as soon as its sensitivity can be proved&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Study and treatment of carriers</span><p id="par0250" class="elsevierStylePara elsevierViewall">It is estimated that 19&#46;3&#37; of the Spanish population is colonised by <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; of which only 1&#46;3&#37; are MRSA&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">39</span></a> The most frequent areas of colonisation are the nostrils&#44; but axilla inguinal and intestinal carriers have also been described&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> Considering the low incidence of MRSA in paediatrics&#44; the systematic study of persons living with the patient is not recommended&#44; and should be limited to outbreaks in limited communities &#40;families&#44; institutions&#44; etc&#46;&#41; and recurrent infections<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">3</span></a> &#40;C-III&#41;&#46; In these cases&#44; decolonisation in the child and carriers living in their household should consist of nasal mupirocin every 12<span class="elsevierStyleHsp" style=""></span>h and washing the body and hair with 4&#37; chlorhexidine soap for 5&#8211;10 days &#40;C-III&#41;&#46; In the event of therapeutic failure with mupirocin&#44; topical fusidic acid every 12<span class="elsevierStyleHsp" style=""></span>h along with oral trimethoprim&#8211;sulfamethoxazole for 7 days should be used<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">3&#44;35</span></a> &#40;C-III&#41;&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Prevention</span><p id="par0255" class="elsevierStylePara elsevierViewall">The main transmission pathway seems to be intimate skin-to-skin contact&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">40</span></a> General prevention measures consist in minimising the risk of skin trauma &#40;use of protection during sports activities&#44; etc&#46;&#41; &#40;C-III&#41;&#44; keeping wounds clean and covered &#40;A-III&#41;&#44; frequent hand washing and body hygiene &#40;A-III&#41;&#44; avoiding sharing towels and clothes &#40;A-III&#41; and proper disposal of contaminated objects<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">35&#44;40</span></a> &#40;C-III&#41;&#46;</p></span></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Antibiotic treatment of skin infections"
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          "identificador" => "sec0015"
          "titulo" => "Main infectious conditions"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Impetigo"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Perianal bacterial dermatitis"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Infections of hair follicles&#58; folliculitis&#44; furuncle and carbuncle"
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              "identificador" => "sec0035"
              "titulo" => "Acute bacterial lymphangitis"
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              "identificador" => "sec0040"
              "titulo" => "Erysipelas"
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            5 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Cellulitis"
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            6 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Superinfection of bite or puncture wounds"
            ]
          ]
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          "identificador" => "sec0095"
          "titulo" => "Community-acquired methicillin- resistant S&#46; aureus"
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              "titulo" => "Epidemiology"
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              "titulo" => "Treatment"
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              "identificador" => "sec0075"
              "titulo" => "Study and treatment of carriers"
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              "titulo" => "Prevention"
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          "clase" => "keyword"
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            0 => "Bacterial skin infections"
            1 => "<span class="elsevierStyleItalic">Staphylococcus aureus</span>"
            2 => "<span class="elsevierStyleItalic">Streptococcus pyogenes</span>"
            3 => "Treatment"
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            0 => "Infecciones cut&#225;neas bacterianas"
            1 => "<span class="elsevierStyleItalic">Staphylococcus aureus</span>"
            2 => "<span class="elsevierStyleItalic">Streptococcus pyogenes</span>"
            3 => "Tratamiento"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Skin infections are a common cause for dermatological consultations in the paediatric setting&#46; A review is presented of the clinical manifestations&#44; diagnosis and treatment of the main bacterial skin infections&#44; as well as the diagnosis and treatment of super-infected puncture and bite wounds&#46; The most prevalent bacteria in skin infections are <span class="elsevierStyleItalic">Staphylococcus aureus</span> and <span class="elsevierStyleItalic">Streptococcus pyogenes&#46;</span> Treatment is usually empirical&#44; since microbiological studies are only recommended under certain circumstances or lack of improvement with common therapies&#46; Superficial skin infections can be treated with local antiseptics or antibiotics &#40;mupirocin or fusidic acid&#41;&#46; Systemic treatment is usually reserved for patients with extensive or severe disease or with other risk factors&#46; Systemic treatment depends on the suspected infecting bacteria&#44; with penicillin&#44; amoxicillin&#44; amoxicillin&#8211;clavulanic acid and first- or second-generation cephalosporin being the most frequently used drugs&#46; Due to the low incidence of community-acquired methicillin-resistant infection by <span class="elsevierStyleItalic">S&#46; aureus</span> in Spain&#44; the use of clindamycin or co-trimoxazole is only recommended after severe disease&#44; relapses or a clear epidemiological background&#46;</p></span>"
      ]
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las infecciones cut&#225;neas constituyen un motivo de consulta frecuente en dermatolog&#237;a pedi&#225;trica&#46; Se revisan las manifestaciones cl&#237;nicas&#44; el diagn&#243;stico y el tratamiento de los principales cuadros infecciosos bacterianos de la piel&#44; as&#237; como de la sobreinfecci&#243;n de las heridas punzantes y por mordedura&#46; Las bacterias m&#225;s prevalentes en las infecciones cut&#225;neas son <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;<span class="elsevierStyleItalic">S&#46; aureus</span>&#41; y <span class="elsevierStyleItalic">Streptococcus pyogenes&#46;</span> El tratamiento es generalmente emp&#237;rico y solo ante determinadas circunstancias o mala evoluci&#243;n cl&#237;nica se recomienda el estudio microbiol&#243;gico&#46; Las infecciones cut&#225;neas superficiales pueden tratarse con antis&#233;pticos y antibi&#243;ticos t&#243;picos &#40;mupirocina o &#225;cido fus&#237;dico&#41;&#46; El tratamiento sist&#233;mico se reserva para formas extensas&#44; graves o con otros factores de riesgo del hu&#233;sped&#46; En estos casos&#44; el antibi&#243;tico de elecci&#243;n depender&#225;&#44; entre otros factores&#44; de los pat&#243;genos sospechados&#59; los m&#225;s utilizados son penicilina&#44; amoxicilina&#44; amoxicilina-&#225;cido clavul&#225;nico y cefalosporinas de primera o segunda generaci&#243;n&#46; Considerando la baja incidencia de <span class="elsevierStyleItalic">S&#46; aureus</span> resistente a la meticilina de adquisici&#243;n comunitaria en nuestro pa&#237;s&#44; no se recomienda modificar el tratamiento emp&#237;rico salvo en circunstancias de especial gravedad&#44; recurrencia o antecedente epidemiol&#243;gico&#44; en cuyo caso el tratamiento recomendado es clindamicina o trimetoprima-sulfametoxazol&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Conejo-Fern&#225;ndez AJ&#44; Mart&#237;nez-Chamorro MJ&#44; Couceiro JA&#44; Moraga-Llop FA&#44; Baquero-Artigao F&#44; Alvez F&#44; et al&#46; Documento de consenso SEIP&#8211;AEPAP&#8211;SEPEAP sobre la etiolog&#237;a&#44; el diagn&#243;stico y el tratamiento de las infecciones cut&#225;neas bacterianas de manejo ambulatorio&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;84&#58;121&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Taken from Khan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">2</span></a></p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top">Strength of recommendation</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good evidence to support a recommendation for use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate evidence to support a recommendation for use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor evidence to support a recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate evidence to support a recommendation against use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>E&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good evidence to support a recommendation against use&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Quality of the evidence</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence from at least one properly randomised&#44; controlled trial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence from at least 1 well-designed clinical trial&#44; without randomization&#59; from cohort or case-controlled analytic studies &#40;preferably from more than 1 centre&#41;&#59; from multiple time series&#59; or from dramatic results from uncontrolled experiments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evidence from opinions of respected authorities&#44; based on clinical experience&#44; descriptive studies&#44; or reports of expert committees&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Strength of recommendation and quality of evidence&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Taken from Moraga-Llop and Tobe&#241;a Rue<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anatomical location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Scalp&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Abscesses in new borns&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Fingers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Paronychia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blistering distal dactylitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lower limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cellulitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Erysipelas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Folliculitis by <span class="elsevierStyleItalic">P&#46; aeruginosa</span> &#40;hot tubs&#44; depilation&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lymph nodes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Adenophyllum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sweat glands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Eccrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Periporitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Apocrine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Hydrosadenitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Lips&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Angular cheilitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cheeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Erysipelas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bacterial cellulitis&#58; pneumococci&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> type b&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cellulitis-adenitis syndrome by <span class="elsevierStyleItalic">S&#46; agalactiae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Umbilicus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Neonatal omphalitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Outer ear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Auricular chondritis &#40;piercing&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Eyelids&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Periorbital cellulitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Perineum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Balanopreputial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perianal bacterial disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vulvovaginal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Sole of the foot&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Infection by <span class="elsevierStyleItalic">P&#46; aeruginosa</span> &#40;puncture wound&#44; shoes&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pitted keratolysis &#40;keratolysis plantare <span class="elsevierStyleItalic">sulcatum</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Skin folds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Erythrasma by <span class="elsevierStyleItalic">Corynebacterium minutissimum</span>Intertrigo by <span class="elsevierStyleItalic">S&#46; pyogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Clinical forms of most frequent bacterial skin infections according to their location of preference&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Predisposing factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical analysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Blistering distal dactylitis<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">16&#8211;18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Soft part of the fingersInfrequent&#58; other surfaces of palms and soles&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; pyogenes</span>Less frequent&#58; <span class="elsevierStyleItalic">S&#46; aureus</span>&#44; <span class="elsevierStyleItalic">S&#46; agalactiae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wounds&#44; atopic dermatitis&#44; humidity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blister with purulent fluid&#44; slightly tender&#44; with erythematous baseNo general symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; culture<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Incision and drainage<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>amoxicillin&#8211;clavulanic acid 10 daysIf there is poor response cephalosporin&#44; clindamycinMupirocin&#58; optional &#40;not in monotherapy&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ecthyma<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">17&#8211;19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lower and upper limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; pyogenes&#44; S&#46; aureus</span> copathogen&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pruritic lesions&#58; bites&#44; scabies&#44; pediculosis&#59; poor hygiene&#59; malnutrition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ulcer with black crust that becomes chronic and heals leaving a scarComplications&#58;cellulitis lymphagitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; Gram stain and culture of exudate or biopsy of deep tissue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Removal of crusts with moist dressingsTopical fusidic acid&#47;mupirocin if the lesion is small &#40;&#60;2<span class="elsevierStyleHsp" style=""></span>cm&#41;Oral 1st generation cephalosporin&#47;amoxicillin&#8211;clavulanic acid&#47;macrolide 7 days<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">35</span></a>Consider admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Ecthyma gangrenosum<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">17&#44;18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Perineum&#44; glutei&#44; lower limbs&#44; apocrine areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">P&#46; aeruginosa</span>Other bacteria&#44; fungi and virus &#40;<span class="elsevierStyleItalic">immunosuppressed</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Immunosuppression &#40;serious neutropenia&#41;&#44; healthy infants&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Necrotic ulcer with black crust &#40;bacterial vasculitis of small veins&#41;Sepsis by <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; culture of the lesions&#44; haemocultures&#44; skin biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Early systemic treatment &#40;intravenous&#41; anti-<span class="elsevierStyleItalic">Pseudomonas</span> sp&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Erythrasma<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Humid body folds&#58; interdigital spaces of feet&#44; groins&#44; armpits&#44; infra-mammalian and interglutei areas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Corynebacterium minutissimun</span>&#44; mixed flora&#44; <span class="elsevierStyleItalic">S&#46; pyogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heat&#44; humidity&#44; obesity&#44; maceration of the skin&#44; diabetes mellitus&#44; bad hygiene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Red&#47;brown lesions with irregular well-defined&#44; slightly scalingMild pruritus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalWood&#39;s lamp&#58; reddish fluorescence<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>Confirmation&#58; methylene&#47;Gram blue staining<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Topical with erythromycin&#44; clindamycin&#44; mupirocin&#44; imidazoles or Whitfield&#39;s solution<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> 2 times a dayExtensive or persistent cases&#58;oral clarithromycin for 10&#8211;14 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Hidradenitis<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">17&#44;22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Axilla&#44; groins&#44; perineum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&#44; Oropharyngeal anaerobes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heat&#44; humidity&#44; hormonal changes&#44; poor hygiene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Painful nodules causing abscesses leaving hypertrophic scars or fistulasVery frequent recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; culture<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Strict hygiene<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>topical antiseptics&#47;antibiotics<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>early oral amoxicillin&#8211;clavulanic acid&#47;clindamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Neonatal omphalitis<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Umbilicus or umbilical cord&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Gram-negative bacilli<span class="elsevierStyleItalic">S&#46; aureus</span><span class="elsevierStyleItalic">S&#46; pyogenes</span>Less frequent&#58;anaerobes&#44; mixed infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Delivery at home or areas with poor health resources&#44; improper care of cord prematurity&#44; chorioamnionitis&#44; premature rupture of membranes&#44; etc&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Erythema&#44; oedema and bad periumbilical odour&#44; sometimes accompanied by secretion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; exudate culture<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&#58;&#8211;chlorhexidine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>mupirocinModerate&#8211;serious&#58;&#8211;admission&#44; intravenous antibiotic therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Acute paronychia<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Nail folds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span> or mixed aerobe flora &#40;<span class="elsevierStyleItalic">S&#46; pyogenes</span>&#44; <span class="elsevierStyleItalic">Pseudomonas</span> sp&#46;&#41; or anaerobe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Microtrauma&#44; humidity&#44; irritants &#40;onychophagia&#44; finger suction&#41;&#44; contact dermatitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Warn fold&#44; red&#44; swollen&#44; painful and frequently with pus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; culture<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial&#58; warm&#44; moist dressings&#44; 2&#8211;3 times a dayDeep&#58; incision and drainage<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oral amoxicillin&#8211;clavulanic acid or cefadroxil 7 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Periporitis<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">22&#44;24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Occipital region&#44; big folds&#44; back and glutei&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Humidity&#44; lack of hygiene&#44; malnutrition&#44; chronic diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild form&#58; miliaria pustulosaSerious form&#58; nodules&#44; abscesses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalConfirmation&#58; culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Avoid hyperhidrosisMild form&#58; antiseptics &#40;zinc sulfate&#41;&#47;mupirocinSerious form&#58; incision and drainage<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>oral amoxicillin&#8211;clavulanic acid<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>topical mupirocin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pitted <span class="elsevierStyleItalic">keratolysis</span><a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">21</span></a>Keratolysis plantare <span class="elsevierStyleItalic">sulcatum</span><a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">16&#44;24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Soles of the feetRare&#58; palms of the hands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Corynebacterium</span> sp&#46;Others&#58; <span class="elsevierStyleItalic">Dermatophilus congolensis</span> and <span class="elsevierStyleItalic">Kytococcus sedentarius</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Humidity&#58; hyperhidrosis&#44; closed shoes&#44; prolonged submersion in water&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Superficial depressions of the epidermis <span class="elsevierStyleItalic">&#40;pitted&#41;</span>&#44; sometimes with linear pattern <span class="elsevierStyleItalic">&#40;sulcatum&#41;</span>&#44; bad odour&#44; sometimes burning&#44; stinging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalWood&#39;s lamp coral red fluorescence<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>Confirmation&#58; culture<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Treatment of hyperhidrosis<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>wash with antiseptic soap &#43;topical erythromycin&#44; clindamycin&#44; fusidic acid or mupirocinImidazoles<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>topical urea or Whitfield solution<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>2 times a day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cellulitis-adenitis syndrome<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Face and neck&#58; cheeks&#44; submandibular region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">S&#46; agalactiae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Colonisation of mucosa&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">New-borns &#40;2&#8211;6 weeks&#41;Facial&#47;submandibular cellulitisFever&#44; irritability&#44; refusal to feedIpsilateral acute otitis mediaBacteraemia&#58; sepsis&#47;meningitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ClinicalAspirate cultureHaemocultureLumbar puncture&#58; Gram staining&#44; culture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Admission and intravenous treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Not necessary in typical cases&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Whitfield&#39;s solution&#58; 6&#8211;12&#37; benzoic acid and 3&#8211;6&#37; Vaseline-based salicylic acid&#46;</p>"
            ]
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              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Not so useful due to high risk of contamination&#46; Always assess clinical context&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Other clinical forms of bacterial skin infections&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dosage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Maximum permissible dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Penicillin V&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cloxacilin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin &#40;&#177;clavulanic acid&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#8211;60<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 8&#8211;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefadroxil&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefalexin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;25<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>g&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefuroxime&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 months&#8211;5 years&#58; 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 12<span class="elsevierStyleHsp" style=""></span>h5&#8211;12 years&#58; 125<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#62;12 years&#58; 250<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cefaclor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clarithromycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Josamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Midecamicin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#8211;50<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 8&#8211;12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Clindamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#8211;30<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;d every 6<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Trimethoprim&#8211;sulfamethoxazole &#40;TMP&#8211;SMX&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#8211;12<span class="elsevierStyleHsp" style=""></span>mg TMP&#47;kg&#47;d every 12<span class="elsevierStyleHsp" style=""></span>h30&#8211;60<span class="elsevierStyleHsp" style=""></span>mg SMX&#47;kg&#47;d every 12<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TMP&#58; 320<span class="elsevierStyleHsp" style=""></span>mg&#47;dSMX&#58; 1600<span class="elsevierStyleHsp" style=""></span>mg&#47;d&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">General duration of the treatment&#58; 7&#8211;10 days&#44; except for perianal bacterial dermatitis treated with penicillin or amoxicillin &#40;10&#8211;21 days&#41; and erysipelas &#40;10&#8211;14 days&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Posology of most used oral antibiotics in bacterial skin infections&#46;<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a></p>"
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        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Taken from Bangert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a>&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cat and human bites&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dog bites with delay in assistance of &#62;8<span class="elsevierStyleHsp" style=""></span>h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dog bites in hands&#44; feet and face&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Deep puncture wounds&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Wounds with crushing&#44; oedema or requiring debridement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Wounds with infection of tendons&#44; muscles or joints&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Wounds with underlying fractures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Puncture wounds in the sole of the foot with delay in assistance of &#62;24<span class="elsevierStyleHsp" style=""></span>h&#44; with extensive involvement or devitalised tissue&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Underlying disease&#58; immunodepression&#44; risk of endocarditis&#44; chronic pneumopathy&#44; chronic hepatopathy&#44; diabetes mellitu<span class="elsevierStyleItalic">s</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Indications of antibiotic prophylaxis in bites and puncture wounds&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">25</span></a></p>"
        ]
      ]
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        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Taken from &#193;lvez Gonz&#225;lez&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganisms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Allergy to penicillin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dog bite&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Pasteurella canis</span><span class="elsevierStyleItalic">Capnocytophaga canimorsus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Amoxicillin&#8211;clavulanic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No anaphylaxis&#58;<span class="elsevierStyleHsp" style=""></span>&#8211; 2nd or 3rd generation cephalosporin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>clindamycinAnaphylaxis&#58;<span class="elsevierStyleHsp" style=""></span>&#8211; Trimethoprim&#8211;sulfamethoxazole<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>clindamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cat bite&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Pasteurella multocida</span><span class="elsevierStyleItalic">Pasteurella septica</span><span class="elsevierStyleItalic">Corynebacterium</span><span class="elsevierStyleItalic">Bartonella henselae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Dog and cat bites&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Staphylococcus</span><span class="elsevierStyleItalic">Streptococcus</span><span class="elsevierStyleItalic">Enterococcus</span>Anaerobes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Human bite&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus anginosus</span><span class="elsevierStyleItalic">Staphylococus aureus</span><span class="elsevierStyleItalic">Eikenella corrodens</span><span class="elsevierStyleItalic">Fusobacterium</span><span class="elsevierStyleItalic">Peptostreptococcus</span><span class="elsevierStyleItalic">Prevotella</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Puncture wound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Staphylococus aureus</span>Beta-haemolytic StreptococcusAnaerobes<span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wound for &#60;7 daysCefadroxilAmoxicillin&#8211;clavulanic acid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wound for &#60;7 daysNo anaphylaxis&#58;&#8211;cefadroxilAnaphylaxis&#58;&#8211;clindamycin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Wound on foot for &#62;7 daysHospital admissionIntravenous antibiotic therapy antipseudomonic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab982534.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Infections secondary to bites and puncture wounds&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">23</span></a></p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:40 [
            0 => array:3 [
              "identificador" => "bib0205"
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                  "contribucion" => array:1 [
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                  "host" => array:1 [
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                            1 => "S&#46; Khan"
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                  "host" => array:1 [
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            2 => array:3 [
              "identificador" => "bib0215"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infecciones por <span class="elsevierStyleItalic">Staphylococcus aureus</span> resistente a meticilina adquirido en la comunidad en ni&#241;os"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;A&#46; Frick"
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                            "web" => "Medline"
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              ]
            ]
            3 => array:3 [
              "identificador" => "bib0220"
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              "referencia" => array:1 [
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                          "etal" => false
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                          ]
                        ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "titulo" => "Tratado de pediatr&#237;a Cruz"
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                      ]
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                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0225"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Infecciones por estreptococo del grupo A"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "R&#46; Rodr&#237;guez Fern&#225;ndez"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:4 [
                        "titulo" => "Tratado de pediatr&#237;a Cruz"
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            5 => array:3 [
              "identificador" => "bib0230"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
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                            0 => "C&#46; Heath"
                            1 => "N&#46; Desai"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Aislamiento del estreptococo beta hemol&#237;tico del grupo A en ni&#241;os con dermatitis perianal"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Outcomes in children treated for perineal group A beta-hemolytic streptococcal dermatitis"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "D&#46; Olson"
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            8 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Streptococcal perianal infection in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2015.09.016

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2024 November	16	11	27
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2024 March	83	28	111
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2023 October	64	44	108
2023 September	69	29	98
2023 August	62	31	93
2023 July	42	29	71
2023 June	45	30	75
2023 May	60	35	95
2023 April	33	34	67
2023 March	47	27	74
2023 February	49	19	68
2023 January	35	29	64
2022 December	59	36	95
2022 November	109	48	157
2022 October	50	43	93
2022 September	61	46	107
2022 August	79	49	128
2022 July	78	48	126
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2022 May	47	42	89
2022 April	129	48	177
2022 March	147	62	209
2022 February	127	45	172
2022 January	50	49	99
2021 December	65	61	126
2021 November	76	53	129
2021 October	100	67	167
2021 September	80	38	118
2021 August	81	44	125
2021 July	36	40	76
2021 June	57	49	106
2021 May	61	48	109
2021 April	168	92	260
2021 March	94	39	133
2021 February	58	32	90
2021 January	60	40	100
2020 December	67	64	131
2020 November	93	17	110
2020 October	135	23	158
2020 September	244	25	269
2020 August	424	12	436
2020 July	62	19	81
2020 June	112	18	130
2020 May	199	29	228
2020 April	146	17	163
2020 March	78	23	101
2020 February	110	21	131
2020 January	49	24	73
2019 December	61	31	92
2019 November	29	15	44
2019 October	41	13	54
2019 September	38	22	60
2019 August	80	22	102
2019 July	37	38	75
2019 June	37	21	58
2019 May	101	19	120
2019 April	71	29	100
2019 March	43	11	54
2019 February	46	28	74
2019 January	53	20	73
2018 December	65	34	99
2018 November	176	60	236
2018 October	255	19	274
2018 September	218	15	233
2018 August	16	0	16
2018 July	12	0	12
2018 June	22	0	22
2018 May	81	0	81
2018 April	28	0	28
2018 March	52	0	52
2018 February	22	0	22
2018 January	23	0	23
2017 December	24	0	24
2017 November	29	0	29
2017 October	29	0	29
2017 September	27	0	27
2017 August	24	0	24
2017 July	27	0	27
2017 June	35	11	46
2017 May	36	13	49
2017 April	22	11	33
2017 March	16	5	21
2017 February	15	9	24
2017 January	8	6	14
2016 December	45	12	57
2016 November	54	7	61
2016 October	38	11	49
2016 September	44	3	47
2016 August	45	7	52
2016 July	23	4	27

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