The Evolving Management of Complicated Skin and Soft Tissue Infections: Insights from the SIS 2020 Updated Guidelines

January 2025

By: Chandler Hinson

The skin, our body's largest organ system, serves as the primary barrier against external organisms, shielding us from infections and environmental threats

Complicated skin and soft tissue infections (SSTIs) remain a significant cause of morbidity and mortality worldwide, particularly in low- and middle-income countries (LMICs) where access to surgical and antimicrobial interventions may be limited. The Surgical Infection Society (SIS) 2020 Updated Guidelines provide evidence-based recommendations for the management of complicated SSTIs, building upon their 2009 guidelines with a decade of additional research. This blog will explore key findings from the updated guidelines and discuss their implications for LMICs.

Main Findings

The 2020 SIS guidelines reinforce the necessity of early surgical intervention and targeted antimicrobial therapyfor severe SSTIs, particularly necrotizing infections. Notable updates include:

• Greater support for adjuvant antimicrobial therapy after drainage of complex abscesses.

• Updated antimicrobial options for MRSA and gram-negative infections.

• Continued emphasis on early surgical debridement for necrotizing infections to improve outcomes.

• Recommendations on the role of new diagnostic modalities, including point-of-care ultrasound and molecular assays.

Methodology

The guidelines were developed using a systematic review of 2008-2020 literature, including randomized trials, retrospective cohort studies, and case series. The recommendations were graded according to the Guyatt et al. methodology, ensuring the quality and strength of each recommendation.

Context

The guidelines primarily reflect data from high-income countries (HICs), where healthcare infrastructure allows for prompt diagnosis, advanced imaging, and access to a broad spectrum of antibiotics. However, LMICs often face challenges in implementing these recommendations due to resource limitations.

Relevance to LMICs

Feasibility of Implementation

While the guidelines provide critical insights into the management of complicated SSTIs, their direct implementation in LMICs presents challenges. Surgical capacity, antimicrobial stewardship, and diagnostic resources vary widely in these settings.

• Access to timely surgical debridement remains a barrier due to limited operating rooms, trained personnel, and perioperative care.

• Broad-spectrum antimicrobials recommended in the guidelines may not be readily available or affordable.

• Diagnostic technologies such as point-of-care ultrasound may not be universally accessible, limiting rapid differentiation between cellulitis and abscess.

Barriers to Implementation

Several barriers to the adoption of these guidelines in LMICs include:

1. Limited surgical infrastructure – Many LMICs lack the capacity for timely surgical interventions, which are critical for necrotizing infections.

2. Antimicrobial resistance (AMR) concerns – The inappropriate use of antibiotics due to poor diagnostic capabilities increases resistance rates, making guideline-adherent therapy difficult.

3. Financial constraints – The cost of newer antibiotics such as tedizolid, dalbavancin, oritavancin, and omadacycline is prohibitive for many LMICs.

Practicality and Adaptation

To enhance applicability in LMICs, a tiered approach may be necessary:

• Prioritizing early clinical diagnosis when imaging is unavailable.

• Utilizing locally available antibiotics with consideration for regional resistance patterns.

• Enhancing surgical training and capacity-building to facilitate timely debridement.

• Exploring cost-effective point-of-care testing solutions to improve diagnostics without reliance on advanced molecular assays.

Critical Analysis

Strengths

• The updated guidelines provide clear recommendations based on recent evidence, ensuring alignment with current best practices.

• They highlight the role of new antimicrobial agents, which may improve outcomes in severe SSTIs.

• The inclusion of diagnostic advancements such as molecular testing could enhance the precision of antimicrobial therapy.

Weaknesses and Gaps

• Limited inclusion of LMIC studies – The majority of the reviewed literature stems from HICs, limiting its direct applicability to resource-limited settings.

• Over-reliance on advanced diagnostics – Recommendations that depend on imaging and rapid molecular testing may not be practical for hospitals with minimal resources.

• Cost constraints on recommended antimicrobial therapies – Some of the newer antimicrobial agents are expensive and not widely available in LMICs, necessitating alternative treatment strategies.

Conclusion

The SIS 2020 Updated Guidelines on the Management of Complicated SSTIs provide a strong foundation for optimizing patient outcomes. However, to improve their relevance in LMICs, modifications are necessary to accommodate local challenges. Strengthening surgical capacity, ensuring rational antibiotic use, and investing in cost-effective diagnostics will be crucial in adapting these recommendations to low-resource environments.

Future research should focus on contextualizing these guidelines for LMICs, incorporating local resistance data, resource availability, and cost-effective interventions to ensure equitable access to high-quality SSTI care worldwide.