MANAGEMENT OF RECURRENT SKIN INFECTIONS

Rosanna Marsella, DVM, DACVD

College of Veterinary Medicine
University of Florida, Gainesville, FL, USA
Recurrent skin infections have always been a source of frustration in general
practice but now, besides the normal frustration, we are also experiencing a
steep increase of antibiotic resistance which is adding challenge to the
management of these cases. The resistance could be due to a variety of reasons
including widespread and not always appropriately done antibiotic use. For this
reason, is very important to use antibiotics well, using the right dose, for the right
amount of time, at the right dosing interval. Shorter courses of antibiotics
combined with suboptimal doses allow bacteria to build resistance.
Some antibiotics are also more prone to induce resistance and others and in
some cases they can induce resistance to antibiotics that had never been used
before. For this reason it important to consider topical therapy as much as
possible as use systemic antibiotics when really necessary. It is important to
control inflammation in the skin to minimize the conditions that could lead to the
development of a bacterial infection. As a general rule, superficial pyoderma
should be treated for a minimum of 3 weeks or at least 7-10 days past
resolution of all clinical signs. A narrow spectrum antibiotic should be
preferred over a broad spectrum. Good choices for Staphylococcus would be first
generation cephalosporines, clindamycin, lincomycin. Other good choices would
be amoxicillin clavulanic acid keeping in mind that the dose used for skin
infection is higher than the standard dose (22mg/kg BID vs the commonly used
14mg/kg BID). Third generation cephalosporines are not better than first
generation to kill staphylococcus but can increase the risk for resistance due to
the broader spectrum of action.
Fluoroquinolones should not be used as first line of defense and only used when
really necessary and indicated by bacterial culture. It is important to remember
that this category of drugs is concentration dependent and not time dependent.
Thus it is best to give one higher daily dose rather than two smaller daily doses in
the attempt to go above the mutation prevention concentration to minimize the
likelihood of antibiotic resistance. For deep infections, the average case would
require 6-8 weeks of systemic antibiotic. Treatment should be continued for at
least 4 weeks past the resolution of all clinical signs.
When faced with patients that appear to constantly need antibiotics the first thing
to establish is whether this is a recurrent infection, a persistent infection maybe
because it is a resistant infection. Did the patient ever clear? Do we know this
through a recheck or by owner report? If the patient cleared, how long did it take
to relapse? One rule that I use is the 2 week rule. If it takes less than 2 weeks to
relapse I consider the relapse as a continuation of the previous infection. In most

cases, this is due to insufficient length of the antibiotic course. If it takes more
than 2 weeks, then it could be a new bout if infection. Then the appropriate
question is: why is this happening? Clearly the patient has an underlying cause
that either has not been diagnosed or properly addressed.
Due to the increase of antibiotic resistance we now recommend to culture all
dogs with a chronic antibiotic history even if the infection is just a superficial
infection. In the past we would have assumed that the selection of a
cephalosporin would have been sufficient. Now we need a culture to help us
select the proper antibiotic. Out of necessity, we are also prescribing more
antibiotics like chloramphenicol, which had not been used for a long time. Due to
the infrequent use in the past, most staphylococcus is still sensitive to
chloramphenicol. A frequently used dose is 50mg/kg TID. GI upset is common
and clients should be warned about the toxicity and strongly encouraged to use
gloves when handling this drug. Another commonly seen adverse effect in large
breed dogs is peripheral neuropathy which manifests with ataxia and hind limb
weakness.
Topical therapy in the past was mostly used as adjunctive therapy. Currently, we
are using topical therapy sometimes in substitution for systemic therapy, in cases
where we have no systemic antibiotic left to use. Daily chlorhexidine whirlpool
baths followed by topical stannous fluoride at 0.4% are used in patients in whom
no other treatments are possible. Stannous fluoride is the main active ingredient
of toothpaste and is highly bactericidal, virucidal, and fungicidal. In unpublished
in vitro studies at UF, 0.4% stannous fluoride was shown to be highly bactericidal
against multi-drug resistant Staphylococcus. In clinical unpublished studies a
lower % of stannous fluoride was not found to be effective. This emphasizes the
importance of not diluting the product. It is important to apply it directly to the skin
at 0.4%. Another topical frequently used in resistant cases is mupirocin. The best
results are seen with twice daily application. Another topical treatment commonly
used is oxychlorine. This is the equivalent of topical bleach therapy sometimes
implemented in human medicine in children with Methicillin resistant Staph
aureus. Oxychlorine (Vetericyn spray) has the advantage of not bleaching the
coat and surfaces and being less harsh on the coat and skin. It should be done
2-3x/day for maximum benefit.
Finally, a word of caution in terms of possible transmission from dogs to humans
and vice versa may be needed. Healthy owners should not worry about the
possibility of contracting an infection but elderly or severely immunosuppressed
owners should exercise caution when handling dogs with draining tracts and
highly resistant infections. Although not common, such transmission has been
reported in the literature and we need to inform our clients about proper hygiene
to minimize this possibility.