Veterinury Dermutology 1996, 7, 133-143

Review article
Systemic treatment of bacterial skin infections of dogs
and cats
S T E P H E N D. W H I T E
Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State
University, Fort Collins, Colorado 80523, USA

(Received 27 Februury 1996; accepted 16 April 1996)

Abstract Antibiotics and immunostimulants are used in the systemic treatment of bacterial skin infections in
small animals. The major antibiotic groups commonly utilized are the macrolides, Iincosamides, potentiated
sulphonamides, p-lactamase-resistant penicillins, cephalosporins and fluoroquinolones. Empirical usage,
culture and sensitivity, mode of action, dosages, efficacy and side-effects are reviewed. A summary of the
veterinary literature relative to immunostimulants is also included.
Keywords: skin, bacterial infections, dogs, cats

INTRODUCTION 5 The depth of the infection, as determined by

Systemic treatment of bacterial skin infections may
be divided into two modalities: antibiotics and
immunostimulants. The primary pathogen of most
canine pyodermas is the coagulase-positive Staphylo-
coccus intermedius. Older reports prior to the
distinction between Stuphylococcus intermedius and
Staphylococcus aureus mention the latter as the primary
pathogen of canine p y ~ d e r m a . It
~ .is~ uncertain why
recent reports from India' and Poland' have empha-
sized Staphylococcus aweus as the most frequently
isolated pathogen from cases of canine pyoderma.
Either this reflects a different population of patho-
genic staphylococci from those countries, or a fault in
the identification technique." The major pathogens
of feline pyodermas (apart from fight/bite abscesses)
are Staphylococcus intermedius or Staphylococcus aur-
eus."7'2 The majority of this article will deal with
treatment directed against these two organisms.
ANTIBIOTICS
Choice of antibiotic
A clinician considers several factors when choosing
an antibiotic to treat a pyoderma. These include the
factors listed below.
1 The antibiotic sensitivity of the organism isolated
from the pyoderma if culture and antibiotic sensitiv-
ity testing have been performed.
2 The clinician's clinical experience with the efficacy
of various antibiotics.
3 The cost and the frequency of administration with
regard to client compliance, with once or twice daily
administration being preferable.
4 The potential of unwanted side-effects, and any
breed or age predilections for these side-effects.
clinical or histological examination. Deeper infec-
tions may need higher dosages and/or longer treat-
ment regimens, which may then cause increased cost
to the client.
6 The availability of an antibiotic in the clinician's
country, and its legal approval for use in small
animals.
Empirical usage vs. culture and antibiotic sensitivity
testing
Performing culture and antibiotic sensitivity testing
(C & S) on all suspected pyodermas is impractical
due to cost and time considerations. It is also often
unnecessary, if the clinician remembers that most
pyodermas in small animals are caused by the
coagulase-positive staphylococci and chooses anti-
biotics accordingly. It is far more useful to be able to
recognize the clinical signs of pyodermas, such as
pustules, epidermal collarettes and fistulous tracts
as well as to perform cytology on these lesions:
typically cocci are found in varying numbers, along
with neutrophils.13 However, there are some in-
stances in which C & S may be indicated. These are
listed below.
1 Deep pyodermas, i.e. a bacterial infection present
in the dermis, the subcutis and/or dissecting along
tissue planes as a cellulitis. These are most often
presented as fistulous tracts and/or nodules. An
exception to this rule would be canine or feline acne,
on which the author seldom performs C & S.
2 If cytology of pustules or other lesions show large
numbers of bacilli rather than, or in addition to, the
more common cocci.14
3 Any skin disease which has clinical signs suggestive
of pyoderma (epidermal collarettes, pustules, drain-
ing tracts, etc.) but has failed to respond to previous,
well-chosen empirical antibiotic treatment. I4

7: 1996 Blackwell Science Ltd I33

134
Methods of culture. It is important to remember that
the majority of healthy dogs will carry Staphylococcus
intermedius on the hair shafts of their ~ o a t s , ~ , ” ~ ’ to
therefore gently clipping away any haircoat from the
lesion to be cultured is indicated. Because of the
occurrence of Micrococcus sp., Propionibacterium
acnes, and other bacteria on the surface of normal
dogs’ kin'^,'^ surgical preparation of deep lesions
may also be indicated (see below).
The manner in which the clinician may obtain
samples for C & S is largely dependent upon the type
of lesion. Intact pustules may be lanced with a 25-
gauge needle, and the contents expressed on to a
sterile swab/culturette. Large, bullous pustules, which
are rare but may be seen in cases of hyperadreno-
corticism, may have their contents aspirated by syringe.
It is not known whether carefully dripping a dis-
infectant such as alcohol on to these lesions prior to
sampling will decrease contamination by nonpatho-
genic bacteria or, in contrast, interfere with pathogenic
bacteria growth, or do neither. Obviously, performing
surgical preparation would only rupture the contents,
making collection and interpretation difficult.
For nodules a helpful sampling technique is via a
biopsy after the skin has been surgically prepared. This
will insure both that surface organisms do not interfere
with the C & S, as well as enable the clinician to
obtain material for histopathology, if desired. Fistu-
lus tracts may be cultured this way as well, although
the author prefers to simply take a sterile swab/
culturette and insert it into the tract as far as possible.
Information is sadly lacking on practical methods
of performing C & S on epidermal collarettes or
intertrigo (skin fold pyoderma). The author has
occasionally obtained culture samples from epider-
mal collarettes by a punch biopsy from the collarette
and underlying skin, without performing any surgical
preparation. Alternatively, one may carefully lift up
and back the epithelial rim of the lesion with an iris
forceps and roll a sterile swab/culturette on the
underlying skin.
Before obtaining samples for C & S it is important
for the clinician to know what type of medium the
laboratory wishes for transport.
While all samples should be submitted for typical
aerobic culture, the author feels that samples from
nodular and fistulus lesions should also be cultured
for Actinomyces, Nocardia and (especially in cats)
mycobacterial specie^.'^,^' Also in cats, L-form
bacteria and mycoplasma organisms have been rarely
implicated in abscesses,21322 and their culture should
be requested if an abscess fails to resolve with
conventional treatment. While anaerobic organisms
have been isolated from skin disease in the dog23their
significance, other than the anaerobic or micro-
aerophilic Actinomyces sp., is still unknown.
Interpretation of sensitivity testing. Most systems of
sensitivity rely on either an agar diffusion and disc
process (such as the Kirby-Bauer method) or a broth
0 1996 Blackwell Science Ltd, Veterinary Dermatology, 7, 133-143
S. White
diffusion technique.’0924The mean inhibitory concen-
tration (MIC) is the minimal concentration necessary
~ inhibit growth; if the MIC of an antimicrobial
agent for the bacteria isolated can be achieved at the
site of the infection, the organism is said to be
susceptible to that antimicrobial agent. ‘The problem
is defining concentrations achieved at the site of
infection’.24 Most data use blood levels as an
indication of the achievable concentration.’0’2472s
Recently, it has been demonstrated that in design-
ing a dosage regimen for antimicrobial agents both
the mechanism of bacterial killing and post-antibiotic
effect must be c o n ~ i d e r e d Certain.~~~~ antimicro-
~~~~
bials, such as the fluoroquinolones, have concentra-
tion-dependent bactericidal activity; that is, the rate
and extent of the killing increases as the concentra-
tion increases, even as the drug serum concentration
approaches 3 M O times the MIC of the pathogen. It is
the peak serum concentration that is the best correla-
tion with treatment efficacy in these antibiotics.26327
In contrast, erythromycin, the a-lactamase resis-
tant penicillins and the cephalosporins have time-
dependent bactericidal activity in which the total time
the serum drug concentration remains above the MIC
correlates best with treatment efficacy. The rate and
extent of bacterial killing will increase only until serum
drug concentrations reach four to eight times MIC.26,27
These factors will vary with the antibiotic and the
organism. It remains to be seen if re-evaluation of the
pharmacokinetics of a number of compounds will
alter dosing regimens.
The post-antibiotic effect (PAE) is defined as the
persistent, variable suppression of bacterial growth
after serum concentrations decrease below MIC.28
The PAE may be the result of damage to the bacteria
during exposure to the antibiotic which makes the
organism more susceptible to host defence mechan-
isms, or binding of the antibiotic within the bacteria
at concentrations that ultimately prove The
PAE of an antibiotic may be dependent upon intrinsic
properties, concentration, and the presence of neu-
t r o p h i l ~ .Fluoroquinolones
~~ and aminoglycosides
seem to be the antibiotics best able to induce PAE.
Ultimately, as the clinician relies on the laboratory
to whom he/she sends the samples for culutre to
advise on the sensitivity or resistance of the isolate, it
is probably best to deal with laboratories which have
prior experience in dealing with veterinary pathogens,
as this may influence the isolation and sensitivity
techniques used.]’
Sensitivity patterns over the last 20 years for
coagulase-positive Staphylococcus sp. have remained
relatively ~onstant,~’ seemingly throughout the world.
Resistance to the J3-lactamase-resistant penicillins
(oxacillin, dicloxacillin, etc.) and cephalosporins was
quite rare in 1974 in studies in the USA,6 in 1979-86
in Finland,3 in 1989 in the USA and Australia24331
and in 199&5 in the Netherlands, Sweden, the UK
and A ~ s t r a l i a . ’ * In
~ ~contrast,
-~~ resistance to linco-
mycin is apparently increasing from 6.9% of the
 Systemic treatment of bacterial skin infections of dogs and cats 135

isolated coagulase-positive staphylococci in the USA subunits of susceptible organism^.^' Cross-resistance

in 19746 and 7.4% in Australia in 198431to 15% in among these antibiotics, and with clindamycin, is a
Finland in 19863 and to 26% in the Netherlands and ~roblem.~"~~
Australia in 1994-5.5,34 A similar increase in resis-
Erythromycin - This is an inexpensive antibiotic, but
tance to clindamycin was seen in Sweden between
often causes vomiting and/or diarrhoea. These side-
1990 (8%) and 1995 (26.9%).32 It would seem that
effects may be ameliorated by utilizing enteric-coated or
Staphylococcus intermedius is more likely to develop
pediatric syrup preparations; however, this generally
resistance via chromosomal change rather than via
increases the cost. The stearate formulation should be
plasm id^.^^^^^^^^
given on an empty stomach.40 While erythromycin
has been reported to lose efficacy if other antibiotics
Types of antibiotics
were used previou~ly,~' a recent report showed no loss
When choosing antibiotics empirically for use in
of efficacy in vitro against Staphylococcus intermedius
staphylococcal pyoderma, some antibiotics perform
when other antibiotics had been used first.42
so poorly (usually due to their susceptibility to the
bacteria's p-lactamases) that their use is best avoided. Tylosin - Not approved for use in the dog in the
These include penicillin, amoxcillin, ampicillin, tetra- USA (approved for use in Canada, but only for
~ ~ ~ ~ ~ ~ ~ ~gastrointestinal
cycline and the s u l p h ~ n a r n i d e s . ~However, ~'~~~ disease), this antibiotic was recently
ampicillin or amoxicillin is the drug of choice for cat- shown to be effective in 90.5% of cases of dogs with
bite abscesses, which are usually caused by Pasturella Staphylococcus intermedius p y ~ d e r m a . ~ ~
S P . ,penicillin
~~ is the drug of choice for Actinomyces
sp., and tetracycline is one of the drugs of choice for Azolides. These are a new class of antibiotics with a
L-forms21and mycoplasma.22 mechanism of action similar to the m a c r o l i d e ~ . ~ ~
The antibiotics and their dosages used in dogs and
Azithromycin - The pharmacokinetics of this
cats for the treatment of staphylococcal pyodermas
antibiotic have been studied in the dog and the
are listed in Table 1. A summary of recent studies of
cat.43344It may have efficacy against a wide range of
the efficacy of various antibiotics in the treatment of
both Gram-positive and Gram-negative bacteria,
canine pyoderma is presented in Table 2. Relevant
including the mycobacteria. It is quite expensive.
specific comments follow; comments on cost are
based on experience in the USA.
Lincosamides. These antibiotics' antibacterial activity
is similar to that of the macrolide~.~'
Macrolides. These antibiotics inhibit bacterial protein
synthesis by binding reversibly to the 50 S ribosomal Lincomycin - This has been a very effective

Table 1. Antibiotics useful in the treatment of pyodermas in small animals

Antibiotic Reference Dose*
Macrolides
Erythromycin 13, 40 10-15 mg kg-' every 8 h
Tylosin 42 20 mg kg-l every 12 h
Azalides
Azi thromycin 43 5 mg kg-' every 24 h
Lincosamides
Lincomycin 13, 40, 45 22 mg kg-' every 12 h
Clindamycin 40. 45 5.5-11 mg kg-' every 12 h
p-lactamase-resistant penicillins
Oxacillin 13, 40 22 mg kg-l every 8 h
Clavulanic acid-amoxicillin 13, 40, 58, 60 12.5-25 mg kg-' every 8-12 h
Quinolones
Enrofloxacin 67-70 2.5-5 mg kg-' every 12-24 h
Marbofloxacin 74 2 mg kg-' every 24 h
Cephalosporins
Cefadroxil 65, 66 22 mg kg-' every 12 h
Cephalexin 13, 40 22 mg kg-I every 8-12 h
Cephradine 40 22 mg kg-' every 8-12 h
Potentiated sulphonamides
Trimethoprim-sulphadiazine 55 2 6 3 0 mg kg-I every 12 h
Trimethoprim-sulphamethoxazole 40 20-30 mg kg-' every 12 h
Ormetoprim-sulphadimethoxine 49, 55 55 mg kg-' every 24 h on day 1,
then 27.5 mg kg-l every 24 h
Miscellaneous
Chloramphenicol 13, 40 50 mg kg-I every 8 h
Rifampin 40 5-10 mg kg-'every 24 h
Doxycycline 76 5 mg kg-l first dose, then 2.5 mg kg-' b.i.d.
*All doses per 0s.

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136 S. White

Table 2. Results of recent studies: efficacv of various antibiotics in canine ovodermas*

Percentage of cure/excellent response!
very clear improvement

Antibiotics Reference Superficial pyodermas Deep pyodermas

Clindam ycin 45 94
Lincomycin 45 93 ~

46 100 69.5
Tyiosin 42 91 90
Amoxicillin-clavulanic acid 58 89 91
60 90 91
Cephalexin 61 92.9 88.9
63 701-
Cefadroxil 65 100 91
Cephalexin or cefadroxil 66 93.2t
Trimethoprim sulpha 55 75.9
78.6
Ormetoprim sulpha 55 100
49 90t
Enrofloxacin 70 93.3t
67 89.7
68 95.5 -

69 ~
85.2
Marbofloxacin 74
Routine cases 95.8 96.3
Difficult cases ~

84
*Table adapted from reference 39. Results varied depending upon dosage and duration of
treatment.
?Response on the basis of depth of pyoderma not given.

antibiotic in the author’s experience but, as noted
above, staphylococcal resistance to it may be increas-
ing. Its expense often limits its use to small dogs and
cats. It should be given on an empty It
was reported as effective in 100% of a small series of
cases of canine p y o d e r m a ~and
~ ~ its efficacy has been
reported to be equal to that of ~ l i n d a m y c i nUsing
. ~ ~ an
autohistoradiography protocol lincomycin has been
shown to be distributed into the hair follicle, epidermis
and sebaceous gland.47
Clindamycin - This antibiotic is very effective
against anaerobic bacteria and in cases of osteomye-
l i t i ~ The
. ~ ~author prefers clindamycin when dealing
with in’fections involving the oral cavity.
Potentiated sulphonamides. Sulphonamides are com-
petitive inhibitors of the bacterial enzyme responsible
for the incorporation of para-aminobenzoic acid
(PABA) into the immediate precursor of folic acid.48
Thus sensitive bacteria are those which must synthe-
size their own folic acid. Trimethoprim, ormetoprim
and baquiloprim inhibit the reduction of dihydrofolic
acid into tetrahydrofolic acid, thus blocking another
step in the bacterial metabolism of folic acid.48p50
A number of different forms (various sulphon-
amides combined with either trimethoprim or orme-
toprim) of these drugs are available, often reasonably
priced, even for the large-breed dog. However, the
trimethoprim-sulphonamides have a high incidence
of side-effects in Doberman Pinschers; this seems to
be due to the sulphonamide portion of the mole-
c ~ l e . ~The
’ . ~potentiated
~ sulphonamides have also
been implicated in causing keratoconjunctivitis sicca
(KCS).’7353
The results of several recent studies with this group
of antibiotics are: serum and skin concentrations
after multiple-dose oral administration of trimetho-
prim-sulphadiazine in dogs were above the MIC
when given once daily;54 confirmation that twice
daily trimethoprim-sulphadiazine administration is
clinically effective in the treatment of staphylococcal
pyoderma in dogs;55and confirmation that once daily
sulphadimethoxine-ormetoprim administration is
clinically effective in the treatment of staphylococcal
pyoderma in dog^.^',^^ Most of the published data on
baquiloprim deals with large animals.50 However,
when combined with sulphadimethoxine, baquilo-
prim’s treatment efficacy in both superficial and deep
pyodermas in dogs has been observed (P. Bourdeau,
Nantes, France; unpubl. data).
The use of potentiated sulphonamides in the
treatment of Nocardia infections is controversial;
treatment should be based on sensitivity testing. The
combination of surgical removal of the infected
tissues and antibiotic treatment may be more effective
than the use of antibiotic alone.’’
0-lactamase resistant penicillins. Penicillins inhibit
bacterial cell-wall synthesis. The p-lactam ring is a
central part of the structure of the penicillin. Most
staphylococci isolated from small animal pyodermas
produce p-lactamases (penicillinases) which disrupt
this ring. 1333’340356Thus only those penicillins which
are resistant to the P-lactamases are useful in the
treatment of small animal p y ~ d e r m a s . ? ~

c] 1996 Blackwell Science Ltd, Veterinury Dermatology, 7, 133-143

 Systemic treatment of bacterial skin infections of dogs and cats
Clavulanic acid-amoxicillin - This hygroscopic
antibiotic becomes ineffective when it absorbs water
(even that in the atmosphere) prior to ingestion. Its
efficacy in clinical skin infections of the dog has been
reported over the last decade;57358and it lowers,
although does not eliminate the numbers of patho-
genic staphylococci from the skin of healthy dogs5'
Increasing the dosage, from 12.5 mg kg every 12 h
'
to 25 mg kg every 12 h, does not add to efficacy,6'
although this has been debated.4" It is the opinion of
the author that its efficacy is increased when given
every 8 h.
Oxacillin This is a highly effective antibiotic, and
~
the generic in the USA is relatively cost-effective for
large-breed dogs. Oxacillin should be given on an
empty ~tomach.~' Vomiting is an occasional side-effect.
Cephalosporins. These antibiotics inhibit bacterial
cell-wall synthesis in a manner similar to the
penici~lins.~~
While many cephalosporins exist, most veterinar-
ians have experience with cephalexin6' 64 or cefa-
d r o ~ i lThe
. ~ ~former is approved for use in the dog in
various European countries, while the latter is also
approved in the USA. These are very effective
antibiotics for treatment of small animal pyoderma,
with few side-effects. In the USA cephalexin is
available as a generic at low cost, which facilitates
its usage in large-breed dogs. No difference in efficacy
was seen when comparing cefadroxil and both the
brand name and generic cephalexin.66 The usage of
another cephalosporin available as a generic in the
USA, cephradine, has been ~uggested.~'While these
drugs are effective at twice daily dosage, the author
and others4' prefer a three times a day dosage for
deep pyodermas. The author has seen cases of
presumed immune-mediated cutaneous drug reac-
tions to cephalexin, but these seem to be quite rare.
Fluoroquinolones. These drugs inhibit bacterial DNA
gyrase, an enzyme necessary for normal DNA tran-
scription and replicati~n.~"~' Their activity is antag-
onized by agents that inhibit bacterial protein synthesis
(chloramphenicol) and RNA synthesis ifam amp in).'^,^^
While cross-resistance between this group of drugs and
other antimicrobials is uncommon, cross-resistance
among the fluoroquinolones can occur.29 They have
excellent activity against Pseudomonns sp2'
In this category are two drugs which have been
approved in various countries for veterinary usage in
small animals: enrofloxacin and marbofloxacin. En-
rofloxacin (not approved in France) has been used in
the treatment of staphylococcal p y ~ d e r m a , ~ ' - ~as'
well as skin infections caused by Mycobucteria sp."
Its dosage regimens may need to be modified
depending upon the organism suspected (see above).27
Marbofloxacin (soon to be available in the USA) also
has been proven effective in treatment of staphylo-
coccal pyoderma in dogs.72-74
C 1996 Blackwell Science Ltd, Veterinary Dermatology, I , 133- 143
137
The fluoroquinolones should not be used in small-
and medium-breed dogs between 2 and 8 months of
age, large-breed dogs until 12 months of age and
giant-breed dogs until 18 months of age. This is
because the fluoroquinolones may cause damage to
the articular cartilage in skeletally immature
dogs.29,75Cats appear less likely to be afflicted.29
Miscellaneous antibiotics. Chloramphenicol ~- The
mechanism of action of this antibiotic is similar to
the macrolides." While effective against staphylo-
coccal pyoderma in the dog, chloramphenicol can
cause serious and fatal blood dyscrasias in humans.3x
Its usage is therefore dificult to recommend in the
light of the alternative agents a ~ a i l a b l e . ~Plasmid-
'
mediated resistance to this antibiotic may be im-
p ~ r t a n tAs
. ~ noted
~ above its use with enrofloxacin is
~ontraindicated.~~
Doxycycline - Like all tetracyclines, this antibiotic
inhibits bacterial protein synthesis with its site of
action being the bacterial r i b ~ s o m e . ~Doxycycline
'
was recently shown to induce partial to complete
clinical response in greater that 50% of canine and
feline coagulase-positive staphylococcal pyodermas
after 3 weeks of use. Clinical response did not
correlate well with culture and sensitivity results, as
only 6% of the staphylococci exhibited in vitro
. ~ ~use has also been advocated in cases
r e ~ i s t a n c e Its
of mycobacterio~is,~'and the author has used it in
cats for that purpose with good success.
Rifampin - This antibiotic inhibits the DNA-
dependent RNA polymerase of micro- organism^.^'
Potentially hepatotoxic, rifampin is to be used with
caution. Its advantage is its excellent penetration of
granulomatous lesions. It should be used in associa-
tion with p-lactamase-resistant antibiotic^.^'^^' As noted
above, its use with enrofloxacin is contraindicated.2y
Aminoglycosides. The site of action for these anti-
biotics is the 30 S ribosomal subunit, where they
inhibit protein synthesis and interefere with trans-
lation of messenger RNA.79 The aminoglycosides
typically do well against staphylococcal organisms.'
Due to the parental administration of these drugs and
their renal side-effects, their use is limited to cases of
sepsis (such as a mixed staphylococcal and Pseudo-
monus sp. infecti~n),"~'~or in some cases, initial
treatment of mycobacterial organisms.71
Duration of untibiotic therapy
The length of time an antibiotic should be given
varies with the organism, the depth of the pyoderma,
any underlying causes present, and the type of
For superficial staphylococcal infec-
tions, 3 weeks is usually a sufficient time to judge the
efficacy of the treatment; if the animal's condition has
improved but the lesions have not resolved totally,
continuing 2 weeks past resolution of signs is
indicated.X13" For deep staphylococcal pyodermas,
 138 S. White
at least 6 weeks of treatment is preferred.13~8i~82 For
deep infections caused by actinomycosis, mycobac-
teria, or Nocardiu spp., 3-6 months, or longer, may
be indicated.'"''
Recurrent staphylococcal pyodermas (particularly
superficial folliculitis or superficial spreading pyoder-
ma) frequently have underlying causes, such as
a t ~ p y , ' ~food
, ~ ~ a l l e ~ - g y , ~ ~fleas,"
.~' hypothyroid-
ism,88or hyperadrenocorti~ism.~~ While investigating
these underlying causes, or waiting until treatment of
such causes takes effect, the clinician may need to
maintain the dog on long-term antibiotics. If the
recurrent pyoderma has no identifiable underlying
cause life-long antibiotics may need to be instituted.
Occasionally, the frequency of recurrence may be
quite low (three or four times per year)82 in which
case the antibiotics may merely be prescribed on an
as-needed basis. Frequently, however, the recurrence
is within 2-3 weeks of stopping antibiotic treatment.
For economic reasons in such cases, once antibiotic
administration is resumed and the animal has shown
the optimal clinical response (usually within 2-3
weeks) the dosage may be gradually reduced over a
month's time to the lowest possible amount that can
maintain clinical response. This is generally one-half
of the normal daily dosage, given daily or every other
day. Other reports suggest using 'pulse therapy' of
the antibiotic: a 'week on, week of7 schedule,
gradually extending the time the dog is off the
antibiotic. 82383
The author and others64382usually use cephalexin
in these circumstances and, despite theoretical con-
cerns of development of antibiotic resistance," this
seems to be rare when using the cephalosporins.9'
One report suggests that the usage of potentiated
sulphonamides, lincomycin, or erythromycin as long-
term treatment will eventually lead to the patient's
relapse due to development of antibiotic resistance.x2
The author has also managed two cats with long-term
antibiotic treatment using oxacillin. l 2
Adverse ejects
Many antibiotics may occasionally cause vomiting
and/or diarrhoea, whether through causing nausea or
altering the intestinal flora. Drug-induced pemphigus
foliaceus has been reported in cats due to ampicillin92
and do~ycycline.'~As mentioned above, some anti-
biotics have specific adverse effects.
Potmtiuted sulphonamides: KCS, immune-mediated
dermatitis, arthritis and uveitus, and hepatobiliary
disease,'7.5 1,52.94,95 The adverse reactions have gen-
erally been considered the fault of the sulphonamide
portion of the These drugs may also cause a
decrease in thyroid function, lasting as long as 3
months following cessation of treatment.96
Fluoroquinolones; potential for injury of the articular
cartilage in skeletally immature dogs," crystalluria in
adult dogs.97
#( 1996 Bldckweil Science Ltd, Vetermur) Derrnutofogj, 7, 133-143
Rfumpin: hepatotoxicity, thrombocytopaenia, hae-
molytic anaemia, anorexia, vomiting, diarrhoea,
death.39,40
Erythromycin: vomiting.
A recent report found that owners' observations
(based on 699 questionnaires) showed that erythro-
mycin was the most common antibiotic associated
with adverse side-effects, usually vomiting. By con-
trast, trimethoprim-sulphonamide, the antibiotic
most often used in dogs among the owners of the
study, did not result in a substantial number of
adverse reactions.98
IMMUNOSTIMULANTS
Immunostimulants are usually either bacterins or
oral drugs. Bacterins may be autogenous or com-
mercial. Autogenous bacterins are made from the
staphylococci isolated from the dog's lesions. Because
dogs may in fact be infected by either multiple strains
of Staphylococcus intevmedius4 or by both Staphylo-
coccus intermedius and Staphylococcus a ~ r e u s , ~ ~
theoretically the providing of an antigenic stimulus
as close as possible to the infective organism@)
should be more effect than a standardized commer-
cial bacterin, particularly as none of the commercial
bacterins in the USA is derived from Staphylococcus
intermedius. However, this remains to be proven.'*
Three commercial bacterins have been commonly
used in canine pyoderma in North America. One is
derived from Staphylococcus aureus by lysing it with a
polyvalent bacteriophage (Staphage Lysate, Delmont
Laboratories, Swarthmore, PA, USA) and may be
given subcutaneously; another is prepared from killed
Propionibucterium acnes organisms (ImmunoRegulin,
ImmunoVet, Tampa, FL, USA) which must be given
intravenously; a third bacterin is made from killed
Staphylococcus aureus organisms and also contains
staphylococcal alpha and beta toxins (Staphoid AB;
Cooper's Animal Health, Mundelein, IL, USA) and
is given in a combination of subcutaneous and
intradermal injections.82 The first two products have
been shown to be effective in double-blind studies in
either achieving remission in dogs with the concur-
rent use of antibiotics (the Propionibacterium acnes
product)99 or keeping dogs in remission without the
use of long-term antibiotics (the Staphylococcus aureus
product)"' The third product has been reported as
effective in the treatment of canine pyoderma."'
Dosage regimens have been reviewed elsewhere.'*
The author's experience has been primarily with
the Staphylococcus aureus products, the one given by
subcutaneous injection being preferred for ease of
client instruction. It should be emphasized that these
products should be used only in cases of idiopathic
recurrent pyoderma. The author's success rate in
controlling pyodermas with these products is only
 Systemic treatment of bacterial skin infections of dogs and cats
about 50%; therefore the clinician must choose the
case and the client carefully. Antibiotics given during
the initial phase of treatment lead to a higher chance
of success. Even when immunostimulants are success-
ful in controlling pyodermas, intermittent use of
antibiotics may still be needed.
Two oral medications have been promoted as
possible immunostimulatory drugs for the treatment
of idiopathic recurrent pyoderma in dogs.
Originally developed as an antihelmintic, levami-
sole is thought to be able to restore normal function
to immunosuppressed lymphocytes. Dosage is
2 mg kg-’ every 48 h; overdosing may be immuno-
depressive.82 This drug has been unimpressive when
used by the author. Side-effects (vomiting, ataxia,
disorientation, depression) are common. Dogs must
be heartworm negative. Cimetidine is a blocker of the
H-2 histamine receptor site, such as those on sup-
pressor T lymphocytes. Theoretically, the blocking of
these receptor sites reduces the suppressive activities
of these lymphocytes. The dosage suggested for
cimetidine is 3 4 mg kg-’ every 12 h. The drug is
continued 10 weeks past clinical resolution of the
pyoderma. This drug should not be used in conjunc-
tion with monamine oxidase inhibitors, such as
amitraz. Other than isolated case reports, the efficacy
of this protocol has not yet been documented.
Cimetidine is expensive.82 With both these drugs,
antibiotics must be given during the intial phase of
treatment to resolve the pyoderma; the drugs are then
used in an attempt to keep the pyoderma in remission.
C O N C LU S I O N S
The clinician has a wide choice of antibiotics with
which to treat dogs and cats afflicted with bacterial
skin infections. The personal choices of the author for
first-time pyodermas seen in private practice would
be to use lincomycin for small dogs, oxacillin or
ormetoprim-sulphadimethoxine for large dogs (but
using only oxacillin for Doberman Pinschers). While
fluoroquinolones and cephalosporins may be used
successfully in first-time pyodermas, the author tends
to use them more in difficult or non-responsive
pyodermas. As outlined at the beginning of this article,
however, each clinician’s choice of antibiotic will be
based on several determinant facors, including per-
sonal experience. As stated by Powers et al., in 1984:
Some consider antimicrobial therapy an art
rather than a science.25
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Resume Antibiotiques et immunostiniulants sont utilises dans le traitement systkmique des infections
bacteriennes cutanees des animaux de compagnie. Les familles d’antibiotiques les plus utilisees sont les
macrolides, les lincosanides, les sulfonamides potentialises, les penicillines resistantes a la lactamase, les
cephalosporines et les fluoroquinolones. L’utilisation empirique, I’isolement et l’antibiogramme, le mode
d’action, les dosages, I’efficacitk et les effets secondaires sont presentis. Un resume de la litterature veterinaire
concernant les immunostiinulants est egalement inclus. [White, S. D. Systemic treatment of bacterial skin
infections of dogs and cats. (Traitement systemique des infections bacteriennes cutanees du chien et du chat).
Veterinary Dermatology 1996; 7: 133-143.1

Resurnen Para el tratamiento sistemico de Is infecciones bacterianas cutaneas en pequefios animales se usan
antibioticos e inmunoestimulantes. Los grupos de antibioticos mas frecuentemente utilizados incluyen 10s
macrolidos, lincosamidas, sulfonamidas potenciadas, penicilinas beta-lactamasa resistentes, cefalosporinas y
fluoroquinolonas Se revisan su us0 empirico, cultivo y sensibilidad, mecanismo de accion, dosis, eficacia y
efectos colaterales. Se incluye un resumen de la literatura veterinaria sobre immunoestimulantes. [White, S. D.
Systemic treatment of bacterial skin infections of dogs and cats. (Tratamiento sistemico de las infecciones
bacterianas cutaneas de perros y gatos). Veterinary Dermatology 1996; 7: 133-143.1

9, 1996 Blackwell Science Ltd, Veterinar) Dermntofogy, 7, 133-143

 Systemic treatment of bacterial skin infections of dogs and cats 143

Zusammenfassung Antibiotika und Immunstimulantien werden in der systemischen Behandlung von

bakteriellen Hautinfektionen bei Kleintieren eingesetzt. Die Hauptgruppen der gewohnlich verwendeten
Antibiotika sind Markrolide, Lincosamide, potenzierte Sulfonamide. beta-Laktamase-resistente Penicilline,
Cephalosporine und Fluroquinolone. Die empirische Anwendung, Kultur und Empfindlichkeit,
Wirkungsweise, Dosierung, Wirksamkeit und Nebenwirkungen werden dargestellt. Eine Zusammenfassung
der Veteriniirliteratur bezuglich Immunstimulantien wird miteingeschlossen. [White, S.D. Systemic treatment
of bacterial skin infections of dogs and cats (Systemische Behandlung von bakteriellen Hautinfektionen bei
Hund und Katze). Veterinary Dermutology 1996; 7: 133-143.1

f 1996 Blackwell Science Ltd, VererinnrJ Dermatology, 7, 133-143