For recurrent S. aureus abscesses consider: a) decolonization with twice daily intranasal mupirocin for 5 days, b) daily chlorhexidine washes, c) daily decontamination of personal items such as towels, sheets, and clothes.
Pen G IV or pen V PO, probably the drug of choice for streptococci.
If the patient is sick enough to be admitted, this drug is a good option if MRSA not suspected.
Effective against group A Strep and MSSA but not MRSA.
Along with minocycline, often thought of as an oral alternative to TMP/SMX for community-acquired MRSA, the drug has a reputation as having poor anti-streptococcal activity and should not be relied upon alone for typical cellulitis unless strongly thought to be related to S. aureus.
Very convenient once daily dosing and effective against Staphylococcus aureus (MSSA and some CA-MRSA), but may represent abusive prescribing as has much more spectrum of coverage than typically needed for S. pyogenes and some S. aureus.
Broad Gram positive activity. Use if MRSA proven/suspect. Oral dosing makes conversion from IV vancomycin attractive. Though now generic in U.S., remains expensive.
Concern is C. difficile infection.
Active vs. >95% community-acquired MRSA, but less active vs. hospital strains. Has relatively poor streptococcal coverage.
Staphylococcus aureus (methicillin-sensitive)
Staphylococcus aureus (methicillin-resistant)
Comment: Foundation for recommendations presented in this module.
Comment: Adults and children with a single skin abscess 5 cm in diameter or smaller were randomly assigned to receive oral clindamycin, TMP-SMX, or placebo in addition to incision and drainage. In patietns with S. aureus infections, patients on the abx groups had a higher cure rate and less likey to have a recurrent infection at 1 month. Adverse events were common in the abx groups.
Comment: Cellulitis failure rates according to literature review vary widely (6-37%). The author speculates that this reflects many cases that simply mimic cellulitis.
Comment: A retrospective review of 28 cases of orbital infections, including 15 (54%) with cellulitis and abscesses accounted for 68%. S. aureus with the most common pathogen and 93% had a good outcome.
Comment: Comparative trial of 524 patients with cellulitis, cutaneous abscess or both using TMP/SMX vs clindamycin x 10 days. Abscesses were drained. Outcome of the 2 groups were similar (cure rates of 90% vs 88%; P=0.8)
Comment: Letter to editor noted 30% in each group had abscesses that may only need drainage without antibiotics. Authors respond that this query was not addressed so their trial could not answer it.
Comment: Review of 13 guidelines for skin infections from 9 European countries. Conditions included erysipelas, folliculitis, cellulitis, impetigo and furuncle. All recommended beta-lactam agents, mainly those with limited spectrum. Seven also recommended topical fusidic acid. The beta-lactam recommended for adults varied including penicillin (2), flucloxacillin (4), oxacillin (1); duration was 7-14 days, usually 10 days.
Comment: The skin conditions that mimic cellulitis include stasis dermatitis, contact dermatitis, lymphedema, eosinophilic cellulitis, and papular urticaria.
Comment: Literature review of patients hospitalized with cultures were positive in 4.6% of 607 cases of which Group A strep accounted for 65%, S. aureus for 14% and Gram negative bacilli, 11%. Conclusion is that these results show most cellulitis cases are caused by Group A strep.
Comment: Clean dermatologic surgery database was reviewed for use of topical antibiotics. Topical antibiotics were used in 8 million of 212 million cases (5%), which the authors considered inappropriate use. Note that this reiew was selected because of the useless but sometimes common practice of using topical antibiotics on clean wounds.
Comment: Evaluation of sensitivity tests of 58 community-acquired MRSA isolates from soft tissue infections in an emergency room in Salt Lake City -- 51 (98%) were sensitive to TMP/SMX -- 50 (80%) sensitive to tetracycline -- 47 (81%) sensitive to clindamycin. Note that this sensitivity pattern is similar to that of many other reports for the past 4 years. TMP/SMX or clindamycin are usually "preferred."
Comment: Evaluation of treatment of cellulitis in 405 patients. Success rate was 91% with TMP/SMX vs. 74% (P=< 0.001). factors associated with treatment failure were: antibiotic inactive in vitro (OR=4.2) and cellulitis severity (OR=3.7). This report is testimony to the need to treat with antibiotics and value of TMP/SMX for CA-MRSA infections.
Comment: This is a report of 179 patients with diffuse, non-culturable cellulitis using serology (ALSO and DNase B), which was positive in 73%. A separate analysis of 73 showed 71 (97%) responded to a β-lactam. Note that cellulitis with no pus and negative cultures is usually caused by Group A Strep.
Comment: Review of 3,566 serious streptococcal infections in England 2003-04. Cellulitis was the most common (30%) and necrotizing fasciitis was the most commonly fatal (34%).
Comment: Review of 90 cases and 90 controls. Most common pathogen was Group G strep -- 26 (29%) of cases. also in throat of 7% of cases, 13% household contacts and no controls. Group A strep found in 7%. Recurrent infection in 7%.
Comment: Authors describe 8 patients with A. baumannii infections associated with war wounds. The presentation was cellulitis with "peau d'orange" appearance, with vesicles and progressed to necrosis with bullae.
Comment: Retrospective review of 282 patients with MRSA soft tissue infections showed doxycycline in 90 patients and was active vs the MRSA in 95%. Doxycycline was significantly better than a beta-lactam (OR 3.9, p=0.02).
Comment: Leg erysipelas/cellulitis is common - 1/1000 persons/year. Group A strep still most common, foot intertrigo is common risk.
Comment: Mayo Clinic review of cellulitis in population based cohort. There were 209 cases of cellulitis and 35 (17%) recurred within 2 years. Most common findings in the cellulitis group - tibial involvement, malignancy and dermatitis. These risks correlated with risk of recurrence.
Comment: Review of recurrent erysipelas in 47 patients. Average was 4.1 recurrences, most had cutaneous disruption (81%) usually due to intertrigo (60%). Antibiotic prophylaxis was given to 68% - no recurrences were noted in 72% at 2 years.
Comment: Group A Strep: lymphedema, early post op wound infections, perianal cellulitis; Crepitant cellulitis: Clostridia and other anaerobes; Bites: Human - anaerobes, Eikenella, S. aureus, cats/dogs - Pasteurella; Diabetic foot: GNB and anaerobes; Blood cultures: Usually Group A strep.
Comment: Review of emerging problem of community-acquired MRSA. Though most often identified in children, sporadic and outbreak cases seen in adults (IDU, HIV, sports teams). Routine management of suspected staphylococcal skin and soft-tissue infection as MSSA may need to change in the next few years.
Comment: Randomized trial of linezolid vs vancomycin for soft tissue infections involving MRSA. Clinical cure rates were 73% in both groups.
Comment: Randomized trial of oxacillin - dicloxacillin vs linezolid for 826 patients hospitalized with complicated skin and soft tissue infections. Cure rates were 70% for linezolid and 65% for oxacillin - dicloxacillin (p=0.1).
Comment: Anal colonization with Group G and possibly Group A and other Beta-hemolytic streptococci may be the reservoir for the pathogen in recurrent erysipelas. In recurrent cases, it may be worth educating patients about this possible source of infection.
Comment: Retrospective review of 757 patients admitted with community acquired cellulitis over a 41 month period shows that the yield of blood cultures is very low (2%), has a marginal impact on clinical management and is not cost effective for most patients with cellulitis.
Comment: Placebo-controlled trial of antibiotic with or without prednisolone for erysipelas. Steroid treatment hastened response.
Comment: Microbiology studies in 50 patients hospitalized with cellulitis showed pathogen in blood - 5, needle aspirate - 5, and punch biopsy - 10.
Comment: Randomized trial for 5 vs 10 days of treatment showed uncomplicated cellulitis could be treated for 5 days.
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