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.
Drug | Recommendation |
Pen G IV or pen Vk PO is probably the drug of choice for streptococci. | |
Not effective against Staphylococcus aureus, ex., for the rare isolate that remains penicillin-susceptible, but good coverage against Group A Strep. Group A Strep is always sensitive to penicillin and amoxicillin. Inexpensive oral medication. | |
Good oral drug for Group A Strep and Staphylococcus aureus (MSSA but not MRSA). | |
Effective against group A Strep and MSSA but not MRSA. | |
Also a good choice for covering both group A Strep and methicillin-sensitive Staphylococcus aureus in patients with mild to moderate disease that can be treated with oral antibiotics. | |
Along with minocycline, often thought of as an oral alternative to TMP/SMX for community-acquired MRSA. | |
Very convenient for once-daily dosing and effective against Staphylococcus aureus (MSSA and some CA-MRSA), but it may represent abusive prescribing as it has much more spectrum of coverage than typically needed for S. pyogenes and some S. aureus. | |
It may favor patients with previous vancomycin-associated nephropathy or at high risk for nephrotoxicity. Also, consider for patients who may clear Vanc very quickly and might be challenging to achieve adequate therapeutic levels. Oral dosing makes conversion from IV vancomycin attractive. | |
Concern is C. difficile infection. | |
Active vs. >95% community-acquired MRSA, but less active vs. hospital strains. |
Pathogen | First-Line Agent | Second-Line Agent |
Staphylococcus aureus (methicillin-sensitive) | ||
Staphylococcus aureus (methicillin-resistant) | ||
Amoxicillin clavulanate, ampicillin/sulbactam | ||
Cefotaxime, ceftazidime | ||
Doxycycline | ||
Erythromycin |
Comment: This meta-analysis explored the benefit of antibiotics for managing cutaneous abscess post-I&D. Four studies (n=2,406 participants) were identified. There were 89 treatment failures (7.7%) in the antibiotic group and 150 (16.1%) in the placebo group. There was also a decreased incidence of new lesions in the antibiotic group (risk difference -10.0%, 95% CI -12.8% to -7.2%; odds ratio 0.32, 95% CI 0.23 to 0.44) and a mildly increased risk of minor adverse events (risk difference 4.4%, 95% CI 1.0% to 7.8%; odds ratio 1.29, 95% CI 1.06 to 1.58).
Comment: Foundation for recommendations presented in this module.
Comment: Meta-analysis could not find any evidence to support a difference between shorter or longer durations of therapy although there were only 2 trials that had the same drug as a comparator.
Comment: A small trial showed that regular use lowered risk by about 80% in analysis with up to three years of follow-up.
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 patients with S. aureus infections, patients in the abx groups had a higher cure rate and were less likely to have a recurrent infection at 1 month. Adverse events were common in the abx groups.
Rating: Important
Comment: According to the literature review, cellulitis failure rates vary widely (6-37%). The author speculates that this reflects many cases that mimic cellulitis.
Comment: Comparative trial of 524 patients with cellulitis, cutaneous abscess or both using TMP/SMX vs clindamycin x 10 days. Abscesses were drained. Outcomes of the two groups were similar (cure rates of 90% vs. 88%; P=0.8).
Comment: The letter to the editor noted 30% of each group had abscesses that may only need drainage without antibiotics. The 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), and oxacillin (1); the duration was 7-14 days, usually 10 days.
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%. The conclusion is that these results show most cellulitis cases are caused by Group A strep.
Rating: Important
Comment: The skin conditions that mimic cellulitis include stasis dermatitis, contact dermatitis, lymphedema, eosinophilic cellulitis, and papular urticaria.
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 many other reports for the past 4 years. TMP/SMX or clindamycin are usually "preferred."
Rating: Important
Comment: Evaluation of treatment of cellulitis in 405 patients. The 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 the value of TMP/SMX for CA-MRSA infections.
Rating: Important
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. Group A Strep usually causes cellulitis with no pus and negative cultures.
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.
Rating: Important
Comment: Review of 90 cases and 90 controls. The most common pathogen was Group G strep -- 26 (29%) cases. Also, in the throat of 7% of cases, 13% of household contacts and no controls. Group A strep was found in 7%. Recurrent infection in 7%.
Comment: The authors describe eight patients with A. baumannii infections associated with war wounds. The presentation was cellulitis with a "peau d’orange" appearance, with vesicles and progressed to necrosis with bullae.
Rating: Important
Comment: A 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 beta-lactam (OR 3.9, p=0.02).
Comment: Leg erysipelas/cellulitis is common - 1/1000 persons/year. Group A strep is still the most common, and foot intertrigo is a common risk.
Comment: Mayo Clinic review of cellulitis in a population-based cohort. There were 209 cases of cellulitis, and 35 (17%) recurred within 2 years. The most common findings in the cellulitis group are tibial involvement, malignancy and dermatitis. These risks correlate with the risk of recurrence.
Rating: Important
Comment: Review of recurrent erysipelas in 47 patients. The 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 two 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.
Rating: Important
Comment: Review of the emerging problem of community-acquired MRSA. Though most often identified in children, sporadic and outbreak cases are 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: A retrospective review of 757 patients admitted with community-acquired cellulitis over 41 months 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: A controlled trial showed the benefit of prophylactic clindamycin (150mg/d) to prevent recurrent S. aureus skin infections.
Comment: Microbiology studies in 50 patients hospitalized with cellulitis showed pathogen in blood in 5 (10%), by needle aspirate in 5 but with higher yield by skin punch biopsy - 10 (20%), but the latter is rarely performed.
Comment: A randomized trial for 5 vs. 10 days of treatment showed uncomplicated cellulitis could be treated for 5 days.
Cellulitis developing after an immunization (for smallpox with vaccinia!). There is spreading erythema and swelling as well as bulla.
Source: CDC/A. W. Mathies, MD
Typical cellulitis of the left leg with line drawn at time of evaluation. Despite effective antibitoics, erythema may extend somewhat in the first day or two but not reflect lack of therapeutic effect.
Source: John Campbell
Wikimedia Commons