para>For purulent infections, consider surgical drainage and debulking, wound culture, and narrow-spectrum antimicrobials:
Successful I&D may have more impact than antibiotics in mild cases for both adults and children.
Moist heat may work for small furuncles.
Patients with an abscess are frequently cured by incision and drainage alone.
Packing does not appear to improve outcomes (3)[A].
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First Line
CA-MRSA SSTIs: 7- to 14-day course (depends on severity and clinical response): � �
- Trimethoprim/sulfamethoxazole (TMP-SMX): DS (160 mg TMP and 800 mg of SMX) 1 to 2 tablet(s) PO BID daily (8 to 12 mg/kg/day of trimethoprim component in 2 divided doses for children)
- Doxycycline or minocycline: 100 mg PO BID (children >8 years and <45 kg; 2 to 5 mg/kg/day PO in 1 to 2 divided doses, not to exceed 200 mg/day; children >8 years and >45 kg, use adult dosing), taken with a full glass of water
- Clindamycin: 300 to 450 mg PO QID (30 to 40 mg/kg/day PO in 3 divided doses for children), taken with full glass of water. Check D-zone test in erythromycin-resistant, clindamycin-susceptible S. aureus isolates (a positive test indicates induced resistance " �choose a differnt antibiotic).
- CA-MRSA is resistant to � �-lactams (including oral cephalosporins and antistaphylococcal penicillins) and often macrolides, azalides, and quinolones.
- Although most CA-MRSA isolates are susceptible to rifampin, this drug should never be used as a single agent because of concerns regarding resistance. The role of combination therapy with rifampin in CA-MRSA SSTIs is not clearly defined.
- There has been increasing resistance to clindamycin, both initial ( � � �33%) and induced.
- Although CA-MRSA isolates are susceptible to vancomycin, oral vancomycin cannot be used for CA-MRSA SSTIs due to limited absorption.
Second Line
Treat severe CA-MRSA SSTIs requiring hospitalization and HA-MRSA SSTIs using: � �
- Vancomycin: Generally, 1 g IV q12h (30 mg/kg/day IV in 2 divided doses; in children: 40 mg/kg/day IV in 4 divided doses) vancomycin-like antibiotics that require only 1 or 2 doses may soon be more broadly available (5)[A].
- Linezolid: 600 mg IV/PO BID uncomplicated: children <5 years of age, 30 mg/kg/day in 3 divided doses; 20 mg/kg/day IV/PO in 2 divided doses for children 5 to 11 years of age; children >11 years, use adult dosing. Complicated: birth to 11 years, 30 mg/kg/day IV/PO in 3 divided doses; older, use adult dosing)
- Linezolid seems to be more effective than vancomycin for treating people with SSTIs, but current studies have high risk of bias.
- Clindamycin: 600 mg IV TID; in children, 10 to 13 mg/kg/dose q6 " �8h up to 40 mg/kg/day
- Daptomycin: 4 mg/kg/day IV (safety/efficacy not established in patients <18 years of age) if no pulmonary involvement
- Ceftaroline 600 mg BID IV (for adults)
Pediatric Considerations
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Pregnancy Considerations
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Geriatric Considerations
A recent review notes no prospective trials in this age group and recommends use of general adult guidelines.
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ISSUES FOR REFERRAL
Consider consultation with infectious disease in cases of � �
- Refractory CA-MRSA infection
- Plan to attempt decolonization
SURGERY/OTHER PROCEDURES
Progression to serious SSTIs, including necrotizing fasciitis, is possible and mandates prompt surgical evaluation. � �
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
Consider admission if: � �
- Systemically ill (e.g., febrile) with stable comorbidities
- Systemically well with comorbidities that may delay or complicate resolution of SSTI
- Presence of SSTI complications (sepsis, necrotizing fasciitis) and comorbidities
- If indicated, alternatives to inpatient admission include observation units and outpatient parenteral antimicrobial therapy (OPAT) programs
Nursing
Contact precautions � �
Discharge Criteria
If admitted for IV therapy, assess the following before discharge: � �
- Afebrile for 24 hours
- Clinically improved
- Able to take oral medication
- Has adequate social support and is available for outpatient follow-up
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
For outpatients: � �
- Return promptly with systemic symptoms, worsening local symptoms, or failure to improve within 48 hours. Consider a follow-up within 48 hours of initial visit to assess response and review culture.
PATIENT EDUCATION
- Keep wounds that are draining covered with clean, dry bandages.
- Clean hands regularly with soap and water or alcohol-based gel. Hot soapy shower daily.
- Do not share items that may be contaminated (including razors or towels).
- Clean clothes, towels, and bed linens
- National MRSA Education Initiative: www.cdc.gov/mrsa/
- A mixture of � �;-cup household bleach diluted in 1 gallon of water can be used to clean surfaces.
PROGNOSIS
In outpatients, improvement should occur within 48 hours. � �
COMPLICATIONS
- Necrotizing pneumonia or empyema (after an influenza-like illness)
- Necrotizing fasciitis
- Sepsis syndrome
- Pyomyositis and osteomyelitis
- Purpura fulminans
- Disseminated septic emboli
- Endocarditis
REFERENCES
11 Uhlemann � �AC, Dordel � �J, Knox � �JR, et al. Molecular tracing of the emergence, diversification, and transmission of S. aureus sequence type 8 in a New York community. Proc Natl Acad Sci U S A. 2014;111(18):6738 " �6743.22 Stevens � �DL, Bisno � �AL, Chambers � �HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10 " �e52.33 Mistry � �RD. Skin and soft tissue infections. Pediatr Clin North Am. 2013;60(5):1063 " �1082.44 Singer � �AJ, Talan � �DA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. N Engl J Med. 2014;370(11):1039 " �1047.55 Chambers � �HF. Pharmacology and the treatment of complicated skin and skin-structure infections. N Engl J Med. 2014;370(23):2238 " �2239.
ADDITIONAL READING
- Amin � �AN, Cerceo � �EA, Deitelzweig � �SB, et al. Hospitalist perspective on the treatment of skin and soft tissue infections. Mayo Clin Proc. 2014;89(10):1436 " �1451.
- Chen � �LF, Chastain � �C, Anderson � �DJ. Community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections: management and prevention. Curr Infect Dis Rep. 2011;13(5):442 " �450.
- Fenster � �DB, Renny � �MH, Ng � �C, et al. Scratching the surface: a review of skin and soft tissue infections in children. Curr Opin Pediatr. 2015;27(3):303 " �307.
- Fitch � �MT, Manthey � �DE, McGinnis � �HD, et al. Videos in clinical medicine. Abscess incision and drainage. N Engl J Med. 2007;357(19):e20.
- Gurusamy � �KS, Koti � �R, Toon � �CD, et al. Antibiotic therapy for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in surgical wounds. Cochrane Database Syst Rev. 2013;(8):CD009726.
- Holmes � �NE, Howden � �BP. What 's new in the treatment of serious MRSA infection? Curr Opin Infect Dis. 2014;27(6):471 " �478.
- Ramakrishnan � �K, Salinas � �RC, Agudelo Higuita � �NI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474 " �483.
CODES
ICD10
- A49.02 Methicillin resis staph infection, unsp site
- A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
- J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
- Z22.322 Carrier or suspected carrier of methicillin resis staph
- Z86.14 Personal history of methicillin resis staph infection
- B95.62 Methicillin resis staph infct causing diseases classd elswhr
ICD9
- 041.12 Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site
- 038.12 Methicillin resistant Staphylococcus aureus septicemia
- 482.42 Methicillin resistant pneumonia due to Staphylococcus aureus
- V02.54 Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
SNOMED
- 266096002 methicillin resistant Staphylococcus aureus infection (disorder)
- 448812000 Sepsis due to methicillin resistant Staphylococcus aureus (disorder)
- 124691000119101 Pneumonia due to methicillin resistant Staphylococcus aureus (disorder)
- 308155002 MRSA infection of postoperative wound
- 423561003 community-acquired methicillin-resistant Staphylococcus aureus infection (disorder)
CLINICAL PEARLS
- Incise and drain purulent lesions and send for wound culture if abscess is present.
- Local susceptibility patterns of CA-MRSA dictate antibiotic treatment. The CDC has a helpful algorithm for outpatient treatment of CA-MRSA: http://www.cdc.gov/mrsa/pdf/Flowchart_pstr.pdf
- CA-MRSA skin lesions are commonly misidentified as "spider bites " �.