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For further information, see CMDT Part 33-04: Staphylococcus aureus Infections

Key Features

  • Localized erythema with induration and purulent drainage

  • Abscess formation

  • Gram stain of pus shows gram-positive cocci in clusters

Clinical Findings

  • May begin around one or more hair follicles, causing folliculitis

  • May become localized to form boils (or furuncles)

  • May spread to adjacent skin and deeper subcutaneous tissue (ie, a carbuncle)

  • Deep abscesses involving muscle or fascia may occur, often in association with a deep wound or other inoculation or injection

  • Necrotizing fasciitis has been reported with community strains of methicillin-resistant S aureus (MRSA)

Diagnosis

  • Cultures of the wound or abscess material almost always yields the organism

  • In patients with systemic signs of infection, blood cultures should be obtained because of potential bacteremia, endocarditis, osteomyelitis, or metastatic seeding of other sites

  • Patients who are bacteremic should have blood cultures taken early during therapy to exclude persistent bacteremia, an indicator of severe or complicated infection

Treatment

  • Proper drainage of abscess fluid or other focal infections is the mainstay of therapy

  • Incision and drainage alone is highly effective for the treatment of most uncomplicated cutaneous abscesses

  • A small benefit can be obtained from the addition of antimicrobials following incision and drainage.

  • In areas where methicillin-resistance among community S aureus isolates is high, recommended oral antimicrobials agents include

    • Clindamycin, 300 mg three times daily

    • Trimethoprim-sulfamethoxazole, given in two divided doses based on 5–10 mg/kg/day of the trimethoprim component

    • Doxycycline or minocycline, 100 mg twice daily

  • When the risk of methicillin-resistance is low or methicillin-susceptibility has been confirmed by testing of the isolate, consider

    • Dicloxacillin or cephalexin, 500 mg four times a day

  • For complicated infections with extensive cutaneous or deep tissue involvement or fever, initial parenteral therapy is often indicated

  • When methicillin resistance rates are high (above 10%) empiric therapy with vancomycin, 1 g intravenously every 12 hours, is a drug of choice

  • For infections caused by methicillin-susceptible isolates

    • Cefazolin 1 g intravenously or intramuscularly or

    • A penicillinase-resistant penicillin such as nafcillin or oxacillin in a dosage of 1.5 g every 6 hours intravenously

  • For treatment of skin and skin-structure infections

    • Linezolid, 600 mg orally or intravenously twice a day for 10–14 days

      • Effective for MRSA

      • However, considerable cost makes it an unattractive choice for most routine outpatient infections

    • Other alternatives

      • Tedizolid, 200 mg orally once daily for 6 days

      • Daptomycin, 4 mg/kg once daily intravenously for 7–14 days

      • Tigecycline, 100 mg intravenously once, followed by 50 mg intravenously twice a day for 7–14 days

      • Ceftaroline, 600 mg intravenously twice a day for 7–14 days

      • Dalbavancin, a single intravenous dose of 1500 mg

      • Oritavancin, 1200 mg as a single intravenous dose

      • Telavancin, 10 mg/kg intravenously once daily for 7–14 days

      • Delafloxacin, 450 mg orally or 300 intravenously twice daily for 5–14 days

  • Duration of therapy

    • Total duration of therapy for soft ...

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