News, Views, and Reviews. Less May Be More for MRSA: The Latest on Antibiotics, the Utility of Packing an Abscess, and Decolonization Strategies
January 2014 | Volume 13 | Issue 1 | Feature | 89 | Copyright © 2014
Kendra Gail Bergstrom MD FAAD
The management of skin infections has evolved over time
and new evidence suggests that less acute intervention may
be as good or better. For acute treatment, evidence from
the emergency medicine literature shows that empiric oral
antibiotics may not improve outcomes relative to incision and
drainage alone. The use of packing material for wounds after
draining does not lead to a decreased rate of recurrence, more
rapid healing, or fewer physician visits, but does cause more
pain. For patients with multiple or recurrent skin and soft tissue
infections, a comprehensive decolonization or eradication
strategy is the most effective at preventing further recurrences.
Several decolonization approaches exist and can be tailored to
find the most appropriate for a particular individual.
J Drugs Dermatol. 2014;13(1):89-92.
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In the outpatient setting, skin and soft tissue infections of all types, including community-acquired methicillin-resistant staphylococcus aureus (MRSA), remain common. While the nares is the most common site of colonization, genitals, skin folds, rashes such as atopic dermatitis, and wounds can harbor colonization. Among individuals with recurrent skin infections, acute treatment and subsequent decolonization strategies benefit not only them but their community as well. Groups with higher risk of colonization with resistant organisms and recurring skin infections include:
- Active duty military personnel
- Participants in contact sports
- Living in crowded conditions: college dormitories, incarceration, child care facilities
- Residents of long term care facilities.
Acute Treatment: Empiric Antibiotics for MRSA?
When skin and soft tissue infections are extensive, spreading, causing systemic illness, or arise in an ill patient, aggressive treatment including empiric antibiotics is indicated. However, among healthy individuals with skin and soft tissue infections, incision and drainage alone and holding antibiotics until culture results and clinical response are assessed can lead to equal outcomes while mitigating the risk of adverse events or later antibiotic resistance.
In the outpatient setting, incision and drainage alone has been found to be as effective as incision combined with empiric antibiotic prescription. A group in the Philadelphia area1 tested this question in a randomized controlled trial in adults presenting to the emergency department with an uncomplicated skin and soft tissue infection. After incision and drainage, patients were randomized to a course of trimethoprim-sulfamethoxazole or placebo. Outcomes measured were treatment failure necessitating further drainage or change in antibiotic in the 7 days after incision, and new lesion formation in the following 30 days. Patients were followed with emergency department rechecks at 2 and 7 days after initial visit, and thereafter by telephone follow up for a 30-day period.
Of 212 patients randomized, 190 were available for 7-day follow up and 69% at 30 days. Treatment failure, where a patient required a second incision and drainage was statistically similar in both groups at approximately 20%. At the one-month mark, oral antibiotics did decrease the incidence of new lesions, from 28% for the placebo group to 9% for the treated group (P=0.02).
Indicators for Empiric Anti-MRSA Antibiotics2
- Size > 5 cm
- Surrounding erythema > 2 cm
- Skin barrier compromise-rash such as atopic dermatitis, underlying wound or other dysfunction in skin barrier
- Immunosuppressed patient
- Presence of artificial heart valve or other indwelling medical device.
No Evidence That Packing Is Helpful
One standard of care for abscesses includes incision and drainage and subsequent packing placement into the abscess cavity. Studies from the emergency department literature in both adult and pediatric populations show that packing a wound after incision and drainage showed no benefit in preventing short-term failure or long-term recurrences. Packing did, however increase patients' pain and need for pain medication.