Abscesses ========= þ Antibiotics? Maybe. - Per Dave Talan, may still be appropriate in some cases despite a recent study. [Talan, D. A. (2010). "Lack of antibiotic efficacy for simple abscesses: have matters come to a head?" Ann Emerg Med 55(5): 412-414.] þ Antibiotics, yes or no? - Not unless, in peds, there is an area 5 cm or bigger of cellulitis/abscess. [Lee, M. C., A. M. Rios, et al. (2004). "Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin- resistant Staphylococcus aureus." Pediatr Infect Dis J 23(2): 123-127. BACKGROUND: Although the epidemiology of community- acquired methicillin- resistant Staphylococcus aureus (CA-MRSA) has been explored in many investigations, management of this emerging infection has not been well- studied. For non-methicillin-resistant Staphylococcus aureus skin and soft tissue abscesses, incision and drainage is generally adequate therapy without the use of antibiotics, but this has not been established for CA-MRSA. METHODS: Children presenting to Children's Medical Center of Dallas for management of skin and soft tissue abscesses caused by culture-proved CA-MRSA were prospectively followed. We analyzed data from the initial evaluation and from two follow-up visits that focused on the management and outcome of CA- MRSA infection. Retrospective chart review was performed 2 to 6 months after the initial visit. RESULTS: Sixty-nine children were identified with culture- proved CA-MRSA skin and soft tissue abscess. Treatment consisted of drainage in 96% of patients and wound packing in 65%. All children were treated with antibiotics. Five patients (7%) were prescribed an antibiotic to which their CA-MRSA isolate was susceptible before culture results were known. Four patients (6%) required hospital admission on the first follow-up; none of these patients had received an antibiotic effective against CA-MRSA. A significant predictor of hospitalization was having a lesion initially >5 cm (P = 0.004). Initial ineffective antibiotic therapy was not a significant predictor of hospitalization (P = 1.0). Of the 58 patients initially given an ineffective antibiotic and managed as outpatients, an antibiotic active against CA-MRSA was given to 21 (36%) patients after results of cultures were known. No significant differences in response were observed in those who never received an effective antibiotic than in those who did. CONCLUSIONS: Incision and drainage without adjunctive antibiotic therapy was effective management of CA-MRSA skin and soft tissue abscesses with a diameter of <5 cm in immunocompetent children.] - No. (But before MRSA) [Llera, J. L. and R. C. Levy (1985). "Treatment of cutaneous abscess: a double-blind clinical study." Annals of emergency medicine 14(1): 15-19.] Controversy exists about the value of antibiotic therapy following incision and drainage of cutaneous abscess. We undertook a randomized double-blind study to clarify the controversy. Adult patients with cutaneous abscesses who received outpatient surgical therapy were entered into the study. Following incision and drainage, patients received cephradine or placebo for seven days using a randomized code in a double-blind fashion. At the end of seven days, patients were reevaluated. Twenty-seven patients were treated with cephradine, and 23 with placebo. Ninety-six percent of the patients in each group were improved clinically after seven days. We conclude that cephradine did not alter the outcome of cutaneous abscesses at one week after incision and drainage. The implications are twofold: patients are not exposed to the potential side effects and allergic reactions of antibiotics, and the cost of health care can be reduced by not prescriNbing antibiotics in these patients. - No. [Liu, C., A. Bayer, et al. (2011). "Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin- resistant Staphylococcus aureus infections in adults and children: executive summary." Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 52(3): 285-292.] Evidence-based guidelines for the management of patients with methicillin- resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures. I. What is the management of skin and soft-tissue infections (SSTIs) in the era of community-associated MRSA (CA-MRSA)? SSTIs 1. For a cutaneous abscess, incision and drainage is the primary treatment (A-II). For simple abscesses or boils, incision and drainage alone is likely to be adequate, but additional data are needed to further define the role of antibiotics, if any, in this setting. 2. Antibiotic therapy is recommended for abscesses associated with the following conditions: severe or extensive disease (eg, involving multiple sites of infection) or rapid progression in presence of associated cellulitis, signs and symptoms of systemic illness, associated comorbidities or immunosuppression, extremes of age, abscess in an area difficult to drain (eg, face, hand, and genitalia), associated septic phlebitis, and lack of response to incision and drainage alone (A-III). 3. For outpatients with purulent cellulitis (eg, cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess), empirical therapy for CA-MRSA is recommended pending culture results. Empirical therapy for infection due to b-hemolytic streptococci is likely to be unnecessary (A-II). Five to 10 days of therapy is recommended but should be individualized on the basis of the patient’s clinical response. 4. For outpatients with nonpurulent cellulitis (eg, cellulitis with no purulent drainage or exudate and no associated abscess), empirical therapy for infection due to b-hemolytic streptococci is recommended (A-II). The role of CA-MRSA is unknown. Empirical coverage for CA-MRSA is recommended in patients who do not respond to b-lactam therapy and may be considered in those with systemic toxicity. Five to 10 days of therapy is recommended but should be individualized on the basis of the patient’s clinical response. 5. For empirical coverage of CA-MRSA in outpatients with SSTI, oral antibiotic options include the following: clindamycin (A-II), trimethoprim-sulfamethoxazole (TMP-SMX) (A-II), a tetracycline (doxycycline or minocycline) (A-II), and linezolid (A-II). If coverage for both b-hemolytic streptococci and CA-MRSA is desired, options include the following: clindamycin alone (A-II) or TMP-SMX or a tetracycline in combination with a b-lactam (eg, amoxicillin) (A-II) or linezolid alone (A-II). 6. The use of rifampin as a single agent or as adjunctive therapy for the treatment of SSTI is not recommended (A-III). 7. For hospitalized patients with complicated SSTI (cSSTI; defined as patients with deeper soft-tissue infections, surgical/ traumatic wound infection, major abscesses, cellulitis, and infected ulcers and burns), in addition to surgical debridement and broad-spectrum antibiotics, empirical therapy for MRSA should be considered pending culture data. Options include the following: intravenous (IV) vancomycin (A-I), oral (PO) or IV linezolid 600 mg twice daily (A-I), daptomycin 4 mg/kg/dose IV once daily (A-I), telavancin 10 mg/kg/dose IV once daily (A-I), and clindamycin 600 mg IV or PO 3 times a day (A-III). A b-lactam antibiotic (eg, cefazolin) may be considered in hospitalized patients with nonpurulent cellulitis with modification to MRSA-active therapy if there is no clinical response (A-II). Seven to 14 days of therapy is recommended but should be individualized on the basis of the patient’s clinical response. 8. Cultures from abscesses and other purulent SSTIs are recommended in patients treated with antibiotic therapy, patients with severe local infection or signs of systemic illness, patients who have not responded adequately to initial treatment, and if there is concern for a cluster or outbreak (A-III). Pediatric considerations 9. For children with minor skin infections (such as impetigo) and secondarily infected skin lesions (such as eczema, ulcers, or lacerations),mupirocin 2% topical ointment can be used (A-III). 10. Tetracyclines should not be used in children <8 years of age (A-II). 11. In hospitalized children with cSSTI, vancomycin is recommended (A-II). If the patient is stable without ongoing bacteremia or intravascular infection, empirical therapy with clindamycin 10–13 mg/kg/dose IV every 6–8 h (to administer 40 mg/kg/day) is an option if the clindamycin resistance rate is low (eg, ,10%) with transition to oral therapy if the strain is susceptible (A-II). Linezolid 600 mg PO/IV twice daily for children >12 years of age and 10 mg/kg/dose PO/IV every 8 h for children <12 years of age is an alternative (A-II). þ Are anti-MRSA antibiotics better than plain old Keflex? No. [Chen, A. E., K. C. Carroll, et al. (2011). "Randomized controlled trial of cephalexin versus clindamycin for uncomplicated pediatric skin infections." Pediatrics 127(3): e573-580 OBJECTIVE: To compare clindamycin and cephalexin for treatment of uncomplicated skin and soft tissue infections (SSTIs) caused predominantly by community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA). We hypothesized that clindamycin would be superior to cephalexin (an antibiotic without MRSA activity) for treatment of these infections. PATIENTS AND METHODS: Patients aged 6 months to 18 years with uncomplicated SSTIs not requiring hospitalization were enrolled September 2006 through May 2009. Eligible patients were randomly assigned to 7 days of cephalexin or clindamycin; primary and secondary outcomes were clinical improvement at 48 to 72 hours and resolution at 7 days. Cultures were obtained and tested for antimicrobial susceptibilities, pulsed-field gel electrophoresis type, and Panton-Valentine leukocidin status. RESULTS: Of 200 enrolled patients, 69% had MRSA cultured from wounds. Most MRSA were USA300 or subtypes, positive for Panton-Valentine leukocidin, and clindamycin susceptible, consistent with CA- MRSA. Spontaneous drainage occurred or a drainage procedure was performed in 97% of subjects. By 48 to 72 hours, 94% of subjects in the cephalexin arm and 97% in the clindamycin arm were improved (P = .50). By 7 days, all subjects were improved, with complete resolution in 97% in the cephalexin arm and 94% in the clindamycin arm (P = .33). Fevers and age less than 1 year, but not initial erythema > 5 cm, were associated with early treatment failures, regardless of antibiotic used. CONCLUSIONS: There is no significant difference between cephalexin and clindamycin for treatment of uncomplicated pediatric SSTIs caused predominantly by CA-MRSA. Close follow-up and fastidious wound care of appropriately drained, uncomplicated SSTIs are likely more important than initial antibiotic choice. þ Adam Singer: Randomizing to primary vs. delayed primary closure: in progress. Llera: Ann Emerg Med 1985: if I and D, antibiotics don't help Abraham Aus New A J Surg 1997:67:173 closed excision technique heals better in a week. Treatment of cellulitis and abscesses rarely depend upon results of culture and gram stain with the possible exception of patients who are immunocomprimized (9) or those with suspected clostridial myonecrosis (12). (9) Meislin HW Pathogen identification of abscesses and cellulitis. Ann Emerg Med 1986 Mar;15(3):329-32 The goal of culturing abscesses and/or cellulitis is to identify the offending pathogen in order to understand and treat the infection. Abscesses respond to incision and drainage. Antibiotics are not indicated in the patient with normal host defense, and thus in these patients cultures and Gram stains are not indicated. In immunocompromised patients, in patients with abscesses of the central face, and in those with abscesses that contain gas or involve muscle or fascia, Gram stain, culture, and antibiotics are necessary. The Gram stain is a reliable indicator of sterile abscesses, abscesses in pure culture (especially Staphylococcus aureus), and those in mixed anaerobic culture. Location and odor of abscesses are clues to offending bacteria. Cultures of tissue or blood in patients with cellulitis usually are positive in less than 40% of cases, regardless of the technique used. Hemophilus influenzae cellulitis in pediatric patients is an exception; blood cultures are positive in more than two-thirds of cases. Although not specific, certain types of cellulitis show different clinical characteristics. Treatment with elevation, warm soaks, and antibiotics is still the mainstay of therapy. Gram stain and culture are limited to those patients who do not respond to initial therapy or who are immunocompromised. (12) Miskew DB, Pinzur MS, Pankovich AM Clostridial myonecrosis in a patient undergoing oxacillin therapy for exacerbation of chronic foot ulcers and osteomyelitis. A case report. Clin Orthop 1979 Jan-Feb;(138):250-3 Gas gangrene developed from a chronic foot ulcer in the absence of periferal vascular disease or diabetes mellitus in a hospitalized patient undergoing parenteral antibiotic therapy. Within a 6 hour period the patient developed profound toxemia necessitating emergency and life saving leg amputation. Classically clostridial myonecrosis is diagnosed by the clinical course and the gram stain. In this case, 2 preoperative gram stains failed to show gram-positive rods. At the time of surgery, frank fasical and muscle necrosis in the peroneal compartment dictated extending the below knee amputation to above the knee. In retrospect demonstration of clostridial species and myonecrosis in the pathological specimen confirmed the clinical impression. The identified organism, Clostridium sporogenes has rarely been implicated as a cause of gas gangrene.