An 18-year-old man originally presented to your urgent care clinic 4 weeks ago with a small abscess on his knee. He was otherwise healthy and taking no medications. The abscess was incised and drained at the clinic, and the culture and susceptibility studies showed this lesion to be a methicillin-resistant Staphylococcus aureus infection. He now presents with a new abscess ().
Abscess on upper extremity of an 18-year-old man who presented previously with an abscess on his knee.
On physical examination, his temperature is 37°C, blood pressure is 118/76 mm Hg, and heart rate is 80 beats/min. Skin examination shows a 2×2-cm erythematous plaque on the forearm with a central fluctuant area. There are areas of healing skin on the knee.
After incision and drainage of the current abscess, which one
of the following is the most important
intervention to prevent recurrence of infections in this patient?
a Education on wound care and personal hygiene
b Oral rifampin
c Intravenous vancomycin
d Oral clindamycin
e Combination treatment with oral trimethoprim-sulfamethoxazole and minocycline
This patient presents with the typical history and physical findings of a skin and soft tissue infection (SSTI) with community-associated methicillin-resistant S aureus (CA-MRSA). Infections caused by CA-MRSA usually present as a solitary abscess, cellulitis, or soft tissue infection, often with central necrosis, but there are no specific findings to differentiate it from a methicillin-sensitive staphylococcal infection. Recurrence in an individual is common, as are community clusters or involvement of multiple household members.
Currently, CA-MRSA is the most common cause of SSTIs encountered in most urban emergency departments. This strain of MRSA has a distinct genetic resistance element (SCCmec IV) and toxin (Panton-Valentine leukocidin toxin) and develops in populations with close physical contact, such as children/young adults, prisoners, homeless persons, intravenous drug users, and people involved in contact sports (football, fencing, rugby, wrestling, etc). While resistant to β-lactam antibiotics, CA-MRSA isolates often remain sensitive to other antibiotics such as clindamycin, trimethoprim-sulfamethoxazole, and minocycline. Antibiotic susceptibility patterns differ throughout the country.
The primary treatment for a small, simple cutaneous abscess is incision and drainage of the abscess. Management of recurrent MRSA SSTIs should focus on education about appropriate wound care and personal hygiene. Instruction should include keeping draining wounds covered with clean, dry bandages, maintaining good personal hygiene with regular bathing and cleaning of hands, and avoiding reusing or sharing personal items (disposable razors, linens, and towels). Environmental hygiene measures should focus cleaning efforts on “high-touch” surfaces using commercially available cleaners or detergents.
Clinicians should consider attempting decolonization if a patient experiences a recurrent SSTI despite optimal wound care and hygiene measures or if ongoing transmission is occurring among household members despite these measures.4
Decolonization strategies may include nasal decolonization with mupirocin twice a day for 5 to 10 days and body decolonization with a skin antiseptic solution (chlorhexidine) for 5 to 14 days or dilute bleach baths.
Prevention of recurrent CA-MRSA should focus first on wound care and personal hygiene education.