What is the best method for resolving and preventing recurrent acneiform cysts on the back, potentially caused by Methicillin-resistant Staphylococcus aureus (MRSA) exposure, in a physician who frequently drains abscesses?

From the Guidelines

For acneiform cysts on the back that developed recently, I recommend a multi-faceted approach to manage the current infection and prevent future occurrences, prioritizing the patient's morbidity, mortality, and quality of life. Given the potential exposure to MRSA, it is crucial to consider this in the treatment plan. The most recent and highest quality study, 1, provides guidance on the management of skin and soft tissue infections, including those caused by MRSA.

Current Infection Management

• Apply warm compresses to the affected areas 3-4 times daily for 10-15 minutes to help bring the cysts to a head and promote drainage.
• Use a topical antibiotic such as clindamycin 1% solution or mupirocin 2% ointment twice daily to the lesions.
• Consider oral antibiotics like doxycycline 100mg twice daily for 7-10 days, especially given the potential MRSA exposure, as recommended by 1.

Prevention of Future Occurrences

• Maintain good hygiene practices, including using an antibacterial soap containing benzoyl peroxide 4-5% or chlorhexidine gluconate 4% when showering, paying special attention to the back area.
• Change scrubs or work clothes daily to reduce the risk of transmission.
• Consider using benzoyl peroxide wash preventatively to reduce the bacterial load on the skin.
• As a healthcare worker with potential MRSA exposure, decolonization might be beneficial using intranasal mupirocin 2% ointment twice daily for 5 days and chlorhexidine body washes for the same period, as suggested by 1 and 1.

Key Considerations

• The patient's occupation as a healthcare worker and potential exposure to MRSA necessitate a thorough approach to prevent future infections.
• The use of antibiotics should be guided by the most recent and highest quality evidence, taking into account the potential for antibiotic resistance.
• Good hygiene practices and environmental decontamination are crucial in preventing the spread of infections, as emphasized by 1.

From the Research

Treatment Options for Acneiform Cysts

The patient's symptoms of 4 tender acneiform cysts spread randomly around his back that began in the last few days may be related to a skin and soft-tissue infection, possibly caused by methicillin-resistant Staphylococcus aureus (MRSA) given his exposure to abscesses in other patients.

• Incision and drainage is often used as a treatment for uncomplicated skin and soft-tissue abscesses caused by MRSA 2, 3.
• Antibiotic therapy may also be necessary, with options including clindamycin, doxycycline, trimethoprim-sulfamethoxazole (TMP-SMX), and minocycline 2, 3, 4, 5.
• Minocycline has been shown to be effective in treating uncomplicated community-acquired MRSA (CA-MRSA) skin and soft-tissue infections when other antibiotics such as doxycycline or TMP-SMX fail 2.
• Doxycycline or TMP-SMX with incision/drainage may be used as initial therapy for skin and soft-tissue infections when MRSA is suspected 3.

Preventing Future Infections

To prevent future infections, the patient may want to consider taking precautions when exposed to abscesses in other patients, such as wearing protective gear and following proper hygiene procedures.

• There is limited evidence on the effectiveness of antibiotics such as doxycycline, TMP-SMX, clindamycin, and minocycline in preventing MRSA infections 4.
• Further research is needed to determine the best methods for preventing MRSA infections in individuals who are frequently exposed to abscesses in other patients.

Antibiotic Susceptibilities

The patient's isolates may be susceptible to various antibiotics, including:

• Clindamycin: 88% of MRSA isolates were sensitive to clindamycin in one study 3, and 93% were susceptible in another study 5.
• Doxycycline: all MRSA isolates were sensitive to doxycycline in one study 3, and 100% were susceptible in another study 5.
• Trimethoprim-sulfamethoxazole (TMP-SMX): all MRSA isolates were sensitive to TMP-SMX in one study 3, and 100% were susceptible in another study 5.
• Minocycline: there is limited evidence on the effectiveness of minocycline in treating MRSA infections, but it may be a viable option when other antibiotics fail 2, 4.