What antibiotic is recommended for erysipelas (erysipelas is a type of bacterial skin infection) on the face with concern for Methicillin-resistant Staphylococcus aureus (MRSA)?

From the Guidelines

For erysipelas on the face with concern for MRSA, I recommend empiric coverage with trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets (160mg/800mg) twice daily for 5-10 days, plus either cephalexin 500mg four times daily or clindamycin 300-450mg three times daily for the same duration. This combination approach provides coverage for both MRSA (with TMP-SMX) and beta-hemolytic streptococci (with cephalexin or clindamycin), which are the most common causes of erysipelas, as suggested by the Infectious Diseases Society of America guidelines 1. Facial erysipelas requires prompt treatment due to the risk of complications including cavernous sinus thrombosis. If the infection is severe or the patient is immunocompromised, consider intravenous therapy with vancomycin 15-20mg/kg every 12 hours, as recommended by the 2014 IDSA guidelines for the management of skin and soft-tissue infections 1. Patients should be monitored closely for clinical improvement within 48-72 hours. If there's no improvement, reassessment and possibly wound culture should be performed. Warm compresses, elevation of the affected area when possible, and adequate hydration are important supportive measures. The dual antibiotic approach is necessary because while erysipelas is typically caused by streptococci, the concern for MRSA requires specific coverage, especially in areas with high MRSA prevalence or in patients with risk factors such as previous MRSA infections or recent hospitalization, as highlighted in the 2018 WSES/SIS-E consensus conference recommendations for the management of skin and soft-tissue infections 1. Key considerations in the management of erysipelas include:

• Prompt initiation of antibiotic therapy
• Coverage for both MRSA and beta-hemolytic streptococci
• Monitoring for clinical improvement and potential complications
• Supportive measures such as warm compresses and elevation of the affected area. It is essential to note that the choice of antibiotic therapy may vary depending on the severity of the infection, patient comorbidities, and local resistance patterns, as emphasized in the clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children 1.

From the FDA Drug Label

Daptomycin for injection is indicated for the treatment of adult and pediatric patients (1 to 17 years of age) with complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of the following Gram-positive bacteria: Staphylococcus aureus (including methicillin-resistant isolates)

The antibiotic to use if erysipelas is on the face and there is a concern for MRSA is daptomycin (IV), as it is indicated for the treatment of complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of Staphylococcus aureus, including methicillin-resistant isolates 2.

From the Research

Antibiotic Treatment for Erysipelas on the Face with Concern for MRSA

• Erysipelas is generally caused by group A streptococci, but MRSA can also be a concern in some cases 3, 4.
• For erysipelas on the face, treatment with antibiotics such as penicillin G, amoxicillin, or macrolides may be effective 3, 4.
• However, if there is a concern for MRSA, alternative antibiotics such as linezolid, vancomycin, or daptomycin may be considered 5, 6, 7.
• Linezolid has been shown to be effective against MRSA-caused skin and soft tissue infections, including those with inducible clindamycin resistance 5, 6, 7.
• Vancomycin and daptomycin are also effective against MRSA, but linezolid may have superior tissue penetration and clinical success rates 5, 6.

Considerations for Antibiotic Choice

• The choice of antibiotic should be based on the severity of the infection, the presence of any underlying medical conditions, and the potential for antibiotic resistance 3, 4, 5, 6, 7.
• It is essential to consider the pharmacodynamic properties of the antibiotic, such as tissue penetration and bactericidal activity, when selecting an antibiotic for treatment 5, 6, 7.
• The potential for adverse effects and drug interactions should also be considered when choosing an antibiotic 5, 6, 7.