What is the treatment for recurrent bacterial skin infections?

From the Guidelines

Treatment for recurrent bacterial skin infections should involve a combination of antibiotics, improved hygiene practices, and addressing underlying causes, with the goal of reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study, 1, published in 2017, provides guidance on the management of skin abscesses, which are a common manifestation of recurrent bacterial skin infections.

Key Recommendations:

• Incision and drainage of the abscess, with culture of the wound to identify the causative agent and its antimicrobial susceptibility pattern, is the primary treatment for skin abscesses.
• Antibiotic choices should be guided by knowledge of local patterns of susceptibility, especially for methicillin-resistant Staphylococcus aureus (MRSA).
• For patients with recurrent abscesses, a 5- to 10-day course of an antibiotic active against the pathogen isolated from the culture should be considered, as recommended by 1 and 1.
• Preventive measures, such as daily chlorhexidine washes or bleach baths, nasal decolonization with mupirocin ointment, and good skin hygiene practices, can help reduce the risk of recurrence, as suggested by 1 and 1.
• Identifying and managing underlying conditions, such as diabetes, immunosuppression, or eczema, is crucial to prevent recurrent infections, as emphasized by 1 and 1.

Antibiotic Options:

• Oral antibiotics, such as cephalexin, dicloxacillin, or clindamycin, may be prescribed for active infections, as recommended by 1 and 1.
• For MRSA, trimethoprim-sulfamethoxazole or doxycycline may be used, as suggested by 1 and 1.

Preventive Measures:

• Daily chlorhexidine washes or bleach baths can help reduce skin bacterial colonization, as recommended by 1 and 1.
• Nasal decolonization with mupirocin ointment may be recommended for patients with confirmed Staphylococcus aureus colonization, as suggested by 1 and 1.
• Good skin hygiene practices, such as keeping skin moisturized, avoiding sharing personal items, and promptly treating any skin injuries, are essential to prevent recurrent infections, as emphasized by 1 and 1.

From the FDA Drug Label

Doxycycline is indicated for the treatment of infections caused by the following gram-positive microorganisms when bacteriologic testing indicates appropriate susceptibility to the drug: Upper respiratory infections caused by Streptococcus pneumoniae Anthrax due to Bacillus anthracis, including inhalational anthrax (post-exposure): to reduce the incidence or progression of disease following exposure to aerosolized Bacillus anthracis. When penicillin is contraindicated, doxycycline is an alternative drug in the treatment of the following infections: Uncomplicated gonorrhea caused by Neisseria gonorrhoeae. Syphilis caused by Treponema pallidum. Yaws caused by Treponema pertenue. Listeriosis due to Listeria monocytogenes. Vincent’s infection caused by Fusobacterium fusiforme. Actinomycosis caused by Actinomyces israelii. Infections caused by Clostridium species.

The treatment for recurrent bacterial skin infections may include doxycycline, but only if the causative bacteria are susceptible to the drug, as evidenced by bacteriologic testing.

• Key considerations:
  • Bacteriologic testing to determine susceptibility
  • Local epidemiology and susceptibility patterns
  • Selection of alternative therapy if doxycycline is not appropriate 2

From the Research

Treatment for Recurrent Bacterial Skin Infections

• The treatment for recurrent bacterial skin infections often involves a combination of antibiotic therapy and decolonization strategies to reduce the risk of reinfection 3, 4, 5.
• Topical antibiotics can be used as primary therapy to avoid the risk of systemic allergic reactions or generalized side effects, and to provide a high antibiotic concentration at the site of infection 3.
• Systemic antibiotics, such as penicillinase-resistant semi-synthetic penicillins, first-generation cephalosporins, macrolides, and combination antibacterials, may be used when indicated 3.
• Decolonization strategies, including the use of intranasal mupirocin and antiseptic body washes with chlorhexidine or dilute bleach water baths, can be effective in reducing the incidence of recurrent infections 4, 5, 6.

Decolonization Strategies

• Decolonization regimens, such as the use of topical chlorhexidine gluconate and intranasal mupirocin, can be effective in eradicating methicillin-resistant Staphylococcus aureus (MRSA) colonization 4, 6.
• Systemic decolonization regimens, including the use of oral rifampin and doxycycline, may be more effective in achieving initial MRSA clearance, but there is no significant difference in the probability of sustained MRSA clearance compared to standard decolonization regimens 6.
• Education on personal and household hygiene measures, and avoidance of sharing personal hygiene items, is an essential component of prevention efforts 5.

Prevention Strategies

• Prevention strategies, including decolonization and education on hygiene measures, can be effective in reducing the incidence of recurrent bacterial skin infections 5, 7.
• Providers may prefer different treatment and prevention strategies, with 70% preferring trimethoprim-sulfamethoxazole for directed treatment of community-associated MRSA skin and soft-tissue infections, and 88% employing at least one topical decolonization strategy for recurrent infections 7.