From the Guidelines
For a patient with worsening infected contact dermatitis due to poison ivy that is unresponsive to cefixime, I strongly recommend switching to trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin.
Reasons for Recommendation
- Cefixime has limited coverage against Staphylococcus aureus and streptococci, which are common causes of skin infections 1.
- TMP-SMX provides excellent coverage against methicillin-resistant Staphylococcus aureus (MRSA) and can be prescribed at a dose of 1-2 double-strength tablets (160mg/800mg) twice daily for 7-10 days 1.
- Clindamycin is effective against both streptococci and staphylococci, including some MRSA strains, and can be given at 300-450mg orally four times daily for the same duration 1.
Additional Considerations
- The patient should continue topical corticosteroids for the poison ivy dermatitis, keep the area clean with gentle soap and water, and avoid scratching to prevent further infection.
- If there's no improvement within 48-72 hours of the new antibiotic, the patient should be reevaluated as culture and sensitivity testing may be necessary to guide therapy.
- The choice between TMP-SMX and clindamycin should be based on the patient's specific situation, including allergy history and local resistance patterns, as suggested by the Infectious Diseases Society of America guidelines 1.
Key Points to Consider
- The most recent and highest quality study, which is from 2014, supports the use of TMP-SMX and clindamycin for the treatment of skin and soft tissue infections, including those caused by MRSA 1.
- The study also emphasizes the importance of individualizing treatment based on the patient's clinical response and considering the potential for resistance and side effects 1.
From the Research
Infected Contact Dermatitis Due to Poison Ivy
- The patient's condition is worsening while taking cefixime, indicating a need to switch to a different antibiotic.
- The ideal antibiotic should be effective against common bacterial pathogens causing skin infections, including methicillin-resistant Staphylococcus aureus (MRSA) 2, 3.
- Delafloxacin, a novel fluoroquinolone, has shown promise in treating acute bacterial skin and skin structure infections (ABSSSI), including those caused by MRSA 3.
- First-generation cephalosporins may not be the best option due to potential resistance issues, but they can still be considered for empiric therapy in some cases 4.
- For patients with a history of MRSA, doxycycline or trimethoprim-sulfamethoxazole (TMP-SMX) could be considered as alternative empiric therapies 4.
Considerations for Antibiotic Selection
- The chosen antibiotic should have broad-spectrum coverage, including gram-negative pathogens and multidrug-resistant gram-positive bacteria 2, 3.
- The severity of the allergic contact dermatitis and the presence of any underlying conditions, such as atopic dermatitis, should be taken into account when selecting an antibiotic 5, 4.
- The patient's response to previous antibiotic treatments, including cefixime, should be considered when choosing a new antibiotic 6.