What is the recommended treatment for a patient with Methicillin-resistant Staphylococcus aureus (MRSA) folliculitis and neutropenic fever?

Treatment of MRSA Folliculitis with Neutropenic Fever

For patients with MRSA folliculitis and neutropenic fever, hospitalization and empiric antibacterial therapy with vancomycin plus an antipseudomonal antibiotic such as cefepime, a carbapenem (imipenem-cilastatin, meropenem, or doripenem), or piperacillin-tazobactam is strongly recommended. 1

Initial Management

Antibiotic Regimen

1. Primary combination therapy:

   • Vancomycin (15 mg/kg IV every 6 hours, targeting trough levels of 15-20 mg/L) 1, 2
   • PLUS one of the following antipseudomonal agents:
     • Cefepime (2g IV every 8 hours)
     • Meropenem (1g IV every 8 hours)
     • Imipenem-cilastatin (500mg IV every 6 hours)
     • Piperacillin-tazobactam (4.5g IV every 6 hours) 1

2. Duration of therapy:

   • 7-14 days for most bacterial skin and soft tissue infections (SSTIs) 1
   • Continue until neutrophil recovery and resolution of symptoms

Rationale for Vancomycin

Vancomycin is included in the initial regimen due to:

• Confirmed MRSA infection (folliculitis)
• Skin/soft tissue infection
• Neutropenic fever, which represents a high-risk situation 1

Specific Management of MRSA Folliculitis Component

Antibiotic Options

• Vancomycin remains the primary treatment for MRSA in neutropenic patients 1, 3
• For small follicular lesions that are not extensive, consider adding:
  • Clindamycin (600mg IV three times daily) if susceptible 4
  • Trimethoprim-sulfamethoxazole (4 mg/kg/dose based on TMP component every 8-12 hours) once patient is stable 4

Drainage Considerations

• Surgical intervention for drainage of soft tissue abscess should be performed only after marrow recovery 1
• For small abscesses with surrounding cellulitis, incision and drainage is essential when clinically appropriate 4

Monitoring and Adjustments

Vancomycin Dosing

• Standard 1g every 12 hours dosing is inadequate to achieve therapeutic levels 2, 5
• Weight-based dosing at 15 mg/kg every 6 hours is necessary to achieve target trough concentrations of 15-20 mg/L 2
• Monitor vancomycin trough levels before the fourth dose

Clinical Response Assessment

• Reassess after 48-72 hours of therapy
• If blood cultures are positive for MRSA, adjust therapy based on antimicrobial susceptibilities 1
• If fever persists beyond 3-5 days, consider adding empiric antifungal therapy 1

Special Considerations

Colony-Stimulating Factors

• Adjunct colony-stimulating factor therapy (G-CSF, GM-CSF) is not routinely recommended but may be considered in specific high-risk situations 1

Persistent or Recurrent Fever

• If fever persists or recurs, add empiric antifungal therapy (e.g., fluconazole, voriconazole, or liposomal amphotericin B) 1

Prevention of Recurrence

Once the acute infection resolves and neutropenia improves:

• Consider decolonization with mupirocin nasal ointment and chlorhexidine body washes 4
• Maintain good personal hygiene and keep wounds covered with clean, dry bandages 4

The IDSA guidelines strongly support this approach for managing neutropenic patients with MRSA skin infections, emphasizing the importance of prompt, aggressive treatment to reduce morbidity and mortality in this high-risk population.