What is the best approach for managing a patient with a residual lump after abscess treatment who is MRSA positive?

Management of Residual Lump After MRSA Abscess Treatment

For a patient with a residual lump after abscess treatment who is MRSA positive but showing clinical improvement with resolved inflammation, no further treatment is necessary beyond monitoring for recurrence.

Assessment of Current Status

The patient presents with:

• Previously treated abscess with completed course of cotrimoxazole (TMP-SMX)
• Used Foban (mupirocin) cream as prescribed
• Known MRSA positive status
• Residual small, non-tender lump deep to the skin
• No overlying redness or signs of inflammation
• No systemic symptoms (afebrile, no pain unless firm pressure applied)
• Normal vital signs

Management Approach

1. Interpretation of Current Findings

• The residual lump likely represents post-inflammatory changes or scar tissue formation following successful treatment
• The absence of erythema, tenderness, and systemic symptoms indicates resolution of active infection 1
• The hardness is consistent with normal healing after abscess drainage and antibiotic treatment

2. Recommended Actions

• No further antibiotic treatment is required since:

  • The patient has completed an appropriate course of cotrimoxazole (effective against MRSA)
  • Clinical signs show resolution of active infection
  • The World Journal of Emergency Surgery guidelines support that once adequate drainage and appropriate antibiotic therapy have been completed, further treatment is not necessary for resolved abscesses 2

• Patient education:

  • Explain that the residual lump is normal and represents healing tissue
  • Advise that the lump will likely resolve gradually over weeks to months
  • Provide clear return precautions (see below)

3. Follow-up Recommendations

• Routine follow-up in 2-4 weeks to ensure continued resolution
• Return sooner if any of these warning signs develop:
  • Increasing pain, swelling, or redness at the site
  • Development of fever or chills
  • Enlargement of the residual lump
  • Drainage from the area

Special Considerations for MRSA-Positive Patients

• MRSA prevalence in skin and soft tissue abscesses is significant (19-35% in various studies) 3, 4
• The patient has already received appropriate MRSA-targeted therapy with cotrimoxazole 1
• No evidence suggests that extending antibiotic therapy beyond the initial course provides additional benefit in clinically resolved cases 5

Potential Pitfalls to Avoid

1. Unnecessary antibiotic extension: Continuing antibiotics when clinical improvement has occurred does not improve outcomes and may contribute to antibiotic resistance 1, 6

2. Failure to recognize treatment success: The presence of a residual lump without other signs of infection represents successful treatment, not treatment failure 5

3. Unnecessary repeat drainage: In the absence of fluctuance, tenderness, or signs of active infection, repeat drainage procedures are not indicated 1

4. Inadequate patient education: Patients should be clearly informed about signs of recurrence that would warrant prompt reevaluation 6

By following these recommendations, you can ensure appropriate management of this patient's resolved MRSA abscess while avoiding unnecessary interventions.