What is the best initial treatment for a patient with a suspected skin infection, presenting with erythema, edema, warmth, and purulent drainage?

From the Guidelines

The best initial treatment for a patient with a suspected skin infection, presenting with erythema, edema, warmth, and purulent drainage, is incision and drainage, with consideration of antibiotic therapy, such as clindamycin, if there are signs of systemic illness or severe disease. This patient presents with classic signs of a skin and soft tissue infection, likely cellulitis with a possible abscess. According to the guidelines by the Infectious Diseases Society of America 1, incision and drainage is the primary treatment for a cutaneous abscess, and antibiotic therapy may be recommended for abscesses associated with severe or extensive disease, signs and symptoms of systemic illness, or lack of response to incision and drainage alone.

Key Considerations

• The presence of purulent drainage suggests a deeper infection that requires an antibiotic with good tissue penetration, such as clindamycin.
• Clindamycin provides good coverage against common skin pathogens, including Staphylococcus aureus (including many MRSA strains) and Streptococcus species.
• The typical dosing for clindamycin in this scenario would be 300-450 mg orally four times daily for 7-10 days, with instructions to return if symptoms worsen or fail to improve within 48-72 hours.
• Other antibiotic options, such as trimethoprim-sulfamethoxazole, doxycycline, or minocycline, may also be considered, but clindamycin is a preferred choice due to its broad coverage and good tissue penetration.

Additional Recommendations

• Cultures from abscesses and other purulent skin and soft tissue infections are recommended to guide antibiotic therapy and to identify potential antibiotic resistance 1.
• Patients with severe or extensive disease, signs and symptoms of systemic illness, or lack of response to initial treatment should be considered for hospitalization and intravenous antibiotic therapy 1.
• The use of rifampin as a single agent or as adjunctive therapy for the treatment of skin and soft tissue infections is not recommended due to the risk of resistance development 1.

From the FDA Drug Label

CLINICAL STUDIES The efficacy of topical mupirocin ointment in impetigo was tested in two studies. Clinical efficacy rates at end of therapy in the evaluable populations (adults and pediatric patients included) were 71% for mupirocin ointment (n=49) and 35% for vehicle placebo (n=51). In the second study, patients with impetigo were randomized to receive either mupirocin ointment t.i. d. or 30 to 40 mg/kg oral erythromycin ethylsuccinate per day (this was an unblinded study) for 8 days. Clinical efficacy rates at the follow-up visit in the evaluable populations (adults and pediatric patients included) were 93% for mupirocin ointment (n=29) and 78. 5% for erythromycin (n=28).

The best initial treatment for a patient with a suspected skin infection, presenting with erythema, edema, warmth, and purulent drainage, is topical mupirocin ointment 2.

• Clinical efficacy rates for mupirocin ointment were 71% and 93% in two studies.
• Pathogen eradication rates were 94% and 100% for mupirocin ointment in the two studies.

From the Research

Initial Treatment for Suspected Skin Infection

The initial treatment for a patient with a suspected skin infection, presenting with erythema, edema, warmth, and purulent drainage, depends on the type and severity of the infection.

• For nonbullous and bullous impetigo, an antistaphylococcal oral antibiotic is the preferred treatment 3.
• For cellulitis, a therapeutic agent that is effective against both Staphylococcus aureus and streptococci is appropriate 3.
• For furuncles, carbuncles, cutaneous abscesses, and inflamed epidermal cysts, incision and drainage is the most important therapy, and in most cases, there is no need for antimicrobial therapy 3.

Antibiotic Therapy

The choice of antibiotic therapy depends on the suspected causative organism and its resistance pattern.

• For methicillin-susceptible Staphylococcus aureus (MSSA) infections, penicillinase-resistant penicillins (flucloxacillin, dicloxacillin) are the antibiotics of choice 4.
• For methicillin-resistant Staphylococcus aureus (MRSA) infections, vancomycin or teicoplanin are the preferred treatments 4.
• Clindamycin, a protein synthesis inhibitor antibiotic, may be used as an adjunctive therapy to limit exotoxin production in severe Staphylococcus aureus infections 5.

Severe Skin and Soft Tissue Infections

For severe skin and soft tissue infections, such as necrotizing soft tissue infections (NSTIs), broad-spectrum antibiotic therapy is essential 6.

• A broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy 6.
• Clindamycin may be added to decrease toxin production, particularly in proven or suspected group A streptococcus infections 6.