Treatment of MRSA Skin Abscesses
For MRSA skin abscesses, incision and drainage is the primary treatment, with antibiotics recommended only for specific clinical scenarios such as severe infection, systemic symptoms, or high-risk anatomic locations. 1
Primary Management
- Incision and drainage alone is adequate for simple, uncomplicated MRSA abscesses without surrounding cellulitis or systemic symptoms 1
- Cultures from abscesses should be obtained in patients who will receive antibiotic therapy, have severe local infection, show signs of systemic illness, have not responded to initial treatment, or when there is concern for an outbreak 1, 2
- For small furuncles, moist heat application may be sufficient to promote drainage 1
When to Add Antibiotics
Antibiotic therapy should be added to incision and drainage in the following situations:
- Severe or extensive disease (multiple sites of infection) or rapid progression with associated cellulitis 1
- Signs and symptoms of systemic illness 1, 2
- Associated comorbidities or immunosuppression (diabetes, HIV/AIDS, neoplasm) 1
- Extremes of age (very young or elderly) 1
- Abscess in an area difficult to drain completely (face, hand, genitalia) 1
- Associated septic phlebitis 1
- Lack of response to incision and drainage alone 1
Antibiotic Selection for Outpatient Treatment
For outpatients requiring antibiotics for MRSA abscesses, recommended options include:
- Clindamycin: 300-450 mg PO three times daily for adults; 10-13 mg/kg/dose PO every 6-8 hours (not exceeding 40 mg/kg/day) for children 1
- Trimethoprim-sulfamethoxazole (TMP-SMX): 1-2 double-strength tablets PO twice daily for adults; 4-6 mg/kg/dose (trimethoprim component) PO every 12 hours for children 1, 2
- Doxycycline or minocycline: 100 mg PO twice daily (not for children under 8 years) 1
- Linezolid: 600 mg PO twice daily (more expensive option) 1, 3
Duration of Treatment
- 5-10 days of antibiotic therapy is recommended for uncomplicated MRSA skin infections 1, 2
- Treatment duration should be individualized based on clinical response 1
Special Considerations
- Recent evidence shows that when antibiotics are used for smaller abscesses (≤5 cm), both clindamycin and TMP-SMX significantly improve cure rates compared to placebo (83.1% and 81.7% vs. 68.9%, respectively) 4
- For children with MRSA abscesses <5 cm, incision and drainage alone may be sufficient, even without effective antibiotic therapy 5
- Tetracyclines (doxycycline, minocycline) should not be used in children under 8 years of age 1, 2
- TMP-SMX is not recommended for pregnant women in the third trimester or for children under 2 months of age 1
Management of Complicated MRSA Infections
For hospitalized patients with complicated skin infections (deeper infections, surgical/traumatic wound infections, major abscesses):
- Vancomycin: 15-20 mg/kg/dose IV every 8-12 hours 1
- Linezolid: 600 mg PO/IV twice daily 1
- Daptomycin: 4 mg/kg/dose IV once daily 1
- Clindamycin: 600 mg IV/PO three times daily (if local resistance rates are low) 1
Follow-up Care
- Clinical reassessment within 48-72 hours is essential to ensure appropriate response to therapy 2
- Patients should be educated about keeping draining wounds covered with clean, dry bandages 2
- Good personal hygiene with regular handwashing should be emphasized to prevent recurrence 2
Common Pitfalls to Avoid
- Failure to perform adequate incision and drainage (the primary intervention) 1, 6
- Prescribing antibiotics for all abscesses regardless of size and clinical presentation 6, 7
- Using rifampin as a single agent or as adjunctive therapy (not recommended) 1
- Not obtaining cultures when indicated, especially in treatment failures or recurrent infections 1, 2
- Inadequate follow-up for patients with larger abscesses or those with risk factors for treatment failure 2, 8