What is the next step in managing a tattoo infection with pus, currently being treated with doxycycline (doxy) and mupirocin ointment?

Management of Tattoo Infection with Purulent Drainage

The patient with a tattoo infection showing purulent drainage despite current treatment with doxycycline and mupirocin requires incision and drainage of the infected area, bacterial culture of the pus, and possible adjustment of antibiotic therapy based on culture results. 1

Assessment of Current Treatment

• The patient is currently on doxycycline and mupirocin ointment but is showing signs of treatment failure with purulent drainage from the tattoo site 1
• Mupirocin ointment should show clinical response within 3-5 days; continued purulence indicates inadequate treatment 2
• Doxycycline is an appropriate empiric oral antibiotic for skin infections but may be insufficient if there is an abscess or resistant organism 1

Immediate Management Steps

1. Incision and drainage:

   • When pus is present in a skin infection, incision and drainage is the primary treatment 1
   • This is essential for adequate treatment of any purulent collection, regardless of antibiotic therapy 1

2. Obtain bacterial culture:

   • When infection is suspected and not responding to initial treatment, a bacterial culture must be obtained 1
   • Culture of the purulent material is crucial to identify the causative organism and determine antibiotic sensitivities 1

3. Continue current antibiotics pending culture results:

   • Maintain doxycycline therapy as it provides good coverage against common skin pathogens 1
   • Continue mupirocin application three times daily to affected areas 2

Considerations for Tattoo-Related Infections

• Tattoo infections can involve common skin pathogens (Staphylococcus aureus, Streptococcus) but may also include atypical organisms 3
• Mycobacterial infections (including Mycobacterium fortuitum) have been reported in tattoo-associated infections and require specialized treatment 3
• Inadequate response to conventional antibiotics should raise suspicion for atypical organisms 3

Antibiotic Adjustment Based on Clinical Response

• If no improvement is seen within 72 hours after drainage and current antibiotic therapy, consider:
  • Broadening antibiotic coverage to include MRSA if not already covered 1
  • Adding an aminoglycoside if deep infection is suspected 1
  • Extending the antibiotic course to 14 days total for adequate treatment 1

Follow-up Recommendations

• Patient should be reassessed within 48-72 hours to evaluate response to drainage and antibiotics 1
• If culture reveals resistant organisms or atypical pathogens (like mycobacteria), antibiotic therapy should be adjusted accordingly 3
• Complete resolution of infection should be confirmed before discontinuing antibiotics 1

Prevention of Recurrence

• Once infection resolves, proper tattoo aftercare should be emphasized 4
• Avoidance of excessive washing with hot water 1
• Use of alcohol-free moisturizing creams 1
• Avoidance of skin irritants during healing phase 1

Common Pitfalls to Avoid

• Relying solely on antibiotics without adequate drainage when purulent material is present 1
• Failing to obtain cultures in non-responsive infections 1
• Not considering atypical organisms in tattoo-related infections that don't respond to conventional therapy 3
• Discontinuing antibiotics prematurely before complete resolution of infection 1