What are the antibiotics of choice for treating resistant abscesses (Abscesses)?

From the Guidelines

For resistant abscesses, the antibiotics of choice typically include vancomycin, linezolid, daptomycin, or trimethoprim-sulfamethoxazole (TMP-SMX), depending on the suspected organism and severity, as recommended by the Infectious Diseases Society of America 1. For MRSA abscesses, vancomycin 15-20 mg/kg IV every 8-12 hours is often first-line therapy for severe infections. For less severe cases, oral options include:

• TMP-SMX (1-2 double-strength tablets twice daily)
• clindamycin (300-450 mg orally three times daily)
• linezolid (600 mg orally twice daily) as outlined in the guidelines 1. Treatment duration typically ranges from 7-14 days, depending on clinical response. Incision and drainage remains the primary intervention for abscesses, with antibiotics serving as adjunctive therapy. Cultures should be obtained before starting antibiotics to guide targeted therapy. For polymicrobial abscesses, broader coverage with piperacillin-tazobactam, meropenem, or combinations including metronidazole may be necessary. The choice of antibiotic should consider local resistance patterns, patient allergies, and comorbidities. Resistant abscesses often contain biofilms that protect bacteria from antibiotic penetration, so adequate surgical drainage is essential for treatment success alongside appropriate antibiotic therapy. Key considerations for antibiotic selection include the severity of the infection, the presence of systemic symptoms, and the potential for resistance, as highlighted in the guidelines 1. In general, the treatment approach should be individualized based on the specific clinical scenario and patient factors, with a focus on minimizing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Table 16: Clinical Success Rates by Infecting Pathogen in the cSSSI Trials in Adult Patients (Population: Microbiologically Evaluable) Pathogen Success Rate n/N (%) Daptomycin for Injection Comparator* Methicillin-resistant Staphylococcus aureus (MRSA) † 21/28 (75%) 25/36 (69%) The antibiotics of choice for resistant abscess, specifically MRSA, are:

• Daptomycin: with a success rate of 75%
• Vancomycin: with a success rate of 69%
• Anti-staphylococcal semi-synthetic penicillin: with a success rate of 69% 2

From the Research

Antibiotics of Choice for Resistant Abscess

• The choice of antibiotic for resistant abscess, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA), depends on various factors including the severity of the infection, the susceptibility of the isolate, and the clinical context 3, 4, 5, 6.
• Vancomycin remains an acceptable treatment option for MRSA infections, but its use is often limited by concerns regarding clinical utility and growing resistance 3, 6.
• Linezolid is a potential first-line drug against MRSA bacteremia, with studies showing comparable effectiveness and safety to vancomycin, teicoplanin, or daptomycin 4.
• Daptomycin is currently the only antibiotic to have shown noninferiority to vancomycin in the treatment of MRSA bacteremia, and may be a viable option for patients with MRSA infections 3, 6.
• Tedizolid is a newer antibiotic that has shown potent activity against Gram-positive pathogens, including MRSA and enterococci with reduced susceptibility to vancomycin, daptomycin, or linezolid 7.
• Combination antibiotic treatment for MRSA infections is an attractive alternative, but the theoretical promise of combination therapy has not been borne out in most in vitro and animal studies, and there are currently insufficient data to recommend β-lactam combination therapy in routine clinical use 5.
• Other antibiotics, such as ceftaroline, telavancin, and tigecycline, may also be effective against MRSA infections, but their use is often limited by concerns regarding resistance, toxicity, and clinical efficacy 3, 6.

Treatment Options for Resistant Abscess

• Linezolid, vancomycin, and daptomycin are commonly used antibiotics for the treatment of MRSA infections, including resistant abscess 3, 4, 6.
• Tedizolid may be a viable treatment option for patients with MRSA infections, particularly those with reduced susceptibility to other antibiotics 7.
• Combination antibiotic therapy, including the use of β-lactam antibiotics, may be considered in certain clinical contexts, but its use is often limited by concerns regarding resistance and toxicity 5.
• The choice of antibiotic should be guided by the results of susceptibility testing, as well as clinical factors such as the severity of the infection, the presence of comorbidities, and the potential for adverse effects 3, 4, 6.