Levofloxacin is NOT Recommended for Skin Abscesses Caused by Staphylococcus aureus
Levofloxacin (Levaquin) should not be used as first-line therapy for skin abscesses caused by Staphylococcus aureus, as it is not included in any major guideline recommendations for this indication and lacks adequate anti-staphylococcal activity for purulent skin infections. 1
Why Levofloxacin is Inappropriate for Staph Aureus Skin Abscesses
Guideline-Recommended Agents for Skin Abscesses
The 2014 IDSA guidelines for skin and soft tissue infections specifically recommend the following for purulent infections (abscesses) caused by S. aureus 1:
For simple abscesses:
- Incision and drainage alone is often sufficient (85-90% cure rates without antibiotics) 1
- When antibiotics are indicated, use agents active against MRSA 1
Oral antibiotic options when needed:
- TMP-SMX: 1-2 double-strength tablets twice daily 1
- Doxycycline or minocycline: 100 mg twice daily 1
- Clindamycin: 300-450 mg every 6-8 hours (only if local MRSA resistance <10%) 1, 2
- Linezolid: 600 mg twice daily 1
For complicated/severe infections requiring IV therapy:
- Vancomycin: 15 mg/kg every 8-12 hours 1
- Linezolid: 600 mg IV every 12 hours 1
- Daptomycin: 4 mg/kg IV daily 1
- Ceftaroline: 600 mg IV twice daily 1
Why Fluoroquinolones Are Not Listed
Levofloxacin and other fluoroquinolones are conspicuously absent from guideline recommendations for staphylococcal skin abscesses because 1:
- Inadequate anti-MRSA activity: Community-acquired MRSA is now the predominant pathogen in purulent skin infections, and fluoroquinolones have poor activity against MRSA 1
- Variable activity against MSSA: Even for methicillin-susceptible S. aureus, fluoroquinolones are not optimal choices 1
- Resistance concerns: Using fluoroquinolones for infections where better alternatives exist promotes unnecessary resistance 3
The Correct Approach to Staph Aureus Skin Abscesses
Step 1: Incision and Drainage
- Primary treatment is surgical drainage 1, 2
- For simple abscesses <5 cm without surrounding cellulitis, drainage alone achieves 85-90% cure rates 1, 2
Step 2: Determine if Antibiotics Are Needed
Antibiotics ARE indicated when: 1
- Multiple abscesses present
- Extensive surrounding cellulitis (>5 cm)
- Systemic signs of infection (fever, tachycardia)
- Immunocompromised host
- Extremes of age
- Lack of response to drainage alone
- Difficult drainage location (face, hands, genitalia)
Step 3: Choose Appropriate Antibiotic
For outpatient oral therapy (5-10 days): 1, 2
- TMP-SMX 1-2 double-strength tablets twice daily (preferred for most cases)
- Doxycycline 100 mg twice daily (alternative)
- Clindamycin 300-450 mg every 6-8 hours (if local MRSA clindamycin resistance <10%)
For hospitalized patients requiring IV therapy (7-14 days): 1
- Vancomycin 15 mg/kg IV every 8-12 hours (first-line)
- Linezolid 600 mg IV every 12 hours (alternative)
- Daptomycin 4 mg/kg IV daily (alternative)
When Levofloxacin IS Appropriate
Levofloxacin 750 mg daily for 7-14 days is FDA-approved and guideline-recommended for complicated skin and skin structure infections when the pathogen spectrum includes gram-negative organisms 4, but this is distinctly different from simple staphylococcal abscesses. The FDA label shows 84% success rates in complicated skin infections, but these studies included mixed infections requiring broad-spectrum coverage 4.
Critical Pitfalls to Avoid
- Do not use fluoroquinolones as empiric therapy for purulent skin infections in the current era of CA-MRSA predominance 1
- Do not prescribe antibiotics without adequate drainage for abscesses—this is the most common cause of treatment failure 1, 2
- Do not assume all skin infections are the same—purulent (abscess) and non-purulent (cellulitis) infections require different antibiotic approaches 1