Is cefuroxime (Cefuroxime) suitable as a first-line treatment for skin infections, such as furuncles, potentially caused by Methicillin-resistant Staphylococcus aureus (MRSA)?

Cefuroxime is NOT Appropriate for Furuncles When MRSA is Suspected

Do not use cefuroxime as first-line treatment for furuncles (boils) if there is any possibility of MRSA involvement, as cefuroxime has no activity against methicillin-resistant Staphylococcus aureus and treatment failure will result. 1, 2

Why Cefuroxime Fails for MRSA-Related Skin Infections

• MRSA has emerged as the leading cause of postoperative and skin infections, making empiric coverage with agents like cefuroxime increasingly problematic 1
• Cefuroxime is only active against methicillin-sensitive Staphylococcus aureus (MSSA), not MRSA strains 3, 4
• The FDA label for cefuroxime explicitly lists only penicillinase- and non-penicillinase-producing strains of S. aureus as susceptible organisms for skin infections 3

When Cefuroxime Could Be Considered (Limited Scenarios)

Cefuroxime might be acceptable only if:

• Local MRSA prevalence is documented to be very low in your community 2
• The patient has no risk factors for MRSA (no prior MRSA infection, no recent hospitalization, no recent antibiotics, no injection drug use, no incarceration history) 2
• The infection is mild and uncomplicated 1

Even in these scenarios, better first-line options exist (see below).

Superior First-Line Alternatives for Furuncles

For Suspected MRSA or Unknown Susceptibility:

• Trimethoprim-sulfamethoxazole (oral, covers MRSA) 2, 4
• Doxycycline (oral, covers MRSA) 2, 4
• Clindamycin (oral, covers MRSA but check local resistance patterns) 2, 4

For Confirmed MSSA Only:

• Cephalexin is the preferred first-generation cephalosporin, recommended by WHO as first-choice for mild skin infections 2
• Dicloxacillin (penicillinase-resistant penicillin) remains the gold standard for serious MSSA infections 4

Critical Clinical Pitfall

The most common mistake is assuming furuncles are caused by MSSA when community-acquired MRSA is now prevalent. 1, 5 Starting cefuroxime empirically without considering local MRSA epidemiology leads to:

• Treatment failure requiring antibiotic change 1
• Prolonged infection and potential complications 1
• Increased healthcare costs and patient morbidity 1

Why Cefuroxime is Mentioned in Guidelines (Context Matters)

The evidence showing cefuroxime for skin infections refers to:

• Intra-abdominal infections (not skin furuncles) where it's combined with metronidazole for anaerobic coverage 1
• Mixed polymicrobial surgical site infections where broader coverage is needed 1, 3
• Historical recommendations from 2008 before MRSA became the dominant pathogen in skin infections 1

These contexts do not apply to simple furuncles in 2025.

Bottom Line Algorithm

1. Is MRSA suspected or prevalence >10% locally? → Use TMP-SMX, doxycycline, or clindamycin 2, 4
2. Is MSSA confirmed by culture? → Use cephalexin or dicloxacillin 2, 4
3. Is the infection severe or necrotizing? → Hospitalize for IV vancomycin or daptomycin 2, 4
4. Never use cefuroxime empirically for furuncles in the current era of MRSA prevalence 1, 2