What is the appropriate emergency management for a female patient presenting with multiple pus‑filled skin lesions (furunculosis/carbuncle) and a temperature of 41 °C?

Emergency Management of Pus-Filled Skin Lesions with High Fever

A 41-year-old female presenting with multiple pus-filled bumps and fever of 41°C requires immediate incision and drainage of all large lesions plus systemic antibiotics active against MRSA, as this presentation meets criteria for systemic inflammatory response syndrome (SIRS) requiring urgent intervention. 1

Immediate Assessment and Stabilization

Recognize This as a Medical Emergency

• A temperature of 41°C (105.8°F) with purulent skin lesions indicates SIRS and potential sepsis, requiring urgent treatment. 1
• The presence of fever >38°C automatically triggers the need for systemic antibiotics as an adjunct to surgical drainage, per IDSA guidelines 1
• Assess for additional SIRS criteria: tachycardia >90 bpm, tachypnea >24 breaths/min, or WBC >12,000 or <4,000 cells/µL 1

Obtain Cultures Before Starting Antibiotics

• Culture pus from the lesions immediately to identify the pathogen and guide antibiotic therapy - this is particularly critical given the high prevalence of MRSA in community-acquired skin infections 1
• Gram stain and culture are strongly recommended for carbuncles and abscesses, especially when systemic treatment is needed 1

Surgical Management

Incision and Drainage is Mandatory

• All large furuncles and carbuncles require incision and drainage - this is the cornerstone of treatment and takes priority over antibiotics alone 1, 2
• Perform thorough evacuation of pus and probe to break up any loculations 2
• After drainage, cover the wound with a dry sterile dressing rather than packing with gauze, as packing increases pain without improving outcomes 1, 3

Antibiotic Therapy

Start MRSA-Active Antibiotics Immediately

Given the fever of 41°C meeting SIRS criteria, systemic antibiotics are mandatory:

First-line oral options (if patient can tolerate oral intake and is not severely ill):

• Trimethoprim-sulfamethoxazole (TMP-SMX) 1, 3
• Doxycycline 1, 3
• Clindamycin 1, 3

Consider hospitalization and IV antibiotics if:

• Hemodynamic instability is present 2
• Altered mental status occurs 2
• Concern exists for deeper or necrotizing infection 2
• Patient cannot tolerate oral medications 2

Duration of Antibiotic Therapy

• Treat for 5-10 days with an antibiotic active against the isolated pathogen once culture results return 1
• Extend treatment only if infection has not improved within this timeframe 2

Critical Pitfalls to Avoid

• Never treat carbuncles or furuncles with antibiotics alone without drainage - this approach will fail 2, 3
• Do not use needle aspiration instead of incision and drainage - aspiration is successful in only 25% of cases overall and <10% with MRSA infections 1
• Do not delay surgical drainage while waiting for culture results when SIRS is present 1
• Do not assume methicillin-sensitive S. aureus - MRSA is now the most common pathogen in community-acquired skin and soft tissue infections 3, 4

Disposition and Follow-Up

Hospitalization Criteria

• Temperature of 41°C with purulent lesions warrants strong consideration for admission given the severity of systemic response 2
• Monitor for progression to sepsis or necrotizing soft tissue infection 5

Outpatient Management (Only if Stable After Initial Treatment)

• Ensure close follow-up within 24-48 hours to assess response to drainage and antibiotics 3
• Adjust antibiotics based on culture results and clinical response 1

Address Recurrence Risk

• If this represents recurrent disease, plan for decolonization after acute infection resolves: intranasal mupirocin twice daily for 5 days, daily chlorhexidine washes, and decontamination of personal items 1, 3
• Culture household contacts if transmission is suspected 3