From the Guidelines
The current management plan for this 88-year-old female with a draining left axillary lesion without fluctuant center should focus on continuing doxycycline therapy, as it provides appropriate MRSA coverage, supplemented with supportive measures including warm compresses, gentle cleansing, and application of clean, dry dressings. Given her age and ongoing drainage despite antibiotics, close monitoring is essential to promptly identify any need for adjustment in the treatment plan. The patient's treatment should be guided by the principles outlined in the clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in adults and children 1. Key points from these guidelines include the recommendation for antibiotic therapy in cases of abscesses associated with severe or extensive disease, systemic illness, or lack of response to incision and drainage alone. For outpatients with purulent cellulitis, empirical therapy for community-associated MRSA (CA-MRSA) is recommended, with options including clindamycin, TMP-SMX, a tetracycline (such as doxycycline), and linezolid 1. However, the use of rifampin as a single agent or as adjunctive therapy for the treatment of skin and soft tissue infections (SSTI) is not recommended 1. If no improvement occurs within 48-72 hours on doxycycline, consideration should be given to changing to an alternative antibiotic such as TMP-SMX or clindamycin based on local resistance patterns. Maintaining the scheduled surgical follow-up is crucial, as incision and drainage may become necessary if the lesion develops a fluctuant center or fails to improve with the current management approach. This approach prioritizes the patient's morbidity, mortality, and quality of life by addressing the infection with appropriate antibiotic coverage and supportive care, while being vigilant for signs of treatment failure that would necessitate adjustments to the therapeutic plan.
From the FDA Drug Label
Incision and drainage or other surgical procedures should be performed in conjunction with antibiotic therapy, when indicated.
The patient is already on doxycycline, but the drug label does not directly address the effectiveness of doxycycline against MRSA. However, it does mention that incision and drainage or other surgical procedures should be performed in conjunction with antibiotic therapy, when indicated. Given the patient's ongoing drainage, close monitoring is essential, and if no improvement occurs within 48-72 hours, consider changing to an alternative antibiotic or adding a second agent, as the current management plan may not be effective. 2
From the Research
Management of MRSA Infection
The current management plan for the 88-year-old female with a draining left axillary lesion without fluctuant center, who is already on doxycycline, should focus on supportive measures including:
- Warm compresses applied 3-4 times daily
- Keeping the area clean with gentle washing
- Applying clean dry dressings changed when soiled Given her age and ongoing drainage despite antibiotics, close monitoring is essential.
Antibiotic Treatment
If no improvement occurs within 48-72 hours on doxycycline, consider changing to an alternative antibiotic such as:
- TMP-SMX
- Clindamycin based on local resistance patterns, or adding rifampin as a second agent 3, 4, 5, 6.
Surgical Follow-up
Maintain the scheduled surgical follow-up for potential incision if the lesion develops a fluctuant center or fails to improve with current management.
Evidence for Antibiotic Use
There is limited evidence to support the use of doxycycline, TMP-SMX, clindamycin, or minocycline in the treatment of MRSA infections 7. However, studies suggest that minocycline may be effective in treating uncomplicated skin and soft-tissue abscesses caused by MRSA 3. Clindamycin and TMP-SMX have also been shown to be effective in treating uncomplicated skin infections, including those caused by MRSA 4, 5.