What is the appropriate evaluation and treatment for a female adult with recurrent staphylococcal skin infection presenting with pus‑filled scabs and fever, who is allergic to amoxicillin/clavulanate (Augmentin Duo)?

Evaluation and Treatment of Recurrent Staphylococcal Skin Infection with Augmentin Allergy

For this patient with recurrent staphylococcal skin infection presenting with pus-filled scabs and fever, incision and drainage is the primary treatment, with systemic antibiotics indicated due to fever; given the Augmentin allergy, clindamycin 300-450 mg orally every 6 hours for 5 days is the optimal choice, providing single-agent coverage for both streptococci and MRSA without requiring combination therapy. 1, 2

Immediate Evaluation

Assess for systemic inflammatory response syndrome (SIRS):

• Temperature >38°C or <36°C
• Tachycardia >90 beats per minute
• Tachypnea >24 breaths per minute
• White blood cell count >12,000 or <4,000 cells/µL 1

Examine the lesions carefully:

• Determine if these are furuncles/carbuncles (inflammatory nodules with overlying pustules) versus cellulitis with purulent drainage 1
• Assess for fluctuance indicating drainable abscess 1
• Look for surrounding cellulitis or signs of deeper infection 1

Obtain cultures:

• Gram stain and culture of pus from the lesions is recommended to guide therapy and identify MRSA 1

Primary Treatment Algorithm

If Drainable Abscess or Large Furuncle Present:

Incision and drainage is the primary treatment 1

• Most large furuncles and all carbuncles require incision and drainage 1
• Simply covering the surgical site with a dry dressing is usually most effective; packing causes more pain without improving healing 1

Antibiotic Selection (Given Augmentin Allergy):

Because fever is present, systemic antibiotics ARE indicated 1

Clindamycin 300-450 mg orally every 6 hours for 5 days is the optimal choice 1, 2

• Provides single-agent coverage for both streptococci and MRSA 2
• Eliminates need for combination therapy 2
• Critical caveat: Use only if local MRSA clindamycin resistance rates are <10% 1, 2

Alternative if clindamycin resistance is high:

• Doxycycline 100 mg orally twice daily PLUS cephalexin 500 mg four times daily for 5 days 2
• Never use doxycycline alone as it lacks reliable streptococcal coverage 2

For severe infection requiring hospitalization (if SIRS present):

• Vancomycin 15-20 mg/kg IV every 8-12 hours 1, 3
• Alternative: Linezolid 600 mg IV twice daily 1

Treatment Duration

Treat for 5 days if clinical improvement occurs; extend only if symptoms have not improved within this timeframe 1, 2

Prevention of Recurrent Furunculosis

For patients with repeated attacks, eradication of staphylococcal carriage is essential:

Nasal decolonization:

• Mupirocin ointment twice daily in anterior nares for the first 5 days each month reduces recurrences by ~50% 1

Systemic decolonization (most effective):

• Clindamycin 150 mg orally once daily for 3 months decreases subsequent infections by ~80% 1
• This is the best program for recurrent furunculosis caused by susceptible S. aureus 1

Environmental measures:

• Bathing with chlorhexidine 1
• Thorough laundering of clothing, towels, and bed linens 1
• Separate use of towels and washcloths 1

Consider household decolonization approach:

• Asymptomatic carriers serve as reservoirs for transmission 4
• Household approach is more effective than individual measures alone 4

Common Pitfalls to Avoid

Do not use antibiotics alone without drainage for large furuncles or carbuncles 1

• Drainage is the primary treatment; antibiotics are adjunctive 1

Do not use doxycycline as monotherapy 2

• Lacks reliable activity against beta-hemolytic streptococci 2

Do not reflexively extend treatment beyond 5 days based on residual erythema alone 2

• Some inflammation persists even after bacterial eradication 2

Do not ignore the need for decolonization in recurrent cases 1, 4

• 20-40% of the general population carries S. aureus in the anterior nares 1
• Carriage is the primary risk factor for recurrent furunculosis 1