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Clinical Decisions
Management of Skin and Soft-Tissue Infection
Treatment Option 1 Comments Treatment Option 2 Comments Treatment Option 3 Comments
Treatment Option 1: Incision and drainage alone.
132 Readersʼ Comments
Kingston Okrah | Physician | Disclosure: None
University of Iowa | Coralville, Iowa USA
September 20, 2008
Patient is young and immunocompetent, at the moment he has no indication of disseminated infection and no organism has been
isolated from the abcess yet to direct antibiotic choice. Most cutaneous infections are well treated with just I & D and even though he is
at risk of exposure to MRSA from his involvement in contact sport, I will not start systemic antibiotics until I have evidence of
systemic involvement.
Sausan Campbell MD | Physician | Disclosure: None
BellSouth.net | Asheville, North Carolina USA
September 20, 2008
There is overuse of antibiotics in our medical culture today- largely due to fear rather than valid culture results and in some cases even
if wound cultures are negative most physicians still overtreat. Less is better in this scenario where we are dealing with a healthy active
young male who has the common occasional abscess due to increased sweat production and exposure to different showers in various
places across the country. His exam is only remarkable for skin involvement without any evidence of systemic disease. Given the
growing number of highly resistant organisms, we would be doing a disservice to this young male by altering his own "flora" and
predisposing him to developing a resistant strain in the future.
Junko Okamoto | Physician | Disclosure: None
Kinki University | Osaka-sayama, Japan
September 25, 2008
As the infection is supposed to be localized, systemic anitibiotics seems to be over-indication. I'd add some ointment as local
antibiotics. Culture is neccesary, of course.
Rusty Ellis Human | Other | Disclosure: None
Comcast Cable | Los Gatos, California USA
September 25, 2008
less is more in this case. Begin with less and observe sucess. Additional treatment can be added but not taken away.
N Dua | Physician | Disclosure: None
Columbia University | New York, New York USA
September 25, 2008
Many hospital guidelines would recommend I&D alone in this case. Most of the current literature consists of retrospective reviews with
large variability in inclusion criteria as well as treatment outcomes studied. Interestingly, Dr. Chambers and Dr.Kamitsuka cite the
same article to support their different decision making (Ruhe et al,clin.inf.dis.2007,44:777-84)Though the authors note a statistically
significant impact with active antibiotic use, they recommend limiting antibiotic therapy to patients with a suboptimal response or
significant co-morbidities
Christopher Ward MD | Physician | Disclosure: None
Frontier Communications | Elko,, Nevada USA
September 24, 2008
Failure of incision and drainage alone to cure a cutaneous abscess, even one associated with cellulitis, usually results from inadequate
drainage and debridement, not lack of antibiotic coverage.
anant gandhi MD | Physician | Disclosure: None
Armstrong Cable Services | pittsburgh, Pennsylvania USA
September 24, 2008
Incision and drainage would suffice, but would culture the drainage and follow patient for complete resolution of the infection. Often in
office practice MSSA staph aureus is not sensitive to cephalexin.
Rick Rochetto Clinical Pharmacist | Other health professional | Disclosure: None
Salem Hospital | salem, Oregon USA
September 23, 2008
I/D alone in this patient population should resolve the infection. Antibiotics should not be used in this case unless the infection does not
clear soon after I/D. I would culture with the I/D of course in case antibiotics are needed, but if the infection remains MRSA should be
considered and treated as such.
Jack Hawkins Dr | Medical student/physician in training | Disclosure: None
Telewest Broadband | Birmingham, England
September 23, 2008
no indications for antibiotic treatment just yet
w hunter | Other health professional | Disclosure: None
LenderLive | steamboat springs, Colorado USA
September 22, 2008
nothing else has been shown more effective, antibiotics could hamper performance
Nick Schneider | Physician | Disclosure: None
University of Michigan Medical Center (MCIT) | Ann Arbor, Michigan USA
September 22, 2008
High likelihood this infection will resolve w/ I and D alone/ low morbidity from holding antibiotic therapy. (does anyone really think
this kid won't get completely better after just I and D?)
Allen Frechette | Other health professional | Disclosure: None
State of Minnesota | Shakopee, Minnesota USA
September 22, 2008
Patient should be examined to rule out diabetes as a complication factor for staph infections. Incise and drain only if it appears lesion is
ready to drain. Treat with Phisohex as a topical ointment for three days and reexamine.
William Jantsch MD | Physician | Disclosure: None
Road Runner | Mount Vernon, Ohio USA
September 22, 2008
As an ER doctor I see lesions like this every day. I know that personal experience is no substitute for scientific analysis, but I have
never seen a lesion like this NOT resolve with I&D alone. MRSA is the most common cause of these lesions in our central Ohio
emergency department.
Angela Kirwa | Other health professional | Disclosure: None
Iowa Telecom | West Des Moines, Iowa USA
September 22, 2008
I believe that treatment option 1 is sufficient for this otherwise healthy athlete. Antibiotics should be used only as necessary and
indicated by positive cultures, or prophylactically as with some post-op clients. The overuse of antibiotics, as we know well today, has
been a major factor in resistant organisms. It surprises me that some healthcare providors continue to prescribe antibiotic therapies
without a confirmed bacterial infection.
subhash SLATHIA | Physician | Disclosure: None
JAMMU, India
September 21, 2008
I do agree with all those comments of experts and add that my own boils once drained did not pose any problem. Need to be pressed till
no frank pus comes.
Robert Wolfson MD, MSHA | Physician | Disclosure: None
Comcast Cable | Lakewood, Colorado USA
September 21, 2008
Incision and drainage is adequate as a primary treatment. The patient has already been treated with amoxicillin. If there are further
problems, antibiotic therapy should be considered. Antibiotics at this time could lead to a resistant infection.
Mina Rim | Physician | Disclosure: None
Medical Center of Delaware | Wilmington, Delaware USA
September 21, 2008
It is highly likely that this patient has CA-MRSA cellulitis/abscess with its prevalence in the community and the patient's exposure to
multiple skin flora as a basketball player. However, the lesion is small (5cm), systemic symptoms are absent and the patient is
otherwise young and healthy. It would be reasonable in this situation to treat with I&D only and forego systemic antibiotics.
Ann Weissman MD | Physician | Disclosure: None
University of California at Berkeley | San francisco, California USA
September 24, 2008
My practice is primarily with patients in this age group, and I see a lot of patients with similar problems. They frequently respond to
incision and drainage alone; when they do not, they often have MRSA. So my choice would be incision and drainage with culture and
sensitivity and close follow-up; followed by the appropriate antibiotic if the cellulitis does not resolve in a timely manner, if the patient
becomes systemically ill, or if additional cutaneous infections develop.
yousef hijazi dr | Physician | Disclosure: None
mecca, Saudi Arabia
September 21, 2008
Incision and drainage is the best with taking culture and sensitivity from pus
Hans Kollberg Professor emeritus | Physician | Disclosure: None
Telia Network Services | Uppsala, Sweden
September 20, 2008
Never add an antibiotic if not necessary - it will only increase the burden of antibiotics and promote antibiotic resistance. Reconsider if
not better after 3- 4 days.
Olaf West van | Physician | Disclosure: None
Pop Den Bosch, Ring Den Bosch | Breda, Netherlands
September 20, 2008
Incision and ample drainage should be sufficient, take a culture and give no antibiotics , gives no resistance.
saswati mukherjee sash | Medical student/physician in training | Disclosure: None
CHINANET Sichuan province network | kolkata, India
September 20, 2008
i feel that since the general condition of the patient is normal, and he has no other complications, simply incision and drainage is
required. he has still a week left for his game, if complications occur, it can be dealt. simply prescribing antibiotics in this healthy ,
young patient wont be that useful, further causative agent and its sensitivity towards anti- microbial is also not confirmly known.
David Berry | Physician | Disclosure: None
Smart Systems for Health Agency | Sault Ste. Marie, Ontario Canada
September 19, 2008
more detailed enquiry re:possible use of anabolic steroid injections and consideration of testing for hep and HIV depending on clinical
suspicion. Another "old fashioned" addition is heating a large volume, narrow neck glass bottle and then placing the mouth of the bottle
over the head before and after incision. As the bottle cools the negative pressure aspirates material rather than trying to push it out.
tracy bramlette | Physician | Disclosure: None
Comcast Cable | san francisco, California USA
September 19, 2008
no antibiotics are needed if adequate i and d is performed
James Stone | Physician | Disclosure: None
Road Runner Business | Caribou, Maine USA
September 19, 2008
Treatment of an abscess is drainage. I am disturbed that none of the solutions were written by a surgeon.
Arved Weisswange | Physician | Disclosure: None
France Telecom | Aigues Mortes, France
September 19, 2008
I&D plus C&S is most appropriate.Complete cure is more important than the next match in a week.If one moves too fast one might
loose time.
Salvador Beris | Physician | Disclosure: None
America Online | Tampa, Florida USA
September 18, 2008
Only incision and drainage.I do not think that I will use any antibiotics at this time
Peg Dash Fab | Other | Disclosure: None
Rice University-Sesquinet | Houston, Texas USA
September 18, 2008
Who among us has never had a pimple on his butt? Rubbing alcohol, bacitracin ointment, and a band-aid should suffice to clear this up.
bill rogers | Physician | Disclosure: None
SBC Internet Services | muskogee, Oklahoma USA
September 18, 2008
I and D alone is adequate after 24 hrs of "poultice".
Bonnie May RPh | Other health professional | Disclosure: None
PAETEC COMMUNICATIONS | Worcester, Massachusetts USA
September 18, 2008
I agree with everyone who has recommended I&D with C&S, keeping the addition of antibiotics as "Plan B" if the culture & sensitivity
come back as MRSA.
yu wang | Physician | Disclosure: None
Beijing, China
September 18, 2008
NTM infection should be considered for the shape of the ulcer is like a crater.
Di Holdsworth | Other health professional | Disclosure: None
Thessaloniki, Greece
September 18, 2008
I and D then pour neat salt into the incision after drainage and leave uncovered. This hurts like hell for a minute but the patient will
survive, the remaining bacteria will not! Cheap & effective and used in ancient Greek medicine.
SATHURAGIRI CHAIRMARAJ MBBS | Physician | Disclosure: None
NIB (National Internet Backbone) | TUTICORIN DISTRICT, India
September 18, 2008
No other co existing disease and there is no systemic involvement.The lession is local & evident
jamie calder | Physician | Disclosure: None
iiNet Limited | sydney, Australia
September 18, 2008
I & D alone in healthy young male, with culture. Why give antibiotics and contribute unnecessarily to emergence of resistant strains
unless have bloody good reason.
Frank Ruiz MD | Physician | Disclosure: None
Comcast Cable | Cupertino, California USA
September 20, 2008
The cure rate with adequate incision and drainage alone is extremely high and is not increased by the administration of oral antibiotics.
He does not have an overt cellulitis, nor is there any sign of toxicity, so there is no need for antibiotic therapy. There would, however,
be a benefit to culturing the abscess for MRSA since many patients with MRSA have a high rate of subsequent soft tissue infection.
Tom Perry M.D.,C.M. | Physician | Disclosure: None
TELUS Communications | Vancouver, Brit. Columbia Canada
September 18, 2008
I would expect resolution with drainage alone, and quite promptly. This strikes me as a low risk situation for bacteremia, in comparison
with many other serious S. aureus infections which are recognized late, or under treated, because patients and doctors do not
understand the significance of pain with fever, or of "low grade fever" influenced by abundant use of antipyretics (NSAIDs,
acetaminophen, ASA, corticosteroids). In the absence of nearly immediate improvement/resolution with drainage, one could still add
an antibiotic for spreading cellulitis, increased fever, or malaise/toxicity. My father drained a similar "boil" on the back of my neck
during a 1966 camping trip and I have never forgotten the instantaneous relief which followed a brief sear of pain from the (sterilized)
pocket knife blade. It's a very satisfying action for a competent physician to perform.
Joseph Finkler MD | Physician | Disclosure: None
Telus Corporation | Vancouver, Brit. Columbia Canada
September 20, 2008
Regardless of the etiology (MSSA or MRSA) of this superficial buttock abscess, incision and drainage and insertion of a short length of
ribbon guaze is all that is necessary at this time. I know this from my work in the emergency department of a downtown teaching
hospital, where the most common diagnoses are cellulitis and cutaneous abscesses. The majority of our indigent and addicted patients
will not make the effort to fill a prescription for antibiotics and/or take them as prescribed, even if they do. And amazingly, the majority
of the abscesses resolve. However, our practice pattern is to take a swab of the abscess and send it for culture and sensitivity testing.
That way we will know which antibiotic to use, if the infection does not resolve.
C. Peter Crowe | Physician | Disclosure: None
Covad Communications | Tucson, Arizona USA
September 18, 2008
Would be much happier with this decision if the lesion showed some fluctuance. May be draining a day prematurely.
Jack Arbiser | Physician | Disclosure: None
BellSouth.net | Atlanta, Georgia USA
September 20, 2008
I frequently see MRSA abscesses and they respond to I and D alone. An additional measure of safety might be provided by painting the
inflamed area around the drainage site with gentian violet, which kills MRSA
Ricardo Savaris Ricardo Francalacci | Physician | Disclosure: None
Porto Alegre, Brazil
September 18, 2008
At least this is what I do in clinics, I would suggest warm pads to accelerate a point of flutuation and then incision and drenaige
Janet Arrowsmith MD | Physician | Disclosure: Financial tie to maker of a related drug or device
Valor Telecommunications Enterprises, LLC | Ruidoso, New Mexico USA
September 18, 2008
I D with C&S, including viral C&S. HSV has certainly been reported in other contact sports, particularly football and wrestling. Make
sure you have his contact information for appropriate follow-up as needed.
James Williams | Physician | Disclosure: None
SBC Internet Services | San Antonio, Texas USA
September 18, 2008
Lesion clinically consistent with MRSA infection with evidence of cellulitis (by definition erythema, tenderness, >2cm) therefore
requires I&D (to include margins), irrigation, packing routinely, and Clindamycin 300 q6hrs for 5 days with followup in 3-5 days.
Cultures optional because will adjust treatment on clinical response. Caution player and teammates about hygiene and care of early
lesions.
mohamad elshafii dr | Medical student/physician in training | Disclosure: None
Ramsis-Zone-DSL | mansoura DK Egypt, Egypt
September 18, 2008
hence the patient is young and immunocompetent with no chronic diseases, incision & drainage with follow up is enough supported by
the small size of affected skin . antiallergic medication may be helpful.
JEFFREY MARMELZAT M.D. | Physician | Disclosure: None
Impulse Internet Services | LOS ANGELES, California USA
September 16, 2008
I WOULD ADD C&S AFTER I&D IN CASE IT DOES NOT RESPOND TO I&D ALONE OR BECOMES WIDESPREAD
jose rojas jober | Medical student/physician in training | Disclosure: None
neiva, Colombia
September 18, 2008
in my opinion the case should be trated Drainage the abscess, and wait for a 24-48 hours resolution of cellulitis by the Swell lineal.
takehiko dohi | Physician | Disclosure: None
umassmed.edu | worcester, Massachusetts USA
September 12, 2008
Just drainage is not enough in this case.To prevent the recurrence, complete debridement including the capsule is definitely necessary.
This also makes wound healing faster.
melissa tlougan | Other health professional | Disclosure: None
Mayo Foundation | rochester, Minnesota USA
September 12, 2008
Have this condition and is chronic, drainage is the best method I have found, anti-mrsa drugs do not always work!
Abdu Sharkawy | Physician | Disclosure: None
Toronto, Ontario Canada
September 12, 2008
Given the absence of systemic symptoms (apart from possibly low-grade fever) and assuming that there are no similar clinical
presentations reported by teammates/close contacts, there is no compelling reason to initiate therapy beyond I & D or to assume that
this would represent CA-MRSA infection. Culturing the lesion with I & D followed by observation alone should suffice.
David Mathison | Physician | Disclosure: None
COMPEX Corp. | Washington, DC, Washington DC USA
September 18, 2008
In an afebrile immunocompetent patient with a lesion on a location that is not over a joint and without a cellulitic component, I&D
without antibiotics should be sufficient assuming proper follow-up is established.
Jeannot Dumaresq | Medical student/physician in training | Disclosure: None
Bell Canada | Quebec, Quebec Canada
September 12, 2008
+ open prescription if it doesn't get better by 1 or 2 days (if the pt is reliable) For the moment, we do not have a lot of CA-MRSA in
Quebec.
chandravadan ajmera | Physician | Disclosure: None
NIB (National Internet Backbone) | Rajkot, India
September 18, 2008
while practicing in developing countris like india; this seems to be the best alternative. we get the desirable results most of the times.
however if patient does not respond we may thik of giving the antibiotic at later time.
barry fox | Physician | Disclosure: Financial tie to maker of a related drug or device
University of Wisconsin Madison | madison, Wisconsin USA
September 12, 2008
choosing a 5cm size is potentially misleading........if you chose 7 cm..........option 3 would be the answer..............just at the 5 cm cutoff
makes the answer more difficult
Allison Enwright | Other health professional | Disclosure: None
Columbia Health Care | Derry, New Hampshire USA
September 12, 2008
For an uncomplicated skin infection in this young, healthy man, I&D with a C&S sent and patient education should suffice, with an
early follow up.
Rui Pereira | Medical student/physician in training | Disclosure: None
NOVIS Telecom, S.A. | Lisboa, Portugal
September 8, 2008
No antibiotics inicially. Get swab culture for ID.
Uday Paul | Physician | Disclosure: None
Chicago, Illinois USA
September 12, 2008
I must admit to treating MANY of these in a military setting with incision and drainage and MRSA coverage (my favorites were TMP/
SULFA and/or Clindamycin). However I also had heard many accounts of these sort of abcesses being treated by I+D alone. and I must
say that the logic is compelling to treat such an abcess as a surgical problem rather than a medical one.
Sumire Sakabe Dr | Physician | Disclosure: None
Birmingham, England
September 8, 2008
Localised infection, likely to resolve with drainage (send for MC&S). Close observation and if not improving or worsening in the next
24-48h, for oral anti-MSSA treatment. In light of increasing numbers of CA PVL MSSA/MRSA, would be advisable to create
awareness among the team members regarding recurrent boils.
mehnaz mehboob | Physician | Disclosure: None
glasgow, England
September 8, 2008
localised infection with possible pus collection. I&D should be enough. patient systemically well. dose not need an extra course of
anitbiotics
Steve Croy | Physician | Disclosure: None
Global Crossing | Highwood, Illinois USA
September 8, 2008
I would add local wound care with chlorhexidine. If his wound did not improve or worsened an appropriate antibiotic could be started.
Avoiding contamination of shared atheletic facilities, such as toilets, showers and seating areas should also be discussed with the
patient.
Daniel Winter MD | Physician | Disclosure: None
Uberaba, Brazil
September 12, 2008
Incision and drainage alone are probably most appropriate, since the patient has no systemic complaints and antibiotics would probably
do nothing but favour antibiotic-resistant strains. It looks like most physicians are reading too much but lacking judgement as to make
proper use of what they learn.
Michael Bateman | Physician | Disclosure: None
Comcast Cable | Tacoma, WA, Washington USA
September 7, 2008
Incision and drainage, culture wound and nostrils. Inform all teammates to be vigilant in search for pustules. Eradicate, isolate if
spreads among team.
romero roberto rr | Physician | Disclosure: None
MegaCable SA de CV | cd, obregon, son, Mexico
September 7, 2008
by guidelines and personal experience the best treatment option is dreaneage and curatege twice a day. the patient has no other
comorbilities that might affect the results.
RANJIT MOHITE | Physician | Disclosure: None
KHOPOLI, India
September 7, 2008
i will like I/D and antibiotics if has systemic signs or C/S positive in this 20 Yrs.Immunocompetent male.
Hassan Al-Eid | Physician | Disclosure: None
King Faisal Specialist Hospital and Hospital | Riyadh, Saudi Arabia
September 12, 2008
This is uncomplicated skin infection in healthy indivisual, I&D is the most evidence based option and should be more than adequate
Federico Vancheri | Physician | Disclosure: None
Caltanissetta, Italy
September 7, 2008
Incision and drainage are sufficient followed by 48 hours wait and see for systemic signs
Nelson Velez Dr. | Physician | Disclosure: None
Cogetel Online | Phnom Pehn, Cambodia
September 7, 2008
I would go for Incision and drainage and a close follow up, I think we are used to prescribe antibiotics more than we need to, however
in medicine we make decisions based on experience, madical data, and mainly based on the individual patient. This is a young
basketball player,healthy, with no need for antibiotics for the time being.
Dan Mielnicki | Physician | Disclosure: None
USUHS | Suffolk, Virginia USA
September 7, 2008
This patient with a small "virgin" abscess without any reported co-morbids, surrounding cellulitis, or documented fever will almost
certainly recover promptly following simple incision and drainage with appropriate wound care instructions. Culture of the wound
seems prudent but depending on local MRSA prevalence this step (and added expense) might be avoided along with the antibiotics.
alex rodway | Physician | Disclosure: None
Imperial College London | london, England
September 7, 2008
In my experience, intravenous antibiotics are not usually necessary in abscesses uncomplicated by widespread soft-tissue infection.
Rihi Herewila | Physician | Disclosure: None
PT Telekomunikasi Indonesia | Kediri, Indonesia
September 7, 2008
the patient has not complaint and was not fever, so there is no reason for antibiotics administration except the result of C/S test were
positive.
Delores Nobles | Other health professional | Disclosure: None
Pitt County Memorial Hospital | Greenville, North Carolina USA
September 7, 2008
In the case of a healthy 20 year old, antibiotic therapy is not indicated at this time. With I/D, the wound bioload would be reduced to
allow the natural healing process to take place. In the event the soft tissue wound progresses, antibiotic therapy adjunct should be
considered.
robert Carter | Physician | Disclosure: None
Department of Veterans Affairs | Washington, D.C., Washington DC USA
September 7, 2008
In addition to the I&D a bacterial culture should be sent to the lab for culture & SENSITIVITY.
Don Gentry DDS | Other health professional | Disclosure: None
SBC Internet Services | Corpus Christi, Texas USA
September 5, 2008
I would culture the drainage and do sensitivities on it, to see if MRSA was present, and what therapy it would respond to, if the
infection did not clear, or worsened. Also, I would recommend hot-water irrigation or hot packs to aid in suppuration, pointing, and
cellular migration to the site.
Johnathon Ross MD | Physician | Disclosure: None
Toledo, Ohio USA
September 7, 2008
This young man gives a preference for not taking pills. Given the likelihood of resolution with I and D alone I would start with this
choice. He needs early follow up and careful instruction regarding red flag symptoms such as fever, persistent pain redness or new
lesions. Cultures should be obtained and if MRSA is present then added discussion of the risk vs.benefits of anibiotics should be
considered and antibiotics given if the patient prefers. There is also the issue of exposure to others on the team and potential for spread
should be part of the discussion of risks and benefits to treatment.
Steve Zanders, DO FCCP Steve | Physician | Disclosure: None
Sprint PCS | Coopersburg, Pennsylvania USA
September 4, 2008
I would incise and drain only, with appropriate follow-up. In addition, I would not culture the wound unless exudate was obtained deep
in the incision. I Fear that skin contaminant/colonization would complicate the process. Antibiotics are needed only when mechanical
cure is ineffective or systemic adversity occurs.
Jose Campo | Physician | Disclosure: None
University of Texas | Harlingen, Texas USA
September 4, 2008
An lesion like that should improve only with incision and drainage
Paula Azeredo | Physician | Disclosure: None
TVCABO-Portugal Cable Modem Network | Lisboa, Portugal
September 5, 2008
An abscess, or a furuncle seems to be the dignosis. Drainage when it will be "mature", as for the moment it has no fluctuation and,
meanwhile, a topical antibiotic for ex. fucidic acid, seems to be the best aproach. A culture of the pus, for epidmiologic reasons if he
get worst, should be done
Helen Spratt Ms | Other health professional | Disclosure: None
NTL Internet | Belfast, Ireland
September 4, 2008
Incision and drainage with swab for O & S. Review required as spreading infection and mild pyrexia with likely increased heart rate for
a fit athlete suggesting systemic involvement. Antibiotics required pending organisms and sensitivity and if continued spread of
infection.
Nicholas Sadovnikoff | Physician | Disclosure: None
Partners HealthCare System | Boston, Massachusetts USA
September 4, 2008
Would follow closely post-drainage and have a low threshold for initiating antibiotics (anti-MRSA) if the lesion does not resolve
clinically as expected.
MD Guilherme Fazolo MD | Physician | Disclosure: None
Internet by Sercomtel S.A. | Londrina Parana, Brazil
September 4, 2008
The drainage alone is enough for treatment of abscesses in healthy patients.Antibiotic use has a lot of complications that can be avoided.
With a close observation of the evolution of the inflamatory process if there is an evolution to celulitis ,apropriate antibiotical use can
be initiated in these subjects.
Silvio Pitlik MD | Physician | Disclosure: None
Tel Aviv University Network | Petah Tikva, Israel
September 4, 2008
The fact that all treatment options still include "incision and drainage" mandate a word of admiration for the pioneers of this modality:
Hippocrates (460-377 BC), Claudius Galen ( 1st century AD), Ambrose Pare (1510-1590),Johann Schultes (1595-1645), and others.
Elizabeth Steiner | Physician | Disclosure: None
Oregon Health Sciences University | Portland, Oregon USA
September 4, 2008
Overuse of antibiotics is a major public health issue. Refraining from using them when possible is in the best interest of both the patient
and the community. Treatment without antibiotics is appropriate for this patient, along with close monitoring for resolution of the
abscess & cellulitis.
Steven Smith Pharm.D. | Other health professional | Disclosure: None
University of Florida/University Medical Center | Gainesville, Florida USA
September 7, 2008
Given the uncomplicated nature of this infection in an otherwise healthy young adult, incision & debridement alone should be
sufficient. Antibiotic therapy is often used on top of I&D as "mop-up" therapy, but the evidence supporting this practice is lacking in
this type of case. Furthermore, this practice will invariably select out resistant strains putting the patient at greater risk for future
infections. Does the patient's desire to resolve his infection before the next game mean that we should throw antibiotics on board? This
sounds akin to prescribing antibiotics for children when the suspected pathogen is viral, simply because the parents expect antibiotics.
John Edwards | Other health professional | Disclosure: None
Rockford, Illinois USA
September 4, 2008
The mild fever supports the notion that the body is fighting off the infection effectively. He is a young athlete with a strong immune
system- I&D and let the body do its thing.
Pedro Rito DMD | Other health professional | Disclosure: None
Cabovisao, televisao por cabo, SA | Coimbra, Portugal
September 4, 2008
I&D (with proper antiseptic, i.e. Betadine) followed by C&S. Add Ibuprofen for Pain/Inflammation. Observe in 48h. If more systemic
signs appear or complicate (such as fever) then add the proper antibiotic suggested by the antibiogram. In either case, full strength for
his next basketball game in 1 week's time will be hard to achieve.
Paul Cook MD | Physician | Disclosure: None
Pitt County Memorial Hospital | Greenville, North Carolina USA
September 4, 2008
Antibiotics would be indicated if there were signs of sepsis or if there were signs of superimposed cellulitis. Neither exists in this case.
keesler biloxi | Physician | Disclosure: None
CABLE ONE | biloxi, Military (AA) USA
September 4, 2008
the primary Tx of any abcess involves I&D. Uncomplicated abcess <5cm have not shown a better effect with concomitant Abx therapy
and thus is not indicated at this time
Asghar Naqvi | Physician | Disclosure: None
Longwood Medical Area | Boston, Massachusetts USA
September 4, 2008
Less is more. Wound cultures of the I&D should be sent to the lab. If he shows signs or symptoms of complications (i.e. fever, chills,
increased area of erythema, purulent drainage), then culture-guided antibiotic therapy can be considered at that time.
Steven Ebert PharmD | Other health professional | Disclosure: None
SupraNet Communications | Madison, Wisconsin USA
September 4, 2008
Would not feel comfortable using an antibiotic without susceptibility data. Suggestive of MRSA, but ?activity of clindamycin or TMP/
SMX?
Thomas Morgan | Physician | Disclosure: None
Vanderbilt University | Nashville, Tennessee USA
September 4, 2008
Simple incision and drainage would be my first line treatment, but I would add an antibiotic, most likely dicloxacillin, if the patient did
not have a dramatic improvement by the next day, with persistent areas of heat, pain, and redness prompting me to activate a
prescription. I'd have the patient keep the wound open for 1-2 days and change the dressing daily. Starting an antibiotic right away is
not necessary.
Dongmi Park | Medical student/physician in training | Disclosure: None
New York University | Fresh Meadows, New York USA
September 4, 2008
It would be optimal if I can collect culture and sort out the organism before starting any antibiotic.
Roman Palacios Dr. | Physician | Disclosure: None
UNITEL S.A E.S.P | Cali, Colombia
September 4, 2008
a recent study showed that incision and drainage is enough to manage this type of cases and that there was no difference with the use of
antibiotics.
r finaggan ms. | Other health professional | Disclosure: None
America Online | chicago, Illinois USA
September 4, 2008
Research appears to show that antibiotics are not needed in a healthy young person who is not immunocomprimised. I&D should be
sufficent due to no symptoms of infection and the pt.'s health status.
Vandana Niyyar | Physician | Disclosure: None
THE LEUKEMIA & LYMPHOMA SOCIETY | Atlanta, Georgia USA
September 4, 2008
I would start with an I and D only, get cultures and susceptibility from the wound as well as the blood and then treat with antibiotics
only as needed
Arthur Frank MD | Physician | Disclosure: None
University of Illinois at Chicago | Chicago, Illinois USA
September 4, 2008
This option is simplest and most scientifically correct in the circumstances where drainage is available, practical and successful. In
pediatrics (my field) we have the problems of emotional trauma and physical difficulty with many procedures plus early presentation
before localization. Therefore drainage is often deferred or incomplete/unsuccessful and the use of antibiotics becomes routine even
when option one is actually preferred in theory.
Charles Bodmer | Physician | Disclosure: None
Colchester, England
September 4, 2008
There is no clear need for systemic antimicrobial therapy for this young man. C&S at time of I&D will provide future guidance for
therapy if required. The patient has also made it clear that he does not want systemic therapy, and may well not take them even if
prescribed, when it is explained to him that there is controversy over the need.
Wakinyjan Tabart | Physician | Disclosure: None
Netspace | alice Springs, Australia
September 4, 2008
let's avoid over-using antibiotics in an otherwise healthy young man and try to avoid increasing resistance in staph bacteria to first line
antiobiotics- if the patient had diabetes, chronic kidney disease or other risk factors for a less favourable outcome then I would consider
adding antibiotics
Trish Westbrook, FNP NP | Other health professional | Disclosure: None
CHARTER COMMUNICATIONS | Gainesville, Georgia USA
September 4, 2008
Recent literature indicates that most cutaneous lesions, even MRSA, will resolve with I&D alone.
el samad youssef | Medical student/physician in training | Disclosure: None
Centre Hospitalier Universitaire Amiens | amiens, France
September 4, 2008
antibiotics are not necessary in treating uncomplicated staphylococcal skin infections
Andrew Morris MD, MSc | Physician | Disclosure: None
Performance Systems International | Toronto, Ontario Canada
September 7, 2008
The recent RCT from San Francisco--showing resolution without "effective" antimicrobial therapy--is compelling. That patients can
get complications from antimicrobial therapy (allergic reactions, C. difficile, etc.) is even more compelling. With the principle of
primum non nocere, it is difficult to support giving antimicrobials when the anticipated outcome with incision and drainage alone is
cure.
Muhammad Munir | Physician | Disclosure: None
Karachi, Pakistan
September 4, 2008
If the abscess is drained adequately the antibiotics are not needed.
Ville Lehtinen | Physician | Disclosure: None
Kansanterveyslaitos (National Public Health Instit | Lahti, Finland
September 4, 2008
With no signs of generalized infection, and given the small volume of the abscess, incision and drainage should be enough. This
treatment also prevents from disposing the patient to the harmful side effects of antimicrobial therapy.
M JAWEED MD | Physician | Disclosure: None
MyKRIS Asia Sdn Bhd | KUALALUMPUR, Malaysia
September 4, 2008
well in my opinion , there is no evidence showing that, antibiotics will help and provide more rapid cure for non complicated skin
abscess; as surgeon i will recommend I&D plus C&S and add painkiller for post I&D pain.
Dorothy Hight | Other health professional | Disclosure: None
GCI Communications | Anchorage, Alaska USA
September 4, 2008
Should do hot soaks, bring abscess to a head, I&D with packing. Culture & tx with antibx if abscess does not resolve. Like it or not,
lesion may require time off the athletic field to heal, regardless of Rx. Pt. does not like to take medicine; risks high for incomplete Rx,
ineffective tx, eventual resistance, and a bottle of unused pills lying around to be inappropriately used by someone else at some day in
the future. Hold antibx also until after C&S returns: may have acquired infxn in someone else's community, with different disease
patterns. On re-check, choose to add antibx if cellulitis not responsive. Nearly every abscess I have seen has looked like a tense
cellulitis before it was ready to lance.
Dirk Keldermans | Other health professional | Disclosure: None
TELE2 Belgium | Waremme, Belgium
September 4, 2008
Often a drainage, in combination with Iso-Betadine-irrigation, will satisfy. Using antibiotics is only useful if the infecting bacteria is
known and if the drainage doesn't resolve the problem. It's important to prevent AB-resistance, so using AB must be limited where
possible.
Giraud Alice | Other health professional | Disclosure: None
COLT Internet CH networks | Geneva, Switzerland
September 4, 2008
During the incision, take some liquid to make an antibiogram. Then depending on the outcome of the antibiogram decide if antibiotic
treatment is necessary and which is the most appropriate.
Niklas Storck | Physician | Disclosure: None
Bredbandsbolaget | Stockholm, Sweden
September 4, 2008
We should really try to avoid the use of antibiotic agents if not neccecary. Incision combined with drainage should be suficcient. A
culture should be performed if the patient by any chance should get more infected later.
Martin Xavier Doré Martin Xavier | Physician | Disclosure: None
France Telecom | Le Havre, France
September 4, 2008
I would first treat him by incision and drainage, and see him after 48 h to decide if antimicrobial therapy is necessary. My decision for
oral therapy will be guided by results from cultures and clinical evolution.
Doubravka Kostalova MD | Physician | Disclosure: None
CESNET, z.s.p.o. | Prague, Czech Republic
September 4, 2008
Incision, drainage, culture and susceptibility testing, proper antiseptic. Antibiotics only in case of worsening and culture positivity.
Rajesh John MBBS, MD | Physician | Disclosure: None
Oman | Muscat, Oman
September 4, 2008
I&D but must be followed up with regular wound inspection and dressings
Charles Gillbe MB FRCA | Physician | Disclosure: None
British Telecommunications | London, England
September 4, 2008
Option 2 is muddled and there is a lack of evidence to support option 3. Where, for instance, does the idea that speed of recovery will
be enhanced come from?
Adan Atriham | Physician | Disclosure: None
Baptist Memorial Health Care Corporation | Houston, Texas USA
September 4, 2008
I&D, get C&S, f/u in 2 or 3 days, if cellulitic rash or systemic symptoms occur treat according culture result.
Sergey Shlyapnikov | Physician | Disclosure: None
Saint-Petersburg, Russian Federation
September 4, 2008
This athlete has uncomplicated (without systemic signs) skin infection. It is main reason don't use systemic atibiotic therapy.
Natalie Hendricks | Physician | Disclosure: None
Telkom SA Ltd. | Durban, South Africa
September 4, 2008
I guess most physicians favoring antibioitc treatment will come from areas with high incidence of MRSA. This could be argued from a
Chicken and Egg perspective as the high incidence of MRSA probably comes from previous overuse of antibiotics.
Krispin Hajkowicz MBBS | Physician | Disclosure: None
Northern Territory Government | Darwin, Australia
September 7, 2008
Based on two RCTs (a luxury for skin and soft tissue infections) incision and drainage alone is adequate therapy and will reduce cost,
prevent adverse effects from antibiotics and prevent the emergence of even more bacterial resistance in the future. Pus from the abscess
should be sent at the time of the incision and drainage to guide antibiotic selection if the patient represents with a deterioration.
Barry Lerner | Other health professional | Disclosure: None
Optimum Online (Cablevision Systems) | Rye, New York USA
September 4, 2008
There's always time to prescribe antibiotics if I&D alone fails; why initiate it prior to such eventuality? In addition, waiting will give us
the results of culture and sensitivity, so that the appropriate medication may be administered.
Federico Altuna | Medical student/physician in training | Disclosure: None
CTI Compania de Telefonas del Interior S.A. | Salto, Uruguay
September 4, 2008
The infection this patient presents is probably a MRSA infection. The patient has not compromise of his immune system, and no fever.
Evidence indicates that, in an abscess, if incision and drainage are achieved successfully, there's no need of antibacterial treatment.
That is because an abscess is a collection in a newly formed cavity, so it doesn't imply systemic compromise. I do believe a culture
should be done, in order to knowing the bacteria involved in case the patient doesn't heal with drainage. The use of antibiotics should
be avoided when possible because the more we use them the more resistance we generate. With regards to side effects, the combination
of TMP/SMX is very well tolerated by the patients. I would worry more about resistance. I apologyze in advance for possible spelling
mistakes or for misuse of medical language. I'm not an English native speaker and, even though I've studied the language for years and
taken international examinations, I have finished my studies some years ago and I don't have formation in medical English
Thomas Reynolds MD | Physician | Disclosure: None
Road Runner | Palm Desert, California USA
September 4, 2008
I&D with culture. Wait two days for culture results. Re-evaluate pt, and prescribe appropriate antibiotic if clinical response to I&D has
been unsatisfactory.
Jennifer Christian | Physician | Disclosure: None
Comcast Cable | Wayland, Massachusetts USA
September 4, 2008
Initial treatment choice is not necessarily the end of the episode or treatment options. The development of MRSA has been made
possible by over-use of antibiotics, so I would not begin there. I would ask this patient to talk with other players about any problems
they have had -- and request a report back. That will enable me to make another choice later, but only if indicated.
Mary Ann Banerji | Physician | Disclosure: None
Brooklyn, New York USA
September 4, 2008
I would chose and I& D only and follow the patient clinically- cultures can be taken at the time . If he does not respond I would
reassess the patient clinically and start antibiotics. That he has to have antibiotics to be ready for basketball is not a consideration
Jonathan Mittelman MD MPH | Physician | Disclosure: None
Old Lyme, Connecticut USA
September 4, 2008
Without signs of cellulitis extending beyond the site of the abscess, simple incision & drainage with close follow-up should be
sufficient treatment.
SHARAT SAMANTRAY DR | Physician | Disclosure: None
Oman | IBRI, Oman
September 4, 2008
COMMUNITY ACQUIRED MRSA INFECTION TYPICALLY PRESENTS IN YOUNG ATHLETES, WITH THIS SEVERITY
I&D ALONE IS SUFFICIENT.
Luis Rodríguez Gutierrez Dr. | Physician | Disclosure: None
MegaCable SA de CV | Guadalajara, Mexico
September 4, 2008
I think is better to take a sample to make a direct examination, a gram and culture, to ruled out anothes agents plus Stafilococous
aureus.
Claire Nunes-Vaz MD | Physician | Disclosure: None
Toronto, Ontario Canada
September 4, 2008
I+D and culture and observe. College students are notoriously non-compliant with meds and if he were to get better in 3 days with
antibiotics he might well stop them. If c+s helps and he is not improving I would add the meds as dictated by the culture.
Yousef Binamer | Medical student/physician in training | Disclosure: None
McGill University | Montreal, Quebec Canada
September 4, 2008
Since he is young and healthy without signs or symptoms of toxicity I will do I& D and will check the culture and in one week if he is
not improving I will give him the appropriate antibiotic.
Gary Dunn MD | Physician | Disclosure: None
America Online | Shreveport, Louisiana USA
September 3, 2008
As this patient does not have systemic symptoms or a large area of surrounding cellulitis I+D alone should be sufficient if done
correctly followed by local wound care. Antibiotics may be added after 48 hours if there is not significant improvement or sooner for
worsening. A culture should be done at I+D to direct antibiotic therapy if needed. He is not going to be ready for his game in one week
regardless of therapy and if this is MRSA consideration should be given to holding him out of contact activities until the acute response
is cleared.
JimmieJoe Izanec MD | Physician | Disclosure: None
SBC Internet Services | Pepper Pike, Ohio USA
September 3, 2008
I prefer to do a Gram stain and culture/sensi. Since the person is generally healthy I would I&D, await the culture results and have the
person follow her temperature and symptoms/signs.
Hung Yang MBBS | Physician | Disclosure: None
OPTUS Customer Network | Sydney, Australia
September 3, 2008
If antibiotics are unnecessary in a healthy patient, using them would appear to encourage development of resistant organisms. It would
have been nice to have been able to exclude any possibility of Marfan's (and possible SBE risk) in a basketballer. It is noted that in
practice it can be hard to avoid prescribing antibiotics for obvious bacterial infection; one option could be to arrange review of progress
in 1-2 days time; another to provide a prescription to be filled only if resolution is slow.
ashish kakaria dr | Physician | Disclosure: None
sydney, Australia
September 3, 2008
anitbiotics are not necessary for uncomplicated skin abscess
Don Elliott M.D. | Physician | Disclosure: None
Denver, Colorado USA
September 3, 2008
Follow up temp and visual inspection daily, add antibiotic based on c&s if not rapidly resolving
Jonas Moses | Other | Disclosure: None
Cellco Partnership DBA Verizon Wireless | Austin, Texas USA
September 3, 2008
Having spent several years in clinical Ophthalmology, within a military setting, I developed a rather conservative approach to treatment
of localized infections. I tend to concur with Dr. Chambers in observing that this patient is young, health/active (immunocompetent),
and has no confounding history. Given that well-documented evidence supports incision and drainage without the addition of
antibiotics, and given the growing concern over the development of antibiotic-resistant organisms, a conservative treatment course
seems the obvious choice, here.
peter mahrer MD | Physician | Disclosure: None
LA, California USA
September 3, 2008
I & D plus culture and sensitivities will allow for proper choice of antibiotic were it to become necessary
James Simon M.D. | Physician | Disclosure: None
Tiburon, California USA
September 3, 2008
get a c&s of wound
Daniel Mendoza | Physician | Disclosure: None
National Institutes of Health | Washington, Washington DC USA
September 5, 2008
There is no evidence in this setting that antibiotics provide more rapid resolution of symptoms, prevent further spread of the infection,
and prevent bacteremia with dissemination to other parts of the body. Indeed, they cause important side effects. The use of antibiotics
for skin abscess has not shown to bring any benefit in 2 randomized trials, one of them including cases of MRSA infection. The
biological explanation is that antibiotics cannot penetrate or work properly within an abscess and the resolution of symptoms depends
on the elimination of the source of infection and the immune response.
Treatment Option 1 Comments Treatment Option 2 Comments Treatment Option 3 Comments
Treatment Option 2: Incision and drainage plus anti-MSSA therapy.
95 Readersʼ Comments
Paulo Behar | Physician | Disclosure: None
Porto Alegre, Brazil
September 25, 2008
Criteria for incision and drainage plus antibiotic: local and systemic (37.7oC) inflamatory signs. Criteria for anti-MSSA tharapy:
epidemiology (MSSA more prevalent than MRSA in the comunity), even when particularities of this specific patient are considered. In
this case, patient´s opinion should be considered too.
Peter Taylor MB.BS, FRCPA | Physician | Disclosure: None
Eastern Sydney Area Health Service | Sydney, Australia
September 20, 2008
It is common that staphylococcal skin infections spread among team players and simple drainage would not reduce the bioburden in the
draining fluid. this man will be in mixing in changing rooms and in close contact with his team mates and the chance of secondary
spread is significant. The comments about cellulitis also suggest that antibiotics may help in the resolution of his infection.
José Acuña | Medical student/physician in training | Disclosure: None
Santiago, Chile
September 18, 2008
In my opinion the reason for adding anti-MSSA drugs is the extension of the infection in the skin (cellulitis). Abscess without
extension of the infection should be treated with incision and drainage only. This patient presents cellulitis too.
Cam Tu Nguyen Ms | Physician | Disclosure: None
Ho Chi Minh, Vietnam
September 25, 2008
As a gastrologist I have not many experiences about the lesions on skin, but when I saw that lesion I was sure that it have been caused
by MSSA, which is so common actually, so that the treatment option 2 is the most suitable.
Sambhu Dutta DR. | Physician | Disclosure: None
chilka,balugaon, India
September 23, 2008
to me incision with an antimicrobial with anti mssa activity like cloxacillin or 1st/2nd gen cephalosporin seems to be prudent.
unnecessarily using potent anti mrsa antibiotics will soon create an extradrug resistant staph somewhat like XDR TB.
Barbara Chaffee MD | Physician | Disclosure: None
UHS Hospitals-Binghamton General | Binghamton, New York USA
September 23, 2008
Would culture and change to MRSA therapy if culture shows MRSA
prabhakara chaturvedula dr. | Physician | Disclosure: None
CityOnline Services Ltd | bangalore, india, India
September 22, 2008
i feel in a country like india, antibiotics are always prescribed,
rusli nordin | Physician | Disclosure: None
Johor Bahru, Malaysia
September 22, 2008
I would add that the application of a topical Staph Aureus sensitive Sodium Fusidate, in addition to incision and drainage and oral
cephalexin, appears to accelerate the healing process.
francisco ortega | Physician | Disclosure: None
guatemala, city, Guatemala
September 22, 2008
I belive the option 2 is the best election. A tried some pacients just drainage and the cultive were mssa so they need drug theraphy i
prefiere dicloxacilin
Magdalena Maj | Medical student/physician in training | Disclosure: None
Neostrada Plus | Poznan, Poland
September 21, 2008
As a student I can observe many clinicians with broad experience. Quite often they forget Staphylococcal infections can be due to
MSSA strains. To prevent antibiotics overuse I would choose in the patient anti-MSSA therapy in first place.
Leonardo Lence Barbosa MD | Physician | Disclosure: None
Vila Velha, Brazil
September 21, 2008
Incision and Drainage Plus Anti-MSSA Therapy (with a cephalosporin like cephalexin) it is a good choice for that case.
syed shah | Physician | Disclosure: None
ibd, Pakistan
September 21, 2008
this is staphlococcal skin infection leading to abscess formation.evidence suggests that a week long course of intravenous antibiotics
(amoxycilline and clavulonic acid)will help to recover after incision and drainage.
ravikiran tamragouri MD | Physician | Disclosure: None
SBC Internet Services | downers grove, Illinois USA
September 21, 2008
community acquired skin infections tend to be MSSA. In order not to over use antibiotics typically used for MRSA to avoid induction
of resistance, antibiotic for MSSA seems appropriate, unless culture report indicates otherwise.
Abdelhamid Mohammed | Physician | Disclosure: None
Sudatel | Khartoum, Sudan
September 21, 2008
Clinical trials.Mostly is not caused by MRSA strains
Nicholas Okoh | Physician | Disclosure: None
Leaf Ireland Ltd. | Tullamore, Ireland
September 21, 2008
Though small localised abcess may respond well to incision and drainage alone. In this case with cellulitis with no drainable focus, it
will be of benefit to add anti-microbial agent to the therapeutic regime to avoid spread of the infection.
Vitull K. Gupta Dr. | Physician | Disclosure: None
NIB (National Internet Backbone) | Bhatinda, Punjab, India
September 21, 2008
The epidemiological reality of India is totally different where skin and soft tissue infections are very common. The routine management
regimen followed by majority of primary care doctors is I & D with broad spectrum antibiotics and anti inflammatory drugs without
any culture and sensitivity. The secondary and tertiary care doctors follow the above said regimen but they include the culture and
sensitivity test. I strongly feel that treatment of skin and soft tissue infections are determined by local conditions and prevalent etiology
along with cost effective factors. Regardless of the etiology (MSSA or MRSA) of this superficial buttock abscess, incision and
drainage and insertion of a short length of ribbon guaze is necessary and in Indian setup must include antibiotic and anti inflammatory
drugs with or without culture and sensitivity.
Mariano Mazzei | Physician | Disclosure: None
CABLEVISION S.A. | BsAs, Argentina
September 21, 2008
Clinically, there is an abscess, and it should be drained. I think that the treatment failure is because of the suppurative skin
complication. Community acquiered MRSA infections without treatment have a different outcome than the history given.
Adriano Garcia RS | Medical student/physician in training | Disclosure: None
NET Serviços de Comunicação S.A. | Porto Alegre, Brazil
September 20, 2008
I believe, since the patient is young, imunocompetent and doesn`t present any important systemic reactions, the better option would be
incision and drainage plus antibiotic (anti-MSSA) therapy, such as cephalosporin. Considering the higher incidence of MRSA
infections in the community, the better choice would be waiting for the results from the culture exams, and in case of MRSA, change
the antibiotic drug.
Atul Sattur Dr | Other health professional | Disclosure: None
NIB (National Internet Backbone) | Hubli, India
September 20, 2008
I&D with Amoxycillin-Clavulunate 1 gram ,BID and Ibuprofen400mg+paracetamol 500mg TID for 5days is good enough, with daily
dressing of the wound. Most important give Tetanus prophylaxis.
Christopher Chen | Physician | Disclosure: None
BellSouth.net | miami, Florida USA
September 20, 2008
The possibility of a swifter resolution in pts where follow-up is not always assured encourages me to using some type of antimicrobial
coverage.
Silvia Corvera | Other health professional | Disclosure: None
umassmed.edu | Worcester, Massachusetts USA
September 20, 2008
The last boil with low grade fever I saw in an athlete (tennis player, late 50's, boil in back of neck) was treated non-aggressively. The
patient developed a spinal epidural abscess and is currently paraplegic. In my opinion, a soft tissue infection + low grade fever should
be treated immediately and aggressively with drainage and antibiotics.
wei chih-hung | Physician | Disclosure: None
CHTD, Chunghwa Telecom Co., Ltd. | Taipei, Taiwan
September 20, 2008
better to treat with antibioctics for 1:prophylaxis 2:bactericidal effect 3:avoid legal problems in practice unless culture is free of
bacteria.I & D hold until abscess mature
Rupinder khurana MD | Medical student/physician in training | Disclosure: None
Chandigarh, India
September 20, 2008
If the infection is community acquired as in this case,it becomes mandatory to give antibiotics .It is because ,this patient being an
athlete,would be playing in the worst of weather and other conditions related with hygiene,so other microorganisms could also cause
the cellulitis.Cellulitis present in this case is sufficient for a clinician to decide for the antibiotic treatment with I/D.The antibiotic
prescribed would be dependent on the result of the culture positivity for MRSA.
Dukjae Kim | Physician | Disclosure: None
Korea Telecom | Seoul, Korea (South)
September 20, 2008
Incision and drainage may not be necessary in this lesion which is not so large immature abscess. Anti-MSSA therapy would be
successful for this healthy man.
Natália Castro | Physician | Disclosure: None
Campinas, Brazil
September 18, 2008
besides the patient has fever, he has a infection that isn't a local anymore but a sistemic one, so he really need a antibiotics treatmeant
plus incision and drenage.
Cindy hung | Medical student/physician in training | Disclosure: None
Ministry of Education Computer Center | taipei, Taiwan
September 18, 2008
For a localized abcess formation, surgical drainage is preferred than antibiotics alone. The risk of MRSA infection in this patient was
no high, therefore empyric antibiotics after I&D could choose anti-MSSA first.
subbiah kandsamy dr | Physician | Disclosure: None
NIB (National Internet Backbone) | trichy, India
September 18, 2008
most of the community acquired infections are MSSA ONLY
Tanveer Ahmed Dr | Physician | Disclosure: None
Grameenphone is the largest telecommunication Orga | Dhaka, Bangladesh
September 18, 2008
As the central part is hard and having serrounding cellulitis then only incision and drainage will not be curative alone plus there is a
history of taking amoxycillin within 7 days, so needs dicloxacillin.
Desy Philippe | Physician | Disclosure: None
LDCOM | Saint Nazaire, France
September 18, 2008
Given the importance of cellulitis and the necessity of being fully physically active a week later, I 'll give my preference to drainage
associated with a 5 days treatment of pristinamycine in order to limit the risicos of persisting pus drainage, otherwise local drainage and
local chlorexidine would have been efficent
sener barut | Physician | Disclosure: None
tokat, Turkey
September 18, 2008
this is a community acquired skin infection, so the etiologic agent is most likely Metisilin sensitive Staph aureus. Anti MSSA and
drainage is reasonable and enough.
Enrique Romero | Physician | Disclosure: None
Globalnet.hn | La Lima, Honduras
September 18, 2008
In answering we inevitably take our background and surroundings into account. I deal with banana plantation workers who often times
have their wife and kids with lesions. Penicilin has seemed to work perfectly, but we have not done enough to erradicate bacteria from
family group. We have been recently using dicloxacilin but cannot tell if this is really costeffective.
Carlos R. Silva-Rosas MD | Physician | Disclosure: None
Santiago, Chile
September 20, 2008
I think in the epidemiological reality of my country. So a comunnity staphylococcal skin infection should be treated immediately with a
Anti-MSSA therapy. However I would use local heat in the area of the abscess waiting the appropiate timing for the incision and
drainage of a "mature" abscess in this patient alredy covereded with antimicrobial therapy.
Gulsum Iclal Bayhan | Medical student/physician in training | Disclosure: None
Turk Telekom | Ankara, Turkey
September 18, 2008
I select treatment option 2. I also get cultures of abscess. If it was MRSA, I change antibiotherapy.
Bil Randerson Bassetti | Medical student/physician in training | Disclosure: None
Telemar Norte Leste S.A. | Vitória, Brazil
September 18, 2008
incision + drenage and terapy anti-MSSA is a prudent strategy for the severe soft-tissue infection.
luis gomez rosales | Other | Disclosure: None
guayaquil, Ecuador
September 16, 2008
treatment with dicloxaciline 500mg capsule, every 6 hours for 6 days,
Eduardo A. Muñoz López | Physician | Disclosure: None
Pasto, Colombia
September 18, 2008
I choose treatment option 2, becouse I have been using this terapeutic alternative since 2 years, with excellent results in active soldiers
with skin and soft-tissue infections, working in extreme heat and humidity locations and close contact with the inherent geographic
conditons of Colombian jungle.
Wang Chun | Physician | Disclosure: None
Chengdu Hengyou Industry Co.Ltd | Chengdu, China
September 12, 2008
The patient had fever with body temperature 37.7°C. If antibiotics was not used, nobody could guarantee that the infection didn't
spread. I think oral antibiotics could be chosed.
Leo Sham | Physician | Disclosure: None
Kowloon, Hong Kong
September 12, 2008
Consider a demanding patient with rapidly evolving abscess with surrounding cellulitis in an easily contaminated area (sweaty,
buttock). Most patients don't come in with perfectly mature abscesses the require I&D per se. MRSA is not common in HK but most
strains are keflex-resistent. IV rocephin + PO augmening/falgyl provide rapid resolution. Clorhexidine DELAYS wound healing!
Mariellen Rodman MD | Physician | Disclosure: None
Verizon Internet Services | Acton, Massachusetts USA
September 12, 2008
Also, the patient should be asked about steroid injection as a possible etiology for the abscess, which raises the possibility of exposure
to blood-borne infectious agents
Praveen Cheripalli | Medical student/physician in training | Disclosure: None
Department of Veterans Affairs | Urbana, Illinois USA
September 12, 2008
This particular patient may or may not have an abscess. He also has signs of cellulitis. If the wound is not mature enough to become an
abscess then only I and D may not be a good option. I would not agree to treat all the patients with skin infection for MRSA, in the first
instance. I will start him on MSSA along with I and D and if he does not improve then will think of MRSA.
Ezequiel Zaidel | Physician | Disclosure: None
CABLEVISION S.A. | buenos aires, Argentina
September 12, 2008
Drainage plus anti MSSA therapy seems to be the best option. Although drainage alone may solve most of the times this kind of soft
tissue infection, the addition of an anti MSSA antibiotic eg. cephalexin shortens the healing time. Use of anti MRSA therapy as a first
line treatment not only is more expensive and brings the risk of more serious side effects, but also generates bacterial mechanisms of
resisitance.
Thiruvengadam Ramakrishnan M.D. | Physician | Disclosure: None
ETS TELEPHONE COMPANY | Richmond,, Texas USA
September 18, 2008
Incision and drainage is the mainstay of treatment. Because the abscess is not yet formed (localized) and cellulitis is present, I would
add an antibiotic. It might hasten recovery, which is crucial in this case. A short course of antibiotics would not add appreciably to
expense, side effects or emergence of new drug resistance.
Carlos Scarampi MD | Physician | Disclosure: None
Intertec S.A. | Temperley, Argentina
September 12, 2008
When you have an abcess you must drain it, and then use an antibiotic to treat the infection
lilian muñoz marrugo | Physician | Disclosure: None
bogota, Colombia
September 12, 2008
in my media, mssa is still quite common; over 70% are responsiveness to it, besides the patient doesnt have any sistemic response so
there's no hurry in upgrading the treatment
Camelia Jalaskoski Mrs | Physician | Disclosure: None
Tampere University Hospital | Tampere, Finland
September 16, 2008
MRSA is not so common in Finland. Patient has fever and the generat status was not normal,so my opinion is that antibiotic need.And
in my opinion im or iv.
David Matley Dr | Physician | Disclosure: None
Australian Department of Defence | Brisbane, Australia
September 16, 2008
We are fortunate to have a very low incidence of community acquired MRSA. In the absence of fluctuation I would generally prescribe
an antibiotic and refer for drainage when the abcess is "mature"(usually 24-48hrs).
Raja Muthiah | Physician | Disclosure: None
EUnet France | Chennai, India
September 8, 2008
1.Hot fomentation followed by cleaning the area with soft antiseptic solution with a light dressing. 2.start systemic anti-MSSA therapy
on the same day. 3.If flexuant,do I&D and sent swab for culture and sensitivity followed by simple dressing. 4.If possible, rest to the
region is advisable.
Dr.Guillermo Castrillo | Medical student/physician in training | Disclosure: None
Juigalpa, Nicaragua
September 7, 2008
Even though side efects do appear with the use of penicilin like antibiotics, they are not common, being more common the reinfecction
of the site due to the fistula created bye the abscess, the constant sweating do to the atlethic activitys, and most important the site where
the celulitis is; therefor i support the incision dranage plus anti mssa therapy
Susheel Kapoor Dr | Medical student/physician in training | Disclosure: None
MTNL CAT B ISP | Mumbai(Bombay), India
September 8, 2008
I support option 2 since: 1. the lesion is an erythematous, firm and tender area without drainage; which means it is an area with
cellulitis and possibly an organizing infection. 2. most uncomplicated skin infections in healthy individuals are caused by Streptococci
or S. aureus susceptible to most antibiotics. Therefore, due to the organizing nature of the infection and the probability of it being
caused by a susceptible bacterial strain I would support the treatment of the individual with option 2. Dr Susheel S Kapoor Resident
doctor, Year 2 Mumbai (Bombay), India.
Robert Bernat MD, PhD | Physician | Disclosure: None
Zagreb, Croatia (Hrvatska)
September 7, 2008
I had a similar infection myself. With oral antibiotic, it progressed to near-septic state. It resolved only after i.v. double antibiotic
treatment and subsequent drainage. Always treat with antibiotics!!
jose davis | Other health professional | Disclosure: None
Verizon Internet Services | bethlehem, Pennsylvania USA
September 7, 2008
I$d with app. antibiotic therapy, and cultures of wound and nares, for a young athlete who plays sports to would be the best treatment,
with these cases I have seen if left, just continues to evolve into a deper abcess, and as a young person he prob. has a hx of not
fininshing his antibiotics for prescribed time for his many sinus infect. leading to mrsa
Jyoti Assudani | Medical student/physician in training | Disclosure: None
Cambridge, Massachusetts USA
September 7, 2008
I think surgical drainage is appropriate. antibiotic coverage is essential in the face of there being a possiblity of underlying infection.
however anti mrsa therapy is not indicated since there is no proof of mrsa being present and anti mrsa therapy isnt warranted also
because we dont want to create antibiotic resistance for future.
Onder Ergonul MD, MPH | Physician | Disclosure: None
Turk Telekom | istanbul, Turkey
September 8, 2008
Community acquired MRSA rate is very low (1/1000) in many countries, like in Turkey.
Julio Delgado | Physician | Disclosure: None
CHARTER COMMUNICATIONS | Montgomery, Alabama USA
September 7, 2008
I would do the Incision and drainage and start septra DS or a macrolide and await for culture and sensitivity.
Eugen Hinterbuchner M.D. | Physician | Disclosure: None
LAM plus s.r.o. | Prague, Czech Republic
September 8, 2008
In the Czech Republic the prevalence of MRSA in outpatient departments is very low and therefore unnecessary to cover for initially.
The cultures will provide further necessary information.
Lakshman Khiria | Other health professional | Disclosure: None
Ahmedabad, India
September 7, 2008
Abcess (folliculitis) in the gluteal region is not an unusual problem. As a surgeon I frequently come across these patients. I personally
use amoxicillin and Clavulinic acid combination at the first visit wait for 48 hrs if symtomatic improvement no I&D but if no
improvement than I&D with antibiotic coverage.this patient is young with good general condition without comorbidities should recover
in 3-5 days and will be able to resume his sports activity in a weeks period there is no reason for prolonged recovery.
Ignacio Garcia-Valladares | Medical student/physician in training | Disclosure: None
Guadalajara, Mexico
September 7, 2008
Dicloxacillin! good tolerance and no AE, and maybe if the abscess matures, I and D would help..this is what we commonly see in
mexico but we usually observe a good response with MSSA and I guess always be alert to clinical worsening.
Michael Desjardins Mr. | Other health professional | Disclosure: None
Qwest Communications | Salt Lake City, Utah USA
September 7, 2008
Hello, I have a comment and question. I agree with the incision, drainage and anti-microbial option. I was wondering if anyone has
experience with treatment of recurring abcesses. I have read that bactroban in the nasal cavities and a wash with chlorhexedrine can
provide resolution but i was looking forward to comments on this or any other treatments found successful.
Kavita Chankadyal | Physician | Disclosure: None
Couva, Trinidad And Tobago
September 7, 2008
Incision and drainage may be adequate therapy but the use of antibiotics would shorten and secure the recovery period. It would also
allow the basketball player to return to sport quicker that I & D alone.
Shrikanth Hegde | Physician | Disclosure: None
NIB (National Internet Backbone) | Shimoga, India
September 6, 2008
I & D and Culture sensitivity along with oral drugs like cloxacillin is the initial choice in this pt and it may be sufficient ,but he needs
close follow up for evidence of bacteremia and MRSA infection
enrique kremer | Medical student/physician in training | Disclosure: None
Telefonica de Argentina | Neuquen, Argentina
September 6, 2008
lesion culture + first generation cephalosporine and then with the results decide the treatment
Alison Hannah | Physician | Disclosure: None
America Online | Sebastopol, California USA
September 6, 2008
Treatment Option 1 would also be perfectly valid and equally likely to produce an acceptable outcome.
Salil Gupta Dr | Physician | Disclosure: None
Zee Telefilms Ltd | Bangalore, India
September 6, 2008
I&D alone may not be sufficient in the patient since MSSA is a possibility which will respond better with antibiotics
Janice Taylor | Other health professional | Disclosure: None
Comcast Cable | Bellingham, Washington USA
September 5, 2008
I&D is critical, with this amount of surrounding cellulitis, anti MRSA treatment is prudent. But I disagree with the choice of
antibiotics. Most community acquired MRSA (at least in my community) is also resistant to Diclox and Keflex. My choice is generally
Septra, which is usually sufficient. With larger areas of cellulitis, Clindamycin is another choice, but is much more expensive, and for
severe cases where the patient has systemic signs, IV Vancomycin and admission is often required.
Manish Kak | Physician | Disclosure: None
Videsh Sanchar Nigam Ltd - India. | Mumbai, India
September 5, 2008
Option 2 is the best one, since there is associated risk of bactremia.
clara wekesa | Medical student/physician in training | Disclosure: None
Iway network | kampala, Uganda
September 5, 2008
Unfortunately I live and work in Africa, where anumber of fascilities are not readily at our disposal,and resistance patterns to particular
drugs have not been well studied. I picked option two, because this patient has surrounding skin infection (cellulitis)and having the pus
drained will improve the efficacy of the antimicrobial agent. In that case the latter does not have to be given for long periods of time,
thus preventing accumulative side effects. Am also in an environment where sterility is in question, so to rely on an incision and
drainage alone may not be adequate.
steve Rhyan | Other health professional | Disclosure: None
Cox Communications | Mission Viejo, California USA
September 5, 2008
It may be of interest to "ask" the pt what he "will" comply with? He may be an athlete on scholarship with a "do or die" attitude.
Athletes have a large amount of expectation placed on them to perform. And, if he will not play someone else will. With this in the
"mix" one might review options with the young man. He did state he "felt" febrile the night before. This may be heading to a systemic
effect. Although my clinical experience is only a few years my athletic training background is 20+ and what athletes do is different
than "you" may like. I&D is great & may provide a proper "cure",however, an antibiotic like a 1st generation cephalosporin (Keflex)
may be benefitial due to staph,strep & e.coli coverage. May not be perfect medicine, but you may only have 1 shot at this young man
who "will" be playing to keep his scholarship ride.
Jean Paul Vilchez Tschischke | Medical student/physician in training | Disclosure: None
Telefonica del Peru | Arequipa, Peru
September 5, 2008
I´m a medicine intern in Peru, this patient will benefit the most from the abscess drainage, but with a big area of inflamation, there is a
hi possibility of celulitis that needs antibiotic; for me here in Peru, antibiotic for MSSA
VALERIA BOSCHETTI | Physician | Disclosure: None
COLATINA, Brazil
September 5, 2008
drainage is mandatory, and a regimen of an anti-stafilo therapy too
Kritapath Tharathornkitti Mr. | Physician | Disclosure: None
Chauad, Thailand
September 4, 2008
I usually do by this option in my practice, and the result is good without need anti-MRSA therapy
Mark D. Sugi | Medical student/physician in training | Disclosure: None
University of California, Los Angeles | Los Angeles, California USA
September 4, 2008
Without a strong clinical suspicion or results from laboratory cultures suggesting MRSA, the use of first-line antibiotics with good
coverage of MSSA and the ß-hemolytic streptococci seems appropriate. In the context of infection by MSSA, the confluence of overprescription of anti-microbial agents for resistant strains of S. aureus with periodic patient non-adherence raises the potential for an
increase in the prevalence of resistance and a contemporary diminution in the efficacy of agents to which resistant bacteria are currently
susceptible.
Milton Carrero | Physician | Disclosure: None
Puerto Rico Telephone Company | Mayaguez, Puerto Rico USA
September 4, 2008
This is the most cost/effective treatment based in the experience with these infections.
eric higgins | Physician | Disclosure: None
Bell Nexxia | montreal, Quebec Canada
September 4, 2008
Actually, I wouln`t add AB with localized Sx. I would recommend close F-Up (48h) of the pt and initiate AB if no significant change
early on during Tx.
Jeremy Adams | Medical student/physician in training | Disclosure: None
St. Michael's Hospital | Toronto, Ontario Canada
September 4, 2008
no good evidence to support empiric MRSA coverage. little downside to covering with anti-MSSA antibiotic.
sivaram upadhyaya Dr | Physician | Disclosure: None
Cox Communications | New Delhi, India
September 4, 2008
The lesion is indurated not fluctuating.If US of lesion reveals underlying pus,ID plus appropriate antibiotics. He has to play a match
after a week. Anti biotic like cloxacillin or cephelexin is first choice; ID followed if necessary.
Jean Bowyer | Physician | Disclosure: None
Safaricom Limited | nairobi, Kenya
September 4, 2008
Young man with no risk factors for MRSA
DR.SANDEEP DOSHI M.D. | Physician | Disclosure: None
| MUMBAI, India
September 4, 2008
Incision & drainage with Cephalexin or Cefixime is most likely to yeild a complete satisfactory response. An anti-inflammatory agent
could also be added in the first 48 hours of management.
Dave Smith MD | Physician | Disclosure: None
Social Security Administration | WDM, Iowa USA
September 4, 2008
A short course of antibiotics will diminish the pain and hasten healing over I&D alone in this physically active young male.
saul weinstein M.D. | Physician | Disclosure: None
NewSouth Communications | Jacksonville, Florida USA
September 4, 2008
I&D will be incomplete if there is a phlegmon as a component to the purulence. This, plus the fact that there is approx. 5 cm of
cellulitis, and the patient is febrile, albeit low grade would lead me to Rx an antibiotic. I would obtain a gram stain and C&S for aerobic
and anaerobic bacteria and RX cephalexin. If it turns out to be MRSA, I would switch to the appropriate Abx as identified in the C&S
Muhammed Naseem M H | Physician | Disclosure: None
Internet Service Provider in Sri Lanka. | Gampola, Sri Lanka
September 4, 2008
Incision & drainage with culture and wait for culture report to start any antibiotics.
Teodor Todhe | Physician | Disclosure: None
ClearBlue Technologies | Hawthorne, New Jersey USA
September 4, 2008
I do think that incision and drainage combined with abx is a safe way to go as we are not sure whether an abses has been formed as of
yet. Otherwise drainage alone would be enough in this young men with no comorbidities known to sustain these kind of infections.
However my main comment was regarding the options to choose as our responses. I did not see a difference between the option 2 and 3
Caron D'Ambruso RN | Other health professional | Disclosure: None
Sprint | Pinebluff, North Carolina USA
September 4, 2008
I believe this may be hirudintis with MSRA infection. Surgery and drainage should work well in taking care of the hirudinitis and an
appropriate antibiotic for the MRSA. Once the lesion is excised, a large opening from removal of the abcess should be treated with
iodiform gauze healing the excision site from the inside out without the use of sutures.
Radomir Stevanovic MD | Physician | Disclosure: None
America Online | Georgetown, Texas USA
September 4, 2008
I agree with option #2. It is reasonable to perform an incision and drainage and to start with treatment of MSSA. Should the cultures
reveal MRSA, treatemnt can then be appropriately changed
Ehsan Chitsaz MD | Physician | Disclosure: None
ParsOnline Corp. | Tehran, Iran
September 4, 2008
It is evident that there are controversial evidences for the use of antibiotics in soft tissue infections. The characteristics of the lesion
represent a furuncle that is in develop to be an abscess. the fact that the lesion does not have any discharge or fluctuation leads to the
diagnosis of an immature abscess. Immature abscess means that the organisms are still actively making inflammations and may not yet
be limited by the immune system. So, drainage alone cannot be helpful and antibiotics may be of help. Although the incision and
drainage is a must for almost all abscesses, the relatively large size of the abscess and the peripheral cellulitis may also be other
rationales toward use of antibiotics.
John Rose Dr | Physician | Disclosure: None
America Online | Headley, England
September 4, 2008
I would not incise in the absence of any fluctuation but there is no voting option to allow this view. If there were no abscess, how
would incision and 'drainage' help? Many of the treatment options presuppose Staph. aureus infection, but as Dr Moellering (proponent
for treatment option 2) points out that, in immune competent hosts, Gp A Streptococci may be the primary infection. The patient may
be immune competent, but for 3x5cm of tender erythema, a temp 37.7d C would be unusual. There is already systemic upset...a pulse
of 78 cannot be considered normal in a highly trained athlete. I would take a swab for culture and treat with flucloxacillin 500mg four
times daily, pending the C&S result and review the wound and temperature/pulse after 48 hrs. He should not be training, nor
competing, until temperature and pulse return to his normal.
Torben Ek | Physician | Disclosure: None
Halmstad, Sweden
September 7, 2008
In Sweden the prevalence of MRSA in outpatient populations is very low and therefore unnecessary to cover for initially. The cultures
will provide information.
Miguel Restrepo | Physician | Disclosure: None
Comcast Cable | Fresno, California USA
September 4, 2008
When we are giving the incision and drainage only option we are giving the chance to a bacteria most likely Staph infection to become
stronger due to persistence of the bacterial multiplication and the potencial disemination through the blood stram. In the I and D plus
anti-MRSA option you have already assumed that MRSA is the pathogen and you have lost the opportunity to treat a sensitive staph
with the appropiate low spectrum antibiotic creating more chances that the bacteria evolve in the future to create resistence. If the
second treatment is given and fails you still have the chance to swith to the MRSA antibiotic and if it worked you have not created any
more chances for resistance
Josh VonMoss | Medical student/physician in training | Disclosure: None
Clearwater, Florida USA
September 4, 2008
I would be hesitant to prescribe anti-MRSA drugs without a positive culture for fear of furthering the problem of resistant organisms.
However, the size of the erythmatous area does warrant some treatment other than I&D alone, especially given that the patient is
unlikely to comply with any orders limiting his activity and is thus likely to aggravate the site.
Dr Viraj Rajadhyaksha | Physician | Disclosure: Employee of maker of a related drug or device
Warner-Lambert Company | Mumbai, India
September 7, 2008
Surgical drainage alone may not be sufficient and treatment with MRSA medications may be unnecessary at this stage. The clinical
information does not reveal any suspicion of MRSA. The clinical plan would be as follows: Drainage at the earliest along with
antibiotics (Cephalexin preferably) to manage MSSA for a specified duration of time. The safety profile of MSSA agents is quite
encouraging and may not be a major issue in this patient. Secondly, we will continue to observe the patient for any suspicion of MRSA
both clinically as well as microbiologically(antibiotic susceptibility) If results of any or both of these indicate a MRSA infection,
appropriate therapy may be initiated at the earliest. This is based on two important premises: utmost patient care, at the same time
preventing unnecessary exposure to agents which may be life saving at some later stage.
Anindita Das Dr | Physician | Disclosure: None
Telstra Internet | Canberra, Australia
September 4, 2008
Incision and drainage is required for complete healing. Ideally, antibiotics should be started only after culture and sensitivity testing.
Anti-MRSA therapy should be given only after documented culture of MRSA, unless the patient is at high risk of acquiring CAMRSA. In the absence of culture and sensitivity the best option for treatment is incision and drainage combined with anti-MSSA drugs.
Puthanveetil Subhas Dr | Physician | Disclosure: Employee of maker of a related drug or device
NIB (National Internet Backbone) | Palghat, Kerala State, India
September 4, 2008
I suggest option 2 since only drainage may not prevent systemic spread of the infection and will help resolving the lesion faster
Ricardo Guraieb | Physician | Disclosure: None
Mexico City, Mexico
September 3, 2008
I would favor anti-MSSA therapy because it can be given as an outpatient basis. In case cultures of isolates taken after the incision and
drainage show that S. Aureus is MRSA then I could always switch to treatment option 3. So the least agressive and the most reasonable
is to initiate Dicloxacillin four times a day, after incission and drainage then follow the patient, 48 hs after incission to see how the
cultures and antibiotic sensitivities are going, and then decide to further advance therapy, then the patient must be in-hospital and
therapy would have to be against MRSA by intravenous route.
Jaime Costa | Physician | Disclosure: None
NET Serviços de Comunicação S.A. | São Paulo, Brazil
September 3, 2008
I agree with Dr. Robert Moellering, mainly to prevent further spread of the infection and bacteremia.
Jim Richards PhD | Other | Disclosure: None
Charter Cable/Monterey Park LAN | Sudbury, Massachusetts USA
September 4, 2008
Ball player has been in many geographically distinct places. The probability of a CA-MRSA may be higher than typical for the home
base incidence. Have the student check his temperature over the next 5 days and if elevated go to the hospital for more aggressive
therapy.
francisca s | Physician | Disclosure: None
stgo, Chile
September 3, 2008
I would give this young man antibiotic and hot compresses on the first day and the day after I will drainage the abcess. If I do the
surgery first, It will not be succesfull because the skin is firm. I always use antibiotics before and after the drainage and specially in this
case because the patient has fever
Treatment Option 1 Comments Treatment Option 2 Comments Treatment Option 3 Comments
Treatment Option 3: Incision and drainage plus anti-MRSA therapy.
146 Readersʼ Comments
Ramesh Nathan | Physician | Disclosure: None
Thousand Oaks, California USA
September 21, 2008
Probability of CA-MRSA is overall much higher and clinical experience has led me to believe that surrounding cellulitis of 5 or more
cm will respond better to I&D plus antibiotics active against CA-MRSA
David Stewart, PharmD | Other health professional | Disclosure: None
East Tennessee State University | Johnson City, Tennessee USA
September 19, 2008
This patient is an athlete and at higher risk for CA-MRSA than the average individual. I have seen too many patients return with
worsening infection from both I&D alone and oral antibiotics alone. Depending on severity of lesion, antimicrobials could include IV
vancomycin followed by oral agents or oral agents, but in either case, the lesion should be I&D. Don't forget about inducible resistance
to clindamycin (D-test). In our region, clindaymycin is not a good empiric choice because most isolates are D-test positive.
Susan Pandya | Physician | Disclosure: None
Longwood Medical Area | Boston, Massachusetts USA
September 18, 2008
Agree that management of an uncomplicated abscess first requires an incision and drainage. There is minor amount of surrounding
cellulitis and the location of the abscess would make continued draining slightly more difficult. I would add antimicrobial coverage and
culture the specimen. In a 20yr old male athlete in contact with multiple other players and contacts in the locker room, coverage for
methicillen resistant staph aureus (MRSA) would be adviseable given the increased incidence of community acquired MRSA and its
tragic consequences.
Octavio Saenz | Physician | Disclosure: None
Albuquerque, New Mexico USA
September 18, 2008
The patient "believes he may have had a low-grade fever the night before but did not take his temperature" is an important piece in this
history, which tips the scale toward antibiotic therapy. He is a young athlete who travelled throughout the U.S. where prevalence of
MRSA is high, and his lesion is 5cm in size within 48 hours. All indications to be aggressive in your treatment.
Mike Mallin | Physician | Disclosure: None
Intermountain Health Care | Salt Lake City, Utah USA
September 22, 2008
There is yet no good data supporting incision and drainage alone in suspected simple MRSA cutaneous abscesses. In this new era of
MRSA, a more virulent bug, I support abx coverage untill more research is performed.
David Allain David | Other | Disclosure: None
Louisiana State University | Mobile, Alabama USA
September 22, 2008
Now before we justify this treatment we should remember that MRSA is the result of the abuse of antibiotics. Since Staph skin
infections, including MRSA, generally start as what has been described in our case an this patient is an athlete spending hours on end,
in a setting where community MRSA is most definitely present. These can quickly turn into deep, painful abscesses that require
surgical draining, but luckily our patient is very aware of his body and came in within two days from recognition. Since MRSA can
also penetrate into the body, causing potentially life-threatening infections throughout, the most responsible treatment for a patient this
age is to take every precaution and prevent the spread of MRSA to his fellow teammates.
Ricardo Lemos | Physician | Disclosure: None
Verizon Internet Services | Bryan, Texas USA
September 22, 2008
The third option is the only addressing the problem of recurrence. If that is not addressed, both intrafamilial spread as well as
recurrences are possible if not likely. Physical risk factors that led to the initial abscess need to be addressed (shaving, injury, tight
fitting garments, etc)
Poornima Padellapalli Dr | Physician | Disclosure: None
Comcast Cable | Great falls, Virginia USA
September 22, 2008
The lesion is not fluctuating.If usg reveals an absess I&D is a better choice.If the absess is small aspiration and culture is a better
choice. Pending culture report anti MRSA tretment is better option as he has to play a match after a week.
Dr. Abrar Ali Katpar | Physician | Disclosure: None
Hail, Saudi Arabia
September 22, 2008
Don't leave any chance to put patient in trouble or wait for the c/s results.Your Patient needs full cover. Do as best GP can do and make
him well in comming week for the games.
David Dickensheets | Physician | Disclosure: None
Comcast Cable | roswell, Georgia USA
September 22, 2008
based on experience as a community ID doc, seeing easily 2 or 3 cases of this a week, there is no question in my mind that aggressive
therapy is needed.
Richard Lari | Physician | Disclosure: None
PeaceHealth | Eugene, Oregon USA
September 21, 2008
The arguments presented by the expert in option 3 are compelling and well referenced. Although its hard to tell just from the picture,
the description seems to indicate that there is significant surrounding cellulitis in addition to the abcess - given that, I think it would be
hard to not give this patient antibiotics. While I don't think "defensive medicine" should be a significant driver of medical decisions,
awareness of medicolegal issues is a fact of life. How would a physician be able to defend him/herself if this patient who appears to
have a cellulitis in association with this abcess was not given antibiotics and then developed a significant complication e.g. severe
sepsis.
David Mandelblum | Physician | Disclosure: None
Comcast Cable | Sarasota, Florida USA
September 21, 2008
PT,physical findings , and his expossure to MRSA, support 3 option treatmen
dick goldstein md | Physician | Disclosure: None
harvey cedars, New Jersey USA
September 21, 2008
think this is best option for earliest resolution
Panagiotis Renieris Dr | Medical student/physician in training | Disclosure: None
ADSL users of | Athens, Greece
September 21, 2008
Low grade fever may be concidered a sign of systemic reaction to local inflammation, so antibiotic use would be a reasonable choice
given the immaturity of the abscess. Community prevalence is high enough to support the use of anti-MRSA ABs. I would also suggest
physical exam for a fistula by use of syringe and plastic IV line tube given the patient's age to exclude fistula creating underlying cause
(such as CD), but no further workup.
Dr. Mukund kakade Doc | Medical student/physician in training | Disclosure: None
MTNL CAT B ISP | Mumbai, India
September 21, 2008
The most appropriate therapy with proper use of antibiotics
Norris Payne MD | Physician | Disclosure: None
Houston, Texas USA
September 20, 2008
Here in Houston, TX, as a child and adolescent physician, we see this at least twice a week and have for years. Bactrim is the only drug
that works consistently for MRSA, ollowed closely by Clindamycin. Other PO meds nearly always fail. I&D is almost as important as
the antibiotic and in fact the antibiotic may not work at all without appropriate drainage of abscess.
Cheri Sandberg FNP | Other health professional | Disclosure: None
EarthLink | San Anselmo, California USA
September 20, 2008
I would certainly culture the wound, but if this young man were in this area I'd certainly start him on anti-MRSA meds and teach him
about how to stop the spread amongst his teammates. I've seen this stuff spread through a group of students in close confinement, and
it's not pretty. If he's positive for MRSA, I like to use bactroban ointment nasally in patient and housemates, too.
Howard Lyon | Physician | Disclosure: None
ScrippsHealth | San Diego, California USA
September 19, 2008
Although option one cites literature from the 1950s suggesting surgical drainage alone to be definitive treatment, the emergence of
community acquired MRSA renders these conclusions invalid. In clinical practice I agree with the study quoted in option 3, that there
is a high rate of recurrence in MRSA mediated STI treated with surgery alone. I would therefore give adjunctive antibiotic treatment
after I and D.
Steven Miller | Physician | Disclosure: None
SBC Internet Services | Chicago, Illinois USA
September 19, 2008
Why does an athlete get an abscess in the buttock? Possibly injecting something he shouldn't. Higher risk for MRSA in this situation.
Rick Blume | Other health professional | Disclosure: None
Verizon Internet Services | Boston, Massachusetts USA
September 18, 2008
It is surprising that none of the others elect to test for MRSA with the reletively new GeneOhm/BD quick sensitive test for MRSA.
Facilitating appropriate drainage and treating for MRSA seems appropriate given the case as presented.
ABDERRAZAK MAGHEZZI | Physician | Disclosure: None
Jetmultimedia Hosting | BESANCON, France
September 18, 2008
I agree with the treatment with drainage and antibiotherapy
Leonard Johnson | Physician | Disclosure: Financial tie to maker of a related drug or device
ST. JOHN HEALTH SYSTEM | Detroit, Michigan USA
September 18, 2008
As 70% of patients presenting with this clinical syndrome will have MRSA infection, treatment for MSSA achieves little. The question
of whether active therapy is needed vs. I&D alone was addressed by Ruhe et al (Clin Infect Dis, 2007). They found a 13% vs. 5% rate
of treatment failure in those receiving inactive vs. active therapy (OR 2.82).
Oliver Torrefranca M.D. | Physician | Disclosure: None
British Telecommunications | Coventry, England
September 18, 2008
All treatment Options are universallly acceptable paths to go, especially Option 1 which proved successful in some of my patients but
NOT those patients with active exposure i.e. contact sports with epidemical concerns, but Option 3 offers quicker fix and can safely
discharge the patient to engage in their sport of interest.
Maurice Carter M.D. | Physician | Disclosure: None
Verizon | New York, New York USA
September 18, 2008
There is a considerable risk that the athlete mightbe in a position to pass his infection to team mates and others in the locker room.
Aggresive treatment seems to be indicated for rapid resolution and eradication of a serious infectious agent.
Fel Stancioiu | Other health professional | Disclosure: Employee of maker of a related drug or device
Jump Network Services S.R.L. | Bucharest, Romania
September 18, 2008
Incision and drainage plus wound "toilet" with clorhexidine plus topical antibiotic on the edges of the wound (on skin; neosporin may
be fine) may be a good option. A systemic Abx for the localized infection in a immunocompetent patient without antibiogram may be
too nonspecific (perhaps with the exception of azythromycin, which gets concentrated preferentially in the infected tissue). The size of
the infected tissue and the rapid spreading indicates that local defenses are overwhelmed and some local antibacterial intervention is
needed to stop the infectious process and promote healing.
Muhammad Khurram Shahzad | Other health professional | Disclosure: None
Dancom OnLine Services (Pvt.) Ltd. | Lahore, Pakistan
September 18, 2008
As there is fever also so the first treatment will not work efficiently, mostly in such cases isolation of MRSA had been observed so 3rd
option is the best of as a treatment.
Yasmin Hamirani | Medical student/physician in training | Disclosure: None
Road Runner | Torrance, California USA
September 18, 2008
I would do Incision and drainage if there is an abcess. Certainly there is cellulitis but he does not seem to be bacteremic. Location is
vulnerable in this athlete and community acquired MRSA is quite common in US. Keeping all this in front, I would treat emperically
with Anti-MRSA and follow up with him in few days.
Abigail Martinez Abigail | Physician | Disclosure: None
Chicago, Illinois USA
September 18, 2008
I don't always have the opportunity to see patients for follow up, my patients have poor access to medical care, and I see multiple cases
of complicated MRSA abscess and cellulitis on a daily basis. Hence, I would prefer to I+D as well as use antibiotics from the onset.
Lee Bowman | Other health professional | Disclosure: None
Cox Communications | Phoenix, Arizona USA
September 18, 2008
Why not cover all bases. Given his possible exposure to the organism in locker rooms, I feel it is the viable alternative. That said, I
could be wrong.
Daniel Allan MD | Physician | Disclosure: None
TULAROSA COMMUNICATIONS | Las Cruces, New Mexico USA
September 18, 2008
Many pts. with MRSA are afebrile. In our community, MRSA is so prevalent that the assumption is warranted until cultures prove
otherwise.
William DeMedio | Physician | Disclosure: None
D&E Communications | Lancaster, Pennsylvania USA
September 18, 2008
I vote for the safest option. If it were my son, I would take this approach. I also have my own anecdotal evidence to back up my
comments.
Edwin Serrano | Physician | Disclosure: None
Mexico City, Mexico
September 18, 2008
In my daily practice with children, I prefer to initiate a course of treatment with antibiotics specially for MRSA (ie dicloxacillin 25-50
mg kg day qid) at least 7 days prior consideration of drainage according to evolution, and most patients do not actually need drainage,
leaving no added scars or lacerated tissue due incisions, prolonging antibiotics to 14 or 21 days as necesary.
eric jackson | Physician | Disclosure: None
Optimum Online (Cablevision Systems) | north arlington, New Jersey USA
September 18, 2008
with such significant surrounding cellulitis, i would also treat him post i&D with oral antibiotic therapy. since there is a large incidence
of mrsa in outpatients in my area, i would add therapy for mrsa.
John Morrison | Physician | Disclosure: None
SBC Internet Services | Carmel, California USA
September 18, 2008
The history of athletic activity and the probability of MRSA persuades me to select Option 3.
Doug Skura MD | Physician | Disclosure: None
Marysville, Ohio USA
September 18, 2008
I have come in as a surgeon to help the care of patients who have had their infection get "away" from the other treating doctor with
usually the ineffective MSSA antibiotic tried first with or without the necessary I&D. This lesion for this case is so much more likely to
be MRSA related that tetracycline or Bactrim po should be started along with the absolutely necessary I&D with removal of the
necrotic tissue. I believe the antibiotic will reduce the chance of the lesion becoming more "rodent-like" and help to prevent less tissue
loss. Admission for IV Vanco for larger or more "angry" lesions should have a low threshold to reduce systemic and local effects of the
infection. Rest, soaks and cleansing still go a long way to help ease these infections.It remains to see if the use of antibiotics and
Chlorhexidene scrubs will reduce the colonization or infection of other close / intimate contacts with MRSA as one couple I helped
gave it back and forth until both got treated.
Carrie Perez | Other health professional | Disclosure: None
Level 3 Communications | Dade City, Florida USA
September 18, 2008
Yes, Anti-MRSA therapy is a good idea but should never include antibiotics unless cellulitis and/or fever presents. However, I urge all
physicians/surgeons/students to investigate Dr. Cutler's (University of East London) stabalized allicin therapy as a preventative and
treatment for CA-MRSA and HA-MRSA. It is taken orallly and also used topically without the risk of mutation.
Jose Stoute | Physician | Disclosure: None
Comcast Cable | Hershey, Pennsylvania USA
September 18, 2008
I feel that with this large abscess and the amount of cellulitis present a short course of antibiotics following incision and drainage is
prudent to prevent further spread of cellulitis and bacteremia. I argue also that a temperature of 37.7oC is elevated.
Bernard Boutet | Physician | Disclosure: None
IOSCO | Quebec city, Quebec Canada
September 18, 2008
MRSA must always, in my opinion, be considered in such a clinical setting; meanwhile, this lesion must be surgically addressed by
incision and drainage.
Dawn Pirri | Other health professional | Disclosure: None
America Online | Fairfield, Maine USA
September 18, 2008
I am in favor of incision and drainage plus anti-MRSA therapy. MRSA is so easily transmitted with atheletes, locker rooms and
equipment. The benefit of antibiotics will certainly be wise and a culture can be done to confirm the results. The betadine wash is also a
wise decision to keep the bacteria at bay, especially while using restroom facilities.
MaryMargaret Breed, RN RN | Other health professional | Disclosure: None
Randolph, Vermont USA
September 18, 2008
I&D plus 2% chlorhexidine for daily bathing and C&S, and instructions to call back in two days after I&D to report on trends, plus
questioning on history of activities that could have led to this infection. Also instruct to maintain strict personal hygiene including
frequent handwashing and clean gauze 4 x 4's to absorb drainage, and at least daily change of cotton brief. After two days, unless
healing rapidly, prescribe antibiotic appropriate to C&S results, plus followup. A young athlete has every opportunity to spread this
rather nasty infection on his or her buttock to others and/or to other areas of his or her own skin. Should not be taken lightly, regardless
of any literature favoring I&D only.
Christina Panait | Other health professional | Disclosure: None
Videotron Ltee | Gatineau, Quebec Canada
September 18, 2008
In my oppinion (as a RN student) I would say that the young athlete which travel a lot, lots of citys lot of peoples + the signs of
cellulitis he has to be drained, and preventive anti MRSA therapy, as well should be better to have as well a sample for culture.
Glen Tamura | Physician | Disclosure: None
Children's Hospital | Seattle, Washington USA
September 18, 2008
All of these three are reasonable options. Local epidemiology is critical in the decision-making. In some regions, including where I
practice, the vast majority of these abscesses grow MRSA, so options 1 and 3 make the most sense, as option 2 is likely to lead to side
effects without benefit. On the other hand, if MRSA is less prevalent, option 2 is reasonable. It is important to use a brief course of
antibiotics to minimize side effects.
Claire Richardson | Other health professional | Disclosure: None
Evergreen Medical Group | Seattle, Washington USA
September 18, 2008
Virtually every athlete who showers, changes clothes in a common shared area, has physical contact with other athletes of other
facilities, or goes to other facilities and showers, etc, can unknowingly, at any time, come into contact with mrsa. One cannot assume
based on one person's hygiene/appearance that contact wasn't/isn't possible. In some cases the athlete may not be allowed to participate
in certain sports until the lesion/abscess is resolved to protect both the athlete and whoever, or whatever(equipment)from coming in
contact with any wound or drainage regardless of bandaging.
MUHAIRWE Ninsiima | Medical student/physician in training | Disclosure: None
Afsat Communications Ltd | Gulu University, Uganda
September 18, 2008
i think antibiotic therapy secondary to incision and drainage will do for this patient, and we'll avoid bacteria spreading to another region
Erin Schaaf PharmD | Other health professional | Disclosure: None
Community Hospitals, Indianapolis | Westfield, Indiana USA
September 18, 2008
I & D could work but we don't know at this time if there is anything to drain. Also, I've seen many patients who have experienced
clearing of presumed "CA-MRSA" bumps on the skin with mupirocin only to have multiple bumps appear elsewhere. Also, the followup can be terrible in regard to patients that only receive I & D and fail this therapy. So, many others could be exposed, infected, and
who knows at this point the innoculum needed to cause necrotizing CA-MRSA pneumonia. It is better to be proactive.
John Crane | Physician | Disclosure: None
State University of New York at Buffalo | Buffalo, New York USA
September 18, 2008
Many of our surgical colleagues are not doing Option 1, 2, or 3, but instead admitting such patients to the hospital for I.V. vancomycin
for 7- 10 days, sometimes sending patients home on home I.V. vanco. I do not agree with the latter approach and hope some expert will
say so.
franck tirgari Dr. | Physician | Disclosure: None
Mid-Hudson Cablevision, Inc. Catskill | HUdson, New York USA
September 18, 2008
I work in Hudson as a hospitalist and we have a big jail population, often they come with a blister and in 90% of the time it's MRSA,we
drain the abscess and always put them on antibiotics.
ana leon | Physician | Disclosure: None
miami, Florida USA
September 16, 2008
due to the high incidence of community acquired MRSA, specially among this group of patients, we should alwais covered for this
organism under this circumstances.
DEEPA SHAH | Physician | Disclosure: None
New York, New York USA
September 18, 2008
We have noted an increase in "sexually transmitted MRSA" in community. This is skin to skin transfer of MRSA, which responds well
to oral treatment. So it will be prudent to add MRSA coverage in addition to I and D. As high as 70% of the skin and subcutaneous
infections in community setting can be due to MRSA according recent data from ER studies.
pooneh badre | Physician | Disclosure: None
St. Mary's Hospital | waterbury,ct, Connecticut USA
September 12, 2008
Drainage will be essential ,however due to prevalence of MRSA in my area and eagerness of patient to be treated before next
basketball game should be place don MRSA coverage .
eric carter | Other health professional | Disclosure: None
Road Runner Business | wilmington, North Carolina USA
September 12, 2008
There is no telling where he has been sitting / who sat there before him. Have seen the complications of I&D / culture only of
community mrsa. The problem of treatment failure (I&D only) if comm mrsa suspected is sometimes severe (hospitalization / death).
Large practice and frequently see community mrsa abscess as well as carriage.
Go Yoshida | Medical student/physician in training | Disclosure: None
Japan Communication Inc. | Tokyo, Japan
September 12, 2008
Skin inflammatory lesions should be aggressively treated by means of incision and drainage. The exception is a furuncle in the face,
since incision may let bacteria into sinus cavernosus. The presented image shows redness, edema and swelling, which suggests it also
pulsating pain. The question is whether or not the responsible bacteria have resistance to controversial antibiotics. However, there is
more reason to justify the administration of antibiotics plus incision and drainage. Toxic shock-like syndrome is rarely seen, but once
this happens, DIC and multi-organ failure lead the boy to lethal conditions. The empirical administration should be needed when
considering the potential case.
Zain Chagla | Medical student/physician in training | Disclosure: None
UUNET Technologies | Kingston, Ontario Canada
September 12, 2008
In the context of organized sports in the United States, CA-MRSA has become an appreciable entity requiring empiracle treatment
brian hung dr. | Physician | Disclosure: None
CHTD, Chunghwa Telecom Co., Ltd. | chutung, Taiwan
September 12, 2008
Nowaday, overutilization of antimicrobial agents in our daily practice in almost every field of medicine has resulted in lots of resistant
strains such as MRSA and without aggressive management after surgical I&D sometime may end up with undesirable outcome and
serious consequences. Therefore,it is reasonable to use agents against MRSA until it will be proved otherwise.
MARCELO MIMICA MD | Physician | Disclosure: None
SÃO PAULO, Brazil
September 18, 2008
Given the prevalence of CA-MRSA in the US, and the possibility of associated celulitis and also metastatic infection, the safest option
is drainage plus anti-MRSA therapy. In addition, the use of antimicrobial therapy in these cases could decrease the transmission rate.
Edgar Murguia MD | Physician | Disclosure: None
CABLEVISION SA DE CV | Mexico City, Mexico
September 12, 2008
The patients primary concern strongly advices to administer antibiotics and the activity he's involved in suggests anti-MRSA, as the
most accurate choice.
Margaret Paredez MD | Physician | Disclosure: None
Solana Beach, California USA
September 12, 2008
No. 3 brings up a point that like in our community, you assume MRSA until proven otherwise. We would consider I.V. (parenteral)
antibiotics if cellulitis increases in a 12 hour period and use Vancomycin. Most of us are I&D first, then add oral doxycycline or
bactrim + cephalexin and await cultures. We do frequent rechecks at our ER and often repeat Vacomycin doses in a 24 hour period. We
all become frustrated if we feel we need frequent repeat vacomycin doses to get a cellulitis but often after ID and orals, there is
minimal improvement.
David Webb | Physician | Disclosure: None
Department of Veterans Affairs | Long Beach, California USA
September 12, 2008
Would like to know if each of the authors really advocates their position or if they were asked to defend the position only in the spirit
of a debate.
Lanny Copeland MD | Physician | Disclosure: None
Columbia Health Care | Brentwood, Tennessee USA
September 12, 2008
MRSA is a community acquired infection now; I&D pluse anti MRSA antibiotic would be indicated
Leah Amir MS, MHA | Other health professional | Disclosure: None
CHARTER COMMUNICATIONS | St. Louis, Missouri USA
September 12, 2008
The patient should be screened for MRSA or community acquired MRSA. Given his overall health, one should consider any
underlying health status, ie. diabetic or poor insulin / sugar metabolism as well as verify he has sufficient protein to aid his immune
system. There is a reason the abcess was caused and is not progressing toward healing. Once any underlying causes are ruled out or
identified and corrected, the patient should begin treatment with sharp debridement, followed by a dressing. Once results are received
(24hours) regarding the bacterial flora, such as Strep or Staph each of which prevent healing in a different manner, he may be followed
by appropriate antibiotic therapy. Testing for various strains of Strep or Staph would be prudent and then focus the antibiotic therapy
accordingly. Follow up with the patient in 3 days after antibiotic adminstraiton and dressing of the abcess to check for improvement.
Deepa Patel RN, BSN, CCRN | Other health professional | Disclosure: None
Lewisville, Texas USA
September 12, 2008
These is a classic presentation of a MRSA infecion. His risk factors would support MRSA as well(amoxcillin use, basketball player,
played at various universities, low grade fever etc). MRSA is all over the news about its rise in the community as well. TWU NP
student.
Diljit Karayil | Physician | Disclosure: None
Cherry Street Health Services | Grand Rapids, Michigan USA
September 12, 2008
In my practice i have seen better results with I&D and sending the swab for culture and also a nasal swab along with antibiotics.I&D
alone does not help a lot of patients. MRSA is very dominant in the community i practice and commonly seen in inmates,shelter and
college sport teams.I do agree with being vigilant if other team personnels presenting with the same symptoms.
Maximino Bello | Physician | Disclosure: None
BROADBAND PHILIPPINES | Manila, Philippines
September 12, 2008
The lession is large. I and D alone is insufficient. Taking in account the patients profile and his desire of rapid resolution of the problem
anti-MRSA is appropriate
William L Hoppes MD | Physician | Disclosure: None
Canton, Ohio USA
September 12, 2008
The size of the area of cellulitis (5 cm) makes me want to use antibiotics. The likelihood of CA-MRSA, the possibility of PVL, and the
frequency of occurrence and recurrence of MRSA in athletes (we have had several outbreaks in OHIO)leads me to Rx for MRSA with
Clindamycin or TMP/SMX.
jorge gentile Dr | Physician | Disclosure: None
Telefonica de Argentina | Tandil, Argentina
September 12, 2008
This patient need resolve his problem quikly , and the option that covers the different posibilities is the 3. We are seeing a growing
number of skin and soft tissue infection secondary to MRSA , and there is not clear evidence to help clinicians in his/her decitions.
Moises Auron MD FAAP | Physician | Disclosure: None
Cleveland Clinic Foundation | Cleveland, Ohio USA
September 12, 2008
The treatment of choice for an abscess is just plain Incision and drainage; however, there is an increasing prevalence of community
acquired MRSA - this occurs in the multiple settings (athletes, public baths and pools, tattoo and piercing parlors, etc). The wound
should be cultured after performing an adequate incision and drainage - which would guide further therapy. In light of this player most
likely behavior - which will be to go an play as soon as he can; the safest choice in order to provide a faster resolution of the abscess as
well as minimize the spread of MRSA - would be to treat it with oral antibiotics (co-trimoxazole or clindamycin) with clinical followup and medical clearance before he returns to the game.
Tayo O | Other health professional | Disclosure: None
Boston University | Boston, Massachusetts USA
September 12, 2008
Having seen this several times in many of the young adults presenting to the hospital (Boston area), I have to say that though I agree
that Incision and drainage (cold blue steel) is essential, I would advocate for adjunctive treatment with bactrim or clindamycin (dosed
appropriately)
SUDERSHAN ADMAL | Physician | Disclosure: None
Department of Veterans Affairs | ALEXANDRIA, Louisiana USA
September 12, 2008
WE ARE TREATING MANY SUCH INFECTION IN ED AND AMBULATORY CARE SETTINGS.ANTIBIOTICS GIVEN
WHEN POSITIVE FOR MRSA.
Devapiran Jaishankar | Physician | Disclosure: None
AreaNet | Johnson City, Tennessee USA
September 12, 2008
Extensive evidence of recurrent MRSA infection noted in practice
Nicola di Meo MD | Medical student/physician in training | Disclosure: None
Trieste, Italy
September 16, 2008
Community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) infection has become common worldwide. Skin and
soft-tissue infections (SSTIs) are the most frequent forms of the disease. Many studies show a significant and ongoing increase in the
incidence of MRSA in patients with SSTIs. Therefore, if a young and healthy patient comes in with a skin and soft tissue infection that
forms an abscess, it is necessary to have CA-MRSA as part of differential about the etiological causes of that infection. Obtainment of
culture specimens is important for documentation of the presence of MRSA and for susceptibility testing to guide therapy. Purulent
lesions should be incised and drained and an empiric coverage with an MRSA antimicrobial should be used as first-line therapy in
order to avoid local and systemic relapses.
Kurt Wargo | Other health professional | Disclosure: None
Tuskegee University | Huntsville, Alabama USA
September 12, 2008
As a clinical pharmacist who sees these infections on a daily basis, I can say, in my patient population I would opt to I&D and treat this
as MRSA until proven otherwise. This wound clearly has an area of induration surrounded by erythema...HIGHLY indicative of
Staphylococcus aureus. In 2008, one must rule out MRSA until you prove it is not. In addition, because of the high virulence of
community-acquired MRSA, one must consider antibiotic therapy in addition to simple I&D, to prevent the spread and toxin
production. Our typical treatment regimen would include a combination of Vancomycin and Clindamycin in order to acheive "The
Eagle Effect."
Ivan Vucina | Physician | Disclosure: None
Antofagasta, Chile
September 12, 2008
I think that this young basket-ball player, was playing basket-ball throug many places in USA, has high possibilities that his skin
lession could be produced by Staph. Aureus Meticillin-resistant.With Antibiotics, we can eliminate a focus and potential transmission
to others players or persons
richard garceau | Physician | Disclosure: None
Stentor National Integrated Communications Network | dieppe, New Brunswick Canada
September 12, 2008
Altough drainage was proven sufficient to clear such an infection, I fell uncomfortable not to prescribe a systemic antimicrobial. Due to
participation in contact sports, the patient has a very significant risk of MRSA cutaneous abscess. I would prescribe Septra
Roger Alvarez OMS-IV | Medical student/physician in training | Disclosure: None
The Johns Hopkins Medical Institutions | Davie, Florida USA
September 12, 2008
CA-MRSA is now the most frequently cultured organism in skin and soft tissue infections presenting to Emergency Departments in the
US. CA-MRSA may present without discernible risk factors. While it is likely that the patient's infection will respond well to simple
incision and drainage, adding an anti-MRSA antibiotic increases the likelihood of cure. One option not listed but frequently
encountered in the ambulatory setting (namely, prescribing an oral antibiotic without I&D) must be avoided. Physicians may be
reluctant to perform incision and drainage in an office setting, and reluctant to refer a patient to a surgeon with an uncertain diagnosis.
The surrounding area of cellulitis may lead some physicians to lean towards a diagnosis of cellulitis and prescribe cephalexin. In my
experience with various preceptors, I have noticed that bias in the ambulatory setting, and I have frequently seen such patients return
with obvious fluctuance, new drainage, and systemic symptoms. Instead, this patient deserves incision and drainage with additional
coverage by an anti-CA-MRSA antibiotic, such as trimethoprim sulfamethoxazole.
Janet WIlson | Other health professional | Disclosure: None
TDS TELECOM | Lavergne, Tennessee USA
September 8, 2008
I see many of these in my practice and usually find that MRSA is tx best with anitbiotics and I&D
Denis Rodriguez | Physician | Disclosure: None
Telefonica del Peru | Lima, Peru
September 8, 2008
The anti-MRSA therapy seems to be the most clinically correct guess after reading patient's history.
Jabu Mbokazi Dr | Physician | Disclosure: None
Medical University of South Africa | Polokwane, South Africa
September 8, 2008
Incision and drainage alone will not take care of possible new eruption of abcesses at other sites. Combining I&D with anti-MRSA
treatment will ensure that bacteria lurking elsewhere will be taken care of. In an athlete playing contact sport MRSA infection is the
most likely offending organism.
Ronald Angoff MD | Physician | Disclosure: None
New Haven, Connecticut USA
September 12, 2008
There is approximately 30% MRSA in our community. Most of similar lesions have proved sensitive to sulfatrim in our experience, so
we have chosen this oral antibiotic pending culture results.
Rahulkumar Singh MD | Medical student/physician in training | Disclosure: None
Comcast Cable | Baltimore, Maryland USA
September 8, 2008
I think MRSA treatment start once patient comes to Hospital even before culture is back in most of case as the incidence of MRSA is
very high in US now.As an Intern in community hospital when i get a patient with abcess most of the time i try covering MRSA. I have
seen patients recovering very well post I $ D with MRSA antibiotic coverage
Miluy Guerrero Mario | Physician | Disclosure: None
Ya.com Internet Factory | Lorca, Spain
September 7, 2008
big abscess, in a player risk for MRSA, rapidly evolving
Brenda Gumz | Medical student/physician in training | Disclosure: None
Sao Paulo, Brazil
September 8, 2008
This patient give us only one chance to be cured: in one week, he needs to be 100% performed for his competition. So, we can't drain
his abscesse and watch carefully, waiting for a fever to start an oral therapy. So, knowing the prevalence of MRSA S. aureus in USA
comunity, I would associate anti-MRSA therapy plus I&D as frontline therapy. In Brazil, MSSA S. aureus are prevalent and I would
choose anti-MSSA therapy.
Crystal Cardwell | Medical student/physician in training | Disclosure: None
Fargo, North Dakota USA
September 7, 2008
I have trained in numerous hospitals across the United States and the pattern that I found is the following. MRSA was prevalent in
every age range,ethnicity, sex, and health status. Young children, adolescents, and young adults, who did not have any health problems,
nor were in an environment of illness, come up positive for MRSA. So the hospitals started to put any one who had a draining abscess
or cellulitis on contact precaution. I thought that when I moved to North Dakota, in a city that was spread out and deemed the cleanest
according to the EPA, that I would experience a decreased incidence and resume the typical presentation of MRSA infected
individuals. This was not the case. Again, the same pattern was surfacing. So this is why I feel that prophylactic treatment of MRSA is
a good choice for soft tissue or draining abscesses. If we do not stop MRSA it will continue to spread at a high rate.
Arvinder Singh (Ipoh) Mr. | Medical student/physician in training | Disclosure: None
TMnet TELEKOM MALAYSIA, | AIMST University, Malaysia
September 7, 2008
I agree with treatment option 3. Yes, we have to indeed think of MRSA due to significant abuse and misuse of Abx in today's world of
medicine. Treatment 3 offers the best option of taking a culture&sensitivity, performing an I&D as well as covering antibiotics. Had
this case presented 5 years ago- probably the diagnosis of MRSA would have been a last option diagnosis. I would also like to state that
we even consider VRSA here, as the option said that it should be made based on incidence in the area of residence. Since the recent
availability of Vancomycin as an over-the-counter drug from pharmacies in certain countries, it shouldn’t be ruled out. Another ddx
which I may like to add if there is re-occurrence of the problem is a diagnosis of gluteal hernia (enterocele type)- it can present with
purulent pus in the gluteal region. Maybe percussion and an X-ray should be done to rule that out as well.
Kevin Kon, PA-C PA-C | Other health professional | Disclosure: None
TCSN Internet | Peoria, Arizona USA
September 7, 2008
All the treatments are valid. I agree with the 3rd choice but before I/D an indurated infectious process I would needle asperate or
perform an US to verify purulent matter. Most indurated lesion will yeild no purulent d/c.
Peggy Gildersleeve | Other health professional | Disclosure: None
RCN Corporation | Lexington, Massachusetts USA
September 7, 2008
Just curious, is he a D1 athlete? Regardless, I'd select Treatment Option #3.
Satish Madiraju | Physician | Disclosure: None
ST. VINCENT HOSPITAL | Worcester, Massachusetts USA
September 7, 2008
In this patient with significant surrounding area of cellulitis, empiric antibiotic therapy with an agent active against community
acquired MRSA strains is a prudent course of action in addition to Incision and Drainage of the abscess.
John Paul Schwartz D.O. | Physician | Disclosure: None
CACTUS HEALTH SERVICES-060118042012 | Sanderson, Texas USA
September 6, 2008
In far West Texas MRSA is the primary infection due to the high prevalence of this organism in rural prison populations that spread to
the community. Antibiotics are essential, even after I and D of the lesion. I don't like this approach, but the spread is so rampant here.
Thomas Russo | Physician | Disclosure: None
State University of New York at Buffalo | Buffalo, New York USA
September 6, 2008
Besides potentially enhancing resolution of the local infection, antimicrobial treatment in addition to I&D will preemptively treat
possible metastatic infection. This complication is always a concern when dealing with probable S. aureus infection. Although this is an
uncommon complication; infection of bone, heart valves and/or the epidural space with S. aureus can be catastrophic. Therefore, this is
clearly a setting where one should be conservative. Further, treatment choices such as TMP-sulfa, doxycycline and clindamycin are
inexpensive and reasonably well tolerated.
Kathy Thomas | Other health professional | Disclosure: None
FARRIS CHRYLSER DODGE JEEP | Raleigh, North Carolina USA
September 5, 2008
Working in at a homeless clinic located in a homeless shelter I have seen the best results with I & D plus anti-MRSA therapy. Those
treated without antibiotics were more likely to return with re-infection.
Alisa Baer | Physician | Disclosure: None
University of Pennsylvania | Philadelphia, Pennsylvania USA
September 5, 2008
If he presented to his primary care physician's office I would be inclined to just do I&D as I would feel more comfortable about his
follow-up - but in an ER setting I am not sure if he will follow-up if it gets worse, and am more likely to treat with an antibiotic in
addition to I&D
Michael Sinclair | Physician | Disclosure: None
America Online | Allentown, Pennsylvania USA
September 5, 2008
options two and three were the same==the right choice is antibiotics alone
Bryan Cole Smith Ed. M. | Other | Disclosure: None
America Online | Wenonah, New Jersey USA
September 5, 2008
As a layperson who has personally experienced MRSA, I was rather surprised that not one of the three options took into consideration
the fact that the patient did not like to take medications! Listen to your patients and prescribe accordingly.
Carl Sufit | Physician | Disclosure: None
SBC Internet Services | Modesto, California USA
September 4, 2008
Our urgent care is seeing about 3-4x the number of cutaneous abscesses as 5 years ago. ~70% are MRSA. We see many patients with
recurrences, multiple family members, school athletes, etc. I am aware of studies suggesting antibiotics aren't helpful but I wouldn't feel
comfortable not treating with them; if it were me or a family member, I'd take them.
CESAR CRUZ | Physician | Disclosure: Employee of maker of a related drug or device
Baxter Healthcare Corporation | BOGOTA, Colombia
September 4, 2008
MRSA risk is big across the USA, and dont forget about the chance colonization issue in this patient
R. Doug Hardy, MD MD | Physician | Disclosure: None
University of Texas | Dallas, Texas USA
September 7, 2008
I would perform adequate incision and drainage and then treat with doxycyline. Although I was the principle investigator and senior
author for the Lee et al. paper referenced in the case study, I would still use anti-MRSA therapy. Currently, my group is conducting a
prospective, randomized trial of SSTI incision and drainage with or without anti-MRSA therapy to help answer this question.
Prospective randomized data shows doxycycline to be effective in this type of patient and probably superior to trimethoprimsulfamethoxazole (MJ Cenizal, D Skiest, S Luber, R Bedimo, P Davis, P Fox, K Delaney, RD Hardy. A Prospective Randomized Trial
of Empiric Therapy with Trimethoprim-Sulfamethoxazole or Doxycycline for Outpatient Skin and Soft Tissue Infections in an Area of
High MRSA Prevalence. Antimicrobial Agents and Chemotherapy 51:2628-2630, 2007).
Frank Lastra | Physician | Disclosure: None
Peak 10 | New Port Richey, Florida USA
September 4, 2008
This case is not atypical in my rural community. Having isolated cases of MRSA recently in similar patients to the one presented, I
would incise and drain plus add antibiotic for MRSA. I believe this would be the most prudent way to treat.
Adam Bursua Pharm.D., BCPS | Other health professional | Disclosure: None
University of Illinois at Chicago | Chicago, Illinois USA
September 4, 2008
In addtion to I&D would empirically cover CA-MRSA because the patient fits profile for CA-MRSA infections including: Close
contact with others including possible sharing of athletic equipment (basketball player), previous antibiotic use, presence of abscess.
Would chose clindamycin if local sensitivity patterns allow, because of its good staph and strep coverage and suppression of PVL
toxin. Would avoid beta-lactams as pt already failed amoxicillin alone, although presence of abscess may have confounded this result.
Some studies have suggested I&D alone is appropriate, but another suggests antibiotic choice influences outcomes.
Edna PIERRE | Physician | Disclosure: None
VSAT-Systems, LLC | Port-au-Prince, Haiti
September 4, 2008
In this context,the prevalence of MRSA infection, the patient occupation, the size of the lesion justitify the use of anti-MRSA therapy.
The patient' story doesnt show any particular conditions that can prevent the use of antibiotics, while we waiting for culture and
antibiogram results.
Janis Wilkinson | Other health professional | Disclosure: None
Clovis, California USA
September 4, 2008
recommend since there is a high rate of mrsa in the community with athletes i/d and coverage for mrsa
David Young MD | Physician | Disclosure: None
Kaiser Permanente Medical Care Program | Fresno, California USA
September 4, 2008
Over half of our community acquired staph infections are MRSA. There is a quicker resolution of sx's with I&D and antibiotics than
with I&D alone. Antibiotics alone is a course that frequently leads to grief with the pt much sicker and having a bigger abscess/furuncle
that needs to be drained and/or debrided a few days later, or even with positive blood cultures and sepsis in a minority of patients.
francy yepes | Medical student/physician in training | Disclosure: None
bogota, Colombia
September 5, 2008
in this case of the infection whit mrsa, the dreinage alone is not beneficial because is necesary oral antimicrobial therapy; the infection
whit mrsa is very dangerous and progressive, whit a short course antibiotics can limit the infection without opening the skin and
diminish the focus for other opportunistic infection, in a person exposed to this risk in their day to day.
Warren Tripp MD, FACEP | Physician | Disclosure: None
CHARTER COMMUNICATIONS | Stoughton, Wisconsin USA
September 4, 2008
The key to success is adequate drainage and the key to that is visualization of the liquid debris with bedside ultrasound
Geren Nichols MD | Physician | Disclosure: None
Kaiser Permanente Medical Care Program | Fresno,CA, California USA
September 4, 2008
These MRSA abscesses involve more necrotic fat than pus and the debridement should more resemble excision and drainage than stab
incision and drainage. This rather characteristic looking MRSA infection (in this case a early example) has been our standard outpatient
subcutaneous infection since 2000.
Gabriel Israel Soto | Physician | Disclosure: None
Mexico, Mexico
September 4, 2008
MRSA is one of the leading causes of skin and soft tissue infection acquired in the community
Chitra Iravatham Dr. | Other health professional | Disclosure: None
Hyderabad, India
September 4, 2008
Apart from the treatment suggessted i would also would like to screen for AFB . As unhealead ulcer or infection abscess sometimes
reveals Acid fast bacilli. We have dealt few cases in which MRSA associated ulcers have co infection with AFB.
juan gomez | Physician | Disclosure: None
WAW NETWORKS LTDA | bogota, Colombia
September 4, 2008
Results from several emergency room departments throughout US show how frequent CA_MRSA occurs; and Yes, he has risk factors
for harboring this organism such as playing contact sports and finally we would not want to risk his next game. Drain, culture and
explain possible side effects of a short course of Tmp/sx avoiding risk of antibiotic colitis or induction of resistance. If resistance is
found on Staph, this will serve too for conseling of the team and appropiate maneuvers.
Elle Gold M.D. | Physician | Disclosure: None
Comcast Cable | Decatur, Georgia USA
September 4, 2008
would obtain culture & sensitivity before starting therapy.
Gustavo Galue | Physician | Disclosure: None
Carle Clinic Association | Bloomington, Illinois USA
September 4, 2008
Practical clinical data assures that safety of patient is paramount and that benefit from treatment and redcution of complications
outweigh the risks
Michael Shay Sabom, M.D. | Physician | Disclosure: None
BellSouth.net | Norcross, Georgia USA
September 4, 2008
I believe the other options listed are not only incorrect but they are negligent. Doxycycline and Bactrim are cheap, generally well
tolerated when taken with food, and show good effectiveness against MRSA. You cannot take a chance with this bug. It's too
aggressive and more than once I have seen patients treated with MSSA regimens go to surgery for operative debridement due to a
DELAY in proper antibiotic coverage.
Scott Camazine MD | Physician | Disclosure: None
Boalsburg, Pennsylvania USA
September 4, 2008
This is the current management we opt to use in our ER in central PA. Here, well over 50% of such skin and soft-tissue infections are
MRSA. I suppose we will have to await further studies to determine whether chlorhexidine scrubs and intranasal bactroban are
warranted in attempts to decolonize patients (and families) where we commonly see the development of multiple recurrent infections.
Jason Tompkins MD, MPH&TM | Physician | Disclosure: None
CHINANET Shanxi(SN) province network | Berrien Springs, Michigan USA
September 4, 2008
If there were no lawyers in the USA I would choose option 1. Lawyers make option 3 the safest, but a short course of doxycycline or
TMP/SMX is favored over more expensive options.
William DeMedio | Physician | Disclosure: None
D&E Communications | Lancaster, Pennsylvania USA
September 4, 2008
Incision and drainage always raises the risk of septicemia. A dentist would not pull an abscessed tooth without antibiotics in the
bloodstream. Nor should we risk sepsis by draining an MRSA abscess. History and standard of practice support my views, as the vast
majority of physicians use antibiotics prior to I&D that I know. I have yet to see sepsis post drainage in my practice or case reports in
the literature. In the same way we have nearly eradicated rheumatic fever;no one would treat strep throat vs non treatment. Look back
on the US civil war statistics if you want to know what happens to people who have infections surgically manipulated-they get what
was called blood poisoning (sepsis).Often they died as a result. A large double blind trial in humans would be unethical regarding the
use vs non use of antibiotics in infected surgery. By the way, I saw no reference to tetanus update. A boil I&D is a tetanus prone
wound; was it overlooked or simply not stated?
Anthony Mollano | Physician | Disclosure: None
Metro2000 | Concord, New Hampshire USA
September 4, 2008
As a hand and orthopaedic surgeon, i see lots of soft tissue infections, mild and severe, and i have very little experience treating this
particualar type lesion with I/D only, and think that is risky. Antiobiotic coverage should just be based on cultures and i start empiric
treatment given the extent of MRSA with anti-MRSA coverage to not risk this become a more serious life threatening problem, and
then tailor down to anti- MSSA therapy only if cultures support this.
John Murphy E. | Physician | Disclosure: None
BellSouth.net | Dayton, Ohio USA
September 4, 2008
In todays world you have to consider MRSA in every open lesion. How do we know this was not a fistula from a rectal absces? Where
exactly was the lesion?
Carolyn Fiutem | Other health professional | Disclosure: None
Fuse Internet Access | Cincinnati, Ohio USA
September 4, 2008
In our community, CA-MRSA is very prevalent and a number of cases are seen daily in our ED and physician offices. We have seen
numerous cases associated with student-athletes (including my own daughter) and a significant number have repeated recurrences over
time. I&D and antibiotics (usually Trimethoprim-Sulfa) have been very successful at reducing the number of Returns to the ED within
72 hours. About 70% of all Staph aureus isolates tested at our Micro lab are MRSA with an admission prevalence of 14% at our
institution and another institution in our community. Due to the sequelae associated with CA-MRSA infection in addition to the
apparent prevalence, a decision to use I&D and antibiotics was made by a multi-disciplinary group at our facility.
Ismail Lawal Dr. | Physician | Disclosure: None
NewCom International | Abuja, Nigeria
September 4, 2008
Based on my 5 years experience working in the tropical region like Nigeria, I normally do I&D then follow up with anti biotic based on
the result of microscopy, culture and sensitivity. Simple staining to view the offending organisim guide the choice of drugs, however
I&D goes a long way with nonsteroidal anti inflammatory drugs for 24hours while awaiting the result of MCS.
Thorsten Jørgensen MD | Physician | Disclosure: None
Naerum, Denmark
September 4, 2008
I prefer option 3 due to the addition of chlorhexidine and the consideration on behalf of the patient that addition of antibiotics may get
him back to work(sport) sooner.
shobhana sugirthamuthu | Physician | Disclosure: None
Chennai, India
September 4, 2008
Since more than 50% of soft tissue infections are associated with MRSA infections, option 3 would be the best for this patient
David Ernst MD | Physician | Disclosure: None
Comcast Cable | Fairfax, California USA
September 4, 2008
What about using both anti-MSSA and anti-MRSA antibiotics until culture results are available? Also,would clindamycin cover both
forms of Staph and provide coverage for Strep? Should attempts to eradicate the carrier sites (nares, axilla, groin) with topical
mupirocin and chlorhexidine be tried with the initial infection?
Ramakrishna Pinjala Dr | Physician | Disclosure: None
Hyderabad, India
September 4, 2008
Sports persons are likely to have community acquired MRSA infection and it may result in delayed recovery and healing. Incision
drainage, Personal hygeine, Chlorhexidine soap, Tab. Trimethoprim + Sulphamethoxazole twice daily would be useful in such patients.
This can be cost effective too.
thangam palanichamy | Physician | Disclosure: None
Reliance Infocom Ltd | tricy, India
September 4, 2008
he was already treated with antibiotics without much response. so, incision and drainge , anti mrsa treatment is a must for him
EMILIO CROSBY M.D. | Physician | Disclosure: None
Telefonica del Peru | LIMA, Peru
September 4, 2008
i AGREE WITH OPTION 3 BECAUSE OF THE LIKELIHOOD OF HAVING A MRSA INFECTION.
Jihad Arteh | Medical student/physician in training | Disclosure: None
Memphis, Tennessee USA
September 4, 2008
I would choose option 3. I would like to stress that antibiotic therapy should be based on local epidemiology. In our residency practice
in Memphis for example, we tend to be proactive about treating skin infection with specific coverage for MRSA – and particularly in
this patient who, yes is otherwise healthy but he is an athlete which puts him at risk for Ca-MRSA. We had a similar case just recently,
a young man, basket ball player who came with facial abscess with similar features as mentioned in the Vignette, we empirically
treated him with Abx converging CA-MRSA, we performed I&D and specimen culture grew CA-MRSA. We take this approach for all
the reasons that Dr. Kamitsuka mentioned in his explanation: I would point out the positive effect of Abx on the carriage rate,
recurrence, favorable clinical resolution and last but least the fear of missing an impending doom. Moreover, in this patient, would
recommend to avoid contact sports until his skin infection is healed or completely treated.
Cesar Prinzac | Physician | Disclosure: None
Telemar Norte Leste S.A. | rio de janeiro, Brazil
September 4, 2008
Considering the size of the abscess, the need for a fast recovery and the high prevalence of CA-MRSA in the comunity it would be
reasonable to treat according to the option three. I would also add nostril treatment with mupirocin.
Fortunato Procopio | Physician | Disclosure: None
Cox Communications | Kingston, Rhode Island USA
September 4, 2008
Given his status as a competitive athlete, the size of the lesion and the surrounding erythema and the prevalence of MRSA in my
community, I would be a bit more aggressive regarding treatment because of his close contact with multiple individuals and equipment.
It must be emphasized that his wound must be completely covered for him to return to competition. Treatment is not a reliable
mechanism to erradicate colonization. Re-colonization in the individual is common. The team trainers should be informed of the
infection and advised to re-educate teammates regarding skin infections - what to watch for and how to avoid them. Aggressive
cleaning and covering of wounds to avoid infections is extremely important. Were this someone who was not a competitive athlete I
might have simply advised I & D with very close follow-up. In either case, culture and sensitives are important to direct therapy.
However, I would include an antibiotic effective against MRSA in my initial choice.
Jackie Kirby FNP-BC | Other health professional | Disclosure: None
Greenville, Kentucky USA
September 4, 2008
As a new FNP in my first yr of practice I have treated multiple furuncles that were erythematous, edematous tissue, non-draining with
warm compresses qid to promote drainage and bactrim ds bid x 10 days. If draining at office, I obtained cultures. I don't recall one that
did not respond well to Bactrim.
Ramon Perez | Physician | Disclosure: None
Anaheim, California USA
September 4, 2008
Drain, antibiotic, hygiene, educate, culture and follow-up. MRSA skin infections have been reported in wrestling, football, rugby,
soccer, basketball, field hockey, volleyball, rowing, martial arts, fencing, and baseball. USA300 MRSA is common among men who
have sex with men. Necrotizing fasciitis caused by community-associated MRSA is an emerging clinical entity. MRSA was the most
common identifiable cause of skin and soft-tissue infections among patients presenting to emergency departments in 11 U.S. cities.
Percentage MRSA varied from 18.6% in North America to 46.0% in the Western Pacific. The outpatient prevalence of MRSA in the
USA varied from 36% to 63%. In Los Angeles, the proportion caused by MRSA increased from 29% in 2001 to 2002 to 64% in 2003
to 2004. A study at Rocky Mountain Laboratories in MT showed that the two major epidemic CA-MRSA strains and the same strains
with PVL removed are equally effective at destroying human white blood cells.
Tamara Lyday | Physician | Disclosure: None
Comcast Cable | Western Springs, Illinois USA
September 4, 2008
Majority of cultures are coming back positive for MRSA so my first line treatment involves antibiotic coverage for MRSA.
Denice Barnes M.D. | Physician | Disclosure: None
RCN Corporation | Langhorne, Pennsylvania USA
September 4, 2008
In my pediatric practice north of Philadelphia, almost any abcess is MRSA untill proven otherwise. We started seeing it about 8 years
ago and it has become much more prevalent over time. We now have a number of families who have multiple members with recurrent
infections. When someone has a small lesion with no systemic symptoms we start with warm compresses. I tell them 20 min 6 times a
day in hopes that they will do it at least 3 times a day. I roll the culture swab over the top of the lesion if there is ANY hint of drainage
and send them home with a culturette with instructions to "get me some pus, I LOVE pus!" I have them come back in a few days. Many
times the small lesions will resolve when they drain. If the lesion is large, I send the culture, start them on Bactrim, reinforce the warm
compresses and have them come back in a few days. If the lesion is small, we drain it in the office.
amit taneja | Physician | Disclosure: None
Comcast Cable | chicago, Illinois USA
September 4, 2008
This is a scenario, which is dealt with almost every day in any average to large sized hospital/urgent care center. With increased
prevalence of community acquired MRSA, it would be foolish not to consider that possibility. Clearly he needs I+D. At the same time
one should treat him with cheap oral anti-MRSA antibiotics waiting for culture-sensitivities. I would choose bactrim.
Jay Kleiman MD | Physician | Disclosure: None
Road Runner | Lake Forest, Illinois USA
September 4, 2008
Although each of the 3 options have strong rationale, the sequele of a therapeutic failure is ominous IF MRSA is present and I+D does
not result in complete resolution. Given this awareness, addition of appropriate antibiotics for MRSA to I+D offers the best risk/benefit
approach.
Brian Passalacqua M.D. | Physician | Disclosure: None
University of Nevada, Reno | Reno, Nevada USA
September 3, 2008
This has become a not uncommon presentation in my community. I have seen several young, healthy college-age students with
community acquired MRSA in the last few years.
William Busino Jr MD MD | Physician | Disclosure: None
Capital Care CBO | Scotia, New York USA
September 7, 2008
The clinical scenario is consistent with a cutaneous staphylococcal skin infection which primarily requires incision and drainage.
Empiric antimicrobial therapy is a reasonable option. This therapy should cover the likely pathogens , which in this case include
MRSA. Selection of antibiotics effective against MRSA, pending culture results, is appropriate. Therapy can be adjusted, if indicated.
Stephen Chase Jr. | Other | Disclosure: None
SWIFTEL COMMUNICATIONS | Sydney, Australia
September 3, 2008
Activities of the past several weeks coupled with rapid onset symptoms make for a better than average likelihood of MRSA infection
and perhaps carriage.
Yale Bickel M.D. | Physician | Disclosure: None
Verizon Internet Services | Long Beach ,, California USA
September 3, 2008
The frequency of MRSA infections is increasing generally and especially in the athletic community, starting with wrestlers (with body/
skin to skin contact)... but in all communal living conditions (especially in a locker room set up)... increasing not only in hositals and
nursing homes but in the community particularly with the methods of skin care in a locker room. The downside of treatment for MRSA
with antibiotics is far less in terms of complications than neglect of such infections with I and D only, so post initial incision and
drainage C&S I would start Vancomycin or such agent... until the C&S results return and stop only if the culture fails to reveal MRSA.
Claudine Aguilera MD | Medical student/physician in training | Disclosure: None
Comcast Cable | Oakland, California USA
September 3, 2008
this is the standard treatment in the medicine department, but often not carried out by our surgical collegues
Debra Wechter | Physician | Disclosure: None
Virginia Mason Medical Center | Seattle, Washington USA
September 3, 2008
If not fluctuant, I would treat with antibiotics first and no drainage, then followup closely.
John Jovan Mr. | Other | Disclosure: None
Comcast Cable | Billerica, Massachusetts USA
September 3, 2008
Culture of the pathogen should be definitely taken (at the time of drainage) so that possible further adverse development can be drug
treated.
Joseph Donnelly MD | Physician | Disclosure: None
Road Runner | Austin, Texas USA
September 3, 2008
In our community, upwards of 80% of cultures yield MRSA. Therefore, we rarely perform cultures except in unusual cases, e.g., the
immunosuppressed, or those with multiple drug allergies whom we choose to treat with I&D only. Many of these patients will have
recurrent furunculosis, and this process, based on my clinical experience, seems to be mitigated by oral and intranasal antibiotic therapy
directed against MRSA.
marysia meylan, bsn, msph | Other health professional | Disclosure: None
santa monica, California USA
September 3, 2008
I am an epidemiologist with 20 years of experience in Infection Control. I spent the last 10 years at Childrens Hospital Los Angeles. I
have watched the march of CA_MRSA & kept data on patients and statistics on the relative prevalence of both MSSA & MRSA. It
soon became clear that starting ER patients, in the absence of rapid laboratory results (i.e.: PCR), on MSSA therapy was a poor option.
It was decided to use clindamycin as therapy of choice for all patients presenting with an abcess or a suspicious wound.
Jasper Ho | Other | Disclosure: None
Air Products and Chemicals | Allentown, Pennsylvania USA
September 3, 2008
A generous dose of plain old TINCTURE of IODINE works wonders for killing all sorts of bacteria including MRSA, Flesh-Eating
Bacteria, and the like. Repeat the application of iodine every three hours for a total of three applications the first 24 hours and then once
a day after that. First few times, the sting of the iodine is a sign that it works... if it doesn't sting, it means the wound has "scabbed"
over. Won't hurt to also bandage a soap-cleaned silver coin over the wound. This is entirely optional... it would speed the healing if we
use the silver coin.
Nan-Yao Lee | Physician | Disclosure: None
Tainan, Taiwan
September 3, 2008
Concern about Community acquired MRSA
John Duldner MD | Physician | Disclosure: None
Strongsville, Ohio USA
September 3, 2008
the key elements are I&D and culture. I start MRSA therapy and non-MRSA therapy for 3 days. Patient calls me for culture results and
I tailor therapy that way. saves 2 full abx courses ad i know exactly what i am treating
Robert Douglas M.D. | Physician | Disclosure: None
MidMichigan Regional Health System | Midland, Michigan USA
September 3, 2008
Treat the infection clinically as a MRSA infection. Wait for the culture and sensitivities or clinical response to the antibiotics chosen. I
would choose Bactrim and Doxycycline for double coverage in my local area. If sensitivities show MSSA then I would consider
changing antibiotics. I have seen MRSA infections rapidly worsen in individuals; therefore, I tend to be more aggressive.
elizabeth gabay md | Physician | Disclosure: None
Comcast Cable | bellingham, Washington USA
September 3, 2008
MRSA is common in the community, so trimethoprim-sulfa has become my first choice for antibiotic therapy of uncomplicated
cellulitis in most patients. Although incision and drainage may be enough to cure this infection, there is no way to predict whether or
not this young man will go on to develop a more severe cellulitis even after drainage. If he lived in my household and I could see the
wound every day, I would feel good about incision and drainage alone. But the reality of practice is that we cannot monitor our patients
as closely as we like. A few days of an antibiotic is a small price to pay to ensure that he doesn't develop a more agressive infection.
Erica Phillips-Caesar | Physician | Disclosure: None
Joan and Sanford I. Weill Medical College and Grad | NY, New York USA
September 3, 2008
Based on incidence of community acquired MRSA in our hospital and NYC I would treat this athelete with antiobiotics for MRSA in
addition to I & D