Antibacterials as Adjuncts to Incision and Drainage for Adults with Purulent Methicillin-Resistant Staphylococcus aureus (MRSA) Skin Infections

Abstract

The annual incidence of skin and soft tissue infections (SSTIs) has nearly tripled in the US since the early 1990s. Many purulent SSTIs in the community setting are caused by methicillin-resistant Staphylococcus aureus (MRSA). Incision and drainage (I&D) are indicated for most purulent MRSA infections; however, the use of adjunctive antibacterials is controversial. The objective of this study was to systematically evaluate studies that have investigated whether or not antibacterials provide added benefit to I&D alone for purulent MRSA SSTIs. We included articles from MEDLINE and The Cochrane Library that fulfilled the following criteria: (i) original research; (ii) English language; (iii) compared I&D alone versus I&D plus antibacterials for purulent MRSA SSTIs; and (iv) compared patient outcomes. We also reviewed the references of these articles to identify other relevant studies. Studies that solely examined paediatric patients were excluded. To facilitate cross-study comparison, we systematically evaluated the following study characteristics: (i) study design; (ii) patient population; (iii) comparator groups; (iv) sample size; (v) outcome measures; (vi) outcome definitions; (vii) duration of follow-up; and (viii) measurement and adjustment of potential confounding variables. Eleven studies, spanning more than 30 years, met inclusion criteria. Two of these were conducted prior to the emergence of MRSA in the community; another evaluated cephalexin versus placebo for MRSA. None of these found added benefit of adjunctive antibacterials. Four studies compared health outcomes between patients who received 'active' or 'appropriate' therapy and those who received 'inactive' or 'inappropriate' therapy after I&D for purulent MRSA SSTIs. Two of these studies found 'active' or 'appropriate' therapy to be beneficial, while two others did not. Four studies compared health outcomes between patients who received anti-MRSA antibacterials plus I&D with those who received alternative antibacterials plus I&D for purulent MRSA SSTIs. Three of these reported improved outcomes with anti-MRSA antibacterials, while another reported mixed findings. Presently, the bulk of the available evidence suggests anti-MRSA antibacterials provide added benefit to I&D alone for purulent MRSA SSTIs; however, the current evidence is limited to small, case-control, observational studies.

Facing Antibiotic Resistance: Staphylococcus aureus Phages as a Medical Tool

“…A 43% mortality rate in patients with MRSA bacteraemia was reported and compared to 20% mortality rate in patients with methicillin-sensitive S. aureus (MSSA) bacteraemia [47,48]. Many other MRSA-related problems have been reported: osteomyelitis [49], nasopharyngeal colonization [50], skin infections [51], acute musculoskeletal infections [46], food-chain animal infections [52], and a wide range of infections in immunocompromised patients [53,54]. …”

Treatment Failure and Costs in Patients With Methicillin-Resistant Staphylococcus aureus (MRSA) Skin and Soft Tissue Infections: A South Texas Ambulatory Research Network (STARNet) Study

“…These recommendations are supported by a recent systematic review which suggests oral generic anti-MRSA antibiotics (e.g., clindamycin, doxycycline, and trimethoprim-sulfamethoxazole) may provide additional benefit to I&D alone for purulent MRSA SSTIs. 10 Taken together, this information indicates that I&D plus anti-MRSA antibiotics is the standard-of-care for most patients with purulent MRSA SSTIs.…”

Methicillin-Resistant Staphylococcus aureus in Obstetrics

“…21 In most studies, the addition of MRSA-appropriate antibiotics has not improved outcomes. 22,[42][43][44] Antibiotic therapy is added to patients undergoing incision and drainage if the SSTI is severe, fails to respond, occurs in patients with comorbidities, or is otherwise complicated. Purulent cellulitis should be treated empirically for CA-MRSA and nonpurulent cellulitis treated with traditional β-lactam therapy; medication adjustment is made based on culture results.…”