Is Community-Acquired Methicillin-Resistant Staphylococcus aureus Coverage Needed for Cellulitis?

Abstract

Methicillin-resistant Staphylococcus aureus (MRSA) has become the dominant strain of Staphylococcus aureus in many communities of the United States. As a result, many clinicians are now empirically covering for this pathogen in the treatment of various skin and soft-tissue infections. Should this practice apply to cellulitis? In order to answer this question, we defined cellulitis and reviewed the pathogenesis, microbiology, and current studies of inpatient and outpatient antimicrobial therapy. The current evidence suggests empirical MRSA coverage for community-acquired cellulitis may not be necessary in non-purulent (non-suppurative) forms of this infection. Most cases are non-purulent and not amenable to culture although antibody studies indicate streptococci are the most common etiologic agents. Current studies of antimicrobial therapy tend to agree with this finding. Empirical beta-lactam therapy directed primarily at streptococci appears sufficient for non-purulent cellulitis regardless of the prevalence of MRSA in the community.

Clinical and microbiological characteristics of purulent and non-purulent cellulitis in hospitalized Taiwanese adults in the era of community-associated methicillin-resistant Staphylococcus aureus

“…The risk factors and the clinical and microbiological features of purulent and non-purulent cellulitis among hospitalized Taiwanese adults in the current study were remarkably similar to those reported in Western countries [ 20 – 24 ]. In the present study, patients with non-purulent cellulitis were more likely to have lower limb involvement, stasis dermatitis, and tinea pedis, along with a higher likelihood of recurrence than those with purulent cellulitis.…”

Suppurative Tonsillitis Caused by Suspected Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection: A Case Report

“…Thus, MRSA coverage is not needed. However, for patients with suppurative cellulitis having underlying diseases (such as diabetes), anti-MRSA infective therapy is needed [4]. Xu et al have investigated the etiologies and drug sensitivity in suppurative tonsillitis, and found that the most common pathogenic bacteria for suppurative tonsillitis in children included S. pyogenes, Haemophilus influenzae, S. aureus, and S. pneumoniae.…”

Daptomycin-Based 3 Week Treatment Scheme for the First Cellulitis Episode: Low Recurrence Rate Indicative of Decreased Recurrence Propensity?

“…To date the concept of modifying cellulitis recurrence risk by the selection of different treatment schemes for the first disease episode has not been adequately addressed. However, the treatment choice for the first cellulitis episode may confer protection against the risk of future relapses by different mechanisms: (1) Targeting bacterial protein synthesis by the antibacterial scheme could inhibit toxin synthesis and inflammatory mediators production during infection and thus protect tissues from excess damage (e.g., lymphedema perpetuation) [ 3 , 4 ]; (2) prolonged treatment duration (>2 weeks) may effectively eradicate latent infection foci in the relatively immunocompromised compartment of the tibial skin [ 8 , 9 ]; (3) It is further conceivable that the pathogenetic potential of the infecting bacterial strain, as denoted by the species and subspecies status, could variably predispose to subsequent relapses [ 10 ]. Daptomycin and roxithromycin target a broader species spectrum than traditional beta-lactam antibacterials.…”

“…Recurrences are frequent affecting 15–40% of patients in the first 3 years and constitute a significant risk factor for further disease episodes [ 1 , 3 ]. Common causative agents comprise Gram-positive aerobes, particularly Streptococci (groups A, B, C and G) and Staphylococcus aureus [ 2 , 4 ]. Widely used recommendations for initial empirical treatment include short schemes (5–10 days) with beta-lactam antimicrobials [ 2 ].…”