RISK FACTORS: Carriage of pathogenic strain of Staphylococcus in nares, skin, axilla, and perineum, Rarely, polymorphonuclear leukocyte defect or hyperimmunoglobulin- E/Staphylococcus abscess syndrome, Diabetes mellitus, malnutrition, alcohol
GENERAL MEASURES :
. Moist, warm compresses (provides comfort, encourages localization/pointing/drainage) 30 minutes, 4 times
a day
. If pointing or large, incise and drain
. Consider packing to promote drainage
. Routine culture not necessary for localized abscess in non-diabetic patients with normal immune system
. Systemic antibiotics usually unnecessary, unless extensive surrounding cellulitis or fever
. If recurrent, problem usually related to chronic skin carriage of particular strain of Staphylococcus in nares
or on skin. Treatment goals are to 1) decrease or eliminate pathogenic strain or 2) in very diffi cult cases,
implant less aggressive strain.
. Suppression of pathogenic strain
. Culture nares, skin, axilla, perineum
. Begin therapeutic antibiotic doses
. Wash entire body and fi ngernails (with nailbrush) daily for 1-3 weeks with povidone-iodine (Betadine),
hexachlorophene (Hibiclens), or pHisoHex soap (all can cause dry skin)
. After shower ointments
. Sanitary practices - change towels, washcloths and sheets daily; clean shaving instruments; avoid nosepicking; change wound dressings frequently
. Replacement of pathogenic strain with nonpathogenic strain (502A bacterial interference)
. Culture nose and lesions to document pathogenic strain
. Culture family members if disease involves them
. Treat patient and infected household members with antibiotics
. Discontinue topical/oral antibiotics 48 hours then inoculate anterior nares with Staphylococcus aureus
502A (stock bacteria) (tilt head back, swab each anterior nares with 2 soaked cotton swabs of culture while patient sniffs material into nares and nasopharynx)
. Followup 1 month later; repeat process if abscesses not controlled
DRUG(S) OF CHOICE
. If abscesses multiple, if lesions have marked surrounding inflammation, or if immunocompromised
. Obtain culture and place on antibiotics for at least 14 days
. Cloxacillin (Tegopen) or dicloxacillin (Dynapen, Pathocil) 250 mg qid, or
. Erythromycin (E-mycin, PCE) 250-500 tid
. Suppression of pathogenic strain
. Dicloxacillin or cloxacillin 250 mg qid x 21 days
. Erythromycin 250-500 mg tid (if penicillin allergic) x 21 days
. If above fails - begin 1-3 month course of antibiotics. May need to add rifampin 600 mg q day x 10 days
. After showering - bacitracin ointment or mupirocin to both anterior nares with cotton swab tid-qid x > 14
days
. Replacement of pathogenic strain
. Treat patient and infected household members with dicloxacillin 250 mg qid or if child/infant with 50 MG/kg/day qid x 7-10 days
ALTERNATIVE DRUGS
. Resistant strains of Staph. aureus: first generation cephalosporins, clindamycin, ciprofl oxacin + rifampin
(rifampicin), Trimethoprim-sulfamethoxazole (cotrimoxazole) + rifampicin
. If known or suspected impaired neutrophil function (i.e., impaired chemotaxis, phagocytosis, superoxide
generation), add vitamin C 1000 mg/day for 4-6 weeks (prevents oxidation of neutrophils)
. If fail with antibiotic regimens
. May try oral pentoxifylline 400 mg tid for 2-6 months
. Contraindications - recent cerebral and/or retinal hemorrhage; intolerance to methylxanthines (i.e., caffeine, theophylline)
. Precautions - prolonged prothrombin time and/or bleeding; if on warfarin, frequent monitoring of prothrombin time
PATIENT MONITORING : Instruct patient to see physician if compresses unsuccessful
PREVENTION/AVOIDANCE : Patient education regarding self care (see General Measures section.
POSSIBLE COMPLICATIONS:
β’ Scarring
β’ Bacteremia
β’ Metastatic seeding (i.e., septal/valve defect, arthritic
joint)
EXPECTED COURSE/PROGNOSIS :
β’ Self-limited (usually drains pus spontaneously and will heal with or without scarring within several days)
β’ Recurrent/chronic lasting for months or years