An 18-year-old man comes to the office due to a painful left elbow lesion. The patient has a history of atopic dermatitis and recently had a moderate to severe flare with a "weeping" rash in the creases of his elbows and knees. A few days ago, he noticed a small red nodule in his left elbow crease that progressively enlarged and became painful. He has not had fever or chills. The patient has no other medical problems, and his only medication is topical corticosteroid. He does not use alcohol, tobacco, or illicit drugs.
Temperature is 36.7 C (98.1 F), blood pressure is 126/80 mm Hg, pulse is 80/min, and respirations are 12/min. Skin examination shows a 4-cm tender and fluctuant lesion in the left antecubital area with erythema and induration of the surrounding skin. The flexural surfaces of the knees and elbows have an eczematous skin rash with lichenification. The remainder of the physical examination is within normal limits.
Incision and drainage of the fluctuant lesion yields approximately 3 mL of purulent material, which is sent to the laboratory for culture and sensitivity.
Which of the following is the most appropriate recommendation regarding antimicrobial therapy for this patient?

Question

An 18-year-old man comes to the office due to a painful left elbow lesion.  The patient has a history of atopic dermatitis and recently had a moderate to severe flare with a "weeping" rash in the creases of his elbows and knees.  A few days ago, he noticed a small red nodule in his left elbow crease that progressively enlarged and became painful.  He has not had fever or chills.  The patient has no other medical problems, and his only medication is topical corticosteroid.  He does not use alcohol, tobacco, or illicit drugs.
Temperature is 36.7 C (98.1 F), blood pressure is 126/80 mm Hg, pulse is 80/min, and respirations are 12/min.  Skin examination shows a 4-cm tender and fluctuant lesion in the left antecubital area with erythema and induration of the surrounding skin.  The flexural surfaces of the knees and elbows have an eczematous skin rash with lichenification.  The remainder of the physical examination is within normal limits.
Incision and drainage of the fluctuant lesion yields approximately 3 mL of purulent material, which is sent to the laboratory for culture and sensitivity.
Which of the following is the most appropriate recommendation regarding antimicrobial therapy for this patient?

Quizplus · Accepted Answer

Skin abscesses are encapsulated pus collections that typically develop due to bacterial invasion through hair follicles (furuncles) or breaks in the skin. Risk is increased in those with skin inflammation (eg, atopic dermatitis), trauma, or edema. Staphylococcus aureus is the most common cause. The foundation of treatment is incision and drainage, but empiric antibiotics should be considered for those with: An abscess ≥2 cmExtensive surrounding cellulitisSystemic signs of infection (eg, fever, chills, tachycardia, leukocytosis)NeutropeniaMultiple abscessesExtremes of ageLack of response to incision and drainage An abscess ≥2 cm Extensive surrounding cellulitis Systemic signs of infection (eg, fever, chills, tachycardia, leukocytosis) Neutropenia Multiple abscesses Extremes of age Lack of response to incision and drainage For these individuals, the debrided material from incision and drainage should be sent for Gram stain and culture. Empiric treatment with oral trimethoprim-sulfamethoxazole or doxycycline is generally curative, but parenteral antibiotics should be considered for those with systemic signs of infection, rapidly progressive symptoms, persistent symptoms after 48 hours of oral antibiotics, or inability to tolerate oral therapy. (Choice A) Topical antibiotics are often used to treat impetigo, a superficial bacterial infection of the skin. Topical antibiotics are not sufficient for skin abscess or cellulitis. (Choice B) Treatment should not be delayed for culture and sensitivity results as the infection is likely to worsen. Empiric therapy with trimethoprim-sulfamethoxazole or doxycycline is usually curative. (Choice C) Cephalexin is frequently used for the empiric treatment of cellulitis, which is usually caused by hemolytic streptococci and methicillin-susceptible S aureus. Because skin abscess is more likely to be due to community-acquired methicillin-resistant S aureus, treatment with trimethoprim-sulfamethoxazole or doxycycline is recommended. (Choice E) An abscess ≥2 cm should generally be treated with both incision and drainage and empiric antibiotics. Educational objective: The foundation of treatment for skin abscess is incision and drainage. Empiric antibiotic therapy is generally added for those with an abscess ≥2 cm, extensive surrounding cellulitis, systemic signs of infection, neutropenia, multiple abscesses, extremes of age, or lack of response to incision and drainage. __________ References: Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/24947530) A placebo-controlled trial of antibiotics for smaller skin abscesses. (http://www.ncbi.nlm.nih.gov/pubmed/28657870)

An 18-Year-Old Man Comes to the Office Due to a Painful