A 25-year-old previously healthy male presented to his general practitioner with a painful lesion on his right leg. On examination, he appeared generally fit and well, but had a temperature of 37.8°C. There was a large carbuncle on the upper anterior aspect of his right thigh, with surrounding cellulitis and associated tender inguinal lymphadenopathy. The general practitioner prescribed oral dicloxacillin 250 mg four times daily and advised local application of heat to the area to encourage spontaneous drainage of the carbuncle.
The patient presented to the local emergency department 72 hours later with fevers, rigors and severe pain. He was commenced on intravenous flucloxacillin, and underwent incision and drainage of the carbuncle in theatre later that day. Methicillin-resistant Staphylococcus aureus (MRSA) was cultured from the copious pus. The organism was susceptible to erythromycin, clindamycin, doxycycline and trimethoprim with sulfamethoxazole. After discussion with a clinical microbiologist, treatment was changed to oral clindamycin 450 mg three times daily and the patient was discharged to complete a seven-day course of treatment.
Antistaphylococcal/streptococcal beta-lactam antimicrobials are currently still recommended for empiric treatment of most uncomplicated skin or soft tissue infections. However, MRSA is an increasingly important cause of these and other infections acquired in the general community. If practical, clinical specimens should be submitted to the microbiology laboratory in order to detect infection with community-acquired MRSA. Antimicrobial therapy should be reviewed once results are available, or if the clinical response to empiric therapy is not as expected.
Dr Murray has received funding from Pfizer to attend an international conference.
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