Clinical Manual for Management of the HIV-Infected ... - myCME.com

Known or suspected MSSA SSTI
Treat known or suspected MSSA SSTIs for 7-14 days.
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Dicloxacillin 500 mg orally 4 times per day
Cephalexin 500 mg orally 4 times per day
Clindamycin 300-450 mg orally 4 times per
day; if the patient has been taking azithromycin
for Mycobacterium avium complex prophylaxis,
staphylococcal infections may be resistant to
clindamycin
Doxycycline 100 mg twice daily orally
TMP-SMX 2 double-strength tablets orally twice
daily
Known or suspected MRSA SSTI
Treat according to the patient’s culture and sensitivity
results, or according to local trends in MRSA
susceptibility (see “Treatment note” below). The
following are often effective:
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Clindamycin 300-450 mg orally 4 times per day
Doxycycline 100 mg orally twice daily
TMP-SMX 2 double-strength tablets orally twice
daily
For severe infections, use intravenous antibiotics
selected according to S aureus susceptibility. For
MRSA, consider vancomycin, clindamycin, linezolid, or
daptomycin, if available.
Recurrent lesions may indicate MRSA carriage in
the nose or elsewhere. Nasal carriage can be treated
with topical mupirocin ointment to the anterior nares
3 times daily for 7 days. If nasal mupirocin fails and
MRSA SSTI recurs frequently, consider the addition
of a quinolone or TMP-SMX (2 double-strength
tablets twice daily) plus rifampin (600 mg twice daily)
to mupirocin nasal ointment for 14-21 days may be
effective. With all treatments, staphylococcal eradication
may be temporary.
Treatment note
To guide empiric antimicrobial therapy, monitor the
percentage of staphylococcal isolates that are MRSA
in the particular clinical setting, as well as local MRSA
antibiotic sensitivities. (The laboratory must perform
the “D-test” to rule out erythromycin induction of
clindamycin resistance.)
Section 6—Disease-Specific Treatment | 6–31
Patient Education
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Patients should be informed that impetigo and
some other staphylococcal infections are highly
contagious. Patients should avoid hand contact with
lesions, and should not allow other people to touch
the affected areas.
Antibiotics should be taken exactly as prescribed.
Patients should call or return to the clinic if
symptoms do not improve in 3-5 days or if
symptoms worsen.
Instruct patients to wash the affected area with
antibacterial soap (such as Hibiclens, Betadine,
or benzoyl peroxide wash). If living quarters are
shared, patients should clean contaminated surfaces
to protect others from MRSA colonization or
infection.
Instruct patients to use of warm soaks in aluminum
acetate astringent solution (Domeboro solution) if
needed for discomfort or irritation.
References
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Berger TG. Dermatologic Care of the AIDS Patient.
In: Sande MA, Volberding PA, eds. The Medical
Management of AIDS. 6th ed. Philadelphia: WB
Saunders; 1999:185-194.
Ruhe JJ, Monson T, Bradsher RW, et al. Use of longacting
tetracyclines for MRSA infections: case series and
review of the literature. Clin Infect Dis. 2005 May
15;40(10):1429-34.
Sande MA, Eliopoulos GM, Moellering RC, et al.
The Sanford Guide to HIV/AIDS Therapy, 14th ed.
Hyde Park, VT: Antimicrobial Therapy, Inc.; 2005.
Stevens DL, Bisno AL, Chambers HF, et al. Practice
guidelines for the diagnosis and management of skin
and soft-tissue infections. Clin Infect Dis. 2005 Nov
15;41(10):1373-406.