The information you provided is very helpful indeed.
I reckon your "adult" ID friend was overzealous in the management of your
patient. I have retrieved some data for you to share with him/her. I would
let the individual know they may be contributing to overuse of ABX in your
There is evidence that furuncles that have an infected area < 5 cm do not
warrant any ABX after adequate IND. [Lee MC, et al. PIDJ.2004;23:123-127].
Clindamycin and TMP-SMX have both shown to be effective in CA-MRSA. The only
caveat being that, approximately 2% of isolates had inducible resistance.
[Martinez-Aguilar G et al. PIDJ. 2003; 22:593-598]. Hence caution is advised
if the isolate was also resistant to Macrolides. Therefore, my curiosity
about prior sensitivities in your patient.
Having said that, in a commentary by Dr. Hal Jenson, Prof. and Chief of
Pediatrics/ID at Norfolk, close to your neck of the woods, resistance
patterns of CA-MRSA versus Hospital Acquired HA-MRSA are different. CA-MRSA
are less likely to develop resistance to Clindamycin because the gene
responsible may be different.
Currently, there is no clinical data with TMP-SMX. Additionally, because of
residual concerns about it's effectiveness in soft tissue infections with
pus (products of tissue necrosis --PABA ---inhibit the action of
sulfonamides), a recent update from the CDC [Ann Emerg Med. 2004;43:45-47]
recommends addition of Rifampin to Bactrim for treatment of invasive MRSA
In summary, given your case, I would have discharged the family without any
ABX. At 2-3 day follow up, if there was residual tenderness or purulence,
Clindamycin as monotherapy would be an appropriate choice. Hopefully, you
would have had sensitivities by then.
BTW, the dose of Bactrim is 1 cc/kg divided BID.
Hope that helps.
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