Are you following best practice in the management of boils or recurrent skin infection?  We’ve previously addressed this matter detailing a NEJM study that indicated that a majority of US doctors surveyed use incision and drainage only.

This recent Australian study investigated treatment of community staphylococcal skin abscesses by GPs and showed that a majority do not follow current guidelines. The study looked at 66 cases of uncomplicated skin abscess from the frequency-matched MRSA and MSSA Community-Onset Staphylococcus aureus Household Cohort (COSAHC) study (Melbourne, Australia, 2008-2012).  A random sample of 41 doctors treating community-onset S. aureus infections that had previously been studied in the COSAHC and 39 non-COSAHC GPs were then surveyed regarding their preferred treatment practices.

The study found that of the COSAHC cohort:

• Highest sites of infection included leg/foot, torso and arm/hand.
• 100% of these patients were prescribed antibiotics.
• 61% of these patients had an incision and draining (I & D) performed.
• Of the antibiotics MSSA patients received, 17% were inactive against the strain of S. aureus isolated.
• Of the antibiotics MRSA patients received, 62% were inactive
• Of the 41 COSAHC GPs surveyed, 71% preferred I & D and antibiotics, 20% I & D only and 7% antibiotics only.

Of the combined cohort, findings included:

• MRSA was 3 times more likely to be cultured from an abscess than MSSA.
• Patients treated with I & D and antibiotics did no better than those treated with only I & D.
• 30% of GPs reported they would routinely collect swabs
• 23% of GPs identified the rise of MRSA in community as a reason for being more likely to wait for results now before prescribing antibiotics.

The Australian Therapeutic Guidelines: Antibiotic (version 15; Antibiotic Expert Groups, 2014) recommends uncomplicated abscesses should be managed with incision and drainage (I&D) alone – without antibiotics.

Antibiotic treatment is required, in addition to incision and drainage, only if there is spreading cellulitis and/or when systemic symptoms are present.  For therapeutic advice based on local HNE antibiograms, see https://aimed.net.au/antibiograms/ .

TG: Antibiotic also says to  “perform microscopy and cultures on all lesions if antibiotic therapy is considered, due to the rapid increase in the incidence of community-associated methicillin-resistant S. aureus (CA-MRSA) and the difficulty of its clinical diagnosis. Modify therapy based on clinical response to empirical therapy and the results of cultures and susceptibility testing. Even if CA-MRSA is isolated, empirical therapy may be adequate depending on the response to drainage. Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection.”

Another important issue is to intervene effectively for those patients or families suffering from recurrent boils / skin infection to prevent recurrence. Treating underlying skin conditions, regular bleach bathing and potentially staphylococcal decolonisation can all be considered. See this posting.

An example promotional poster:

References

• Parrott, C., Wood, G., Bogatyreva, E., Coombs, G.W., Johnson, P. and Bennett, C.M., 2016. A prescription for resistance: management of staphylococcal skin abscesses by General Practitioners in Australia. Frontiers in Microbiology, 7, p.802.
• Skin and soft tissue infections: bacterial – Boils and carbuncles [revised 2014 Nov]. In: eTG complete [Internet]. Melbourne: Therapeutic Guidelines Limited; 2016.