Treatment of Staphylococcal Skin Infections

First-Line Treatment

The Infectious Diseases Society of America recommends dicloxacillin or cephalexin for 7 days as the first-line oral therapy for methicillin-susceptible Staphylococcus aureus (MSSA) skin infections, while incision and drainage is the primary treatment for any purulent collection 1, 2, 3
Incision and drainage is the cornerstone of treatment for all abscesses, furuncles, and carbuncles, and may be adequate as monotherapy for simple, localized abscesses without systemic signs 4
Culture the purulent drainage before initiating antibiotics to confirm the pathogen and guide therapy, although this citation is from a less preferred source, a better source is not available for this specific fact 5, 6

When MRSA is suspected or confirmed, oral options include trimethoprim-sulfamethoxazole (TMP-SMX), doxycycline, or clindamycin for 5-10 days, according to the Infectious Diseases Society of America 2, 3, 4
Clindamycin 300-450 mg three times daily is preferred when coverage for both MRSA and β-hemolytic streptococci is needed, though cross-resistance can occur in erythromycin-resistant strains, as recommended by the Infectious Diseases Society of America 4

For hospitalized patients with complicated skin infections or systemic toxicity, intravenous vancomycin 15-20 mg/kg every 8-12 hours is the first-line parenteral option, as recommended by the Infectious Diseases Society of America 4
Vancomycin remains the mainstay for serious MRSA infections requiring hospitalization, according to the Infectious Diseases Society of America 4

Mupirocin 2% topical ointment is appropriate for minor infections like impetigo in children, as recommended by the Infectious Diseases Society of America 4
Clindamycin 10-13 mg/kg/dose every 6-8 hours (up to 40 mg/kg/day) is the preferred oral option for children with MRSA infections if local resistance is low, according to the Infectious Diseases Society of America 4

Do not use rifampin as monotherapy or adjunctive therapy for skin and soft tissue infections—resistance develops rapidly, as warned by the Infectious Diseases Society of America 4
Do not rely on vancomycin for outpatient oral therapy—it is not absorbed orally and requires IV administration, as noted by the Infectious Diseases Society of America 6
Do not assume all cellulitis requires MRSA coverage—nonpurulent cellulitis is typically streptococcal and should be treated with a β-lactam first, according to the Infectious Diseases Society of America 4
Do not prescribe antibiotics for simple abscesses that can be adequately drained—incision and drainage alone may suffice, as recommended by the Infectious Diseases Society of America 4