The Correct Answer is B: Incise and drain the lesion, and send some purulent material for bacterial and fungal culture with reflex sensitivity.
Any hot, tender, fluctuant nodule, especially in an immunosuppressed patient, is a staphylococcal abscess until proven otherwise. In today’s world, moreover, methicillin-resistant Staphylococcus aureus (MRSA) is the culprit until objective culture results prove otherwise. Thus, the provider is faced with a rather sizable acute, presumed MRSA abscess of the face in a host with a depressed immune response. Septicemia, a bacterial embolus, and MRSA pneumonia are all potential sequelae of this lesion if it is not handled properly and in a timely fashion.
Recent guidelines for the handling of MRSA-induced abscesses clearly indicate that incision and drainage is the key first step in management. Administration of antibiotics concurrent with or immediately following incision and drainage is reasonable in special situations: very young or elderly patients, severely symptomatic or large lesions, associated infectious lymphangitis or surrounding cellulitis, failure to heal following surgical intervention, and immunosuppression.
Several antibiotic agents would be considered first-line: doxycycline(Drug information on doxycycline), minocycline, trimethoprim(Drug information on trimethoprim)-sulfamethoxazole and clindamycin(Drug information on clindamycin) (with a negative D-test for inducible resistance). It is important for a clinician to know the local pattern of antibiotic susceptibility (antibiogram) in order to choose a specific anti-infective agent expeditiously and appropriately.
1. Kuehn BM. IDSA creates MRSA treatment guideline. JAMA. 2011;305:768–69.
2. Liu C, Bayer A, Cosgrove ES, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52:285–92.