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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.

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A 78-year-old woman is hospitalized for management of acute worsening of chronic kidney disease. On the third hospital day, she develops a painful nodule under the tape adjacent to the site of a peripheral intravenous catheter on her left forearm. Medical history is also significant for hypertension and type 2 diabetes mellitus. She currently takes amlodipine, insulin, and furosemide.

On physical examination, temperature is 38.3°C (100.9°F), blood pressure is 125/85 mm Hg, pulse rate is 70/min, and the respiration rate is 12/min. A tender, fluctuant, erythematous nodule with 2 cm of surrounding erythema is present on the left forearm. There is no lymphadenopathy. The remainder of the physical examination is noncontributory.

The leukocyte count is 13,000/μL (13 x 109/L). The nodule is incised and drained. Microscopic examination shows numerous leukocytes and small gram-positive cocci; culture results are pending.


Which of the following is the most appropriate antibiotic therapy for this patient?

This patient should be treated with vancomycin. Hospital-acquired skin and soft-tissue infections should be treated as a methicillin-resistant Staphylococcus aureus (MRSA) infection until culture results are received and therapy can be tailored appropriately. Hospital-acquired skin infections are increasingly caused by MRSA, and coverage against this organism in the hospital setting is important to prevent further morbidity and mortality, particularly in high-risk patients. Once culture and sensitivity results are known, antibiotic therapy can be focused toward a specific organism. In the patient described here, a local abscess and surrounding cellulitis with corresponding fever and leukocytosis suggests the potential for systemic involvement.

Amoxicillin-clavulanate should not be used because these antibiotics do not provide coverage against MRSA organisms.

Similarly, cephalexin is often effective against multiple skin and soft-tissue infections and may be considered first-line therapy for an abscess and cellulitis in the ambulatory setting; however, it too is ineffective against MRSA.

Although meropenem is a potent antibiotic with broader antimicrobial coverage, it is not effective against MRSA infection and thus would not be an appropriate choice for this patient.

Several strategies may be used to attempt to reduce rates of MRSA infection in hospitalized patients. Routine screening and active surveillance cultures for MRSA colonization are obtained in some institutions to identify carriers and to guide use of contact precautions and possibly attempted decontamination with intranasal mupirocin. However, the efficacy of this practice is not clear except in the setting of an acute outbreak. Daily chlorhexidine bathing has been shown to decrease the risk of colonization and infection with drug-resistant and other organisms in ICU settings.

Key Point

  • Vancomycin, an empiric antibiotic therapy against methicillin-resistant Staphylococcus aureus, is the treatment of choice for most hospitalized patients with skin and soft-tissue infections until culture results are available.
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