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==Medical Therapy==
==Medical Therapy==
===Antibiotics===
===Antibiotics===
As ''[[Staphylococcus aureus]]'' [[bacteria]] is a common cause, an anti-staphylococcus antibiotic such as [[flucloxacillin]] or [[dicloxacillin]] is used.  With the emergence of community-acquired methicillin-resistant staphylococcus aureus [[MRSA]], these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline.  (However, if cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin.) It is important to note that [[antibiotic]] therapy alone ''without surgical drainage of the abscess'' is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low [[pH]] levels.
As ''[[Staphylococcus aureus]]'' [[bacteria]] is a common cause, an anti-staphylococcus antibiotic such as [[flucloxacillin]] or [[dicloxacillin]] is used.  With the emergence of community-acquired methicillin-resistant staphylococcus aureus [[MRSA]], these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline.  (However, if cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin.) It is important to note that [[antibiotic]] therapy alone ''without surgical drainage of the abscess'' is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low [[pH]] levels.
A [[clinical practice guideline]] by the [[Infectious Disease Society of America]] concludes that "[[Gram stain]], culture, and systemic antibiotics are rarely necessary"<ref name="pmid16231249">{{cite journal |author=Stevens DL, Bisno AL, Chambers HF, ''et al'' |title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections |journal=Clin. Infect. Dis. |volume=41 |issue=10 |pages=1373–406 |year=2005 |month=November |pmid=16231249 |doi=10.1086/497143 |url=http://www.journals.uchicago.edu/cgi-bin/resolve?CID37519 |issn=}}</ref>; however, according the [http://guidelines.gov National Guideline Clearinghouse] summary of this guideline, the guideline was not a [[systematic review]] of the evidence.<ref name="urlPractice guidelines for the diagnosis and management of skin and soft-tissue infections.">{{cite web |url=http://guidelines.gov/summary/summary.aspx?ss=15&doc_id=8206&string=#s22 |title=Practice guidelines for the diagnosis and management of skin and soft-tissue infections. |author=Anonymous |authorlink= |coauthors= |date=2005 |format= |work= |publisher=National Guidelines Clearinghouse |pages= |language= |archiveurl= |archivedate= |quote= |accessdate=}}</ref>
Antibiotics should be considered if there is significant overlying [[cellulitis]]. [[Systematic review]]s of relevant studies concluded that:<ref name="pmid17577944">{{cite journal |author=Hankin A, Everett WW |title=Are antibiotics necessary after incision and drainage of a cutaneous abscess? |journal=Annals of emergency medicine |volume=50 |issue=1 |pages=49-51 |year=2007 |pmid=17577944 |doi=10.1016/j.annemergmed.2007.01.018 }} PMID 17577944</ref><ref name="pmid17934031">{{cite journal |author=Korownyk C, Allan GM |title=Evidence-based approach to abscess management |journal=Canadian family physician Médecin de famille canadien |volume=53 |issue=10 |pages=1680–4 |year=2007 |pmid=17934031 |doi=}}</ref>
:"the current literature does not support the routine practice of prescribing antibiotics after incision and drainage of simple cutaneous abscesses, even in high-MRSA-prevalence areas"
:"our conclusions cannot be extrapolated to those cases in which there is a significant degree of overlying cellulitis"
====Randomized controlled trials====
There are conflicting [[randomized controlled trial]]s to guide the decision for antibiotics.<ref name="pmid26962903">{{cite journal| author=Talan DA, Mower WR, Krishnadasan A, Abrahamian FM, Lovecchio F, Karras DJ et al.| title=Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. | journal=N Engl J Med | year= 2016 | volume= 374 | issue= 9 | pages= 823-32 | pmid=26962903 | doi=10.1056/NEJMoa1507476 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26962903  }} </ref><ref name="pmid3880635">{{cite journal |author=Llera JL, Levy RC |title=Treatment of cutaneous abscess: a double-blind clinical study |journal=Annals of Emergency Medicine |volume=14 |issue=1 |pages=15–9 |year=1985 |pmid=3880635 |doi=10.1016/S0196-0644(85)80727-7 |quote=Ninety-six percent of the patients in each group were improved clinically after seven days}}</ref><ref name="pmid322789">{{cite journal |author=Macfie J, Harvey J |title=The treatment of acute superficial abscesses: a prospective clinical trial |journal=The British journal of surgery |volume=64 |issue=4 |pages=264–6 |year=1977 |pmid=322789 |doi=}} Among patients who had incision and drainage, none recurred among patients randomized to receive [[clindamycin]] whereas 7.3% recurred in those who did not received [[clindamycin]]</ref><ref name="pmid4191960">{{cite journal |author=Rutherford WH, Hart D, Calderwood JW, Merrett JD |title=Antibiotics in surgical treatment of septic lesions |journal=Lancet |volume=1 |issue=7656 |pages=1077–80 |year=1970 |month=May |pmid=4191960 |doi= |url= |issn=}} Patients randomized to receive cloxacillin has an insignificant trend to improve one half day faster</ref><ref name="pmid13608051">{{cite journal |author=Anderson J |title=Dispensability of post-operative penicillin in septic-hand surgery |journal=Br Med J |volume=2 |issue=5112 |pages=1569–71 |year=1958 |month=December |pmid=13608051 |pmc=2028058 |doi=|quote=17% were penicillin-resistant...Routine post-operative penicillin does not hasten healing in septic lesions of the hand which require surgical treatment |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=citizendium&pubmedid=13608051 |issn=}} However, this was an insignificant trend towards more complications in the group without antibiotics</ref><ref name="pmid20346539">{{cite journal| author=Schmitz GR, Bruner D, Pitotti R, Olderog C, Livengood T, Williams J et al.| title=Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. | journal=Ann Emerg Med | year= 2010 | volume= 56 | issue= 3 | pages= 283-7 | pmid=20346539 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20346539 | doi=10.1016/j.annemergmed.2010.03.002 }} 17% failure with TMP/SMX versus 26 failure in placebo. However, not significant - perhaps due to size of the study.</ref><ref name="pmid26578074">{{cite journal| author=Holmes L, Ma C, Qiao H, Drabik C, Hurley C, Jones D et al.| title=Trimethoprim-Sulfamethoxazole Therapy Reduces Failure and Recurrence in Methicillin-Resistant Staphylococcus aureus Skin Abscesses after Surgical Drainage. | journal=J Pediatr | year= 2015 | volume=  | issue=  | pages=  | pmid=26578074 | doi=10.1016/j.jpeds.2015.10.044 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26578074  }} </ref> The largest trials found benefit from [[trimethoprim–sulfamethoxazol]]e versus placebo. <ref name="pmid26962903"/> Some trials are undersized.<ref name="pmid20346539"/>The strongest support for using antibiotics is from a trial of clindamycin.<ref name="pmid322789"/> and a trial of trimethoprim-sulfamethoxazole<ref name="pmid26578074"/>. The strongest refutations of antibiotics were a trial of cephradine<ref name="pmid3880635"/> and maybe an older trial of penicillin<ref name="pmid13608051"/>. In the most recent trial, although 87.8% of isolates were methicillin-resistant [[staphylococcus aureus]] (MRSA), the antibiotic used was [[cephalexin]] which is inactive against MRSA. It is not known if an antibiotic effective against MRSA would have reducted the rate of treatment failures below the 10% failure rate observed in the trial.<ref name="pmid17846141">{{cite journal |author=Rajendran PM, Young D, Maurer T, ''et al'' |title=Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection |journal=Antimicrob. Agents Chemother. |volume=51 |issue=11 |pages=4044–8 |year=2007 |pmid=17846141 |doi=10.1128/AAC.00377-07}}</ref> However, the clindamycin trial above<ref name="pmid322789"/> and one [[cohort study]] below<ref name="pmid17304447">{{cite journal |author=Ruhe JJ, Smith N, Bradsher RW, Menon A |title=Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome |journal=Clin. Infect. Dis. |volume=44 |issue=6 |pages=777–84 |year=2007 |month=March |pmid=17304447 |doi=10.1086/511872 |url=http://www.journals.uchicago.edu/doi/abs/10.1086/511872?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dncbi.nlm.nih.gov |issn=}}</ref> suggests effective antibiotic therapy helps.
Additional trials exit, however, one did not have a placebo group.<ref name="pmid13446439">{{cite journal |author=Burn JI, Curwen MP, Huntsman RG, Shooter RA |title=A trial of penicillin V; response of penicillin-resistant staphylococcal infections to penicillin |journal=Br Med J |volume=2 |issue=5038 |pages=193–6 |year=1957 |month=July |pmid=13446439 |pmc=1961881 |doi= |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=citizendium&pubmedid=13446439 |issn=|quote=patients were treated in alternate periods of six weeks by injection or penicillin V by mouth...therefore no control group...25% were infected with penicillin resistant strains of ''Staph. pyogenes''}}</ref> A pediatric trial found short term benefit from [[trimethoprim-sulfamethoxazole]] after [[incision and drainage]].<ref name="pmid19409657">{{cite journal |author=Duong M, Markwell S, Peter J, Barenkamp S |title=Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient |journal=Ann Emerg Med |volume= |issue= |pages= |year=2009 |month=April |pmid=19409657 |doi=10.1016/j.annemergmed.2009.03.014 |url=http://linkinghub.elsevier.com/retrieve/pii/S0196-0644(09)00270-4 |issn=}}</ref>
For infected wounds, [[clindamycin]] and [[trimethoprim-sulfamethoxazole]] may be similar.<ref name="pmid27025829">{{cite journal| author=Talan DA, Lovecchio F, Abrahamian FM, Karras DJ, Steele MT, Rothman RE et al.| title=A Randomized Trial of Clindamycin versus Trimethoprim-Sulfamethoxazole for Uncomplicated Wound Infection. | journal=Clin Infect Dis | year= 2016 | volume=  | issue=  | pages=  | pmid=27025829 | doi=10.1093/cid/ciw177 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27025829  }} </ref> .<ref name="pmid27025829">{{cite journal| author=Talan DA, Lovecchio F, Abrahamian FM, Karras DJ, Steele MT, Rothman RE et al.| title=A Randomized Trial of Clindamycin versus Trimethoprim-Sulfamethoxazole for Uncomplicated Wound Infection. | journal=Clin Infect Dis | year= 2016 | volume=  | issue=  | pages=  | pmid=27025829 | doi=10.1093/cid/ciw177 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27025829  }} </ref>
No trial has separately reported the role of antibiotics for large abscesses (> 5 cm). Large abscesses may be less likely to respond without antibiotics.<ref name="pmid14872177">{{cite journal |author=Lee MC, Rios AM, Aten MF, ''et al'' |title=Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus |journal=Pediatr. Infect. Dis. J. |volume=23 |issue=2 |pages=123–7 |year=2004 |month=February |pmid=14872177 |doi=10.1097/01.inf.0000109288.06912.21 |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0891-3668&volume=23&issue=2&spage=123 |issn=}}</ref>


===Recurrent infections===
===Recurrent infections===

Latest revision as of 14:10, 27 March 2017

Abscess Main page

Patient Information

Overview

Causes

Classification

Anal Abscess
Appendicular Abscess
Brain Abscess
Breast Abscess
Colon Abscess
Cutaneous Abscess
Liver Abscess
Lung Abscess
Pancreatic Abscess
Retropharyngeal Abscess
Splenic Abscess
Tonsillar and Peritonsillar Abscess

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Treatment of abscess depends on the type of infection. The antibiotic sensitive for MRSA is used to treat recurrent abscess. Antibiotics along with surgical drainage is the most effective way of treating the abscess.

Medical Therapy

Antibiotics

As Staphylococcus aureus bacteria is a common cause, an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin is used. With the emergence of community-acquired methicillin-resistant staphylococcus aureus MRSA, these traditional antibiotics may be ineffective; alternative antibiotics effective against community-acquired MRSA often include clindamycin, trimethoprim-sulfamethoxazole, and doxycycline. (However, if cellulitis rather than abscess, consideration should be given to possibility of strep species as cause that are still sensitive to traditional anti-staphylococcus agents such as dicloxacillin or cephalexin.) It is important to note that antibiotic therapy alone without surgical drainage of the abscess is seldom effective due to antibiotics often being unable to get into the abscess and their ineffectiveness at low pH levels.

A clinical practice guideline by the Infectious Disease Society of America concludes that "Gram stain, culture, and systemic antibiotics are rarely necessary"[1]; however, according the National Guideline Clearinghouse summary of this guideline, the guideline was not a systematic review of the evidence.[2]

Antibiotics should be considered if there is significant overlying cellulitis. Systematic reviews of relevant studies concluded that:[3][4]

"the current literature does not support the routine practice of prescribing antibiotics after incision and drainage of simple cutaneous abscesses, even in high-MRSA-prevalence areas"
"our conclusions cannot be extrapolated to those cases in which there is a significant degree of overlying cellulitis"

Randomized controlled trials

There are conflicting randomized controlled trials to guide the decision for antibiotics.[5][6][7][8][9][10][11] The largest trials found benefit from trimethoprim–sulfamethoxazole versus placebo. [5] Some trials are undersized.[10]The strongest support for using antibiotics is from a trial of clindamycin.[7] and a trial of trimethoprim-sulfamethoxazole[11]. The strongest refutations of antibiotics were a trial of cephradine[6] and maybe an older trial of penicillin[9]. In the most recent trial, although 87.8% of isolates were methicillin-resistant staphylococcus aureus (MRSA), the antibiotic used was cephalexin which is inactive against MRSA. It is not known if an antibiotic effective against MRSA would have reducted the rate of treatment failures below the 10% failure rate observed in the trial.[12] However, the clindamycin trial above[7] and one cohort study below[13] suggests effective antibiotic therapy helps.

Additional trials exit, however, one did not have a placebo group.[14] A pediatric trial found short term benefit from trimethoprim-sulfamethoxazole after incision and drainage.[15]

For infected wounds, clindamycin and trimethoprim-sulfamethoxazole may be similar.[16] .[16]

No trial has separately reported the role of antibiotics for large abscesses (> 5 cm). Large abscesses may be less likely to respond without antibiotics.[17]

Recurrent infections

Recurrent abscesses are often caused by community-acquired MRSA. While resistant to most beta lactam antibiotics commonly used for skin infections, it remains sensitive to alternative antibiotics, ie clindamycin (Cleocin), trimethoprim-sulfamethoxazole (Bactrim), and doxycycline (unlike hospital-acquired MRSA that may only be sensitive to vancomycin IV).

To prevent recurrent infections due to Staphylococcus, consider the following measures:

  • Topical mupirocin applied to the nares [18]. In this randomized controlled trial, patients used nasal mupirocin twice daily 5 days a month for 1 year.
  • Chlorhexidine baths [19], In a randomized controlled trial, nasal recolonization with S. aureus occurred at 12 weeks in 24% of nursing home residents receiving mupirocin ointment alone (6/25) and in 15% of residents receiving mupirocin ointment plus chlorhexidine baths daily for the first three days of mupirocin treatment (4/27). Although these results did not reach statistical significance, the baths are an easy treatment.

Magnesium Sulphate Paste

Historically abscesses as well as boils and many other collections of pus have been treated via application of magnesium sulfate paste. This works by drawing the infected pus to the surface of the skin before rupturing and leaking out, after this the body will usually repair the old infected cavity. Magnesium sulphate is therefore best applied at night with a sterile dressing covering it, the rupture itself is not painful but the drawing up may be uncomfortable. Magnesium sulphate paste is considered a "home remedy" and is not necessarily an effective or accepted medical treatment.

Treatment Regimen

Splenic abscess

  • 1. Endocarditis, bacteremia[20]
  • 2. Contiguous from intra-abdominal site
  • 2.1. Mild-moderate disease[21]
  • 2.2. Severe life-threatening disease[22]
  • Preferred regimen (1): Imipenem 500 mg IV q6h
  • Preferred regimen (2): Meropenem 1 g IV q8h
  • 3. Immunocompromised[23]
  • Preferred regimen: Amphotericin B 0.7 mg/kg IV daily
  • Alternative regimen (1): Fluconazole 800 mg (12 mg/kg) loading dose, then 400 mg daily IV or PO
  • Alternative regimen (2): Caspofungin 70 mg IV loading dose, then 50 mg IV daily (35 mg for moderate hepatic insufficiency);

References

  1. Stevens DL, Bisno AL, Chambers HF; et al. (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". Clin. Infect. Dis. 41 (10): 1373–406. doi:10.1086/497143. PMID 16231249. Unknown parameter |month= ignored (help)
  2. Anonymous (2005). "Practice guidelines for the diagnosis and management of skin and soft-tissue infections". National Guidelines Clearinghouse.
  3. Hankin A, Everett WW (2007). "Are antibiotics necessary after incision and drainage of a cutaneous abscess?". Annals of emergency medicine. 50 (1): 49–51. doi:10.1016/j.annemergmed.2007.01.018. PMID 17577944. PMID 17577944
  4. Korownyk C, Allan GM (2007). "Evidence-based approach to abscess management". Canadian family physician Médecin de famille canadien. 53 (10): 1680–4. PMID 17934031.
  5. 5.0 5.1 Talan DA, Mower WR, Krishnadasan A, Abrahamian FM, Lovecchio F, Karras DJ; et al. (2016). "Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess". N Engl J Med. 374 (9): 823–32. doi:10.1056/NEJMoa1507476. PMID 26962903.
  6. 6.0 6.1 Llera JL, Levy RC (1985). "Treatment of cutaneous abscess: a double-blind clinical study". Annals of Emergency Medicine. 14 (1): 15–9. doi:10.1016/S0196-0644(85)80727-7. PMID 3880635. Ninety-six percent of the patients in each group were improved clinically after seven days
  7. 7.0 7.1 7.2 Macfie J, Harvey J (1977). "The treatment of acute superficial abscesses: a prospective clinical trial". The British journal of surgery. 64 (4): 264–6. PMID 322789. Among patients who had incision and drainage, none recurred among patients randomized to receive clindamycin whereas 7.3% recurred in those who did not received clindamycin
  8. Rutherford WH, Hart D, Calderwood JW, Merrett JD (1970). "Antibiotics in surgical treatment of septic lesions". Lancet. 1 (7656): 1077–80. PMID 4191960. Unknown parameter |month= ignored (help) Patients randomized to receive cloxacillin has an insignificant trend to improve one half day faster
  9. 9.0 9.1 Anderson J (1958). "Dispensability of post-operative penicillin in septic-hand surgery". Br Med J. 2 (5112): 1569–71. PMC 2028058. PMID 13608051. 17% were penicillin-resistant...Routine post-operative penicillin does not hasten healing in septic lesions of the hand which require surgical treatment Unknown parameter |month= ignored (help) However, this was an insignificant trend towards more complications in the group without antibiotics
  10. 10.0 10.1 Schmitz GR, Bruner D, Pitotti R, Olderog C, Livengood T, Williams J; et al. (2010). "Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection". Ann Emerg Med. 56 (3): 283–7. doi:10.1016/j.annemergmed.2010.03.002. PMID 20346539. 17% failure with TMP/SMX versus 26 failure in placebo. However, not significant - perhaps due to size of the study.
  11. 11.0 11.1 Holmes L, Ma C, Qiao H, Drabik C, Hurley C, Jones D; et al. (2015). "Trimethoprim-Sulfamethoxazole Therapy Reduces Failure and Recurrence in Methicillin-Resistant Staphylococcus aureus Skin Abscesses after Surgical Drainage". J Pediatr. doi:10.1016/j.jpeds.2015.10.044. PMID 26578074.
  12. Rajendran PM, Young D, Maurer T; et al. (2007). "Randomized, Double-Blind, Placebo-Controlled Trial of Cephalexin for Treatment of Uncomplicated Skin Abscesses in a Population at Risk for Community-Acquired Methicillin-Resistant Staphylococcus aureus Infection". Antimicrob. Agents Chemother. 51 (11): 4044–8. doi:10.1128/AAC.00377-07. PMID 17846141.
  13. Ruhe JJ, Smith N, Bradsher RW, Menon A (2007). "Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome". Clin. Infect. Dis. 44 (6): 777–84. doi:10.1086/511872. PMID 17304447. Unknown parameter |month= ignored (help)
  14. Burn JI, Curwen MP, Huntsman RG, Shooter RA (1957). "A trial of penicillin V; response of penicillin-resistant staphylococcal infections to penicillin". Br Med J. 2 (5038): 193–6. PMC 1961881. PMID 13446439. patients were treated in alternate periods of six weeks by injection or penicillin V by mouth...therefore no control group...25% were infected with penicillin resistant strains of Staph. pyogenes Unknown parameter |month= ignored (help)
  15. Duong M, Markwell S, Peter J, Barenkamp S (2009). "Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient". Ann Emerg Med. doi:10.1016/j.annemergmed.2009.03.014. PMID 19409657. Unknown parameter |month= ignored (help)
  16. 16.0 16.1 Talan DA, Lovecchio F, Abrahamian FM, Karras DJ, Steele MT, Rothman RE; et al. (2016). "A Randomized Trial of Clindamycin versus Trimethoprim-Sulfamethoxazole for Uncomplicated Wound Infection". Clin Infect Dis. doi:10.1093/cid/ciw177. PMID 27025829.
  17. Lee MC, Rios AM, Aten MF; et al. (2004). "Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus". Pediatr. Infect. Dis. J. 23 (2): 123–7. doi:10.1097/01.inf.0000109288.06912.21. PMID 14872177. Unknown parameter |month= ignored (help)
  18. Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y (1996). "A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection". Arch Intern Med. 156 (10): 1109–12. PMID 8638999.
  19. Watanakunakorn C, Axelson C, Bota B, Stahl C (1995). "Mupirocin ointment with and without chlorhexidine baths in the eradication of Staphylococcus aureus nasal carriage in nursing home residents". Am J Infect Control. 23 (5): 306–9. PMID 8585642.
  20. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.
  21. Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.
  22. Ferri, Fred (2015). Ferri's Clinical Advisor 2016: 5 Books in 1, 1e (Ferri's Medical Solutions). ISBN 978-0323280471.
  23. Gilbert, David (2015). The Sanford guide to antimicrobial therapy. Sperryville, Va: Antimicrobial Therapy. ISBN 978-1930808843.

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