COMMENTARY

When Staph Won't Go Away: Recurrent Boils

Part 2

Paul G. Auwaerter, MD

Disclosures

January 18, 2012

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Hi. I am Paul Auwaerter, from Johns Hopkins University School of Medicine, for Medscape Infectious Diseases. This is part 2 of [what to do] "When Staph Won't Go Away." Part 1 covered persistent bacteremia and consideration of different treatment options, but today I will discuss a more pedestrian problem.

One of our most frequent outpatient consultations is from physicians referring patients for recurrent boils. This problem might be worth a few minutes, especially since the Infectious Disease Society of America (IDSA) has issued methicillin-resistant Staphylococcus aureus (MRSA) treatment guidelines,[1] which include a small section on recurrent skin- and soft-tissue infections due to MRSA.

For many of us, the concept of recurrent staphylococcal infections might boil down to nasal colonization or colonization in other areas of the skin. Studies suggest that approximately 20% of people are persistently colonized with staphylococcus, and another 30% are intermittently colonized; why the other 50% are not remains an enigma. The thought is that if we can decolonize these patients, perhaps they would experience fewer of these recurrent infections that can be quite bothersome.

The recommendations given in the IDSA guidelines include maintaining good personal hygiene as well as cleaning high-touch surfaces (for example, in the bathroom or doorknobs) with commercial cleansers to reduce staphylococcal transmission. However, the decolonization strategies include using topical mupirocin in the nares, where staphylococcus might be frequently carried, as well as consideration of using mupirocin with antibacterial soap such as chlorhexidine for periods of 5-14 days, or taking dilute bleach baths, which might be a cheaper option because you could dump a quarter cup of bleach in approximately 13 gallons of water in your bathtub and take a soak.

Andrew Simor has just written a very thoughtful appraisal of many recommendations, published in the December issue of Lancet Infectious Diseases,[2] noting that these recommendations carry an evidence grade of "C," meaning that the evidence is from small trials and those trials have mixed results.

The evidence for trying to decolonize at all, as Dr. Simor points out, has not shown great impact in reducing infections even when examined in populations such as cardiac surgical patients or patients on dialysis. So, what should you do with your patient in the office who has a recurrent staphylococcal infection? Personally, I do make some effort to decolonize the patient; if anything, this reinforces the aspects of trying to maintain good and better hygiene. I use mupirocin and chlorhexidine or hexachlorophene soaps. When patients have recalcitrant infections, I advance to what I call "phase B" and try to be certain that their partners or household members also have taken baths or even have attempted some mupirocin ointment eradication. I typically recommend 5 days out of every month for the mupirocin treatment for a period of 3-4 months.

After that, in many patients, the storm passes. The tendency towards recurrent infection seems to be in a very small minority of patients. This can result in a greater struggle, and occasionally I will prescribe systemic antibiotic therapy, often minocycline or doxycycline plus rifampin. Very little good evidence supports this in a regular population of patients, but it may have some role; whether it will work for your patient, you will have to see.

Many patients are quite frustrated by this, but with some care and attention, usually they improve. Hopefully, some better and larger trials might help answer some of these questions about management, but until then, the approach is often individualized. For many patients, host factors are likely to be more important (which we don't completely understand) than any genuine antimicrobial strategy.

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