Treatment options for MRSA.

As medical director for Homeless Health Care Los Angeles, where I run a clinic at a needle exchange on Skid Row, and as a staff physician at the free Venice Family Clinic, where 25% of our patients are homeless, I treat wounds and abscesses on about 10 patients per week ("MRSA Showing No Mercy in Skin Infections," Oct. 1, 2007, p. 41).

I'm not sure why Dr. Mark Lebwohl recommends doxycycline or minocycline as "the top choices" when he already admitted that trimethoprim-sulfamethoxazole "still works almost everywhere." In my experience, TS is inexpensive and well tolerated, and it works very well and quickly. Doxycycline usually has higher resistance rates and works more slowly.

Dr. Lebwohl also recommends routine culture and sensitivity testing, which might be appropriate in an inpatient scenario, but since methicillin-resistant Staphylococcus aureus is so ubiquitous in the community, this is just an added expense to a clinic. We assume the abscesses and cellulitis we see are caused by MRSA and we treat accordingly. I treat all my patients on Skid Row with TS and get great results. In fact, if the abscess is small enough (less than 5 cm), using antibiotics alone is usually adequate instead of incision and drainage. The study that showed antibiotics weren't helpful and that I & D was recommended as first line only also made this recommendation for abscesses less than 5 cm. Thus, I agree with Dr. Lebwohl to be liberal with the use of antibiotics because most large abscesses will have a significant amount of cellulitis that will not improve with I & D alone.

Susan Partovi, M.D.

Los Angeles

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