MRSA un-complicated soft tissue infection - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Next review: 01/02/2028  
Clinical Guideline
ID: 2258 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2023  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

MRSA uncomplicated skin and soft tissue infection treatment in Primary Care in adults

Skin and soft tissue infections (SSTI) are the most common presentation of MRSA (meticillin-resistant Staph. Aureus) infection, although it can also cause severe, invasive disease. This guideline is for the treatment of uncomplicated skin and soft tissue infection (eg cellulitis, erysipelas, abscess) with MRSA.
It is not applicable to patients with evidence of systemic illness (such as sepsis), necrotising /deep tissue infections, superficial infections (such as pustules and papules), hidradenitis suppurativa, or immunocompromising conditions.

Staphylococcus aureus, including MRSA, is one of the most common pathogens that cause cellulitis/abscesses. MRSA is resistant to penicillin-related antibiotics such as flucloxacillin and most cephalosporins and may be resistant to other antibiotic classes. Lack of response to empiric antibiotics may be due to MRSA.


  • Minor skin and soft tissue infections (SSTIs) (furunculosis, folliculitis, small boils without cellulitis) do not need systemic antibiotic treatment.
  • Non-severe/uncomplicated cellulitis with no systemic illness may be treated with oral antibiotics but consider the need for iv antibiotics/admission for assessment if there are risk factors for treatment failure or poor outcome (cellulitis affecting face or perineum, frail/aged >80 , previous splenectomy, chronic renal or liver disease, immunocompromised, alcohol abuse, treatment failure in the community, diabetes mellitus, chronic venous insufficiency, morbid obesity).
  • Abscesses - incision and drainage is the optimal management for abscesses.     
  • Larger abscesses (> 5cm), multiple abscesses, systemic features of infection, surrounding cellulitis and immunocompromised patients should be treated with oral antibiotics in addition to drainage.
  • small abscesses - consider additional use of antibiotics - discuss potential benefits and side-effects with the patient (antibiotics may reduce risk of treatment failure and recurrence but there is a risk of antibiotic-related side-effects)


 If active infection with MRSA confirmed by lab results, and admission not warranted:

Use sensitivities on report to guide treatment; If no response to treatment, seek advice from Microbiology.

If active infection and patient has MRSA risk factors (see below), and admission not warranted:

  • MRSA should be considered when choosing empirical (best guess) antimicrobial treatment regimens for infection
  • The treatment options below are suitable empirical treatment for uncomplicated SSTI where MRSA is suspected - confirm sensitivities with cultures and adjust antibiotic treatment accordingly.

Risk factors for MRSA infection include:

  • patients who are/have been colonised with MRSA (from screening swabs);
  • patients who have had previous MRSA infections
  • being a resident of a long-term care facility (care home, or any other long term residential facility)
  • patients who have recently been in hospital
prior antibiotic use, particularly cephalosporins and fluoroquinolones.

 Preferred Option

Alternative Option


Doxycycline initially 200 mg daily for 1 dose, then maintenance 100 mg once daily PO 5 days (may be extended up to 14 days depending on clinical response).
200mg od may be used for severe infections.

Co-trimoxazole (contains trimethoprim and sulfamethoxazole) (trimethoprim/sulfamethoxazole) 960mg twice daily PO 5 days (may be extended up to 14 days depending on clinical response) (see BNFc for dosing in children >6 weeks old)
Clindamycin 300 qds PO 5 days (may be extended up to 14 days depending on clinical response).
(see BNFc for dosing in children)

Clarithromycin 500mg bd PO 5 days
(Erythromycin 500mg qds in pregnancy)
(may be extended up to 14 days depending on clinical response).
(see BNFc for dosing in children)

Check the MRSA is susceptible - see culture sensitivity report.
Doxycycline contraindicated in pregnancy and <12years
Co-trimoxazole (contains trimethoprim and sulfamethoxazole) may slightly increase the risk of congenital malformations, including neural tube defects, when prescribed to pregnant women
Clindamycin is considered safe in pregnancy but has a higher risk of diarrhoea

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.


Approximately 1/3 people carry Staphylococcus aureus on their skin/nasal passages. About 10% of these will be MRSA. Antibiotics are not indicated for MRSA colonisation. A topical decolonisation regime may be indicated for MRSA colonisation in some circumstances; decolonisation should be administered according to local screening and decolonisation protocols (d/w community Infection Prevention & Control team or Microbiologist).

Microbiological Samples
Identifying the infecting pathogen may not be necessary for treating uncomplicated skin infections but cultures may be helpful in patients with recurrent abscesses or where there is lack of response to empiric antibiotics. A microbiological diagnosis of cellulitis is often not possible. If there is no wound/skin break, pus or discharge to swab, a skin swab is unlikely to identify the microbiological cause of cellulitis. Send a swab for microbiological culture and sensitivity if there is a wound or penetrating injury, pus or discharge, if there has been exposure to a water-borne organism, if the infection was acquired outside the UK, if there has been no response to empirical treatment or for recurrent infections.

Recurrent skin infections may be due to Panton-Valentine Leukocidin - Staphylococcus aureus (PVL-SA). Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and is excreted by some strains of Staphyloccus aureus including both Meticillin Resistant (MRSA) and Meticillin Sensitive Staphyloccus aureus (MSSA). PVL has been

strongly associated epidemiologically with virulent, transmissible strains of S.aureus, including community-associated (CA) MRSA. Consider testing for PVL-SA if there is a history of recurrent SSTI (the request should give relevant history; staphylococcus aureus isolated from samples may be referred to the Reference lab for PVL detection by WGS). Decolonization may be indicated for patients with PVL-SA skin infections and their family members and should be discussed with community Infection Prevention & Control team or with the Microbiologist.


Record: 2258
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

MRSA un-complicated soft tissue infection

Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

Evidence base

Daum RS, Miller LG, Immergluck L, et al. A Placebo-Controlled Trial of Antibiotics for Smaller Skin Abscesses. The New England journal of medicine 2017; 376(26): 2545-55.

Fahimi J, Singh A, Frazee BW. The role of adjunctive antibiotics in the treatment of skin and soft tissue abscesses: a systematic review and meta-analysis. CJEM 2015; 17(4): 420-32.

Talan et al., Trimethoprim-sulfamethoxazole versus placebo for uncomplicated skin abscess. N Engl J Med2016;374:823-32.doi:doi:10.1056/NEJMoa1507476.pmid:26962903

Wang W et al. Antibiotics for uncomplicated skin abscesses: systematic review and network meta-analysis. BMJ Open 2018;8:e020991

Document history

LHP version 1.0

Related information

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