A 42-year-old woman has had tenderness and pain in the upper outer quadrant of her right breast, several centimeters below the axilla, for about a week. These symptoms have worsened, and she has noted progressive redness, induration, and swelling of the breast. For the past 48 hours, she has also had a fever.
The patient has insulin-dependent type 2 diabetes; her blood glucose level is moderately well controlled. Four months earlier, she had folliculitis with abscess formation in the same breast/axillary area. Surgical drainage and several weeks of dressing changes were required to achieve resolution. When the patient was younger, she used intravenous drugs and alcohol excessively, but she has not done so for several years.
Temperature is 38.5°C (101.3°F); heart rate, 108 beats per minute, with regular rhythm and no gross murmurs; respiration rate, 14 breaths per minute, with oxygen saturation of 98% on room air; and blood pressure, 130/88 mm Hg. Examination of the head, ears, eyes, nose, and throat reveals no abnormalities. Chest is clear.
The right breast is swollen, red, and warm. On the lateral side of the breast, there is a shiny and very tender indurated area that suggests localization; however, an obvious abscess has not yet formed. Several soft, tender lymph nodes are palpable in the axilla.
Results of a chemistry panel are normal except for the blood glucose level, which is 330 mg/dL. There is no anion gap. Hemoglobin level is 12.8 g/dL, and the white blood cell (WBC) count is 19,800/µL, with 6% band forms.
Which of the following is most appropriate for this patient?
A. Oral linezolid.
B. Intravenous cefazolin.
C. Oral trimethoprim/sulfamethoxazole (TMP/SMX).
D. Intravenous vancomycin.
1. Fridkin SK, Hageman JL, Morrison M, et al. Methicillin-resistant Staphylococcus
aureus disease in three communities. N Engl J Med. 2005;352:1436-1444.
2. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing
risk. JAMA. 1998;279:593-598.
3. Miller LG, Perdreau-Remington F, Reig G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles.
N Engl J Med. 2005;352:1445-1453.
4. Chambers HF. Community-associated MRSA—resistance and virulence converge.
N Engl J Med. 2005;352:1485-1487.