A practical guide to community-acquired MRSA

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Case Reports

A practical guide to community-acquired MRSA

J Fam Pract. 2013 November;62(11):624, 626-629

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References

1. Özel G, Aslan V, Bahar Erdem G, et al. Comparison of oxacillin, cefoxitin, ceftizoxime, and moxalactam disk diffusion methods for detection of methicillin susceptibility in staphylococci. Mikrobiyol Bul. 2011;45:258-265.

2. Crum NF, Lee RU, Thornton SA, et al. Fifteen-year study of the changing epidemiology of methicillin-resistant Staphylococcus aureus. Am J Med. 2006;119:943-951.

3. Skov R, Christiansen K, Dancer SJ, et al. Update on the prevention and control of community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA). Int J Antimicrob Agents. 2012;39:193-200.

4. Dantes R, Mu Y, Belflower R, et al. National burden of invasive methicillin-resistant Staphylococcus aureus infections, United States, 2011. JAMA Intern Med. September 16, 2013. Available at: http://archinte.jamanetwork.com/article.aspx?articleid=1738718. Accessed October 15, 2013.

5. Kawaguchiya M, Urushibara N, Kuwahara O, et al. Molecular characteristics of community-acquired methicillin-resistant Staphylococcus aureus in Hokkaido, northern main island of Japan: identification of sequence types 6 and 59 Panton-Valentine leucocidin-positive community-acquired methicillin-resistant Staphylococcus aureus. Microb Drug Resist. 2011;17:241-250.

6. Wiener-Kronish JP, Pittet JF. Therapies against virulence products of Staphylococcus aureus and Pseudomonas aeruginosa. Semin Respir Crit Care Med. 2011;32:228-235.

7. Hansra NK, Shinkai K. Cutaneous community-acquired and hospital-acquired methicillin-resistant Staphylococcus aureus. Dermatol Ther. 2011;24:263-272.

8. Elston DM. Community-acquired methicillin-resistant Staphylococcus aureus. J Am Acad Dermatol. 2007;56:1-16; quiz 17-20.

9. Salgado CD, Farr BM, Calfee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis. 2003;36:131-139.

10. Gorwitz RJ. A review of community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections. Pediatr Infect Dis J. 2008;27:1-7.

11. Klevens RM, Morrison MA, Nadle J, et al; Active Bacterial Core Surveillance (ABCs) MRSA Investigators. Invasive methicillinresistant Staphylococcus aureus infections in the United States. JAMA. 2007;298:1763-1771.

12. NeVille-Swensen M, Clayton M. Outpatient management of community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infection. J Pediatr Health Care. 2011;25:308-315.

13. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52:285-292.

14. Diagnosis and testing for MRSA infections. Centers for Disease Control and Infection Web site. Available at: http://www.cdc.gov/mrsa/diagnosis/index.html. Accessed September 30, 2013.

15. Buehlmann M, Frei R, Fenner L, et al. Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers. Infect Control Hosp Epidemiol. 2008;29:510-516.

16. Simor AE, Phillips E, McGeer A, et al. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44:178-185.

How to manage recurrent infections

Management of recurrent CA-MRSA SSTIs in the outpatient setting poses a challenge. Following successful treatment of active infection, you may want to attempt decolonization in select patients. Those with repeated MRSA infections despite adequate hygiene measures or with a high probability of reexposure to colonized close contacts may be treated, although the evidence supporting such protocols is lacking.^8,13

Acceptable procedures described by IDSA include nasal mupirocin twice daily for 5 to 10 days, mupirocin plus topical antiseptic solution (eg, chlorhexidine, triclosan, or povidone-iodine) for 5 to 14 days, or mupirocin plus dilute bleach baths (1 teaspoon bleach/gallon of water) twice weekly for 15 minutes over 3 months.¹³ Although antibiotics are generally only recommended for active infection, the combination of rifampin and an antibiotic with MRSA coverage may be used for 1 to 2 weeks in cases of recurrent infections despite recommended hygiene and topical decolonization measures.^13,15,16 Rifampin is not recommended as monotherapy for MRSA infection or decolonization.¹³

Unfortunately, even in cases where eradication is initially successful, about half of those with subsequent negative MRSA cultures will test positive before the end of a year.¹⁶ With recurrent or severe infections or immunocompromised patients, it’s advisable to consider an infectious disease consult.

CASE › The patient’s lesion did not require incision as it was already draining. He received a prescription for doxycycline hyclate 100 mg BID for 7 days (since there was evidence of rapidly progressing cellulitis) and was instructed to return to the clinic in 48 hours.

When he returned to the clinic, the patient stated that the pain had improved and the wound was no longer oozing. Culture results confirmed MR SA sensitive to TMP-SMX, doxycycline, and clindamycin. Examination showed improved erythema, a dry wound, and no pain on palpation. He was given a patient information handout on MRSA infection and advised to return to the clinic if the wound did not completely heal within the next 7 days.