| Infectious Disease Update |
"Cootie" Corner
| Infectious Disease Updates by Sarmistha B. Hauger, M.D., Specialist in Pediatric Infectious Disease |
Seton Healthcare Network Outpatient Management of Community-
Acquired MRSA Skin and Skin Structure Infections
Definition:
CDC definition of Community-Acquired MRSA infections:
• Diagnosis of MRSA made in the outpatient setting or by culture positive for MRSA within 48 hrs of hospital admission.
• No medical history of MRSA infection or colonization.
• No medical history in the past year of:
o Hospitalization
o Admission to a nursing home, skilled nursing facility, or hospice
o Dialysis
o Surgery
• The patient has no permanent indwelling catheters or percutaneous medical devices.
Background:
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is now an established pathogen in many areas
of the United States. CA-MRSA is typically associated with skin and soft tissue infections, particularly abscesses and cellulitis.
CA-MRSA can also cause serious and life-threatening infections such as, osteomyelitis, septic arthritis, and complicated
pneumonias. Historically, factors which may increase the risk of CA-MRSA infections include, previously healthy, recurrent
skin diseases, living in crowded settings, ethnic minority group, low socioeconomic status, young age, IV drug abuse, and
possibly, recent antibiotic use. Unlike hospital-associated MRSA, CA-MRSA isolates are typically susceptible to trimethoprim-
sulfamethoxazole, clindamycin, tetracyclines, and fluoroquinolones.
The recent increase in CA-MRSA infections at Brackenridge and the Children’s Hospital has prompted the development of
Network treatment recommendations for the management of CA-MRSA infections. Unfortunately, there are no randomized,
placebo-controlled trials or consensus guidelines to aid in the development of these recommendations. The following treatment
recommendations are based on limited case reports, preliminary data from the CDC, and expert opinion of the AIMS
committee.
Seton Healthcare Network Outpatient Management of CA-MRSA Skin and Skin
Structure Infections
1. First line treatment of soft tissue infections is incision, drainage, and local wound care. Antimicrobial therapy may not
be necessary in certain cases.
2.Culture and sensitivities should be obtained in the following situations:
a. All wounds incised and drained
b. Patients requiring antibiotic therapy
3. If antibiotics are indicated, the patient should be treated for a minimum of 7 days.
For suggested empiric therapy in adults and children click here.
Follow-up on culture results is essential to ensure patients are receiving antibiotics to which the MRSA isolate is
susceptible.
4. The utility of MRSA decolonization with mupirocin (Bactroban®), especially in the community
setting, is not yet known; however, recurrent skin infections may be an indication for intranasal mupirocin. See below.
Mupirocin resistance in the setting of widespread use has been reported.
5. Recurrent skin infections, such as furunculosis, may require daily showers/baths with
antibacterial soaps, such as chlorhexidine for 1 month, intranasal mupirocin 2% BID for 7 days, and clindamycin 150
mg PO QD for 3 months (adults).
References:
1. Martinez-Aguilar G, Hammerman WA, Mason EO Jr, Kaplan SL. Clindamycin treatment of invasive infections
caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children.
Pediatr Infect Dis J. 2003 Jul; 22(7): 593-8.
2. Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus
aureus--an emerging problem for the management of skin and soft tissue infections.
Curr Opin Infect Dis. 2003 Apr; 16(2): 103-24.
3. Siberry GK, Tekle T, Carroll K, Dick J. Failure of clindamycin treatment of methicillin-resistant Staphylococcus
aureus expressing inducible clindamycin resistance in vitro. Clin Infect Dis. 2003 Nov 1; 37(9): 1257-60.
4. CDC MRSA Fact Sheet. www.cdc.gov/incidod/hip/aresist/mrsafaq.htm
5. Infectious Disease Society of America Annual Meeting, October 2003. Update on the IDSA Guidelines for the
Treatment of Skin and Skin Structure Infections.
Acquired MRSA Skin and Skin Structure Infections
Definition:
CDC definition of Community-Acquired MRSA infections:
• Diagnosis of MRSA made in the outpatient setting or by culture positive for MRSA within 48 hrs of hospital admission.
• No medical history of MRSA infection or colonization.
• No medical history in the past year of:
o Hospitalization
o Admission to a nursing home, skilled nursing facility, or hospice
o Dialysis
o Surgery
• The patient has no permanent indwelling catheters or percutaneous medical devices.
Background:
Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is now an established pathogen in many areas
of the United States. CA-MRSA is typically associated with skin and soft tissue infections, particularly abscesses and cellulitis.
CA-MRSA can also cause serious and life-threatening infections such as, osteomyelitis, septic arthritis, and complicated
pneumonias. Historically, factors which may increase the risk of CA-MRSA infections include, previously healthy, recurrent
skin diseases, living in crowded settings, ethnic minority group, low socioeconomic status, young age, IV drug abuse, and
possibly, recent antibiotic use. Unlike hospital-associated MRSA, CA-MRSA isolates are typically susceptible to trimethoprim-
sulfamethoxazole, clindamycin, tetracyclines, and fluoroquinolones.
The recent increase in CA-MRSA infections at Brackenridge and the Children’s Hospital has prompted the development of
Network treatment recommendations for the management of CA-MRSA infections. Unfortunately, there are no randomized,
placebo-controlled trials or consensus guidelines to aid in the development of these recommendations. The following treatment
recommendations are based on limited case reports, preliminary data from the CDC, and expert opinion of the AIMS
committee.
Seton Healthcare Network Outpatient Management of CA-MRSA Skin and Skin
Structure Infections
1. First line treatment of soft tissue infections is incision, drainage, and local wound care. Antimicrobial therapy may not
be necessary in certain cases.
2.Culture and sensitivities should be obtained in the following situations:
a. All wounds incised and drained
b. Patients requiring antibiotic therapy
3. If antibiotics are indicated, the patient should be treated for a minimum of 7 days.
For suggested empiric therapy in adults and children click here.
Follow-up on culture results is essential to ensure patients are receiving antibiotics to which the MRSA isolate is
susceptible.
4. The utility of MRSA decolonization with mupirocin (Bactroban®), especially in the community
setting, is not yet known; however, recurrent skin infections may be an indication for intranasal mupirocin. See below.
Mupirocin resistance in the setting of widespread use has been reported.
5. Recurrent skin infections, such as furunculosis, may require daily showers/baths with
antibacterial soaps, such as chlorhexidine for 1 month, intranasal mupirocin 2% BID for 7 days, and clindamycin 150
mg PO QD for 3 months (adults).
References:
1. Martinez-Aguilar G, Hammerman WA, Mason EO Jr, Kaplan SL. Clindamycin treatment of invasive infections
caused by community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus in children.
Pediatr Infect Dis J. 2003 Jul; 22(7): 593-8.
2. Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus
aureus--an emerging problem for the management of skin and soft tissue infections.
Curr Opin Infect Dis. 2003 Apr; 16(2): 103-24.
3. Siberry GK, Tekle T, Carroll K, Dick J. Failure of clindamycin treatment of methicillin-resistant Staphylococcus
aureus expressing inducible clindamycin resistance in vitro. Clin Infect Dis. 2003 Nov 1; 37(9): 1257-60.
4. CDC MRSA Fact Sheet. www.cdc.gov/incidod/hip/aresist/mrsafaq.htm
5. Infectious Disease Society of America Annual Meeting, October 2003. Update on the IDSA Guidelines for the
Treatment of Skin and Skin Structure Infections.
