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Eric Bosley, MDLaura Stadler, MDJ h D MD

MRSA: A TEAM APPROACHJohn Draus, MD

PART I: OUTPATIENT ISSUES AND MANAGEMENT NOT REQUIRING I&D OR HOSPITALIZATION

Eric L. Bosley, MD, FAAPPediatric Associates, PSCCrestview Hills, KYPresident, Kentucky Chapter of the AAP

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MRSAHISTORICAL PERSPECTIVE

Methicillin-resistant strains of Staphylococcus aureus (MRSA) were first recognized in 1961, one year after the antibiotic methicillin was introduced for treating S. aureus infections

The first documented MRSA outbreak in the United States occurred at a Boston hospital in 1968.

For the next two decades most MRSA infections occurred in persons who had contact with hospitals or other healthcare settings

Beginning in the 1990s community associated MRSA (CA MRSA) infections emerged in persons having none of the risk factors infections emerged in persons having none of the risk factors associated with MRSA in the past. Genetic and epidemiologic evidence shows that CA MRSA is caused by strains of S. aureus different from those associated with HA MRSA.

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HOSPITAL VS. COMMUNITY ASSOCIATED MRSA

HA-MRSA CA-MRSA

H l h Y NHealth care contact Yes NoMean age at infection Older YoungerSkin and soft tissue infections 35% 75%Antibiotic resistance Many agents Some agentsResistance gene SCCmec Types I, II,III SCCmec Type IV, VStrain type USA 100 and 200 USA 300 and 400400PVL toxin gen Rare (5%) Frequent (almost 100%)

RISK FACTORS FOR CA-MRSA INFECTIONS

• History of MRSA infection or colonization in patient or close contact • High prevalence of CA MRSA in local community or patient population • Recurrent skin disease such as eczema • Recurrent skin disease such as eczema • Crowded living conditions (e.g. homeless shelters, military barracks) • History of incarceration • Participation in contact sports • Skin or soft tissue infection with poor response to B-lactam antibiotics • Recent and/or frequent antibiotic use • Injection drug use • Member of Native American, Pacific Island, Alaskan Native populations • Child under 2 years of age • Male with history of having sex with men • Shaving of body hair

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PRESENTATIONS OF MRSA IN OUTPATIENT SETTING THAT DO NOT WARRANT I&D

Cellulitis Impetigo Folliculitis Boil/Furuncle

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CELLULITIS

CELLULITIS

Nonpurulent cellulitis is characterized by area of erythema, edema, warmth, tenderness to palpation, but no fluctuance, , , p p , ,drainage, or central area of pus

While MRSA is an emerging cause of cases of cellulitis overall, many nonpurulent cases of cellulitis are still caused by streptococcus spp. or MSSA

Treatment of nonpurulent cellulitis consists of antibiotic coverage for Streptococcus spp. and/or other suspected coverage for Streptococcus spp. and/or other suspected pathogens, followed by close follow-up, and possible addition of coverage for MRSA if patient does not respond.

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IMPETIGO

BULLOUS IMPETIGO

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IMPETIGO Impetigo is common infection of discrete lesions that are nearly always

caused by β-hemolytic streptococci and/or S. aureus. Nonbullous impetigo is a superficial skin infection that manifests as clusters of vesicles or pustules that rupture and develop a honey-colored crust. p p p yBullous impetigo is a superficial skin infection that manifests as clusters of vesicles or pustules that enlarge rapidly to form bullae. The bullae burst and expose larger bases, which become covered with honey-colored varnish or crust.

Peak incidence in amongst children ages 2-5, although other ages are affected.

Nonbullous impetigo was traditionally caused by streptococcus spp., but g y ynow are more commonly caused by Staphylococcus spp. alone or mixed Staph and Strep spp. Bullous Impetigo is caused by toxin producing Staph Aureus strains with MRSA strains increasing in frequency.

Treatment involves Gentle cleansing, removal of the honey-colored crusts of nonbullous impetigo using antibacterial soap and a washcloth as well as topical antibiotics.

Treatment involves Gentle cleansing, removal of the honey-colored crusts of nonbullous impetigo using antibacterial soap and a washcloth as well as topical antibiotics.

Topical antibiotics alone are often adequate for mild cases while combination topical and systemic antibiotics are used in cases of bullous impetigo, more significant, or poorly responding cases.

Mupirocin with a penicillinase-resistant penicillin or first-generation cephalosporin is considered adequate in most cases where both topical and systemic treatment is required but systemic coverage for MRSA may be needed in some refractory cases.

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FOLLICULITIS

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FOLLICULITIS

Infection in the hair follicles It usually is caused by bacteria It also can be caused by It usually is caused by bacteria. It also can be caused by

yeast or another type of fungus. most common on the face and scalp and areas rubbed

by clothing, such as the thighs and groin "Hot tub folliculitis" most often appears about 72 hours

after you've been in a hot tub or spa. Many small pimples appear on your stomach and sometimes on pimples appear on your stomach and sometimes on your arms and legs. You might have a mild fever and have an upset stomach. Most of the time, this kind of folliculitis goes away on its own in 7 to 10 days.

RISK FACTORS FOR FOLLICULITIS

Use a hot tub, whirlpool, or swimming pool that is not properly treated with chlorine.

Wear tight clothes. Use antibiotics or steroid creams for long periods. Use or work with substances that can irritate or block the

follicles. Examples include makeup, cocoa butter, motor oil, tar, and creosote.

Have an infected cut, scrape, or surgical wound. The bacteria or fungi can spread to nearby hair follicles.or fungi can spread to nearby hair follicles.

Have a disease such as diabetes or HIV that lowers your ability to fight infection

Shaving

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FOLLICULITIS

Treatment can often be accomplished at home and includes such measures as warm compresses pmade with white vinegar or Burow's solution. These may ease itching and help healing. Medicated shampoo. It can be used to treat folliculitis on the scalp or beard.

Failures of these measures may indicate presence of MRSA (or Fungal infection) and use of topical ( g ) pmupirocin can be tried with addition of systemic anti-MRSA antibiotics added if poor response to topical treatment.

BOIL/FURUNCLE

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STYE

BOIL/FURUNCLE

For small furuncles, moist heat, which helps to promote drainage, may be sufficient treatment

It remains controversial whether antibiotics provide any clinically significant additional benefit, but incision and drainage is likely adequate for most simple abscesses. Multiple, mostly observational studies indicate high cure rates (85%–90%) whether or not an active antibiotic is used. Two recently published randomized clinical trials involving adult and pediatric patients showed no g p psignificant difference in cure rates when TMP-SMX was compared with placebo; however, there was a suggestion that antibiotics may prevent the short-term development of new lesions.