Methicillin-Resistant Staphylococcus aureus : a clinical policy
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DESCRIPTIONMethicillin-Resistant Staphylococcus aureus : a clinical policy. John M. Howell, MD, FACEP, FAAEM Best Practices, Inc Inova Fairfax Hospital Department of Emergency Medicine June 25 - 27, 2009. Sometimes MRSA can be intimidating. Even a little scary. But we can usually get what we want. - PowerPoint PPT Presentation
Methicillin-Resistant Staphylococcus aureus: a clinical policyJohn M. Howell, MD, FACEP, FAAEMBest Practices, IncInova Fairfax HospitalDepartment of Emergency MedicineJune 25 - 27, 2009
Sometimes MRSA can be intimidating
Even a little scary
But we can usually get what we want
Lets start with two cases that will lead up to our clinical question.
8 year old boy with ankle painTwisted his ankle playing basketball 6 days priorLateral ankle swellingXray negativeDischarged with ankle sprain
Returns to the ED 3 days laterTemperature 102oFTachycardicLower leg swollen from the knee to the foot, brawny-red appearanceWarm and tender lower legWBC 9,800/mm3CRP - 45
And the MRI shows
In retrospect, there was no history of skin lesion or trauma, although the child did play basketball frequently.
Seven Year Old Male with Cough and Fever3 days of cough, fever, and abd painDecreased intakePMH: ED visit 1/12/08, left hip abscess, grew MRSA, treated with clindamycinBP 104/55; P 118/min, RR 20/min, T 99.7, pulse ox 95% on RA
Seven Year Old with Cough and Fever: Physical ExamWD/WN, alert and laying quietlyHEENT: NormalResp: Tachypnea, nasal flaring, rales L lungCV: TachycardicAbd: Soft, diffusely tender without guarding. Normal BSsSkin: No rashNeuro: Non-focal examination
Seven Year Old with Cough and Fever: Diagnostic StudiesWBC: 20,000, 81S, 12L, 6M, 1EH/H 10.5/32; Plat 382Chemistry: K 3.0Flu Swab: Negative
Seven Year Old with Cough and Fever: Clinical CourseIn ED, child became more SOBpulse ox dropped to 92%.Given IV fluids, Rocephin, ClindamycinAdmitted to IFH PICURemained 12 days. Blood cultures: MRSAChest CT pulmonary consolidation with pleural effusion
MRSA OverviewNosocomial MRSA has been around since the 1960s.Community acquired MRSA became a problem in the 1990s.Although CA MRSA is more virulent, it is usually sensitive to more antimicrobials.
MRSA Virulence FactorsType IV SCC mec - mechanism for antimicrobial resistance
Panton Valentine Leukocidin (PVL) Pokes holes in leukocytesMore prominent in CA MRSAAssociated with pneumonia and severe skin infections
MRSA Community Acquired PneumoniaJan 2007 10 cases of MRSA CAP in healthy kids during flu season: 6 deathsAssociation with flu was either by lab test or clinical presentationAll MRSA isolates positive for PVLAll had 3-4 day interval between presentation and severe illness or death4/10 had documented MRSA in themselves or contacts
So if we know that MRSA has varying levels of antimicrobial resistance and, via PVL, can cause severe disease
Clinical QuestionShould skin abscesses be treated routinely by I and D followed by a course of oral antibiotics that cover MRSA?
Following I and D of a skin abscess, I A. Do not routinely prescribe oral antibioticsB. Routinely prescribe oral antibiotics that cover MRSAC. Routinely prescribe oral antibiotics that cover MSSA (e.g., cephalexin)D. Routinely prescribe oral antibiotics only for pateints with immune compromise
Lets look at the literature
Rajendran et al, J Am Coll Surg, 2006Prospective placebo controlled trial of cephalexin following I and D50% MRSA incidenceHigh prevalence of HIV and other immune issuesIn the MRSA subgroup (about 50 subjects), the rates of abscess recurrence were 88% and 89% for cephalexin vs. placebo.
Lee et al, Pediatr Infect Dis, 2004Prospective observational study of 67 children with MRSA skin abscesses5 treated with appropriate antibiotics, 62 with discordant antibiotics At follow up, all 5 with appropriate therapy improved, but 58 of 62 (94%) in discordant group improved. Most who did not improve were admitted.
Moran et al, NEJM, 2006Prospective cohort of patients with abscesses in an ED78% of staph isolates were MRSAAbout 400 subjects, but 40% dropped out or were excludedNo difference in recurrence rates for concordant and discordant antibioticsTreatment not standardized and many subjects either not included or lost to follow up
Paydar et al, Arch Surg, 2006Restrospective cohort of 280 patients with MRSA abscessesWhen corrected for intention to treat, 99% cure rate for concordant therapy, and 92% cure rate for discordant antimicrobial treatment.
Clinical PolicyGuidelines (2008) for the prophylaxis and treatment of MRSA infections in the United KingdomJournal of Antimicrobial ChemotherapyAntibiotic therapy is not generally required after the I and D of small (< 5 cm) abscesses without surrounding cellulitis.
Clinical PolicyThis clinical policy bases its recommendation on one reference, Rajendran.Prospective cohort of about 50 MRSA abscesses treated with cephalexin or placebo, which found no difference in recurrence rates
I dont know about you, but this can all be a lot to take in
And so, knowing that:MRSA isolates occur frequentlyA small number of patients with MRSA skin infections may develop serious pneumonia, necrotizing fasciitis, and osteomyelitisThe literature is what it is
Where is your acceptable level of risk?Given the risk of distant infection, how many times out of one hundred are you willing to under treat a MRSA skin infection?
1, 2, 5, 10 ???
Our final step is to write a management recommendation for our clinical policy on the treatment of cutaneous abscesses.
Pick one of the following clinical policy recommendations:A. Routinely prescribe oral antibiotics that cover MRSA following I and D of cutaneous abscesses.B. Routinely prescribe oral antibiotics that cover MSSA following I and D of cutaneous abscesses.C. No not routinely prescribe oral antibiotics following I and D of cutaneous abscesses.D. Prescribe oral antibiotics that cover MRSA, following I and D of cutaneous abscesses, only for patients with immune competency issues (e.g., HIV, DM, PVD).
If I did choose to treat, I would prescribe:ClindamycinDoxycyclineTrimethoprim/SulfamethoxasoleCepahlexinAugmentin