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Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA)

Appendix D. Part 1: MRSA: Epidemiology and Treatment


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MRSA: Epidemiology & Treatment

This and all following slides have the logo of the Department of Health and Human Services and Centers for Disease Control.

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MRSA: Epidemiology & Treatment: Points of this Talk

  • MRSA is primarily healthcare-associated.
  • Community-acquired MRSA think skin infections.
  • Drainage: "not just a good idea, it's the law".
  • If you can culture it, you should.
  • Fever + skin infection = blood culture.
  • Pos blood cultures for S. aureus = admission.
  • In 2009, Empiric Rx for skin should cover MRSA.
  • For non-cultured skin, consider Septra + Beta lactam.

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Acknowledgements:

Slides from Rachel Gorwitz, MD, MPH
Centers for Disease Control

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Staphylococcus aureus

  • Staphylococcus aureus: common cause of infection in the community
  • Methicillin-resistant Staphylococcus aureus (MRSA):
    • Increasingly important cause of healthcare-associated infections since 1970s
    • In 1990s, emerged as cause of infection in the community

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A Single Pulsed-Field Type (USA300) has Accounted for Most Community-Associated MRSA Infections in the United States

  • Pneumonia (AL, AR, IL, MD, TX, WA)
  • Missouri, California, Pennsylvania, and Colorado athletes
  • Mississippi, Texas, Georgia, and Tennessee prisoners
  • Texas, Missouri, and California's children.
  • USA300-114 community

USA300 covers about 90 percent of the chart. The two strains below cover about 10 percent of the chart.

  • USA100—hospital strain
  • USA200—hospital strain

Image: The chart shows an ink stain used for genotyping by mapping out the separate bands of the bacteria.

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Outbreaks of MRSA in the Community

 

Outbreaks of MRSA in the Community

  • Often first detected as clusters of abscesses or "spider bites".
  • Various settings:
    • Sports participants
    • Inmates in correctional facilities
    • Military recruits
    • Daycare attendees
    • Native Americans / Alaskan Natives
    • Men who have sex with men
    • Tattoo recipients
    • Hurricane evacuees in shelters

Images: Football game, soccer game, prison, soldier in training, group of young children.

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Map showing range of Recluse (genus Loxosceles) spiders in the United States

  • The range of Recluse spiders covers the northwest tip of Florida, eastern Georgia, Alabama, Mississippi, Louisiana, northeast Texas, most of Oklahoma, Arkansas , most of Kansas, Missouri, southern Iowa, southern Illinois, southern Indiana, southern Ohio, Kentucky, and Tennessee.
  • The range of Devia spiders covers southern Texas. The range of blanda covers southwest Texas and southeast New Mexico.
  • The range of Apaches spiders covers southern New Mexico and southeast Arizona.
  • The range of Arizonica spiders covers southwest Arizona.
  • The range of Deserta covers western Arizona, southern Nevada, and southeast California.

spiders.ucr.edu

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Images of Methicillin-resistant Staphylococcus aureus on the leg of an evacuee from Hurricane Katrina—Dallas, Texas, September 2005. Photo: P Hicks, Children's Medical Center of Dallas. Photograph of Staphylococcus aureus on face of boy, on arm, and on shoulder.

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Factors that Facilitate Transmission

Crowding

< p>Image: crowded barracks.

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Factors that Facilitate Transmission

  • Crowding
  • Frequent contact

Image: crowded barracks, game plan.

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Factors that Facilitate Transmission

  • Crowding
  • Frequent contact
  • Compromised skin

Image: crowded barracks, game plan, legs with sores.

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Factors that Facilitate Transmission

  • Crowding
  • Frequent contact
  • Compromised skin
  • Contaminated surfaces and shared items

Image: crowded barracks, game plan, legs with sores, man covering head with shirt.

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Factors that Facilitate Transmission

  • Crowding
  • Frequent contact
  • Compromised skin
  • Contaminated surfaces and shared items
  • Cleanliness

Image: crowded barracks, game plan, legs with sores, dirty hands, man covering head with towel, dirty hands.

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Factors that Facilitate Transmission

  • Crowding
  • Frequent contact
  • Compromised skin
  • Contaminated surfaces and shared items
  • Cleanliness
  • Antimicrobial use

Image: crowded barracks, game plan, legs with sores, dirty hands, view of bacteria under microscope, open pill bottle.

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CA-MRSA Infections are Mainly Skin Infections

Disease Syndrome(%)
Skin/soft tissue1,266 (77%)
Wound (Traumatic)157 (10%)
Urinary Tract Infection64 (4%)
Sinusitis61(4%)
Bacteremia43 (3%)
Pneumonia31 (2%)

Image: two arms with MRSA infections.

Fridkin et al NEJM 2005;352:1436-44

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CA-MRSA Incidence Varies by Age and Race

Graph 1: Atlanta, 2001-2002, Incidence, (26 per 100,000)

AgeCases per 100,000
Black
Cases per 100,000
White
Less than 27017
2 to 18258
19 to 645018
Over 645235
Graph 2: Baltimore, 2002 (18 per 100,000)
AgeCases per 100,000
Black
Cases per 100,000
White
Less than 24017
2 to 181412
19 to 641925
Over 64310

Fridkin et al NEJM 2005;352:1436-44

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Most Invasive MRSA Infections Are Healthcare-Associated

  • 14 percent community-associated
  • 86 percent health care-associated

Klevens et al JAMA 2007;298:1763-71

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S. aureus-Associated Skin and Soft Tissue Infections in Ambulatory Care

  • 11.6 million ambulatory care visits per year in 2001-03 for skin infections typical of S. aureus
  • Increase in hospital outpatient and ED visits (2001-03 versus 1992-94)

McCaig et al Emerg Infect Dis 2006;12:1715-1723

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Strategies for Clinical Management of MRSA in the Community

CDC report: Strategies for clinical management of MRSA in the community: summary of an experts' meeting convened by the Centers for Disease Control and Prevention, March 2006.

http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html

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Clinical Considerations—Evaluation

  • MRSA belongs in the differential diagnosis of skin and soft tissue infections (SSTI�s) compatible with S. aureus infection:
    • Abscesses, pustular lesions, "boils".
    • "Spider bites".
    • Cellulitis?

Image: lesion on arm

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Clinical Considerations—Evaluation

MRSA should also be considered in differential diagnosis of severe disease compatible with S. aureus infection:

  • Osteomyelitis
  • Empyema
  • Necrotizing pneumonia
  • Septic arthritis
  • Endocarditis
  • Sepsis syndrome
  • Necrotizing fasciitis
  • Purpura fulminans

Image: x-ray image of chest

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.

Image: Hand holding a scapel

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.

Image: Staph gram stain

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.
  • No data to suggest molecular typing or toxin-testing should guide management.

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.
  • No data to suggest molecular typing or toxin-testing should guide management.
  • Empiric antimicrobial therapy may be needed.

Image: open bottle of pills

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.
  • No data to suggest molecular typing or toxin-testing should guide management.
  • Empiric antimicrobial therapy may be needed.
  • Alternative agents have pluses and minuses: More data needed to identify optimal strategies.

Image: open bottle of pills

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.
  • No data to suggest molecular typing or toxin-testing should guide management.
  • Empiric antimicrobial therapy may be needed.
  • Alternative agents have pluses and minuses: More data needed to identify optimal strategies.
  • Use local data for treatment.

Image: example of graph of percentage of CMRSA in unnamed centers

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.
  • No data to suggest molecular typing or toxin-testing should guide management.
  • Empiric antimicrobial therapy may be needed.
  • Alternative agents have pluses and minuses: More data needed to identify optimal strategies.
  • Use local data for treatment.
  • Patient education is critical!

Image: mother and child in doctor's office

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Management of Skin Infections in the Era of CA-MRSA

  • I&D should be routine for purulent skin lesions.
  • Obtain material for culture.
  • No data to suggest molecular typing or toxin-testing should guide management.
  • Empiric antimicrobial therapy may be needed.
  • Alternative agents have pluses and minuses: More data needed to identify optimal strategies.
  • Use local data for treatment.
  • Patient education is critical!
  • Maintain adequate follow-up.

Image: mother and child in doctor's office

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Clinical Considerations' Management

Antimicrobial Selection (SSTIs)

  • Alternative agents (More data needed to establish effectiveness!):
    • Clindamycin-Potential for inducible resistance, Relatively higher risk of C. difficile associated disease?
    • TMP/SMX-Group A strep isolates commonly resistant.
    • Tetracyclines-Not recommended for < 8 years old.
    • Rifampin-Not as a single agent.
    • Linezolid-Expensive, potential for resistance with inappropriate use.

Image: scattered pills

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Clinical Considerations' Management

Antimicrobial Selection (SSTIs)

  • Not optimal for MRSA (High prevalence of resistance or potential for rapid development of resistance):
    • Macrolides
    • Fluoroquinolones

Image: scattered pills

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D-zone test for Inducible Clindamycin Resistance

  • Perform on erythromycin-resistant, clindamycin-susceptible S. aureus isolates.
  • Clinical implications unclear, but treatment failures have occurred.
  • Does not require pre-treatment or co-treatment with erythromycin in vivo.

Image: Petri/culture dish with no bacteria growth seen around the disk of "E" Erythrotomycin and a large D shaped field growth surrounding the disk of "CC" clinydamycin.

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Management of Severe / Invasive Infections

  • Vancomycin remains a 1st-line therapy for severe infections possibly caused by MRSA.
  • Other IV agents may be appropriate. Consult an infectious disease specialist.
  • Final therapy decisions should be based on results of culture and susceptibility testing.
  • Severe community-acquired pneumonia: Vancomycin or linezolid if MRSA is a consideration.*

*IDSA/ATS Guidelines for treatment of CAP in adults: Mandell et al. CID 2007;44:S27-72

Image: scattered pills.

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Screening and Decolonization

  • In general, colonization cultures of infected or exposed persons in community settings are not recommended. (May have a role in public health investigations).
  • Decolonization regimens:
    • May have a role in preventing recurrent infections (more data needed to establish efficacy and optimal regimens for use in community settings).
    • After treating active infections and reinforcing hygiene and appropriate wound care, consider consultation with an infectious disease specialist regarding use of decolonization when there are recurrent infections in an individual patient or members of a household.

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Preventing Transmission

  • Persons with skin infections should keep wounds covered, wash hands frequently (always after touching infected skin or changing dressings), dispose of used bandages in trash, and avoid sharing personal items.
  • Uninfected persons can minimize risk of infection by keeping cuts and scrapes clean and covered, avoiding contact with other person's infected skin, washing hands frequently, and avoiding sharing personal items.

www.cdc.gov

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Preventing Transmission

  • Exclusion of patients from school, work, sports activities, etc. should be reserved for those that are unable to keep the infected skin covered with a clean, dry bandage and maintain good personal hygiene.
  • In general, it is not necessary to close schools to �disinfect� them when MRSA infections occur.
  • In ambulatory care settings, use standard precautions for all patients (hand hygiene before and after contact, barriers such as gloves, and gowns as appropriate for contact with wound drainage and other body fluids).

www.cdc.gov

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Conclusions

  • New strains of MRSA have emerged in the community, with implications for management of skin infections and other staphylococcal infections.
  • Incision and drainage remains a primary therapy for purulent skin infections.
  • Oral treatment options are available for patients with skin infections that require ancillary antibiotic therapy.
  • Patient education on proper wound care is a critical component of case management for patients with skin infections.
  • Strategies focusing on increased awareness, early detection and appropriate management, enhanced hygiene, and maintenance of a clean environment have been successful in controlling clusters / outbreaks of infection.

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DHQP Posters and Patient Tear Sheet

Image: Five posters and a copy of a patient tear sheet.

Posters: Sharing isn't always caring; Don't open the door to infection; Don't give bacteria a free ride (two versions); Is it a spider bite?

http://www.cdc.gov/mrsa

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Questions?

DHQP Inquiries
hip@cdc.gov
 

Image: bacteria under a microscope

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Page last reviewed March 2011
Internet Citation: Cellulitis and Abscess Management in the Era of Resistance to Antibiotics (CAMERA). March 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/mrsa/nc_mrsaapdpt1.html