Thursday, January 6, 2011

New MRSA Treatment Guidelines

I learned of this thanks to a tweet from @OFPC:

New #MRSA guidelines for the treatment of staph infections http://goo.gl/NQ3xZ #medicine

MRSA (methicillin-resistant staphylococcus aureus) infections continue to be a growing public health issue, both hospital-acquired and community-acquired.  These guidelines come from the Infectious Diseases Society of America (IDSA). 

The article is a 38 page document (pdf file, full reference below); the last 10 pages are supporting references.

The major performance measures are:

1. The management of all MRSA infections should include identification, elimination and/or debridement of the primary source and other sites of infection when possible (eg, drainage of abscesses, removal of central venous catheters, and debridement
of osteomyelitis).

2. In patients with MRSA bacteremia, follow-up blood
cultures 2–4 days after initial positive cultures and as needed thereafter are recommended to document clearance of bacteremia.

3. To optimize serum trough concentrations in adult
patients, vancomycin should be dosed according to actual body weight (15–20 mg/kg/dose every 8–12 h), not to exceed 2 g per dose. Trough monitoring is recommended to achieve target concentrations of 15–20 lg/mL in patients with serious MRSA infections and to ensure target concentrations in those who are morbidly obese, have renal dysfunction, or have
fluctuating volumes of distribution. The efficacy and safety of targeting higher trough concentrations in children requires additional study but should be considered in those with severe sepsis or persistent bacteremia.

4. When an alternative to vancomycin is being considered for use, in vitro susceptibility should be confirmed and documented in the medical record.

5. For MSSA infections, a b-lactam antibiotic is the drug of choice in the absence of allergy.

…….

Their recommended management of skin and soft-tissue infections
(SSTIs):

For a cutaneous abscess incision and drainage is the primary treatment.

  • For simple abscesses or boils, incision and drainage alone is likely to be adequate.  Simple boils most likely DON’T need antibiotics.

Antibiotic therapy is recommended for abscesses associated with the following conditions:

  • severe or extensive disease (eg, involving multiple sites of infection)
  • rapid progression in presence of associated cellulitis
  • signs and symptoms of systemic illness
  • associated comorbidities or immunosuppression
  • extremes of age
  • abscess in an area difficult to drain (eg, face, hand, and genitalia)
  • associated septic phlebitis
  • lack of response to incision and drainage alone

……

Antibiotic therapy for outpatients

All antibiotic therapy should be individualized based on the patient’s clinical response.

Patients with purulent cellulitis:  empirical therapy for CA-MRSA is recommended pending culture results.  Five to 10 days of therapy is recommended.

Patients with nonpurulent cellulitis:  empirical therapy for infection due to b-hemolytic streptococci is recommended.  Empirical coverage for CA-MRSA is recommended in patients who do not respond to b-lactam therapy and may be considered in those with systemic toxicity. Five to 10 days of therapy is recommended.

For empirical coverage of CA-MRSA in outpatients with SSTI, oral antibiotic options include the following:

  • clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX),
    a tetracycline (doxycycline or minocycline), and linezolid.

If coverage for both b-hemolytic streptococci and CA-MRSA is desired, options include the following:

  • clindamycin alone or TMP-SMX or a tetracycline in combination with a b-lactam (eg, amoxicillin) or linezolid alone.

Antibiotic therapy for hospitalized patients with complicated SSTI (cSSTI)  -- defined as patients with deeper soft-tissue infections, surgical/traumatic wound infection, major abscesses, cellulitis, and infected ulcers and burns).

In addition to surgical debridement and broad-spectrum antibiotics, empirical therapy for MRSA should be considered pending culture data.  As with outpatients, all antibiotic therapy should be individualized based on the patient’s clinical response.

Options include the following:

  • intravenous (IV) vancomycin, oral (PO) or IV linezolid 600 mg twice daily, daptomycin 4 mg/kg/dose IV once daily, telavancin 10 mg/kg/dose IV once daily, and clindamycin 600 mg IV or PO 3 times a day.
  • A b-lactam antibiotic (eg, cefazolin) may be considered in hospitalized patients with nonpurulent cellulitis with modification to MRSA-active therapy if there is no clinical response. Seven to 14 days of therapy is recommended.

……
Pediatric considerations

Children with minor skin infections (such as impetigo) and secondarily infected skin lesions (such as eczema, ulcers, or lacerations), mupirocin 2% topical ointment can be used.

…..

Patient education is the “heart” of preventing recurrence.

Management of recurrent MRSA SSTIs

Preventive educational messages on personal hygiene and appropriate wound care are recommended for all patients with SSTI.

Instructions should be provided to:

Keep draining wounds covered with clean, dry bandages.

Maintain good personal hygiene with regular bathing and cleaning of hands with soap and water or an alcohol-based hand gel, particularly after touching infected skin or an item that has directly contacted a draining wound.

Avoid reusing or sharing personal items (eg, disposable razors, linens, and towels) that have contacted infected skin.

Environmental hygiene measures should be considered in patients with recurrent SSTI in the household or community
setting:

Focus cleaning efforts on high-touch surfaces (ie, surfaces that come into frequent contact with people’s bare skin each day, such as counters, door knobs, bath tubs, and toilet seats) that may contact bare skin or uncovered infections.

Commercially available cleaners or detergents appropriate for the surface being cleaned should be used according to label instructions for routine cleaning of surfaces.

When decolonization is deemed appropriate (ie prior to elective surgery):

Nasal decolonization with mupirocin twice daily for 5–10 days.

Nasal decolonization with mupirocin twice daily for 5–10 days and topical body decolonization regimens with a skin antiseptic solution (eg, chlorhexidine) for 5–14 days or dilute bleach baths. (For dilute bleach baths, 1 teaspoon per gallon of water [or ¼ cup per ¼ tub or 13 gallons of water] given for 15 min twice weekly for 3 months can be considered.)

Screening cultures prior to decolonization are not
routinely recommended if at least 1 of the prior infections was documented as due to MRSA.

Surveillance cultures following a decolonization regimen are not routinely recommended in the absence of an active infection.

Oral antimicrobial therapy is recommended for the treatment of active infection only and is not routinely recommended for decolonization.

There is much more in the guidelines.  I have focused only on the skin and soft-tissue areas.

 

Related posts:

CAMRSA: Dx and Tx Update for Plastic Surgeons – an Article Review  (January 8, 2009)

Revisit of Community Acquired MRSA--Prevention Tips (October 17, 2007)

 

REFERENCE

Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children; Catherine Liu, Arnold Bayer, Sara E. Cosgrove, Robert S. Daum, Scott K. Fridkin, Rachel J. Gorwitz, Sheldon L. Kaplan, Adolf W. Karchmer, Donald P. Levine, Barbara E. Murray, Michael J. Rybak, David A. Talan, and Henry F. Chambers; Clin Infect Dis. (2011) doi: 10.1093/cid/ciq146 First published online: January 4, 2011

1 comment:

PGY1 said...

Thanks for posting and outlining some of the details! I'm happy to see that we're already following these guidelines at the hospital where I'm training.