New MRSA Treatment Guidelines

Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

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

Infected or Exposed Breast Prosthesis

Updated 3/2017 -- all links (except to my own posts) removed as many no longer active.

This is a tough situation for both patient and surgeon.  Dr. Scott Spear has published an article in the April issue of the Journal of Plastic and Reconstructive Surgery which reviews his management of this issue  (full reference below).

Rates of infection have ranged from 0.4 to 2.5 percent for augmentation mammaplasty and from 1 to 35.4 percent for prosthetic breast reconstruction. Furthermore, rates of exposure have been reported between 0.29 and 2 percent for breast augmentation and between 0.25 and 8.3 percent for device-based breast reconstruction.

Dr. Spear published an algorithm for the management of breast device infection and/or exposure in 2004.   The current article is a retrospective study of his experience with infected or exposed breast prosthesis between 1993 and 2008.   During this 15 year period, he managed 69 patients with 87 events of breast device infection and/or exposure.

The mean patient age was 49.8 years.  The average BMI was 23.4.   Other key traits:  smoking history 18.4%, history of chemotherapy use 35.6%, history of radiation therapy 23%.

Events of device infection and/or exposure were classified into one of seven groups using the published algorithm: 

group I, mild infection; group II, severe infection; group III, threatened exposure; group IV, threatened exposure with mild infection; group V, threatened exposure with severe infection; group VI, actual exposure with no/mild infection; and group VII, actual exposure with severe infection.

Mild infection was defined as warmth, swelling, cellulitis, or nonpurulent drainage that was responsive to initial antibiotic therapy.

Severe infection was defined as persistent or substantial warmth/erythema/swelling despite antibiotic therapy, purulent drainage, atypical organisms on wound culture (e.g., methicillin-resistant Staphylococcus aureus, Gram-negative rods, mycobacteria, or yeast), or serious signs and symptoms of systemic infection (e.g., high fever, hypotension).

“Device salvage” was defined as the continued presence of a prosthetic device after surgical intervention, though not necessarily retention of the original device.

Dr. Spear reports that the mean postoperative time to breast prosthesis infection/exposure was 5.5 months.  He managed to obtain an overall device salvage rate of 64.4%.

Thirty-four events involved breast prostheses with mild infection, classified as group I, and were associated with a 100 percent salvage rate.

Twenty-six events concerned devices with severe infection, categorized as group II, and resulted in a 30.8 percent salvage rate.

He concludes:

Salvage of the infected and/or exposed breast prosthesis remains a challenging but viable option for a subset of patients. Keys to success include culture-directed antibiotics, capsulectomy, device exchange, and adequate soft-tissue coverage.

Relative contraindications to breast device salvage include atypical pathogens on wound culture, such as Gram-negative rods, methicillin-resistant S. aureus, and C. parapsilosis.

Patients with a prior device infection and/or exposure and a history of either radiotherapy or S, aureus on wound culture should be closely monitored for signs of recurrent breast prosthesis infection/exposure and managed cautiously in the setting of elective breast surgery.

REFERENCES

Management of the Infected or Exposed Breast Prosthesis: A Single Surgeon's 15-Year Experience with 69 Patients; Spear, Scott L.; Seruya, Mitchel; Plast Reconstr Surg 125(4):1074-1084, April 2010; doi: 10.1097/PRS.0b013e3181d17fff

Discussion: Management of the Infected or Exposed Breast Prosthesis: A Single Surgeon's 15-Year Experience with 69 Patients; Hammond, Dennis C.; Plast Reconstr Surg.125(4):1085-1086, April 2010; doi: 10.1097/PRS.0b013e3181d18289

The infected or exposed breast implant: Management and treatment strategies; Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse MR.;  Plast Reconstr Surg. 2004;113:1634–1644.

Primary Breast Abscess Risk Factors

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

 

A recent article in the July issue of the Journal of the American College of Surgeons (full reference below) looked at the risk factors for developing a breast abscess.

It is a case control study of 68 patients with a primary breast abscess. Several (36/68) developed a recurrence as defined by the need for repeated drainage within 6 months.

They found

Univariate analysis indicated that smoking (odds ratio [OR] 8.0 [95% CI 3.4 to 19.4]), obesity (OR 3.6 [95% CI 1.5 to 9.2]), diabetes mellitus (OR 5.7 [95% CI 1.1 to 54.9]), and nipple piercing (OR 10.2 [95% CI 1.3 to 454.4]) were significant risk factors for development of primary breast abscess.

Recurrent breast abscess occurred in 36 (53%) patients. Multivariate logistic regression identified significant OR for an increase in recurrence related to age (OR 1.08 [95% CI 1.01 to 1.15] per year), smoking (OR 14.73 [95% CI 3.18 to 68.22]), surgical treatment (11.94 [95% CI 1.08 to 131.72]), and a decrease in recurrence after MRSA infections (OR 0.02 [95% CI 0.00 to 0.72]).

I think perhaps this article has too small a number of individuals, but find their numbers interesting.
The eMedicine overview (second reference below) does not even address possible infections from nipple piercing, suggesting:

Mastitis is usually seen in lactating women, but the presence in a nonlactating woman should spur evaluation for an inflammatory carcinoma or new-onset diabetes.⁶

Causes of primary breast infections are most likely to be Staphylococcus aureus and streptococcal species. Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and anaerobes.

The eMedicine article does recognize a correlation between breast infection and smoking:

A study by Schafer et al found a significant correlation between cigarette smoking and subareolar breast abscess.¹²

So while the article may have a small number of individuals, it is probably safe to say that being overweight, having diabetes mellitus, and smoking all make your risk of having a breast infection higher. By how much is more difficult to say.

REFERENCE

Risk Factors for Development and Recurrence of Primary Breast Abscesses; Vinod Gollapalli, Junlin Liao, Amela Dudakovic, Sonia L. Sugg, Carol E.H. Scott-Conner, Ronald J. Weigel; Journal of the American College of Surgeons - July 2010 (Vol. 211, Issue 1, Pages 41-48, DOI: 10.1016/j.jamcollsurg.2010.04.007)

Breast Abscess and Masses; eMedicine article, May 13, 2010; Andrew C Miller, MD, Tajinderpal S Saraon, MD, and Mark A Silverberg, MD, FACEP, MMB

An Unusual Case of Itching in a Surgery Patient

Patients who are in the early postoperative period (first 2 days) will sometimes complain of itching. I hear this either during the call I make the evening of surgery or when the patient calls the next day. I follow up this complaint up with a few questions:
How severe is it?
Where do you itch?
Is there any rash?
When did it start?
Most often the itching is a minor irritation. Often they or a family member will immediately think they have to be allergic to one of the medications they are taking. Most often this is not the case.

If the itching is localized to the area of the surgery, then most often it is due to the surgical scrubs not being cleaned off well enough (almost impossible to fully do). This itching goes away quickly when the patient takes their shower and can fully cleanse the soaps away.

I worry more about an allergic reaction if the itching is generalized, includes a rash, and has gotten worse after the second or third dose of some medication. When told this I review medications they are taking and stop the most likely offending one.

Regardless of the cause, if it bothers the patient enough I will tell them to try taking Benadryl to ease the irritation of the itch.

…………………

There was an unusual case of itching I encountered once in a postoperative patient. The patient was a 27 yo nurse who developed an elevated temperature (no increased pain, no redness or added tenderness in the surgical area, no pain on urination) and flu like symptoms on the second day after surgery. The rash broke out on the third day after surgery.

Her rash consisted of vesicles located initially on the chest, neck, and later her face and arms.

My initial thought was chicken pox. She initially insisted there was no way it could be, but agreed to see her internist. Turned out I was right.

She was miserable while she recovered, having to deal with the surgery issues AND the chicken pox.

Preoperative Skin Cleanser

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Looks like it’s time for me to rethink my preference for preoperative skin cleanser. This past week there were two new prospective studies published in the Jan. 7 issue of the New England Journal of Medicine, along with an accompanying editorial.

The Centers for Disease Control and Prevention estimates that in American hospitals alone, there are 1.7 million healthcare-associated infections each year. Of these infections, 22% are surgical site infections (SSIs). So if simply changing the preop skin cleanser will reduce my patient’s SSI risk, then I will do so.

Rabih Darouiche, MD and colleagues found using chlorhexidine as the preoperative skin cleanser reduced infections by 41% compared with povidone-iodine. Their study involve randomly assigning 897 adults undergoing clean-contaminated surgery to preoperative skin preparation with chlorhexidine gluconate (CHG) and alcohol or with povidone-iodine (P-I). Patients were assessed for occurrence of SSIs within 30 days postoperatively.

CHG-alcohol use was associated with a lower overall rate of SSIs (9.5% vs. 16.1% for P-I), lower rates of superficial (4.2% vs. 8.6%) and deep (1.0% vs. 3.0%) incisional SSIs. There was no significant difference between the two groups where organ-space infections (4.4% and 4.6%, respectively) or sepsis from SSIs (2.7% and 4.3%) was involved.

Lonneke G.M. Bode, M.D and colleagues found that screening and decolonizing patients who are nasal carriers of S. aureus, combined with washing with chlorhexidine soap reduced the risk of SSIs by 58%.

"The weight of evidence suggests that chlorhexidine–alcohol should replace povidone–iodine as the standard for preoperative surgical scrubs," Dr. Wenzel writes. "The use of intranasal mupirocin and chlorhexidine baths for carriers of S. aureus who have been identified preoperatively by means of a real-time [PCR] assay could be reserved primarily for patients who are undergoing cardiac surgery, all patients receiving an implant, and all immunosuppressed surgical candidates. Currently, the incremental value of preoperative baths with chlorhexidine alone for all surgical patients is unclear, but this relatively straightforward procedure could be examined critically in future studies."

REFERENCES
Minimizing Surgical-Site Infections; N Engl J Med. 2010;362:9-17, 75-77; Richard P. Wenzel, M.D.
Chlorhexidine–alcohol versus povidone–iodine for surgical-site antisepsis; N Engl J Med 2010 Jan 7; 362:18; Darouiche RO et al.
Preventing surgical-site infections in nasal carriers of Staphylococcus aureus; N Engl J Med 2010 Jan 7; 362:9; Bode LGM et al.
Advances in Preventing Surgical-Site Infections. JWatch Infect. Diseases 2010: 1-1