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Methicillin-Resistant Staphylococcus Aureus (MRSA) Skin Infections

para>For purulent infections, consider surgical drainage and debulking, wound culture, and narrow-spectrum antimicrobials:

  • Successful I&D may have more impact than antibiotics in mild cases for both adults and children.
  • Moist heat may work for small furuncles.
  • Patients with an abscess are frequently cured by incision and drainage alone.
  • Packing does not appear to improve outcomes (3)[A].

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First Line

CA-MRSA SSTIs: 7- to 14-day course (depends on severity and clinical response): пїЅ пїЅ

  • Trimethoprim/sulfamethoxazole (TMP-SMX): DS (160 mg TMP and 800 mg of SMX) 1 to 2 tablet(s) PO BID daily (8 to 12 mg/kg/day of trimethoprim component in 2 divided doses for children)
  • Doxycycline or minocycline: 100 mg PO BID (children >8 years and <45 kg; 2 to 5 mg/kg/day PO in 1 to 2 divided doses, not to exceed 200 mg/day; children >8 years and >45 kg, use adult dosing), taken with a full glass of water
  • Clindamycin: 300 to 450 mg PO QID (30 to 40 mg/kg/day PO in 3 divided doses for children), taken with full glass of water. Check D-zone test in erythromycin-resistant, clindamycin-susceptible S. aureus isolates (a positive test indicates induced resistance " пїЅchoose a differnt antibiotic).
  • CA-MRSA is resistant to пїЅ пїЅ-lactams (including oral cephalosporins and antistaphylococcal penicillins) and often macrolides, azalides, and quinolones.
  • Although most CA-MRSA isolates are susceptible to rifampin, this drug should never be used as a single agent because of concerns regarding resistance. The role of combination therapy with rifampin in CA-MRSA SSTIs is not clearly defined.
  • There has been increasing resistance to clindamycin, both initial ( пїЅ пїЅ пїЅ33%) and induced.
  • Although CA-MRSA isolates are susceptible to vancomycin, oral vancomycin cannot be used for CA-MRSA SSTIs due to limited absorption.

Second Line

Treat severe CA-MRSA SSTIs requiring hospitalization and HA-MRSA SSTIs using: пїЅ пїЅ

  • Vancomycin: Generally, 1 g IV q12h (30 mg/kg/day IV in 2 divided doses; in children: 40 mg/kg/day IV in 4 divided doses) vancomycin-like antibiotics that require only 1 or 2 doses may soon be more broadly available (5)[A].
  • Linezolid: 600 mg IV/PO BID uncomplicated: children <5 years of age, 30 mg/kg/day in 3 divided doses; 20 mg/kg/day IV/PO in 2 divided doses for children 5 to 11 years of age; children >11 years, use adult dosing. Complicated: birth to 11 years, 30 mg/kg/day IV/PO in 3 divided doses; older, use adult dosing)Linezolid seems to be more effective than vancomycin for treating people with SSTIs, but current studies have high risk of bias.
  • Clindamycin: 600 mg IV TID; in children, 10 to 13 mg/kg/dose q6 " пїЅ8h up to 40 mg/kg/day
  • Daptomycin: 4 mg/kg/day IV (safety/efficacy not established in patients <18 years of age) if no pulmonary involvement
  • Ceftaroline 600 mg BID IV (for adults)

Pediatric Considerations

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Pregnancy Considerations

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Geriatric Considerations

A recent review notes no prospective trials in this age group and recommends use of general adult guidelines.

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ISSUES FOR REFERRAL

Consider consultation with infectious disease in cases of пїЅ пїЅ

  • Refractory CA-MRSA infection
  • Plan to attempt decolonization

SURGERY/OTHER PROCEDURES

Progression to serious SSTIs, including necrotizing fasciitis, is possible and mandates prompt surgical evaluation. пїЅ пїЅ

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

Consider admission if: пїЅ пїЅ

  • Systemically ill (e.g., febrile) with stable comorbidities
  • Systemically well with comorbidities that may delay or complicate resolution of SSTI
  • Presence of SSTI complications (sepsis, necrotizing fasciitis) and comorbidities
  • If indicated, alternatives to inpatient admission include observation units and outpatient parenteral antimicrobial therapy (OPAT) programs

Nursing

Contact precautions пїЅ пїЅ

Discharge Criteria

If admitted for IV therapy, assess the following before discharge: пїЅ пїЅ

  • Afebrile for 24 hours
  • Clinically improved
  • Able to take oral medication
  • Has adequate social support and is available for outpatient follow-up

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

For outpatients: пїЅ пїЅ

  • Return promptly with systemic symptoms, worsening local symptoms, or failure to improve within 48 hours. Consider a follow-up within 48 hours of initial visit to assess response and review culture.

PATIENT EDUCATION

  • Keep wounds that are draining covered with clean, dry bandages.
  • Clean hands regularly with soap and water or alcohol-based gel. Hot soapy shower daily.
  • Do not share items that may be contaminated (including razors or towels).
  • Clean clothes, towels, and bed linens
  • National MRSA Education Initiative: www.cdc.gov/mrsa/
  • A mixture of пїЅ пїЅ;-cup household bleach diluted in 1 gallon of water can be used to clean surfaces.

PROGNOSIS

In outpatients, improvement should occur within 48 hours. пїЅ пїЅ

COMPLICATIONS

  • Necrotizing pneumonia or empyema (after an influenza-like illness)
  • Necrotizing fasciitis
  • Sepsis syndrome
  • Pyomyositis and osteomyelitis
  • Purpura fulminans
  • Disseminated septic emboli
  • Endocarditis

REFERENCES

11 Uhlemann пїЅ пїЅAC, Dordel пїЅ пїЅJ, Knox пїЅ пїЅJR, et al. Molecular tracing of the emergence, diversification, and transmission of S. aureus sequence type 8 in a New York community. Proc Natl Acad Sci U S A. 2014;111(18):6738 " пїЅ6743.22 Stevens пїЅ пїЅDL, Bisno пїЅ пїЅAL, Chambers пїЅ пїЅHF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10 " пїЅe52.33 Mistry пїЅ пїЅRD. Skin and soft tissue infections. Pediatr Clin North Am. 2013;60(5):1063 " пїЅ1082.44 Singer пїЅ пїЅAJ, Talan пїЅ пїЅDA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. N Engl J Med. 2014;370(11):1039 " пїЅ1047.55 Chambers пїЅ пїЅHF. Pharmacology and the treatment of complicated skin and skin-structure infections. N Engl J Med. 2014;370(23):2238 " пїЅ2239.

ADDITIONAL READING

  • Amin пїЅ пїЅAN, Cerceo пїЅ пїЅEA, Deitelzweig пїЅ пїЅSB, et al. Hospitalist perspective on the treatment of skin and soft tissue infections. Mayo Clin Proc. 2014;89(10):1436 " пїЅ1451.
  • Chen пїЅ пїЅLF, Chastain пїЅ пїЅC, Anderson пїЅ пїЅDJ. Community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections: management and prevention. Curr Infect Dis Rep. 2011;13(5):442 " пїЅ450.
  • Fenster пїЅ пїЅDB, Renny пїЅ пїЅMH, Ng пїЅ пїЅC, et al. Scratching the surface: a review of skin and soft tissue infections in children. Curr Opin Pediatr. 2015;27(3):303 " пїЅ307.
  • Fitch пїЅ пїЅMT, Manthey пїЅ пїЅDE, McGinnis пїЅ пїЅHD, et al. Videos in clinical medicine. Abscess incision and drainage. N Engl J Med. 2007;357(19):e20.
  • Gurusamy пїЅ пїЅKS, Koti пїЅ пїЅR, Toon пїЅ пїЅCD, et al. Antibiotic therapy for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in surgical wounds. Cochrane Database Syst Rev. 2013;(8):CD009726.
  • Holmes пїЅ пїЅNE, Howden пїЅ пїЅBP. What 's new in the treatment of serious MRSA infection? Curr Opin Infect Dis. 2014;27(6):471 " пїЅ478.
  • Ramakrishnan пїЅ пїЅK, Salinas пїЅ пїЅRC, Agudelo Higuita пїЅ пїЅNI. Skin and soft tissue infections. Am Fam Physician. 2015;92(6):474 " пїЅ483.

CODES

ICD10

  • A49.02 Methicillin resis staph infection, unsp site
  • A41.02 Sepsis due to Methicillin resistant Staphylococcus aureus
  • J15.212 Pneumonia due to Methicillin resistant Staphylococcus aureus
  • Z22.322 Carrier or suspected carrier of methicillin resis staph
  • Z86.14 Personal history of methicillin resis staph infection
  • B95.62 Methicillin resis staph infct causing diseases classd elswhr

ICD9

  • 041.12 Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site
  • 038.12 Methicillin resistant Staphylococcus aureus septicemia
  • 482.42 Methicillin resistant pneumonia due to Staphylococcus aureus
  • V02.54 Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus

SNOMED

  • 266096002 methicillin resistant Staphylococcus aureus infection (disorder)
  • 448812000 Sepsis due to methicillin resistant Staphylococcus aureus (disorder)
  • 124691000119101 Pneumonia due to methicillin resistant Staphylococcus aureus (disorder)
  • 308155002 MRSA infection of postoperative wound
  • 423561003 community-acquired methicillin-resistant Staphylococcus aureus infection (disorder)

CLINICAL PEARLS

  • Incise and drain purulent lesions and send for wound culture if abscess is present.
  • Local susceptibility patterns of CA-MRSA dictate antibiotic treatment. The CDC has a helpful algorithm for outpatient treatment of CA-MRSA: http://www.cdc.gov/mrsa/pdf/Flowchart_pstr.pdf
  • CA-MRSA skin lesions are commonly misidentified as "spider bites " пїЅ.