ca-mrsa skin infection ann mcbride, m.d. june 9, 2004
TRANSCRIPT
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CA-MRSA Skin InfectionCA-MRSA Skin Infection
Ann McBride, M.D.Ann McBride, M.D.
June 9, 2004June 9, 2004
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No financial disclosuresNo financial disclosures
HUGE thanks to Patty BoyleHUGE thanks to Patty Boyle
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17 yo high school student, daughter of UW surgeon, with MRSA furunculosis
36 yo F 6 wks after hysterectomy developed extensive furunculosis and skin abscess
51 yo Type 1 DM with chronic neurodermatitis, 2 mos after hospitalization for CAP has + MRSA skin lesions.
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OBJECTIVESOBJECTIVES
Clinical Characteristics CA-MRSA Biological Characteristics CA-MRSA Treatment of MRSA Skin Infection Prevention of Recurrences
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Major Staph clinical syndromes :
skin-related infections, cellulitis,
osteomyelitis, septic arthritis, TSS,
pneumonia
Transmission: person-to-person contact
from individual with Staph infection or
colonization.
Can be transmitted from contact with contaminated
environment. Can remain days (more than a week)
Airborne transmission is prob not frequent route
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S aureus frequently part of transient flora.
Among healthy individuals, carrier rates
est 10 – 30%
Common carrier sites of S.aureus :
anterior nasal vestibule
skin - axilla, perineum- hair, nails
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Duration of carrier state – several months
Mean duration 8-9 months; can last years
Hospital personnel and individuals with
chronic skin condition often have higher
rates and longer duration of colonization
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MRSA first described nosocomial pathogen 1960’s
MRSA = ORSA
resistance to all B-lactams, & cephalosporins
1990’s CA-MRSA vs HCA-MRSA
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CA-MRSACA-MRSA(excludes dx of HCA-MRSA)(excludes dx of HCA-MRSA)
1. Dx in outpt setting or culture + MRSA within 48 hrs after hospital admission
2. No history previous MRSA
3. No hospitalization or exposure to health care facility within previous year
4. No permanent indwelling catheter
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In 2000 CDC surveillance to
characterize clinical, micro-
biological, and molecular features
of CA-MRSA and HCA- MRSA
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JAMA Dec 2003
Comparison of CA-MRSA vs HCA-MRSA
12 labs in MN
½ metropolitan
½ non-metro
All labs served inpt and outpt
10/12 Adults and Peds
1/12 Peds only
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MN Surveillance:MN Surveillance:
¼ all S. aureus cultures = MRSA¼ all S. aureus cultures = MRSA 1100/46121100/4612 Range 10-49%Range 10-49%
Among MRSA:Among MRSA: 85% HCA85% HCA 12% CA12% CA 3% unclear3% unclear
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MN Surveillance:MN Surveillance:
Of CA-MRSAOf CA-MRSA 53% metropolitan53% metropolitan 47% non-metro47% non-metro
Younger median age of CA-MRSA vs HCA-Younger median age of CA-MRSA vs HCA-MRSAMRSA
30 yo vs70 yo30 yo vs70 yo
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mecA gene required for MRSAmecA gene required for MRSAmecA gene codes PBP 2amecA gene codes PBP 2a
Pcn Binding Protein low affinity Pcn Binding Protein low affinity for for B-lactams Thus, more B-lactams Thus, more resistant resistant to B-lactams.to B-lactams.
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Difference in exotoxin genes between CA- and HCA MRSA
PVL (Panton Valentine Leukocidin) gene: * common in CA MRSA (20/26 vs. 1/26) esp. skin infections, necrotizing
pneumonia * codes for Cytotoxin disrupts cell membrane;
cause severe tissue necrosis, destruction WBCs
* facilitates MRSA penetration of intact skin
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Frequency of MRSA colonization
not addressed ** 500 otherwise healthy children
seen UCCH 1996; 132 colonized with S. aureus
11/132 (8.3%) were MRSA
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Pt #1 17 yo recurrent furunculosis Fall 2003
Dau of UW surgeon abscess L arm +MRSA
dau’s skin wound & nares culture +MRSA
- DM, Skin dz, needle use
hs swim team; no skin infctn among teammates
2 households – only father and my pt +MRSA
grandmother in nursing home
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Impr: colonized w/ MRSA and recurrent furunculosis
Management: Decolonization
End of swim team participation
Treatment of recurrent furuncles
--minocycline + rifampin x 2 wks
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Decolonization for CA-MRSA Decolonization for CA-MRSA
Generally NOT recommended for single case MRSA infection
Consider for recurrent MRSA infection
(3 or more infections in 6 months)
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DecolonizationDecolonizationMupirocin ointment anterior nares “match Mupirocin ointment anterior nares “match head size”head size”
½ anterior vestibule one nostril½ anterior vestibule one nostril½ anterior vestibule other nostril½ anterior vestibule other nostril
Press sides of nose togetherPress sides of nose togetherGently massageGently massage
bid x 5 days (to 14??); one week later f/u bid x 5 days (to 14??); one week later f/u nasal culturenasal culture if nasal culture +MRSA if nasal culture +MRSA repeat once repeat once no more than 3 mupirocin treatmentsno more than 3 mupirocin treatments
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Purell hand cleansing
Bath/shower daily with antiseptic
Wet skin thoroughly
Body wash – chlorhexidine (Rx Hibiclens)
Apply disinfectant soap with moistened face cloth
Caution: Skin irritation
? Substitute tree oil cleanser
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Pat skin dry gently; avoid abrading skin Use moisturizer while skin is moist after
bathing Consider D/C shaving temporarily Avoid tightly fitting clothes/bands
could rub skin
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EnvironmentEnvironment
Launder
– Hot water
– Bed sheets, towels, wash cloths
Dryer (med to high heat) for clothes -- not air drying
Wipe down bathroom and kitchen counters, and handles –refrigerator, doors, cabinets (bleach)
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Outbreaks CA-MRSA described in various populations including participants in sports.
Risk factors for Staph infections in athletes:
Contact with lesions of other players
Skin trauma
Sharing of sports equipment
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CDC’s Recommendations for CDC’s Recommendations for Preventing Staph InfectionsPreventing Staph Infections
1. Cover all wounds. If a wound cannot be covered adequately, consider excluding player until lesions healed
2. Encourage good hygiene—showering w/ soap after all practices and competitions
3. Ensure availability of soap and hot water
4. Discourage sharing of towels, clothing, and equipment
5. Establish routine cleaning schedule for shared equipment
6. Educate athletes and coaches re: potentially infectious skin lesion
7. Encourage early reporting/assessment for skin lesions
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With recurrence
minocycline + rifampin
clindamycin + rifampin
TMP-SMX + rifampin
Minocycline has excellent skin penetration
Rifampin + atbtc to reduce emergence of resistance
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Lecture by Dr. Maki
If furuncle appears to develop, apply liberal amount of OTC Bacitracin ointment
Apply Tegaderm (Transparent polyurethene dressing)
This maintains high concentration of drug in lesion x 3-4 days
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Pt #2 36 yo woman undergone Pt #2 36 yo woman undergone hysterectomyhysterectomy
late summer 2003. Developed “bug late summer 2003. Developed “bug bites”bites”
buttocks and thighs fall 2003buttocks and thighs fall 2003
Gyn treated ceph Gyn treated ceph
Next day, came to IM “no better” ; R Next day, came to IM “no better” ; R leg furuncle had small amt of purulent leg furuncle had small amt of purulent drainagedrainage
Diclox initiated, skin lesion +MRSADiclox initiated, skin lesion +MRSA
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RTC 48 hrs; Lesion had drained and improved RTC 48 hrs; Lesion had drained and improved after draining.after draining.
Diclox D/C’d; No systemic antibioticDiclox D/C’d; No systemic antibiotic
Decolonization effort and topical/local Decolonization effort and topical/local treatment of recurrence per Dr. Maki’s treatment of recurrence per Dr. Maki’s recommendationrecommendation
One additonal lesion, did not require po atbtcOne additonal lesion, did not require po atbtc
F/up surveillance cultures negative x 3F/up surveillance cultures negative x 3
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+ MRSA Patient Presenting to Clinic+ MRSA Patient Presenting to Clinic
Pt placed directly into exam room
–Need not be negative flow
–Door may remain open
–Gown, gloves required if touching pt or any item in room
–Mask not usually required (unless +MRSA nares w/ URI)
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Gown, gloves left in room
Stethoscope cleansed with ETOH
Purell hand cleansing before exiting
Room closed until housekeeping cleanses/disinfects
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MRSA precautions in clinic cannot be lifted until three sets of neg surveillance cx
On order card check “MRSA Screen” Each set obtained at least one week apart Swabs from L & R nares combined (single
swab for both nares) Swabs from axilla and groin can be
combined (single swab for both axillae and both sides of groin)
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No role for attempting mupirocin or systemic
(oral antibiotics) decolonization in pt with
chronic skin condition
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Patient #3
50 yo Type 1 DM w/ neurodermatitis chronically excoriated skin
hospitalized Nov 2002 with pneumonia
In Dec 2002, MD in neuroderm clinic +MRSA arm lesion
Early 2003 – appt in IM Clinic; WISCR = +MRSA
No attempt to decolonize
2003 – 2 small skin abscesses
I & D; Consult w/ ID- rec decolonization attempt to decrease bioburden
Decolonization effort has worsened dermatitis
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Three patients -- all three “HCA-MRSA” --
yet clinical presentation assoc with CA-;
atbtc susc pattern ‘typical’ for CA-MRSA
Clinical importance/helpfulness of this distinction???
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Clinical setting most predictive of S aureus infection.
Clinical syndromes CA-MRSA – typically,
skin infections, cellulitis, abscess – closely
resemble clinical syndrome of MSSA in
community
Atbtc selection depends upon susc pattern
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Management Future – PCR testing for mecA gene to est MRSA sooner??