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MRSA in Our Community

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MRSA in Our Community

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    1. MRSA in Our Community Tony Chang, MD Primary Care Case Conference August 2, 2006

    2. Staphylococcus aureus

    3. Objectives What kind of skin infections are associated with Staphylococcus aureus? What is community-acquired methicillin-resistant Staphylococcus aureus (ca-MRSA)? How much of a problem is ca-MRSA around the country? How much of a problem is it in Madison?

    4. Cellulitis

    5. Clinical Case Mr. N is a 58 year old man who presents to with a nonhealing right lower leg skin infection beginning 1 month ago.

    6. PMFS PMH Hypertension Hypothyroidism Depression Glaucoma FH/SH Parents deceased Youngest of 12 4 sisters with diabetes Married with 2 children Quit smoking 1973 6-8 drinks per week Enjoys curling

    7. Meds NKDA Cephalexin 500 mg 4 times daily Atenolol 50 mg daily Synthroid 100 mcg daily Ranitidine 150 mg twice daily as needed Xalatan, Betimol

    8. Exam Afebrile, BP 134/66, HR 72, RR 16 Original scrape: 1 cm ulcer, dark base, partially covered by dry epithelial roof Another 5 mm ulcer similar in appearance 17 satellite lesions 1-3 mm, some pustular Pustule unroofed with #15 scalpel and cultured

    9. Folliculitis Pustules that appeared after treatment with topical steroid and occlusion with plastic wrap.Pustules that appeared after treatment with topical steroid and occlusion with plastic wrap.

    10. Culture Results Resistant to Cefazolin Erythromycin Oxacillin Sensitive to Vancomycin Clindamycin

    11. MRSA in Hospital vs. Community Hospital multiresistant clonal catheter infections Community pauciresistant polyclonal (?) skin diseases pneumonia MRSA in patients at risk are likely to be of the multiresistant hospital type, whereas those in patients without risks are likely to be more susceptible but more invasive.MRSA in patients at risk are likely to be of the multiresistant hospital type, whereas those in patients without risks are likely to be more susceptible but more invasive.

    12. Furuncle (boil) S. aureus is the most common pathogenS. aureus is the most common pathogen

    13. MRSA around the country What is the incidence of ca-MRSA? What type of infections are associated with ca- MRSA? What portion of S. aureus skin infections are caused by ca-MRSA? How serious are these skin infections? How is ca-MRSA transmitted?

    14. Baltimore, Atlanta, Minnesota Study Design: Prospective population-based surveillance supplemented by patient interviews 11 Baltimore hospitals Health District 3 in Greater Atlanta Laboratory-based surveillance in Minnesota 12 Minnesota hospitals Methicillin-Resistant Staphylococcus aureus Disease in Three CommunitiesMethicillin-Resistant Staphylococcus aureus Disease in Three Communities

    15. Baltimore, Atlanta, Minnesota Patients with MRSA: 194 patients excluded from the non-interviewed group for unclear reasons194 patients excluded from the non-interviewed group for unclear reasons

    16. Baltimore, Atlanta, Minnesota

    17. Baltimore, Atlanta, Minnesota

    18. Baltimore, Atlanta, Minnesota

    19. Baltimore, Atlanta, Minnesota

    20. Baltimore, Atlanta, Minnesota Observations: Annual disease incidence 25.7/100,000 in Atlanta 18.0/100,000 in Baltimore 6% were invasive 77% involved skin and soft tissue 23% of patients were then hospitalized

    21. Erysipelas A superficial cellulitis with lymphatic involvement. Group A and Group G Strep. A superficial cellulitis with lymphatic involvement. Group A and Group G Strep.

    22. Los Angeles Study Design: Retrospective review of records of 843 patients Wound cultures that grew MRSA January 15, 2003 – April 15, 2004 14/843 (1.7%) had necrotizing fasciitis Necrotizing Fasciitis Caused by Community-Associated Methicillin-Resistant Staphylococcus aureus in Los Angeles.Necrotizing Fasciitis Caused by Community-Associated Methicillin-Resistant Staphylococcus aureus in Los Angeles.

    23. Los Angeles Observations: Risk factors: injection drug use, diabetes, chronic hepatitis C, cancer, HIV/AIDS All isolates susceptible to clindamycin, TMP-SMX, rifampin All isolates were the same genotype USA300

    24. Necrotizing Fasciitis

    25. Saint Louis Study Design: Retrospective cohort study and nasal-swab survey of 84 St. Louis Rams football players and staff members Investigation of an outbreak of MRSA abscesses A Clone of Methicillin-Resistant Staphylococcus aureus among Professional Football Players.A Clone of Methicillin-Resistant Staphylococcus aureus among Professional Football Players.

    26. Saint Louis Observations: During 2003 season, 8 MRSA infections occurred among 5/58 players Infections occurred at turf-abrasion sites Risk factors: lineman or linebacker position, high BMI All isolates were genotype USA300-0114

    27. Saint Louis Observations: No MRSA recovered from nasal or environmental samples MSSA recovered from whirlpools and taping gel and from 35/84 nasal swabs (42%)

    28. Nasal carriage

    29. Atlanta Study Design: Prospective laboratory surveillance to identify S. aureus recovered from skin and soft tissue Determine the proportion of infections caused by community-acquired MRSA Grady Health System in Atlanta 8/1/2003 – 11/15/2003 Emergence of Community-Acquired Methicillin-Resistant Staphylococcus aureus USA 300 Clone as the Predominant Cause of Skin and Soft-Tissue Infections.Emergence of Community-Acquired Methicillin-Resistant Staphylococcus aureus USA 300 Clone as the Predominant Cause of Skin and Soft-Tissue Infections.

    30. Atlanta Observations: ca-MRSA: USA300 (99% )and USA400 (1%). Other MRSA: USA100 (25%), USA500 (63%), USA800 (12%)ca-MRSA: USA300 (99% )and USA400 (1%). Other MRSA: USA100 (25%), USA500 (63%), USA800 (12%)

    31. Impetigo honey-yellow firmly adherent crust. Primarily a Staph disease, but Strep can also coexist/coinfect.honey-yellow firmly adherent crust. Primarily a Staph disease, but Strep can also coexist/coinfect.

    32. S. aureus at UWHC

    33. MRSA prevalence at UWHC

    34. Brown Recluse Spider Bite

    35. Brown Recluse Spider Bite

    36. Cutaneous Anthrax

    37. Recommendations Be aware that ca-MRSA is on the rise Have a low threshold for obtaining culture especially for “spider bites” Recognize more invasive infections necrotizing fasciitis septic thrombophlebitis pneumonia

    38. Continuing Questions For common skin infections, what empiric antibiotic do I use? What about nasal carriage? Is it useful to obtain nasal cultures? If positive, is attempted eradication recommended?

    39. Special Thanks Carol Spiegel, PhD Department of Pathology & Laboratory Medicine

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