How are you treating MRSA?

[surgblumm]

How are you treating MRSA in the Office, Urgent Care and the ER?

by Bob Blumm, MA, RPA-C, DFAAPA - July 6, 2012

The newest trend in the care of infections that enter our doors is to label them all as MRSA. This ideology became a dominant feature of care when many cases were missed and with the indiscriminate introduction of CA-MRSA which now becomes part of the differential diagnosis. Millions of dollars have been spent on antibiotics that were not needed and mainly to protect the caregiver as well as the patient. In this age of antibiotic overuse and the potential to utilize our most effective weapons to combat infection we are creating a decreased antibiotic sensitivity and creating a nightmare for the future generation in terms of resistance. Earlier this past year the Infectious Diseases society of America published its first ever recommendations for the care and treatment of wounds and infections caused by MRSA. We have all used our bag of tricks and I have read many approaches and verbal arguments on the old PA Forum. Many dealt with the expense of these medications and I have encounter this twice on post surgical cases this past year. So what are we to prescribe? What is recommended? How can we treat our patients and “do no harm?” The approach to all infections and abscess is to utilize I&D as the infectious material must be removed. This is of particular importance in the treatment of the SSTI caused by CA-MRSA, if the area is fluctuant. ED Leadership monthly suggested that when the decision for antibiotics is being made that there are certain criteria that should be considered: Severe or extensive disease involving multiple sites Rapid progression with accompanying cellulites Signs and symptoms of systemic disease Comorbidities, DM, Immunosupression and age extremes Abscess in an area that is difficult to drain such as the hand, face or genitalia; and failure to respond to I&D only What DRUGS MAY I CONSIDER? Clindamycin, TMP/SMX, doxycycline, tetracycline, minocycline and linezolid. Are all considered equally effective? So when you are writing that prescription carefully consider why you would use vancomycin as time and experience have demonstrated that this is no longer a first line drug treatment. Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 300 plus articles and is a sought out conference speaker throughout the United States.

[Joelseff]

I just treated someone the other day for MRSA. Seems MRSA is more common than regular Staph. I treated him with Doxy 100mg BID X 10 days with Mupirocin ointment applied TID x 5 days. I didn't I&D as it wasn't one big abscess but more like impetigo with the cluster of pustules and I cultured one of the lesions but treated empirically.

[KMD16]

Bactrim DS bid x10d.

[True Anomaly]

Obvious MRSA-related abscess: Bactrim DS
Obvious cellulitis: Keflex
Unclear if MRSA abscess or cellulitis: Clindamycin (covers both strep and MRSA)

We stopped culturing abscesses in the ERs in our system because it's just so common to see MRSA.

[surgblumm]

Thank you for your comments which seem logical. The PA who did not do an I&D obviously did not have an abscess but a dermatological disease. The thought that these abscesses need not be cultured would require changing protocol in many institutions to keep everyone safe from malpractice suits.I treated my lad MRSA successfully with Bactrim DS but can appreciate the ancient Doxycycline which is under utilized. Good responses and I appreciate your thoughts.
Bob

[EMEDPA]

SEVERAL issues with bactrim/septra. lots of drug interactions, can't give to folks with poor renal function, in diabetics interacts with common meds to raise sugars, etc etc
clinda is a good choice if in a low resistance area. in my area lots of clinda resistance so we use doxy a lot which also covers several mrsa mimics, latent chlamydia, etc
re: decolonization: in addition to bactroban/bacitracin nasal, chlorhexadine as shower soap for 2 weeks is a good strategy to clear skin of residual mrsa. also, believe it or not, dilute bleach baths...

[Corpsman2PA]

re: decolonization: in addition to bactroban/bacitracin nasal, chlorhexadine as shower soap for 2 weeks is a good strategy to clear skin of residual mrsa. also, believe it or not, dilute bleach baths...

This is what we did at a Marine Training base I was stationed at. Lost of MRSA there, and each individual in addition to the PO abx got the bactroban and chlorhexadine soap. Good stuff.

[EMEDPA]

THE ONLY CAVEAT WITH HIBICLEANS/CHLORHEXADINE IS THAT YOU MUST AVOID THE EYES AS IT CAUSES PERMANENT AND IRREVERSIBLE CORNEAL SCARRING. WHEN i WRITE FOIR IT i SPECIFY APPLY NECK DOWN IN SHOWER . DO NOT GET IN EYES.
(woops, sorry about caps. that happens when you have to look at the keyboard to find the keys....

[Cideous]

IM Gent 80 mg is a good start

[EMEDPA]

im gent 80 mg is a good start

current id recommendations are that you try to not use multiple abx unless you use them consistently(full course doxy+rifampin for example) so i would argue im gent followed by another agent is not a good plan. Our id folks got upset when folks were giving iv clinda x1 followed by a different po med as that just encourages resistance to clinda. The first dose kills the minimally clinda sensitive bugs letting those with intermediate resistance flourish.

[CAdamsPAC]

SEVERAL issues with bactrim/septra. lots of drug interactions, can't give to folks with poor renal function, in diabetics interacts with common meds to raise sugars, etc etc
clinda is a good choice if in a low resistance area. in my area lots of clinda resistance so we use doxy a lot which also covers several mrsa mimics, latent chlamydia, etc



re: decolonization: in addition to bactroban/bacitracin nasal, chlorhexadine as shower soap for 2 weeks is a good strategy to clear skin of residual mrsa. also, believe it or not, dilute bleach baths...

All of the above except out here it's 2 Bactrim DS not ! as MRSA Rx.

[Joelseff]

IM Gent 80 mg is a good start

Isn't that ototoxic?

Sent from my myTouch_4G_Slide using Tapatalk

[eonbluemantra]

Bactrim DS +/- Clindamycin

[Navy PA-C]

MRSA is rampant here on the small Pacific island I am on now. The standard prctice is Bactrim DS bid x 7-10 days but the ENT/OMFS prefer clinda. I just hate the dosing schedule for clinda (we have a low compliance rate here and DMII is common). For serious cases I write for Bactrim + rifampin +/- Mupirocin topical/intranasal.

The inpt service likes to start vanco for all new admits and for some reason sometimes add 1 gm Ancef. Not really sure what is going on there since that represents double coverage...

[EMEDPA]

Our ent guys like dosing clinda as 450mg tid so it is doable.
anyone using tefloro? it's a new cephalosporin that covers mrsa. spendy but no peak/trough and less toxic than vanco and less nursing time so actually cheaper in the long run.