surgblumm Posted July 10, 2012 Share Posted July 10, 2012 [TABLE] [TR] [TD=class: news_heading, width: 100%]How are you treating MRSA in the Office, Urgent Care and the ER?[/TD] [/TR] [TR] [TD][/TD] [/TR] [TR] [TD=class: news_sub_heading] by Bob Blumm, MA, RPA-C, DFAAPA - July 6, 2012 [/TD] [/TR] [TR] [TD] 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. [/TD] [/TR] [/TABLE] Link to comment Share on other sites More sharing options...
Joelseff Posted July 11, 2012 Share Posted July 11, 2012 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. Link to comment Share on other sites More sharing options...
KMD16 Posted July 11, 2012 Share Posted July 11, 2012 Bactrim DS bid x10d. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted July 11, 2012 Moderator Share Posted July 11, 2012 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. Link to comment Share on other sites More sharing options...
surgblumm Posted July 11, 2012 Author Share Posted July 11, 2012 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 Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 11, 2012 Moderator Share Posted July 11, 2012 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... Link to comment Share on other sites More sharing options...
Corpsman2PA Posted July 11, 2012 Share Posted July 11, 2012 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. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 11, 2012 Moderator Share Posted July 11, 2012 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....:) Link to comment Share on other sites More sharing options...
Cideous Posted July 11, 2012 Share Posted July 11, 2012 IM Gent 80 mg is a good start Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 12, 2012 Moderator Share Posted July 12, 2012 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. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted July 12, 2012 Share Posted July 12, 2012 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 etcclinda 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. Link to comment Share on other sites More sharing options...
Joelseff Posted July 12, 2012 Share Posted July 12, 2012 IM Gent 80 mg is a good start Isn't that ototoxic? Sent from my myTouch_4G_Slide using Tapatalk Link to comment Share on other sites More sharing options...
eonbluemantra Posted July 12, 2012 Share Posted July 12, 2012 Bactrim DS +/- Clindamycin Link to comment Share on other sites More sharing options...
OrthoSurgeryPA Posted July 12, 2012 Share Posted July 12, 2012 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... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 12, 2012 Moderator Share Posted July 12, 2012 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. Link to comment Share on other sites More sharing options...
Piper Posted July 12, 2012 Share Posted July 12, 2012 For those who have prescribed it, how well is Rifampin tolerated? I have never written for it and had a well-seasoned ER PA tell me it really "tears a patient's stomach up". Link to comment Share on other sites More sharing options...
surgblumm Posted July 12, 2012 Author Share Posted July 12, 2012 Great forum. You guys have more responses to intelligent clinical question than I have seen at any other site. Kudos to Michael. Bob Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted July 12, 2012 Moderator Share Posted July 12, 2012 For those who have prescribed it, how well is Rifampin tolerated? I have never written for it and had a well-seasoned ER PA tell me it really "tears a patient's stomach up". I don't know about the actual physical tolerance of Rifampin because I've never prescribed it outside of TB, but In the October 2010 issue of Emergency Medicine Practice, entitled "Emergency Department Infections In The Era of Community-Acquired MRSA", Rifampin is discussed as adjuvant therapy when treating MRSA. They make quick to mention that it should never be used as monotherapy, but I think we all know that. What they also mention though is that it develops resistance rapidly, as well as citing a study that showed in-vitro evidence of an antagonistic effect when combining Rifampin with Bactrim/Septra. Link to comment Share on other sites More sharing options...
Hemegroup Posted July 12, 2012 Share Posted July 12, 2012 have had fine success with doxy Link to comment Share on other sites More sharing options...
browndog Posted July 13, 2012 Share Posted July 13, 2012 Group that I work for set protocols as I&D (if fluctuant) and Bactrim DS + Keflex x 10 days. Always culture. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 13, 2012 Moderator Share Posted July 13, 2012 Group that I work for set protocols as I&D (if fluctuant) and Bactrim DS + Keflex x 10 days. Always culture. I agree that c+s is always best however in our pt population(inner city e.d.) this isn't cost effective. many of our pts can't afford a 400 dollar test that likely won't change their tx course. that being said I always get a c+s on kids, the elderly, diabetics, and anyone immunocompromised but the typical 22 yr old otherwise healthy IV meth user is mrsa most of the time and if it is just strep, non-mrsa staph, or a tick borne infection, doxy for 4 dollars will cover it, not to mention the latent chlamydia often seen in this pt population. Link to comment Share on other sites More sharing options...
Cideous Posted July 14, 2012 Share Posted July 14, 2012 Don't give it to kiddo's and yes it works wonderfully. Link to comment Share on other sites More sharing options...
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