Where did I get it?

Healthcare Acquired ORSA

The very first requirement in a hospital is that it should do the sick no harm.
-Florence Nightingale

Community Acquired ORSA

Background

Community-Acquired Methicillin-Resistant Staphylococcus Aureus

Methicillin-resistant S aureus (MRSA) first became prevalent in the 1970s, and has since become a very significant nosocomial pathogen. However, until the late 1990s, MRSA infections in the community were restricted to individuals in long-term care facilities, intravenous drug abusers, or those recently hospitalized. The past few years have seen a dramatic increase in community-acquired MRSA (CA-MRSA) infections in patients who do not have risk factors.[5,32] An increase in the rate of CA-MRSA has been reported in all regions of the United States; in certain areas such as Texas, the rates of resistant strains were as high as 67% in 2002.[33,34]

The virulence of CA-MRSA also appears to be higher than in methicillin-sensitive strains. Although skin and soft-tissue infections still predominate, increased numbers of children with invasive CA-MRSA are being identified.[33]

Dr. Kaplan stated that 10% of cases of CA-MRSA in children present as a very severe infection, warranting critical care management. Usually, these occur in previously healthy patients who present with osteomyelitis or pulmonary involvement.

CA-MRSA isolates from children have tended to be susceptible to diverse nonrelated antibiotics such as vancomycin, clindamycin, gentamicin, and trimethoprim-sulfamethoxazole (TMP-SMX), in direct contrast to nosocomial strains that are frequently resistant to these antibiotics, particularly to clindamycin.[33,35]

In areas where CA-MRSA is prevalent, clindamycin or TMP-SMX has been recommended as initial empiric therapy for non-life-threatening infections (lymphadenitis, cellulitis, soft-tissue abscesses or osteomyelitis).[5,33] A recently published study indicated that skin and soft-tissue abscesses < 5 cm in diameter can be managed with incision and drainage alone, without use of additional antibiotic therapy.[34]

The treatment decision is more complex when confronted with a serious life-threatening infection in which CA-MRSA is thought to be the cause. It is important that rates of circulating clindamycin-resistant strains in the community be known by the treating physician. In some areas of the country, these have been found to be as high as 25%. Therefore, the critically ill patient with a staphylococcal infection should be treated initially with vancomycin until susceptibilities of the isolate are known unless the clinician is absolutely certain there is no clindamycin-resistant CA-MRSA in the community.[5,32]

Further confounding the issue is the fact that clindamycin-susceptible but erythromycin-resistant strains may exhibit inducible resistance to clindamycin (resistance developed on exposure to the antibiotic). CA-MRSA should be identified through use of the "D test"; clinicians should always request this test from their microbiological laboratory. Long-term therapy of CA-MRSA infections, such as osteomyelitis or empyema, cannot be prescribed until the isolate is documented to lack inducible resistance to clindamycin.[5]

Dr. Kaplan also provided very useful recommendations about how to deal with patients with recurrent episodes of CA-MRSA infection. These included keeping the patient's fingernails clipped short; daily changes of sleepwear, underwear, towels and wash cloths; the application of mupirocin to the patient's nares 2-3 times a day for 3-4 weeks, and biweekly baths with Clorox added to the bath water (1 tsp per gallon of water).
[Source: http://www.medscape.com/viewarticle/495300]


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©Helen Gilson 2003-2007
Disclaimer ~ Caveat -- I am not a nurse or doctor. Please see your physician if you think you may have any illness or infection. Do not use any information on these personal pages as a diagnostic tool or attempt to prescribe medication or treatment. No clinical decisions should be made solely on the information contained here. I try to provide quality information, but I make no claims, promises or guarantees about the accuracy, completeness, or adequacy of the information contained in or linked to this web site and its associated sites.