This article is a summery based on the
Guidelines for UK practice for the
diagnosis and management of methicillin-resistant Staphylococcus
aureus (MRSA) infections presenting in the community;
Journal of Antimicrobial Chemotherapy (2008) 61, 976–994
Doctors are debating about how to manage MRSA skin
infections.
Hammond SP and Baden LR. Management of Skin and Soft-Tissue
Infection; N Engl J Med 2008;359:e20.
In early September, NEJM presented a case of a college athlete
with a skin and soft-tissue infection in Clinical Decisions,
an interactive feature designed to assess how readers
would manage a clinical problem for which there may be
more than one appropriate treatment. The result of their
survey is now published.
Introduction
This guidance aims to help UK Doctors (GP) on prevention and
treatment of infections caused by methicillin-resistant
Staphylococcus aureus (MRSA) and focuses on typical common and
less common community-onset infections with an emphasis on
community-associated MRSA (CA-MRSA).
Guidelines is the management of serious infection caused by
CA-MRSA arising in the community. Although such infections are
rare at present, they usually affect young, previously healthy
people and may have a rapid and devastating course.
Specific guidance is given on the management of
staphylococcal pneumonia, although other serious manifestations
of these infections are emerging. Serious S. aureus infections
can be caused by strains that are methicillin-resistant or
-susceptible and which may or may not express the pathogenic
Panton–Valentine leucocidin (PVL) toxin.
The role of the general practitioner (GP) is to recognize
that the patient is seriously unwell and needs to be managed in
hospital.
A summary of the commonest MRSA clinical problems [skin and
soft tissue infections (SSTIs); serious and deep seated
infections] presenting to GPs and guidance on their treatment is
presented in Appendix 1.
Practical advice on the isolation of MRSA in the urine is
also provided in the Appendix but not covered in the main body
of the guidelines because the evidence base for the management
of this situation is poor. The recommendations could be
implemented, for example, by their integration into new or
existing care pathways.
Background Information & Definitions
S. aureus is the major bacterial cause of skin, soft tissue and
bone infections, and one of the commonest causes of
healthcare-associated bacteraemia. About one-quarter of healthy
people carry one or more strains asymptomatically at any given
time and infections are commonly endogenous being caused by the
patient’s colonizing strain.
Antibiotics and surgical drainage are the basis of treatment
of staphylococcal infections, but the emergence of multiple
resistance to penicillin, methicillin and other agents has
compromised therapy. Methicillin resistance was first detected
in S. aureus in 1961, shortly after the agent was introduced
clinically, and over the last four decades, there has been a
global epidemic of MRSA.
MRSA is usually acquired during exposure to hospitals and
other healthcare facilities, and causes a variety of serious
healthcare-associated infections. A number of UK and USA
guidelines have been produced on the prevention, control,
diagnosis and treatment of MRSA infections in hospitals and
other healthcare facilities.
However, there has been an increase in MRSA infections
presenting in the community that has not been properly addressed
by existing guidelines.
Many (and in the UK at the present time, most) MRSA
infections that appear to have a community onset occur in
patients who are found to have had direct or indirect contact
with hospitals, care homes or other healthcare facilities.
These MRSA strains are typical of the local
healthcare-associated MRSA (HA-MRSA) and may be carried
asymptomatically by patients for months after discharge.
However, new strains of MRSA have recently emerged that cause
infections in community patients who have no previous history of
direct or indirect healthcare contact. These strains have been
designated CA-MRSA.
CA-MRSA strains are genetically and phenotypically distinct
from HA-MRSA. They typically resemble some strains of
methicillin-susceptible S. aureus (MSSA) in being susceptible to
a wider range of anti-staphylococcal antibiotics (some are
resistant only to β-lactams), and often produce PVL, a toxin
that destroys white blood cells and is a staphylococcal
virulence factor.
Differences between CA- and HA-MRSA are summarized in Table 1.
PVL-producing strains of CA-MRSA appear to be associated with
increased risk of transmission, complications and
hospitalization. For example, in one large community outbreak of
CA-MRSA, 23% of patients required hospitalization.18
PVL has a clear role in the pathogenesis of severe necrotizing
pneumonia and is associated with greater pulmonary and
bone-related complications. Its role in skin infections is less
certain, although PVL is a potent dermatonecrotic toxin.
In the UK, the overall prevalence of S. aureus strains that
carry the gene for PVL production is believed to be <2%, and
these are mainly MSSA. Although the overall prevalence of
CA-MRSA is also presently low worldwide (thought to be <0.5% of
all MRSA),
there is clear evidence that this is increasing,
particularly in the USA, Canada and Australia. In some areas of
the USA, a significant proportion of serious S. aureus
infections presenting in community practice or at accident and
emergency departments is now due to CA-MRSA types.
There are also emerging reports of CA-MRSA from Europe,
including Scandinavian countries that have, until now, been
almost free of HA-MRSA. There have been relatively few reports
of CA-MRSA from the UK, but experience elsewhere suggests that
these are likely to increase in the future.
In 2007, the Specialist Advisory Committee on Antimicrobial
Resistance also identified the need to produce some specific
guidance around diagnosis and treatment of infections caused by
PVL-positive staphylococci.
The British Society of Antimicrobial Chemotherapy (BSAC) on
the other hand independently wished to consider producing
guidance with the broader remit of diagnosis and management of
community-onset MRSA including infections acquired in the
healthcare setting but which would include PVL-related disease.
HPA members with expertise in this area were included in the
BSAC
Working Party and this guidance recognizes HPA and other
related guidance where appropriate. It is hoped that this will
raise general awareness about the epidemiology and pathological
significance of CA-MRSA. It is hoped that the early
implementation of effective diagnosis, management, prevention
and control of these new infections will prevent some of the
present difficulties with HA-MRSA developing with CA-MRSA.
Definitions
- The internationally agreed definitions of HA-MRSA, CA-MRSA
and other S. aureus strains and their limitations are given
below. The definitions were originally based on
epidemiological features but, for the reasons outlined below,
microbiological characteristics are now also important.
- MRSA (methicillin-resistant S. aureus). Strains of S.
aureus that are resistant to the isoxazoyl penicillins such as
methicillin, oxacillin and flucloxacillin. MRSA are
cross-resistant to all currently licensed β-lactam
antibiotics.
- CA-MRSA (community-associated MRSA). MRSA strains isolated
from patients in an outpatient or community setting (community
onset), or within 48 h of hospital admission (hospital onset).
Patients also typically have no previous history of MRSA
infection or colonization, hospitalization, surgery, dialysis
or residence in a long-term care facility within the previous
year, and absence of indwelling catheters or percutaneous
devices at the time of culture.
- HA-MRSA (healthcare-associated MRSA). MRSA strains that
are transmitted to and circulate between individuals who have
had contact with healthcare facilities. These infections can
present in the hospital or healthcare setting (hospital or
healthcare onset) or in the community (community onset), for
example after hospital discharge.
- However, the boundaries between HA-MRSA and CA-MRSA are
becoming blurred due to the movement of patients and
infections between hospitals and the community, and to
nosocomial outbreaks of CA-MRSA following admission of
colonized or infected patients.
- In the USA, where CA-MRSA is now common, it is becoming
increasingly difficult to distinguish between CA- and HA-MRSA
on clinical and epidemiological grounds.
- Since HA-MRSA and CA-MRSA strains are often genotypically
and phenotypically different (Table
1), the microbiological characteristics of the S. aureus
isolates may help distinguish between HA- and CA-infections.
Advice on Skin Preparation
Make sure
the skin is cleaned properly with chlorxedine solution left on the skin 1-2 minutes
(drying time). You must not touch the area repeatedly with their finger
after they introduce the needle tip through the skin. Demand straight
non-ported cannula for your safety
- Skin
Preparation before Injecting Needle through Skin
- Firmly swipe skin of patient using a fresh swab or soap and
water in circular fashion as shown in the diagram (please start
in the centre and always move outwards)
- Never go over the centre point after you clean
the peripheral area.
- Please repeat this process 2-3 times using
fresh new swab.
- Use the centre point to inject needle or
insert cannula
Further Reading
Using Detergents may increase infections & facilitate bacteria
developing resistance
Download
Drug resistant Staphylococcus aureus "Staph"
Infections
-
Healthcare-Associated MRSA
Information about MRSA acquired in hospitals
and healthcare facilities.
-
Community-Associated MRSA
Information about MRSA acquired outside of hospitals and
healthcare facilities.
-
VISA/VRSA: Vancomycin-Intermediate/Resistant
Staphylococcus
aureus
Other drug-resistant organisms
Useful Information & Testing
