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Simple and complex ways can help ophthalmologists avoid MRSA, MRSE infections
Over and over again, the pathogens that threaten us and our patients every day amaze us in their ability to develop defenses against any and every antimicrobial that we can develop to counter them.
 Richard L. Lindstrom |
Methicillin resolved the issue of penicillin-resistant staph species, but only for a while, and every year the number of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin resistant Staphylococcus epidermidis (MRSE) infections grow in incidence and prevalence. Originally, we thought we could isolate specific classes of patients, such as those who work in hospitals or other health care facilities, as the only class at risk for MRSA or MRSE, but we are now learning that many people with no special environmental exposure carry MRSA or MRSE.
The number of sight-threatening infections in ophthalmology that are caused by MRSA or MRSE advances every year and now approximates 30% plus. Even more frightening, many MRSA and MRSE are also showing significant resistance to our current biggest gun among broad-spectrum antibiotics, the current generation of fluoroquinolones. Fortunately, we still have several tools that can help us avoid these devastating infections, some simple and some more complex.
First, we physicians and surgeons must set the proper example by compulsively washing our hands or using an antiseptic hand gel between patient encounters.
Second, it is up to us to set a high standard for sterile technique and proper draping in the clinic and operating suite when even minimally invasive procedures are performed. Every study in every field of surgery confirms that a compulsive prep with povidone iodine, careful draping and antibiotic prophylaxis can reduce the incidence of infection after a surgical procedure. I believe that for intraocular surgery such as phacoemulsification with lens implantation, the most effective infection prophylaxis includes compulsive prepping, draping, sterile technique, and the combination of preoperative antibiotic application, an intracameral injection at the close of surgery and a short, intense 10- to 14-day postoperative course of an appropriate topical antibiotic. I personally favor a fluoroquinolone for all three, but there is good evidence to support other choices, such as vancomycin and cefuroxime for intracameral use and chloramphenicol or Neosporin for topical use, to name a few.
Third, we need to identify patients who are MRSE or MRSA carriers by history. Some medical centers are requiring a nasal culture before surgery for all patients to identify those who carry MRSA or MRSE in their respiratory tract. We at Minnesota Eye Consultants have not incorporated this routine into our current protocol in our ASC, but many larger institutions now require such cultures routinely.
Finally, we must consider every sight-threatening infection to be MRSA or MRSE until proven otherwise, and we should anticipate a high level of resistance to fluoroquinolones as well. In the U.S., most MRSA and MRSE remain sensitive to vancomycin, bacitracin, Neosporin and Polytrim. Fortunately, all of these except vancomycin are available commercially and can be used for prophylaxis in high-risk patients or as an initial adjunct for therapy. Once the diagnosis of MRSA or MRSE is confirmed, vancomycin remains the primary drug of choice for therapy.
We can only hope that our pharmaceutical industry retains sufficient incentive to continue the extraordinarily expensive process of finding and bringing new therapeutic agents to market, as it is clear that the pathogens that threaten us and our patients daily are quite adept at developing resistance to any antimicrobial we can develop. If not, it may be the pathogens that inherit the earth.