Community-based MRSA infections: A potential problem for all surgical centers

Chief Medical Editor, Douglas W. Jackson, MD, asks Kyle J. Jeray, MD, 4 questions on Methicillin-resistant Staphylococcus aureus hand infections.

Issue: November 2007

4 Questions with Dr. Jackson

Methicillin-resistant Staphylococcal aureus is an area of real concern for all orthopedists who perform surgery and treat patients. Its rising occurrence in hospitals and surrounding communities should raise our index of suspicion on any patient felt to be infected.
I have asked Kyle J. Jeray, MD, to share his experience with this organism in hand wounds for an example of an approach to understanding and controlling Methicillin-resistant S. aureus.
Douglas W. Jackson, MD
Chief Medical Editor

Douglas W. Jackson, MD: What raised your suspicion and how did you document the increase in hand infections related to community acquired Methicillin-resistant S. Aureus (MRSA)?

Kyle J. Jeray, MD: Our index of suspicion for the increase in MRSA started when we noticed patients returning to the emergency room with continued or persistent soft tissue infections in the hand. Initial and repeat cultures were increasingly positive for MRSA. With that initial impression, we elected to retrospectively review the patients with hand infections presenting to our community emergency room (ER). Not surprisingly, the trend was toward a rapid increase in MRSA.

Kyle J. Jeray, MD
Kyle J. Jeray

Jackson: What can our readers take away from the data you obtained in your retrospective chart review?

Jeray: The study revealed a significant increase in MRSA in a community/rural setting. By the end of the study, almost 77% of the hand infections were MRSA. A recently published article out of Cook County Hospital, an urban center, mirrored our results for MRSA infections of the soft tissue of the hand (Bach, 2007). So, MRSA infections can potentially be a problem for all centers urban, community or rural centers. A typical presentation for a patient is with a small ulceration (Figure 1). Many patients state, “I think I was bit by a spider.” But usually the ulceration is a result of the infection draining through the skin.

Figure 1: 35-year-old man with small ulceration over thumb
The finger of a 35-year-old healthy man. Note the small ulceration over the dorsum of the thumb.

Images: Jeray KJ

Jackson: What are the treatment algorithms and antibiotic choice you recommend for consideration in hand infections?

Jeray: Although there is not a prospective randomized study looking at antibiotic choices for MRSA infections in the hand, we have altered our initial empiric antibiotic choice because of the high incidence of community-acquired MRSA infections at our institution.

Initial management in the emergency room begins with incision and drainage of the abscess as indicated along with sending a specimen for culture and sensitivity. Although irrigation and debridement (I&D) alone may be adequate for healthy hosts, empiric antibiotic therapy is started for 5-7 days, starting with trimethoprim/sulfamethoxazole (TMP/SMX) or a tetracycline derivative (i.e. doxycycline), if a sulfa allergy exists (Figure 2).

For younger patients with a sulfa allergy, clindamycin is used.

However, because of the high inducibility of MRSA to become resistant to clindamycin, our infectious disease specialists have recommended to avoid routine use of clindamycin alone. The patients are seen in the office in 3 days where follow-up on the cultures is done and the antibiotics are changed based on the sensitivities. If the clinical picture is worsening, the patient is admitted, a formal I&D is done in the operating room and IV vancomycin is started. If cultures are not able to be obtained (ie, cellulitis) on initial presentation in the ER, at follow up the area is examined and as long as the clinical presentation is improving, the patient is continued on oral antibiotics.

Jackson: What about patients with deep infections and/or comorbidities, what additional treatment should be considered?

Jeray: Patients presenting in the ER with recurrent infections, patients presenting with worsening or systemic symptoms (febrile), or poor hosts (immunocompromised or significant comorbidities) (Figure 3), are hospitalized on presentation and IV vancomycin is started along with surgical I&D. We routinely obtain an infectious disease consult for these patients. The antibiotics are then tailored to the results of the cultures. Deep infections or osteomylitis will have at least a 2-week course of IV antibiotics followed by a 4 to 6 week course of oral antibiotics.

Another question that often arises is the use of alterative oral antibiotics such as quinolones or macrolides, both of which typically have less than 50% effectiveness. More recently linezoid, another oral agent designed to treat MRSA soft tissue infections, is being used. At this point, our institution has reserved the use of this drug, due to its high cost, to the judgment of our infectious disease specialists.

Figure 2: 12-year-old boy with pain and swelling
This 12-year-old healthy boy had a 3-day history of swelling and pain and no previous past medical history. Note appearance of opposite thumb. Treated with irrigation and debridement (I&D) and oral Bactrim (sulfamethoxazole, Roche). Cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA).

Figure 3: 55-year-old with peripheral vascular disease
A 55-year-old, insulin-dependent diabetic male farmer with peripheral vascular disease presented with a 4-day history of increasing pain and swelling. Note drainage, redness and soft tissue swelling of the digit. The patient had pain with passive flexion and extension of the joint. The patient was admitted taken to the OR for I&D and started on IV vancomycin.

For more information:
Kyle J. Jeray, MD, can be reached at Greenville Hospital System, Orthopaedic Surgery Education Department, 701 Grove Road, 2nd Fl., Support Tower, Greenville, SC 29605; 864-455-7878; e-mail:kjeray@ghs.org. He has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
Reference:
Bach HG, Steffin B, Chhadia AM, Kovachevich R, Gonzalez MH. Community-associated Methicillin-resistant Staphylococcus aureus hand infections in an urban setting. J Hand Surg 2007;32A: 380-383.