Centers for Disease Control and Prevention. (2009). National MRSA education initiative: Preventing MRSA skin infections. http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/index.html. Retrieved October 28, 2009.
This website is an invaluable resource for people wanting to know more about MRSA skin and soft tissue infections (SSTIs). It includes information about transmission, signs and symptoms, complications, treatment modalities, and prevention strategies. It also provides numerous pictures of different types and stages of SSTIs and offers materials for consumers as well as health care providers.
Mayo Clinic. (2009). MRSA infection. http://www.mayoclinic.com/health/mrsa/DS00735. Retrieved November 26, 2009.
This website provides useful information for consumers, using simple and accessible language. It covers topics similar to the CDC website, but in much less detail. It also provides a few pictures.
WebMD. (2009). Understanding MRSA (Methicillin resistant Staphylococcus aureus). http://www.webmd.com/skin-problems-and-treatments/understanding-mrsa-methicillin-resistant-staphylococcus-aureus. Retrieved November 26, 2009.
The WebMD website has an effective layout and appears to provide accurate information. This is my least favorite site of the three, but as numerous americans utilize WebMD, I thought I should review their site on MRSA. It includes accessible information about MRSA infection, prevention, signs and symptoms, treatment, etc.
Thursday, November 26, 2009
Friday, November 20, 2009
Tea Tree Oil Regimen for Eradication of MRSA Colonization
Dryden, M.S., Dailly, S., & Crouch, M. (2004). A randomized, controlled trial of tea tree topical preparations versus a standard topical regimen for the clearance of MRSA colonization. J Hosp Infect, 56: 283-286.
In a randomized, controlled trial of hopsitalized patients, Dryden and colleagues compared the standard topical regimen for MRSA eradication with a tea tree oil regimen. The standard treatment (ST) included application of mupirocin nasal ointment (2%, tid), chlorhexidine gluconate body washes (4%, daily), and silver sulfadiazine cream applied to skin lesions (1%, daily). The tea tree oil regimen (TT) included tea tree cream applied intranasally (10%, tid), tea tree body washes (5%, daily), and tea tree cream applied to skin lesions (10%, daily). Both regimens were carried out for 5 days and implemented by the nursing staff.
There was no significant difference in overall eradication of MRSA carriage between the ST group (49%) and the TT group (41%). The mupirocin ointment used in the ST group was more effective at eliminating nasal carriage (78%) than the tea tree cream used by the TT group (47%). However, the tea trea body wash and topical cream was more effective than the chlorhexidine and silver sulfadiazine cream at clearing MRSA from superficial skin sites, including the axilla and groin, as well as from wounds (see below). There were no adverse effects from the topical regimens reported by patients and nursing staff.
Clearance of site-specific MRSA carriage 14 days after treatment
Axilla ST: 2/4 (50%), TT: 8/14 (57%)
Groin ST: 4/14 (29%), TT: 8/10 (80%)
Wound ST: 8/26 (31%), TT: 16/34 (47%)
There is increasing concern about the development of bacterial resistance to standard disinfecting agents such as those used in the ST arm of this study. Furthermore, side-effects such as pruritis may make the use of these agents less than ideal. The findings from this study suggest that topical tea tree preparations may be an effective alternative to chlorhexidine soap and silver sulfadiazine cream. However, the side-effects and optimal dosage of topical tea tree preparations should be evaluated further.
In a randomized, controlled trial of hopsitalized patients, Dryden and colleagues compared the standard topical regimen for MRSA eradication with a tea tree oil regimen. The standard treatment (ST) included application of mupirocin nasal ointment (2%, tid), chlorhexidine gluconate body washes (4%, daily), and silver sulfadiazine cream applied to skin lesions (1%, daily). The tea tree oil regimen (TT) included tea tree cream applied intranasally (10%, tid), tea tree body washes (5%, daily), and tea tree cream applied to skin lesions (10%, daily). Both regimens were carried out for 5 days and implemented by the nursing staff.
There was no significant difference in overall eradication of MRSA carriage between the ST group (49%) and the TT group (41%). The mupirocin ointment used in the ST group was more effective at eliminating nasal carriage (78%) than the tea tree cream used by the TT group (47%). However, the tea trea body wash and topical cream was more effective than the chlorhexidine and silver sulfadiazine cream at clearing MRSA from superficial skin sites, including the axilla and groin, as well as from wounds (see below). There were no adverse effects from the topical regimens reported by patients and nursing staff.
Clearance of site-specific MRSA carriage 14 days after treatment
Axilla ST: 2/4 (50%), TT: 8/14 (57%)
Groin ST: 4/14 (29%), TT: 8/10 (80%)
Wound ST: 8/26 (31%), TT: 16/34 (47%)
There is increasing concern about the development of bacterial resistance to standard disinfecting agents such as those used in the ST arm of this study. Furthermore, side-effects such as pruritis may make the use of these agents less than ideal. The findings from this study suggest that topical tea tree preparations may be an effective alternative to chlorhexidine soap and silver sulfadiazine cream. However, the side-effects and optimal dosage of topical tea tree preparations should be evaluated further.
Sunday, November 15, 2009
Guidelines for Eradication of MRSA Carriage
Simor, A.E., Phillips, E., McGeer, A., Konvalinka, A., Loeb, M., Devlin, H.R., & Kiss, A. (2007). Randomized control trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis, 44: 178-185.
In a randomized trial of 146 hospitalized patients colonized with MRSA, participants were assigned to receive either no treatment or a 7 day treatment with rifampin (300mg bid), doxycycline (100 mg bid), daily chlorhexidine washes, and nasal mupirocin (tid). At three months post-treatment, seventy-four percent of the treatment group were decolonized compared to thirty-two percent of the control group. While these findings support the efficacy of MRSA eradication measures, it is unclear whether routine use of these measures is beneficial due to the potential development of resistant and more virulent strains and the likelihood that patients and healthcare providers in inpatient settings will be recolonized. However, decolonization strategies may serve some utility during hospital-based or household-based MRSA outbreaks and among individuals with recurrent MRSA infections.
[UpToDate] Author: Harris, A. & Boyce, J.M. "Prevention and control of methicillin-resistant Staphylococcus aureus in adults" Last updated May 28, 2009.
Decolonization measures generally include both systemic and topical antimicrobial therapy.
Systemic Therapy:
- A 7-14 day antibiotic regimen may be implemented based on antibiogram findings. Studies have found systemic therapy effective in eliminating MRSA carriage. However, as mentioned previously, systemic antibiotics should be used prudently due to the potential for immerging resistance.
Topical Therapy:
- Mupirocin inhibits bacterial protein and RNA synthesis. Intranasal mupirocin ointmnet is applied to the anterior nares 2-3 times daily for 5-7 days. Findings from studies of intranasal mupirocin monotherapy are mixed.
- Chlorhexidine binds to the bacterial cell wall and alters osmotic equilibrium leading to bacterial cell death. Body washing with chlorhexidine is recommended 1-2 times daily for 5-7 days. Chlorhexidine body washing has only been found to reduce or eliminate MRSA carriage when patients were concurrently applying mupirocin intranasal ointment. Please see my blog posting from 10/25/09 for a description of a RCT on chlorhexidine body washes for MRSA eradication.
Sunday, November 8, 2009
Treatment Guidelines for Skin and Soft Tissue MRSA Infection
Centers for Disease Control and Prevention. (2009). National MRSA education initiative: Preventing MRSA skin infections. http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/index.html. Retrieved October 28, 2009.
Gould, F.K., Brindle, R., Chadwick, P.R., Fraise, A.P., Hill, S., Nathwani, D., et al. (2009). Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the united kingdom. Journal of Antimicrobial Chemotherapy, 63(5), 849-861.
Treatment of skin and soft tissue infections (SSTIs) caused by MRSA may involve incision and drainage of the abcess or boil, oral antibiotics, or IV antibiotics depending on the severity of the infection and the overall health of the patient. Incision and drainage of an abcess involves a health care provider making a small incision into the abcess, discharging any drainage, and packing the wound with sterile material if the incision is large (there are no specific guidelines for when packing is indicated). The packing material is removed within a day or two so that the wound may heal.
Incision and drainage is often sufficient to treat small abcesses without the need for systemic antibiotics. When antibiotic treatment is indicated, e.g. when there is a surgical site infection or an abcess with cellulitis, a culture and sensitivity should be performed to determine the most appropriate antibiotic. Doxycline, trimethoprim-sulfamethoxazole, or clindamycin are often the first choices for treatment. If the organism is not susceptible to these drugs, then oral glycopeptides, linezolid, or co-trimoxazole may be tried. Parenteral therapy with glycopeptides or daptomycin may treat moderately severe to severe cases of SSTIs. Vancomycin is generally reserved for severe cases as there is concern among the field about immerging vancomycin resistant strains of Staphylococcus aureus (VRSA). There are also a number of new antimicrobial agents used to treat SSTIs caused by MRSA that I will not mention here. It should be noted that MRSA is resistant to all beta-lactam agents such as the penicillins and cephalosporins. Fluoroquinolones and macrolides are also not recommended for treatment of MRSA SSTIs because resistance is common.
During treatment for SSTIs, hand hygiene, contact precautions, and proper wound care should be emphasized to patients and caregivers. Strategies to eliminate MRSA carriage among colonized individuals should not be implemented during active infection. Furthermore, the efficacy of these strategies, including oral antibiotics and topical antimicrobial agents, has not been well established.
Gould, F.K., Brindle, R., Chadwick, P.R., Fraise, A.P., Hill, S., Nathwani, D., et al. (2009). Guidelines for the prophylaxis and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in the united kingdom. Journal of Antimicrobial Chemotherapy, 63(5), 849-861.
Treatment of skin and soft tissue infections (SSTIs) caused by MRSA may involve incision and drainage of the abcess or boil, oral antibiotics, or IV antibiotics depending on the severity of the infection and the overall health of the patient. Incision and drainage of an abcess involves a health care provider making a small incision into the abcess, discharging any drainage, and packing the wound with sterile material if the incision is large (there are no specific guidelines for when packing is indicated). The packing material is removed within a day or two so that the wound may heal.
Incision and drainage is often sufficient to treat small abcesses without the need for systemic antibiotics. When antibiotic treatment is indicated, e.g. when there is a surgical site infection or an abcess with cellulitis, a culture and sensitivity should be performed to determine the most appropriate antibiotic. Doxycline, trimethoprim-sulfamethoxazole, or clindamycin are often the first choices for treatment. If the organism is not susceptible to these drugs, then oral glycopeptides, linezolid, or co-trimoxazole may be tried. Parenteral therapy with glycopeptides or daptomycin may treat moderately severe to severe cases of SSTIs. Vancomycin is generally reserved for severe cases as there is concern among the field about immerging vancomycin resistant strains of Staphylococcus aureus (VRSA). There are also a number of new antimicrobial agents used to treat SSTIs caused by MRSA that I will not mention here. It should be noted that MRSA is resistant to all beta-lactam agents such as the penicillins and cephalosporins. Fluoroquinolones and macrolides are also not recommended for treatment of MRSA SSTIs because resistance is common.
During treatment for SSTIs, hand hygiene, contact precautions, and proper wound care should be emphasized to patients and caregivers. Strategies to eliminate MRSA carriage among colonized individuals should not be implemented during active infection. Furthermore, the efficacy of these strategies, including oral antibiotics and topical antimicrobial agents, has not been well established.
Sunday, November 1, 2009
Signs and Symptoms of MRSA Infection
Centers for Disease Control and Prevention. (2009). National MRSA education initiative: Preventing MRSA skin infections. http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/index.html. Retrieved October 28, 2009.
MRSA infection with mild cellulitus
MRSA infection with acne-like appearance
Draining MRSA abcesses
Skin and soft-tissue MRSA infections first present as furuncles (infected hair follicles), carbuncles (coalesced furuncles), and abcesses that may be red, swollen, warm, painful, pus-filled, and exhibit purulent drainage. Infected persons may also be febrile. More severe cases can lead to subcutaneous connective tissue inflammation, bone infection (osteomyelitis), urinary tract infection, pneumonia, and sepsis. The most common sites for MRSA skin infection are the legs, groin, buttocks, neck, and axillary region. Patient complaints of a spider bite are often indicative of staph infections such as MRSA.
Common "bug bite" appearance of MRSA infection
MRSA infection with mild cellulitus
MRSA infection with acne-like appearance
Draining MRSA abcesses
Severe MRSA abcesses
Sunday, October 25, 2009
RCT on Chlorhexidine Washes for MRSA Eradication
Wendt, C., Schinke, S., Wurttemberger, M., Oberdorfer, K., Bock-Hensley, O., & von Baum, H. (2007). Value of whole-body washing with chlorhexidine for the eradication of methicillin-resistant Staphylococcus aureas: A randomized, placebo-controlled, double-blind clinical trial. Infect Control Hosp Epidemiol, 28: 1036-1043.
Chlorhexidine body washing, in addition to intranasal and oral antmicrobial agents, is frequently prescribed for eradication of MRSA in infected or colonized patients. However, there is insufficient evidence to support its efficacy. This study was the first randomized, placebo-controlled trial to examine the use of chlorhexidine body washes for MRSA eradication.
Participants were provided with 5 one liter bottles of either a 4% chlorhexidine solution or water with 0.1% polysorbate 20 that looked and smelled similar to the chlorhexidine. Bottles were provided by the pharmacist and study invesitagators and participants were blind to treatment. Participants were asked to wash daily for 5 days, using 1 bottle a day with a minimum contact time of 30 seconds.
The overall MRSA eradication rate at 30 days post-treatment was 8% for the treatment (tx) group and 13% for the control group. Samples from the groin area were significantly more negative for the tx group at day 3 post-treatment, but by day 5 the differences were not significant. Persons in the tx group were more likely to develop skin fissures (17.7% vs. 1.8%, p=0.01), more likely to report itching (41.5% vs. 10.9%, p=0.001), and more likely to report burning of the skin (50.0% vs. 9.1%, p<.001).
The study findings suggest that chlorhexidine body washing may reduce MRSA colonization in the short-term, particularly in the groin region, but not permanently eradicate it. Furthermore, the side-effects of the chlorhexidine washing, including development of skin fissures and itching, may foster an environment for MRSA to grow.
Chlorhexidine body washing, in addition to intranasal and oral antmicrobial agents, is frequently prescribed for eradication of MRSA in infected or colonized patients. However, there is insufficient evidence to support its efficacy. This study was the first randomized, placebo-controlled trial to examine the use of chlorhexidine body washes for MRSA eradication.
Participants were provided with 5 one liter bottles of either a 4% chlorhexidine solution or water with 0.1% polysorbate 20 that looked and smelled similar to the chlorhexidine. Bottles were provided by the pharmacist and study invesitagators and participants were blind to treatment. Participants were asked to wash daily for 5 days, using 1 bottle a day with a minimum contact time of 30 seconds.
The overall MRSA eradication rate at 30 days post-treatment was 8% for the treatment (tx) group and 13% for the control group. Samples from the groin area were significantly more negative for the tx group at day 3 post-treatment, but by day 5 the differences were not significant. Persons in the tx group were more likely to develop skin fissures (17.7% vs. 1.8%, p=0.01), more likely to report itching (41.5% vs. 10.9%, p=0.001), and more likely to report burning of the skin (50.0% vs. 9.1%, p<.001).
The study findings suggest that chlorhexidine body washing may reduce MRSA colonization in the short-term, particularly in the groin region, but not permanently eradicate it. Furthermore, the side-effects of the chlorhexidine washing, including development of skin fissures and itching, may foster an environment for MRSA to grow.
Sunday, October 18, 2009
Prevalence of MRSA in US Healthcare Facilities
Jarvis, W.R., Schlosser, J., Chinn, R.Y., Tweeten, S.M, & Jackson, M. National prevalence of methicillin-resistant Staphylococcus aureus in inpatients at US health care facilities. Am J Infect Control, 2006; 35(10), 631-637.
This key article describes the prevalence of MRSA infection or colonization in US healthcare facilities. This was a cross-sectional study that evaluated prevalence in every state. The overall prevalence of infection and/or colonization was reported to be 46.3 per 1,000 inpatients. This prevalence is higher than previous findings.
The highest rates of infection were found in Hawaii, New York, Maine, and South Carolina. The lowest rates of infection were found in Western states including Idaho, Montana, North Dakota, Wyoming, South Dakota, Utah, and New Mexico. MRSA infection sites included skin and soft tissue (28%), pulmonary (17%), bloodstream (13%), urinary tract (10%), and surgical site (8%). Of the MRSA isolates, 70% were consistent with hospital-acquired MRSA as opposed to community-acquired MRSA.
Patients in the study were not routinely tested for MRSA colonization and, therefore, prevalence may be higher than reported. Furthermore, due to the cross-sectional design, there was the potential for prevalent case bias which occurs when diseases that last for longer durations are found to be more prevalent by this method of assessment.
This key article describes the prevalence of MRSA infection or colonization in US healthcare facilities. This was a cross-sectional study that evaluated prevalence in every state. The overall prevalence of infection and/or colonization was reported to be 46.3 per 1,000 inpatients. This prevalence is higher than previous findings.
The highest rates of infection were found in Hawaii, New York, Maine, and South Carolina. The lowest rates of infection were found in Western states including Idaho, Montana, North Dakota, Wyoming, South Dakota, Utah, and New Mexico. MRSA infection sites included skin and soft tissue (28%), pulmonary (17%), bloodstream (13%), urinary tract (10%), and surgical site (8%). Of the MRSA isolates, 70% were consistent with hospital-acquired MRSA as opposed to community-acquired MRSA.
Patients in the study were not routinely tested for MRSA colonization and, therefore, prevalence may be higher than reported. Furthermore, due to the cross-sectional design, there was the potential for prevalent case bias which occurs when diseases that last for longer durations are found to be more prevalent by this method of assessment.
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