Interim Guidelines for Management of Suspected Staphylococcus aureus Skin and Soft Tissue Infections* Clinical presentation Risk factors associated with MRSA
History of MRSA infection, colonization
History (within past 12 months) of: hospitalization,
surgery, long term care residence, indwelling catheter
or medical device; dialysis, renal failure, diabetes, or
Close contact with someone known to be infected or
High prevalence of MRSA in community or population
Local risk factors: consult local public health department
Incision & drainage (I & D) of abscesses9 – If I & D not performed, consider culture of
draining wounds, or aspirate or biopsy of central area of inflammation
Culture & antimicrobial susceptibility testing
Include “D-test” for clindamycin resistance if MRSA10
To decrease spread of infection, provide education on infection control measures and wound care to all patients
and/or caregivers of patients with S. aureus infections, esp. those with MRSA per WAC 246.101.105(7)
Moderate8 Severe/Critically Ill8
sepsis syndrome, or limb-or life threatening
Outpatient management Outpatient management Hospital management Low suspicion for MRSA: If oral antibiotics used – If increased suspicion for If increased suspicion for MRSA based on presence of MRSA based on presence ≥ 1 risk factor: Empiric therapy of ≥ 1 risk factor: Consider MSSA:Methicillin susceptible S. aureus
*For details, see full text of Interim Guidelines for Evaluation &
MRSA: S. aureus resistant to all penicillins & cephalosporins
Management of Community-Associated Methicillin Resistant
β-lactam antibiotics: Includes all penicillins & cephalosporins Staphylococcus aureus Skin and Soft Tissue Infections in Outpatient Settings
Interim Guidelines for Empiric Oral Antimicrobial Treatment of Outpatients with Suspected MRSA Skin and Soft Tissue Infections (SSTI)
Selection of empiric therapy should be guided by local S. aureus susceptibility and modified based on results of culture and susceptibility testing. The duration of therapy for most SSTI is 7-10 days, but may vary depending on severity of infection and clinical response. NOTE: Before treating, clinicians should consult complete drug prescribing information in the manufacturer’s package insert or the PDR. Antimicrobial Adult Dose Pediatric Dose
Base dose on TMP: 8-12 mg TMP (& 40-60 mg
SMX) per kg/day in 2 doses; not to exceed adult
Not recommended for pediatric use – suggest consultation with infectious disease specialist before use
10-20 mg/kg/day in 3-4 doses; not to exceed adult
a If considering clindamycin, isolates resistant to erythromycin and sensitive to clindamycin should be evaluated for inducible clindamycin resistance (MLSB phenotype) using the “D test.” Consult with your reference laboratory to determine if “D testing” is routine or must be specifically requested. If inducible resistance is present, an alternative agent to clindamycin should be considered.11
If Group A streptococcal infection is suspected, oral therapy should include an agent active against this organism (β-
lactam, macrolide, clindamycin). Tetracyclines and Trimethoprim-sulfamethoxazole, although active against many MRSA, are not recommended treatments for suspected GAS infections.
Outpatient use of quinolones or macrolides: Fluoroquinolones 13, 21-23 (e.g., ciprofloxin, levofloxacin, moxifloxacin,
gatifloxacin) and macrolides (e.g., erythromycin, clarithromycin, azithromycin) are NOT recommended for treatment of MRSA because of high resistance rates. If fluoroquinolones are being considered, consult with infectious disease specialist before use.
Outpatient use of linezolid in SSTI: 24,25 Linezolid is costly and has great potential for inappropriate use, inducing
antimicrobial resistance, and toxicity. Although it is 100% bioavailable and effective in SSTI, it is not recommended for empiric treatment or routine use because of these concerns. It is strongly recommended that linezolid only be used after consultation with an infectious disease specialist to determine if alternative antimicrobials would be more appropriate.
Eradication of MRSA Colonization
Efficacy of decolonization in preventing re-infection or transmission in the outpatient setting is not documented, and is NOT routinely recommended. Consultation with an infectious disease specialist is recommended before eradication of colonization is initiated.
Possible eradication regimens include: Rifampin (Adult dose: 300mg PO bid x 5 days; pediatric dose: 10-12 mg/kg/day in 2 doses not to exceed 600 mg/d x 5 days) may be used in combination with TMP-SMX, OR rifampin with doxycycline, OR rifampin with minocycline, for recurrent MRSA infection despite appropriate therapy. Never use rifampin monotherapy, due to the rapid emergence of resistance. Rifampin interacts with methadone, oral hypoglycemics, hormonal contraceptives, anticoagulants, protease inhibitors, phenytoin, theophylline, cardiac glycosides and other drugs. Topical intranasal mupirocin may be used bid for 5 days with or without systemic antimicrobial therapy. Skin antisepsis with chlorhexidine or other agents may be used in addition to one or both of the above regimens.
( Concerning Lyme Disease ) Les Roberts, Author – The Poison Plum In 1990 I was 51 years of age and living with my wife and three daughters on lakefront property in rural South Alabama. I was president of an investment brokerage firm based in Pensacola, Florida, which I had founded 13 years earlier. I did not take good health for granted but exercised regularly with weightlifting, r
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