MRSA has been well documented as a significant cause of both healthcare–associated and community–associated infections. It is the predominant cause of skin infections among patients presenting to the emergency room and can also cause more serious, invasive infections, which account for about 18,000 deaths each year in the United States. “MRSA has an enormous clinical and economic impact,” explains Henry F. Chambers, MD. “Many clinicians often have difficulties when managing these infections. When these patients are not properly managed, the results can be severe. Poor management can also promote antibiotic resistance, which is fast becoming a growing concern among clinicians.”
A Framework for Clinicians to Address MRSA
In the February 1, 2011 issue of Clinical Infectious Diseases, an expert panel of the Infectious Diseases Society of America (IDSA) released its first evidence-based, consensus guidelines on the treatment of MRSA infections. The primary objective of the guidelines was to provide recommendations on the management of some of the most common clinical syndromes encountered by adult and pediatric clinicians who care for patients with these infections. The IDSA expert panel addressed issues relating to the use of vancomycin therapy in the treatment of MRSA infections, including dosing and monitoring, current limitations of susceptibility testing, and the use of alternate therapies for those patients with vancomycin treatment failure and infection due to strains with reduced susceptibility to the drug.
“MRSA has an enormous clinical and economic impact. Many clinicians often have difficulties when managing these infections.”
“The guidelines provide a framework to help clinicians determine the most appropriate means to evaluate and treat patients with uncomplicated and invasive infections caused by MRSA,” explains Dr. Chambers, who co-chaired the panel that developed the guidelines. “They discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTIs), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections. These recommendations are provided in addition to those on the appropriate use of vancomycin.” The guidelines have been endorsed by the Pediatric Infectious Diseases Society, the American College of Emergency Physicians, and the American Academy of Pediatrics.
Key Recommendations From MRSA Guidelines
The IDSA guidelines offer primarily expert opinion on the management of MRSA because that is often the only currently available information. “The guidelines are designed to be a living document, meaning they will evolve as new information and antibiotics become available,” says Dr. Chambers. He adds that some of the key recommendations include guidance on when to use antimicrobial therapy after incision and drainage resulting from community-associated MRSA (Table 1). “Incision and drainage alone is likely adequate for most simple abscesses or boils, and antibiotic therapy is not needed. Antibiotic therapy is, however, recommended for other specific situations in the guidelines.”
The management of all MRSA infections should include identification, elimination, and/ or debridement of the primary source and other sites of infection when possible. This includes cases in which there is drainage of abscesses; removal of central venous catheters, prosthetic devices or other implants; and debridement of osteomyelitis. The guidelines also indicate that education on personal hygiene and appropriate wound care is recommended for all patients with SSTIs. Patients should be instructed to keep drained wounds covered with clean, dry bandages and maintain good personal hygiene, particularly after touching infected skin. Patients should also be educated to avoid reusing or sharing personal items that have contacted infected skin. “The guidelines also list key performance measures in managing MRSA infections that all clinicians should follow,” Dr. Chambers says (Table 2). “Within these performance measures is guidance on the appropriate dosing of vancomycin as well as efforts that should be taken to promote good clinical practices.
Looking Ahead To Improve MRSA Management
Each section of the IDSA guidelines begins with a specific clinical question and is followed by recommendations as well as summaries of the most relevant evidence that support the recommendations. “The intent was to create a roadmap for clinicians to follow and the rationale for why these recommendations were made,” says Dr. Chambers. “However, while the guidelines provide good practice recommendations to guide clinicians, we still have knowledge gaps to address. For example, we’re hoping to learn more about the optimal management and duration of therapy for osteomyelitis and SSTIs, among other MRSA infections, and which, among several alternatives, are the most effective regimens. There is much more to be learned so that we can optimize the management of MRSA infections. The current guidelines will hopefully serve as a bridge to covering knowledge gaps in the future.”
Readings & Resources (click to view)
Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus Aureus infections in adults and children. Clin Infect Dis. 2011;52:285-322. Available at:http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full.
Calfee DP, Salgado CD, Classen D, et al. Strategies to prevent transmission of methicillin-resistantStaphylococcus aureus in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S62–S80.
Klevens RM, Morrison MA, Nadle J, et al. Invasive methicillin-resistant Staphylococcus aureusinfections in the United States. JAMA. 2007;298:1763-1771.
Rybak MJ, Lomaestro BM, Rotschafer JC, et al. Vancomycin therapeutic guidelines: a summary of consensus recommendations from the Infectious Diseases Society of America, the American Society of Health-System Pharmacists, and the Society of Infectious Diseases Pharmacists. Clin Infect Dis.2009;49:325-327.