1. Clinical Challenges
Community Acquired Methicillin Resistant Staph. Aureus Infections
Jose R. Jimenez M.D.
Eglin AFB, Florida

6. Emerging Pathogen Increasing incidence over last 10 yr.
107 million ED visits/yr (cut. Abcess)
Frequent reason for treatment failure, patient dissatisfaction.
Suspected significant numbers of CA-MRSA carriers in community, among us.

7. Hospital vs. Community Acquired MRSA
Different sensitivities
Hospital-acquired MRSA generally resistant to multiple drugs, frequently leading to the use of parenteral vancomycin
CA-MRSA resistant to penicillin and cephalosporins, but sensitive to other oral antibiotics, such as clindamycin, TCN, TMP/SMX
CA-MRSA usually sensitive to oral rifampin. Due to rapidly developing resistance to rifampin, the drug must be used in combination with another antibiotic.

8. Hospital vs. Community Acquired MRSA
CA-MRSA produces cytotoxins (Panton-Valentine leukocidin) associated with tissue necrosis. This cytotoxin is not usually found in HA-MRSA.

9. Initial clinic evaluation: History
Onset, duration, severity
Prior episodes
Exposure: Home, work, gym, playground, participation in organized sports (wrestling, football, fencing, etc.), hot tub use.
ROS: Associated symptoms
PMH
Medications,allergies

10. Initial clinic evaluation: History
Soc. Hx.: Tobacco, ETOH, drug use.
Try to elicit any factors that would classify the patient as a compromised host, and/or a special exposure situation.

11. Initial clinic evaluation: Physical Examination
General examination
Skin: lesion, number, size, location, palpation (fluctuant,creppitus, F.B.), ulceration, necrosis, streaking.
Lymph nodes palpable

12. Physical Examination: Adjunct Modalities
Mainly to rule out f.b.
Radiographs CT
Ultrasound
Fluoroscopy
MRI

13. Therapeutic Decisions: Lesion Management
I & D ?
Lesion exploration/ F. B. removal
Lesion C & S
Pack the wound or not, what to use.
Informed Consent/ Permit signed

14. Therapeutic Decisions: Medication Selection
Antibiotic
Analgesic

15. Antibiotic Selection Age <7 yr avoid TCN
Age <18 yr avoid Quinolones
Cost/ Patient resources
Patient compliance
Facility/ Community resources available

16. Antibiotic Selection, Outpatient Management
None
Penicillin and derivatives
Augmentin
cephalosporin
Minocycline, Doxycicline
TMP/SMX
Clindamycin
Fluoroquinolones
Zyvox

17. Antibiotic Selection, Inpatient or Home Health Management
Parenteral: Vancomycin, Synercid, Zyvox, Cubicin

18. Patient Disposition/ Education
Wound care
Medication
Follow up/ reexamination
Earlier reexamination if there is no improvement, or if new symptoms develop
Make sure patient understands you are treating empirically, that there is a possibility of treatment failure, what to do.

19. MRSA Carrier Management
Carried in skin, most frequently in the anterior nasal passages
Recommendation: mupirocin topically to the nasal passages, antibacterial body wash with chlorhexidine

20. CA- MRSA Additional Control Measures
Contact Sports with frequently used protective gear: football, wrestling, fencing
Gear to be washed ideally after every use, at least weekly.
Exercise equipment pads to be cleaned and disinfected regularly

21. CA- MRSA Additional Control Measures
Health Care Personnel: MUST FOLLOW INFECTION CONTROL MEASURES

22. REFERENCES Sanford guide to antimicrobial selection
Tintinalli: Review in Emergency Medicine