1. Methicillin-Resistant Staphylococcus aureus: a clinical policy John M. Howell, MD, FACEP, FAAEM Best Practices, Inc Inova Fairfax Hospital Department of Emergency Medicine June 25 - 27, 2009

2. Sometimes MRSA can be intimidating

3. Even a little scary

4. But we can usually get what we want

5. Let’s start with two cases that will lead up to our clinical question.

6. 8 year old boy with ankle pain Twisted his ankle playing basketball 6 days prior Lateral ankle swelling Xray negative Discharged with ankle sprain

7. Returns to the ED 3 days later Temperature 102 o F Tachycardic Lower leg swollen from the knee to the foot, brawny-red appearance Warm and tender lower leg WBC 9,800/mm 3 CRP - 45

8. And the MRI shows …

10. In retrospect, there was no history of skin lesion or trauma, although the child did play basketball frequently.

11. Seven Year Old Male with Cough and Fever 3 days of cough, fever, and “abd pain” Decreased intake PMH: ED visit 1/12/08, left hip abscess, grew MRSA, treated with clindamycin BP 104/55; P 118/min, RR 20/min, T 99.7, pulse ox 95% on RA

12. Seven Year Old with Cough and Fever: Physical Exam WD/WN, alert and laying quietly HEENT: Normal Resp: Tachypnea, nasal flaring, rales L lung CV: Tachycardic Abd: Soft, diffusely tender without guarding. Normal BSs Skin: No rash Neuro: Non-focal examination

13. Seven Year Old with Cough and Fever: Diagnostic Studies WBC: 20,000, 81S, 12L, 6M, 1E H/H 10.5/32; Plat 382 Chemistry: K 3.0 Flu Swab: Negative

15. Seven Year Old with Cough and Fever: Clinical Course In ED, child became more SOB pulse ox dropped to 92%. Given IV fluids, Rocephin, Clindamycin Admitted to IFH PICU Remained 12 days. Blood cultures: MRSA Chest CT – pulmonary consolidation with pleural effusion

16. MRSA Overview Nosocomial MRSA has been around since the 1960’s. Community acquired MRSA became a problem in the 1990’s. Although CA MRSA is more virulent, it is usually sensitive to more antimicrobials.

17. MRSA Virulence Factors Type IV SCC mec - mechanism for antimicrobial resistance Panton Valentine Leukocidin (PVL) –Pokes holes in leukocytes –More prominent in CA MRSA –Associated with pneumonia and severe skin infections

18. MRSA Community Acquired Pneumonia Jan 2007 – 10 cases of MRSA CAP in healthy kids during flu season: 6 deaths Association with flu was either by lab test or clinical presentation All MRSA isolates positive for PVL All had 3-4 day interval between presentation and severe illness or death 4/10 had documented MRSA in themselves or contacts

19. So if we know that MRSA has varying levels of antimicrobial resistance and, via PVL, can cause severe disease …

20. Clinical Question Should skin abscesses be treated routinely by I and D followed by a course of oral antibiotics that cover MRSA?

21. Following I and D of a skin abscess, I … A. Do not routinely prescribe oral antibiotics B. Routinely prescribe oral antibiotics that cover MRSA C. Routinely prescribe oral antibiotics that cover MSSA (e.g., cephalexin) D. Routinely prescribe oral antibiotics only for pateints with immune compromise

22. Let’s look at the literature

23. Rajendran et al, J Am Coll Surg, 2006 Prospective placebo controlled trial of cephalexin following I and D 50% MRSA incidence High prevalence of HIV and other immune issues In the MRSA subgroup (about 50 subjects), the rates of abscess recurrence were 88% and 89% for cephalexin vs. placebo.

24. Lee et al, Pediatr Infect Dis, 2004 Prospective observational study of 67 children with MRSA skin abscesses 5 treated with appropriate antibiotics, 62 with “discordant” antibiotics At follow up, all 5 with appropriate therapy improved, but 58 of 62 (94%) in discordant group improved. Most who did not improve were admitted.

25. Moran et al, NEJM, 2006 Prospective cohort of patients with abscesses in an ED 78% of staph isolates were MRSA About 400 subjects, but 40% dropped out or were excluded No difference in recurrence rates for concordant and discordant antibiotics Treatment not standardized and many subjects either not included or lost to follow up

26. Paydar et al, Arch Surg, 2006 Restrospective cohort of 280 patients with MRSA abscesses When corrected for intention to treat, 99% cure rate for concordant therapy, and 92% cure rate for discordant antimicrobial treatment.

27. Clinical Policy Guidelines (2008) for the prophylaxis and treatment of MRSA infections in the United Kingdom Journal of Antimicrobial Chemotherapy Antibiotic therapy is not generally required after the I and D of small (< 5 cm) abscesses without surrounding cellulitis.

28. Clinical Policy This clinical policy bases it’s recommendation on one reference, Rajendran. Prospective cohort of about 50 MRSA abscesses treated with cephalexin or placebo, which found no difference in recurrence rates

29. I don’t know about you, but this can all be a lot to take in …

31. And so, knowing that: MRSA isolates occur frequently A small number of patients with MRSA skin infections may develop serious pneumonia, necrotizing fasciitis, and osteomyelitis The literature is what it is

32. Where is your acceptable level of risk? Given the risk of distant infection, how many times out of one hundred are you willing to under treat a MRSA skin infection? 1, 2, 5, 10 … ???

33. Our final step is to write a management recommendation for our clinical policy on the treatment of cutaneous abscesses.

34. Pick one of the following clinical policy recommendations: A. Routinely prescribe oral antibiotics that cover MRSA following I and D of cutaneous abscesses. B. Routinely prescribe oral antibiotics that cover MSSA following I and D of cutaneous abscesses. C. No not routinely prescribe oral antibiotics following I and D of cutaneous abscesses. D. Prescribe oral antibiotics that cover MRSA, following I and D of cutaneous abscesses, only for patients with immune competency issues (e.g., HIV, DM, PVD).

35. If I did choose to treat, I would prescribe: Clindamycin Doxycycline Trimethoprim/Sulfamethoxasole Cepahlexin Augmentin