Guidelines to Manage Community-acquired MRSA
Guidelines to Manage Community-acquired MRSA
The objective of the guidelines of Liu et al was to provide recommendations on the management of the most common clinical syndromes encountered by adult and pediatric providers who treat patients with MRSA infections. Specific clinical questions are followed by numbered recommendations, and a summary of the most relevant evidence is provided in support of the recommendations. The guidelines address controversial areas, limited or conflicting data, and areas in which research is needed for MRSA treatment. Recommendations for CA-MRSA infections include alone, or in combination with, incision and drainage (I&D), culture of the purulent material, and use of systemic antibiotics when indicated.
In contrast to the 2011 guidelines for MRSA in which a culture is recommended for mild, purulent SSTIs, the 2014 SSTI guidelines recommend I&D of SSTIs without culture for mild, purulent infection. Table provides a summary of 2011 and 2014 outpatient management of SSTIs. Figure shows the 2014 IDSA guideline for the management and care of both nonpurulent and purulent SSTIs. NPs should be aware that patients with mild SSTIs do not have symptoms of systemic infection, whereas patients with moderate, purulent infection have systemic signs of infection requiring I&D and C&S.
(Enlarge Image)
Figure.
Management of Purulent and Nonpurulent SSTIs 2014 Practice Guidelines.
Reprinted with permission from the Oxford University Press.
The MRSA 2011 IDSA guidelines and 2014 SSTI guidelines both recommend I&D alone without the use of an antimicrobial because I&D alone will often treat uncomplicated or mild SSTI cases. At this time, however, the practice of performing I&D without prescribing antimicrobials is rare, thus contributing to antimicrobial resistance (AR). CA-MRSA isolates are usually resistant to antimicrobials such as erythromycin and the fluoroquinolones but are typically susceptible to clindamycin and trimethoprim-sulfamethoxazole (TMP-SMX). Children have less resistance to non–β-lactam antibiotics such as clindamycin, but increasing resistance to clindamycin and adverse effects, especially Clostridium difficile, require providers' consideration. Clindamycin is recommended for purulent cellulitis and nonpurulent cellulitis, but clindamycin is resistant to CA-MRSA in many geographical areas. Clindamycin covers staphylococcal and streptococcal isolates, allowing for a safety barrier as a broad-spectrum antimicrobial for providers, but providers should consider ordering a disk diffusion induction test or D-Test to determine clindamycin resistance before initiating treatment. Linezolid is ideal for MRSA, but it too has side effects, and after 2 weeks of therapy, a complete blood count is required. Linezolid also interacts with many medications. Daptomycin and televancin are indicated for severe, purulent infections but are not approved for use in children. Clindamycin can be used if clindamycin resistance is < 10% to 15% in the geographical area of practice per the 2014 guidelines for the treatment of SSTIs, which is a specific recommendation for the use of clindamycin compared with the 2011 guidelines. The 2014 SSTI guidelines address the significance of prescribing clindamycin. Providers should be aware of the prevalence of CA-MRSA in their area of practice, and if the prevalence is high, empirical therapy should be initiated. If the prevalence of CA-MRSA is low, antibiotics should be reserved for MRSA infections associated with illnesses such as osteomyelitis and bacteremia. Integrating the most recent available evidence into clinical practice is essential to addressing the global health threat of AR. In the following case study, a patient presents to the NP with a mild SSTI, and a culture was obtained despite recommendations not to send a culture for patients without systemic symptoms. Clinical acumen, individualized care, and knowledge of the best available evidence guided the patient's initial treatment, showing how clinical knowledge concordant with guidelines improves outcomes.
Current Practice
The objective of the guidelines of Liu et al was to provide recommendations on the management of the most common clinical syndromes encountered by adult and pediatric providers who treat patients with MRSA infections. Specific clinical questions are followed by numbered recommendations, and a summary of the most relevant evidence is provided in support of the recommendations. The guidelines address controversial areas, limited or conflicting data, and areas in which research is needed for MRSA treatment. Recommendations for CA-MRSA infections include alone, or in combination with, incision and drainage (I&D), culture of the purulent material, and use of systemic antibiotics when indicated.
In contrast to the 2011 guidelines for MRSA in which a culture is recommended for mild, purulent SSTIs, the 2014 SSTI guidelines recommend I&D of SSTIs without culture for mild, purulent infection. Table provides a summary of 2011 and 2014 outpatient management of SSTIs. Figure shows the 2014 IDSA guideline for the management and care of both nonpurulent and purulent SSTIs. NPs should be aware that patients with mild SSTIs do not have symptoms of systemic infection, whereas patients with moderate, purulent infection have systemic signs of infection requiring I&D and C&S.
(Enlarge Image)
Figure.
Management of Purulent and Nonpurulent SSTIs 2014 Practice Guidelines.
Reprinted with permission from the Oxford University Press.
The MRSA 2011 IDSA guidelines and 2014 SSTI guidelines both recommend I&D alone without the use of an antimicrobial because I&D alone will often treat uncomplicated or mild SSTI cases. At this time, however, the practice of performing I&D without prescribing antimicrobials is rare, thus contributing to antimicrobial resistance (AR). CA-MRSA isolates are usually resistant to antimicrobials such as erythromycin and the fluoroquinolones but are typically susceptible to clindamycin and trimethoprim-sulfamethoxazole (TMP-SMX). Children have less resistance to non–β-lactam antibiotics such as clindamycin, but increasing resistance to clindamycin and adverse effects, especially Clostridium difficile, require providers' consideration. Clindamycin is recommended for purulent cellulitis and nonpurulent cellulitis, but clindamycin is resistant to CA-MRSA in many geographical areas. Clindamycin covers staphylococcal and streptococcal isolates, allowing for a safety barrier as a broad-spectrum antimicrobial for providers, but providers should consider ordering a disk diffusion induction test or D-Test to determine clindamycin resistance before initiating treatment. Linezolid is ideal for MRSA, but it too has side effects, and after 2 weeks of therapy, a complete blood count is required. Linezolid also interacts with many medications. Daptomycin and televancin are indicated for severe, purulent infections but are not approved for use in children. Clindamycin can be used if clindamycin resistance is < 10% to 15% in the geographical area of practice per the 2014 guidelines for the treatment of SSTIs, which is a specific recommendation for the use of clindamycin compared with the 2011 guidelines. The 2014 SSTI guidelines address the significance of prescribing clindamycin. Providers should be aware of the prevalence of CA-MRSA in their area of practice, and if the prevalence is high, empirical therapy should be initiated. If the prevalence of CA-MRSA is low, antibiotics should be reserved for MRSA infections associated with illnesses such as osteomyelitis and bacteremia. Integrating the most recent available evidence into clinical practice is essential to addressing the global health threat of AR. In the following case study, a patient presents to the NP with a mild SSTI, and a culture was obtained despite recommendations not to send a culture for patients without systemic symptoms. Clinical acumen, individualized care, and knowledge of the best available evidence guided the patient's initial treatment, showing how clinical knowledge concordant with guidelines improves outcomes.
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