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CA-MRSA Skin Infection
Ann McBride, M.D.
June 9, 2004
No financial disclosures
HUGE thanks to Patty Boyle

17 yo high school student, daughter of UW
surgeon, with MRSA furunculosis

36 yo F 6 wks after hysterectomy developed
extensive furunculosis and skin abscess

51 yo Type 1 DM with chronic
neurodermatitis, 2 mos after hospitalization
for CAP has + MRSA skin lesions.
OBJECTIVES

Clinical Characteristics CA-MRSA

Biological Characteristics CA-MRSA

Treatment of MRSA Skin Infection

Prevention of Recurrences
Major Staph clinical syndromes :
skin-related infections, cellulitis,
osteomyelitis, septic arthritis, TSS,
pneumonia
Transmission: person-to-person contact
from individual with Staph infection or
colonization.
Can be transmitted from contact with contaminated
environment. Can remain days (more than a week)
Airborne transmission is prob not frequent route
S aureus frequently part of transient flora.
Among healthy individuals, carrier rates
est 10 – 30%
Common carrier sites of S.aureus :
anterior nasal vestibule
skin - axilla, perineum- hair, nails
Duration of carrier state – several months
Mean duration 8-9 months; can last years
Hospital personnel and individuals with
chronic skin condition often have higher
rates and longer duration of colonization
MRSA first described nosocomial
pathogen 1960’s
MRSA = ORSA
resistance to all Blactams, & cephalosporins
1990’s CA-MRSA vs HCA-MRSA
CA-MRSA
(excludes dx of HCA-MRSA)
1.
Dx in outpt setting or culture + MRSA
within 48 hrs after hospital admission
2.
No history previous MRSA
3.
No hospitalization or exposure to health
care facility within previous year
4.
No permanent indwelling catheter
In 2000 CDC surveillance to
characterize clinical, micro-
biological, and molecular features
of CA-MRSA and HCA- MRSA
JAMA Dec 2003
Comparison of CA-MRSA vs HCA-MRSA
12 labs in MN
½ metropolitan
½ non-metro
All labs served inpt and outpt
10/12 Adults and Peds
1/12 Peds only
MN Surveillance:
¼ all S. aureus cultures = MRSA
1100/4612
Range 10-49%
Among MRSA:
85% HCA
12% CA
3% unclear
MN Surveillance:
Of CA-MRSA
53% metropolitan
47% non-metro
Younger median age of CA-MRSA vs HCA-MRSA
30 yo vs70 yo
mecA gene required for MRSA
mecA gene codes PBP 2a
Pcn Binding Protein low affinity for
B-lactams Thus, more resistant
to B-lactams.
Difference in exotoxin genes
between CA- and HCA MRSA
PVL (Panton Valentine Leukocidin) gene:
* common in CA MRSA (20/26 vs. 1/26)
esp. skin infections, necrotizing pneumonia
* codes for Cytotoxin disrupts cell membrane;
cause severe tissue necrosis, destruction WBCs
* facilitates MRSA penetration of intact skin
Frequency of MRSA colonization
not addressed

** 500 otherwise healthy children seen
UCCH 1996; 132 colonized with S. aureus

11/132 (8.3%) were MRSA
Pt #1 17 yo recurrent furunculosis Fall 2003
Dau of UW surgeon abscess L arm +MRSA
dau’s skin wound & nares culture +MRSA
- DM, Skin dz, needle use
hs swim team; no skin infctn among
teammates
2 households – only father and my pt +MRSA
grandmother in nursing home
Impr: colonized w/ MRSA and recurrent
furunculosis
Management: Decolonization
End of swim team participation
Treatment of recurrent furuncles
--minocycline + rifampin x 2 wks
Decolonization for CA-MRSA

Generally NOT recommended for single case
MRSA infection

Consider for recurrent MRSA infection
(3 or more infections in 6 months)
Decolonization
Mupirocin ointment anterior nares “match head size”
½ anterior vestibule one nostril
½ anterior vestibule other nostril
Press sides of nose together
Gently massage
bid x 5 days (to 14??); one week later f/u nasal
culture
if nasal culture +MRSA  repeat once
no more than 3 mupirocin treatments
Purell hand cleansing
Bath/shower daily with antiseptic
Wet skin thoroughly
Body wash – chlorhexidine (Rx Hibiclens)
Apply disinfectant soap with moistened
face cloth
Caution: Skin irritation
? Substitute tree oil cleanser

Pat skin dry gently; avoid abrading skin

Use moisturizer while skin is moist after
bathing

Consider D/C shaving temporarily

Avoid tightly fitting clothes/bands
could rub skin
Environment
Launder
– Hot water
– Bed sheets, towels, wash cloths
Dryer (med to high heat) for clothes -- not air
drying
Wipe down bathroom and kitchen counters, and
handles –refrigerator, doors, cabinets (bleach)
Outbreaks CA-MRSA described in various
populations including participants in sports.
Risk factors for Staph infections in athletes:
Contact with lesions of other players
Skin trauma
Sharing of sports equipment
CDC’s Recommendations for
Preventing Staph Infections
1.
2.
3.
4.
5.
6.
7.
Cover all wounds. If a wound cannot be covered
adequately, consider excluding player until lesions
healed
Encourage good hygiene—showering w/ soap after all
practices and competitions
Ensure availability of soap and hot water
Discourage sharing of towels, clothing, and equipment
Establish routine cleaning schedule for shared
equipment
Educate athletes and coaches re: potentially infectious
skin lesion
Encourage early reporting/assessment for skin lesions

With recurrence
minocycline + rifampin
clindamycin + rifampin
TMP-SMX + rifampin
Minocycline has excellent skin penetration
Rifampin + atbtc to reduce emergence of
resistance
Lecture by Dr. Maki
If furuncle appears to develop, apply liberal
amount of OTC Bacitracin ointment
Apply Tegaderm (Transparent polyurethene
dressing)
This maintains high concentration of drug in
lesion x 3-4 days
Pt #2 36 yo woman undergone hysterectomy
late summer 2003. Developed “bug bites”
buttocks and thighs fall 2003
Gyn treated ceph
Next day, came to IM “no better” ; R leg
furuncle had small amt of purulent drainage
Diclox initiated, skin lesion +MRSA
RTC 48 hrs; Lesion had drained and improved after
draining.
Diclox D/C’d; No systemic antibiotic
Decolonization effort and topical/local treatment of
recurrence per Dr. Maki’s recommendation
One additonal lesion, did not require po atbtc
F/up surveillance cultures negative x 3
+ MRSA Patient Presenting to Clinic

Pt placed directly into exam room
– Need not be negative flow
– Door may remain open
– Gown, gloves required if touching pt or any
item in room
– Mask not usually required (unless +MRSA
nares w/ URI)
Gown, gloves left in room
Stethoscope cleansed with ETOH
Purell hand cleansing before exiting
Room closed until housekeeping
cleanses/disinfects

MRSA precautions in clinic cannot be lifted
until three sets of neg surveillance cx

On order card check “MRSA Screen”

Each set obtained at least one week apart

Swabs from L & R nares combined (single
swab for both nares)

Swabs from axilla and groin can be
combined (single swab for both axillae and
both sides of groin)
No role for attempting mupirocin or systemic
(oral antibiotics) decolonization in pt with
chronic skin condition
Patient #3
50 yo Type 1 DM w/ neurodermatitis chronically
excoriated skin
hospitalized Nov 2002 with pneumonia
In Dec 2002, MD in neuroderm clinic +MRSA arm
lesion
Early 2003 – appt in IM Clinic; WISCR = +MRSA
No attempt to decolonize
2003 – 2 small skin abscesses
I & D; Consult w/ ID- rec decolonization
attempt to decrease bioburden
Decolonization effort has worsened dermatitis
Three patients
-- all three “HCA-MRSA” --
yet clinical presentation assoc with CA-;
atbtc susc pattern ‘typical’ for CA-MRSA
Clinical importance/helpfulness of this
distinction???
Clinical setting most predictive of S aureus infection.
Clinical syndromes CA-MRSA – typically,
skin infections, cellulitis, abscess – closely
resemble clinical syndrome of MSSA in
community
Atbtc selection depends upon susc pattern
Management Future – PCR testing for mecA
gene to est MRSA sooner??