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Diagnosis and Treatment of Methicillin-resistant Staphylococcus aureus (MRSA)

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MR element. Present. Absent. PVL. 2000. 1983. When ... Necrotizing skin infections (Spider bite abscesses) Necrotizing pneumonia. Necrotizing fasciitis ... – PowerPoint PPT presentation

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Title: Diagnosis and Treatment of Methicillin-resistant Staphylococcus aureus (MRSA)


1
Diagnosis and Treatment of Methicillin-resistant
Staphylococcus aureus (MRSA)
John G. Bartlett, MD Professor of Medicine Johns
Hopkins University School of Medicine
The International AIDS SocietyUSA
2
(No Transcript)
3
Slide 3
From J. G. Bartlett, MD, at 11th RW Program
Clinical Update, IASUSA.
4
(No Transcript)
5
METHICILLIN-RESISTANT S. AUREUS INFECTIONS AMONG
PATIENTS IN THE EMERGENCY DEPARTMENTS(Moran GJ.
NEJM 200635566)
  • GOAL Determine the prevalence of MRSA as cause
    of skin and soft tissue infections in multiple
    communities
  • METHOD
  • 1) EMERGEncy ID Net 11 sites
  • 2) gt 18 yrs, lesion lt1 wk, Aug 2004
  • 3) S. aureus isolates CDC

6
  • TREATMENT
  • ? I D antibiotic 60
  • ? I D only 19
  • Betalactam 198/311 (64)
  • MRSA 100/175 (57)
  • Outcome at 15-21 days
  • ? Resolved in 96
  • ? No correlation with MRSA or treatment with
    active abx
  • Contact similar lesion 18

7
STAPH AUREUS (USA 300 400)NEW SYNDROMES
  • Necrotizing skin infections
  • (Spider bite abscesses)
  • Necrotizing pneumonia
  • Necrotizing fasciitis
  • Septic thrombophlebitis
  • Pelvic syndromes (Peds) Septic
  • arthritis hips, pelvic abscess
  • Waterhouse Friderichsen syndrome

8
CONCLUSIONS
  • MRSA epidemic in the community
  • Differed from nosocomial MRSA
  • Diverse and often unique pathology

9
Slide 9
From J. G. Bartlett, MD, at 11th RW Program
Clinical Update, IASUSA.
10
(No Transcript)
11
PFGE TYPING OF MRSA
  • HA HCA CA TOTAL
  • USA 100 74 62 23 58
  • USA 300 16 22 67 29

12
PROJECTIONS AND CONCLUSIONS
  • US burden invasive
  • MRSA infections 94,360/yr
  • Mortality 18,650/yr
  • Incidence 32/100,000
  • S. pneumonia-----14/100.000
  • Regional differences
  • Portland--------------20/100,000
  • Baltimore------------118/100,00

13
MRSA TREATMENT
  • Work horse Vancomycin
  • Use 16 tons/year
  • Resistance 6 strains in 50 years !!!
  • But (Tenover, CID)
  • Heteroresistance
  • MIC creep
  • Persistant bactermia
  • Nephrotoxicity

14
TREATMENT OF SERIOUS MRSA INFECTIONS VANCOMYCIN
  • Standard 1 gm IV or 15-22 mg/kg Q 12 hr
  • Trough goal mcg/mL
  • MRSA pneumonia 15-20
  • CNS infection 20
  • Endocarditis 10-20
  • Bacteremia 10-15

15
VANCOMYCIN FAILURES
  • Linezolid 600 mg Q 12 h
  • Daptomycin 6-10 mg/kg/d
  • Clindamycin 600 mg Q 8 h
  • Trimethoprim sulfa 10/50
  • mg/kg/d rifampin 30 mg/kg/d

16
ANTIBIOTICS FOR MRSA
17
EPIDEMIOLOGY
  • Source Nose, skin, objects
  • Nose MSSA 30
  • MRSA 2-5
  • St. Louis Rams Objects
  • MSM Genital source
  • (CID 200744410)
  • Intervention Barrier precautions
  • Nose Muperocin
  • Body Hebiclens, Phisohex

18
MRSA (USA 300) in MSM (Diep BA. Ann Intern Med
2008148249)
  • Method 9 hospital survey in SF for MRSA
    infections 2004-06
  • Results Analysis of 532/2495 cases
  • MSM risk RR 13.2
  • Sites Buttocks, genitals, perineum
  • Unrelated to HIV

19
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20
UNIVERSAL SURVEILANCE FOR MRSA IN 3 AFFILIATED
HOSPITALS (Robicsek A et al. Ann Intern Medicine
2008148409)
  • Goal To determine the effect of two expanded
    surveillance methods on rates of MRSA infection

21
RESULTS
  • Prevalence of MRSA 3,926/73,464 (8.3)
  • Aggregate MRSA infections
  • Study period Rate Compared
  • (/10,000 pt d) baseline
  • Control 8.9 -----
  • ICU 7.4 -- 36
  • Universal 3.9 -- 70

22
MRSA CONCLUSIONS
  • S. aureus ? MRSA
  • Incredibly diverse pathogenic resistance
    mechanisms
  • Major bacterial pathogen of 21st century (so far)
  • Epidemiology Human-human
  • Management
  • Abscesses Drain
  • Vancomycin, etc.
  • Epidemiology barrier
  • History If controlled, it will return
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