PERIOPERATIVE GRAND ROUNDS CA-MRSA Skin Infections: An Ounce of Prevention Is Worth a Pound of Cure The Case: A 16-year-old boy on a wrestling team noticed a sore spot on his buttock. He assumed it was a spider bite. Two days later, the bump enlarged with a small amount of pus, which he expressed. As the week progressed, the bump grew larger, red, raised, and warm. He then notified his mother and went to a pediatrician. The pediatrician ruled out brown recluse spider bite and was suspicious of community-acquired methicillinresistant Staphylococcus aureus (CA-MRSA). The pediatrician incised the lesion, expressed pus, and cultured it. He prescribed oral clindamycin with follow-up in seven days and ibuprofen for pain. Four days after starting antibiotics, the patient complained of hip pain with ambulation. He was pale and had chills and a temperature of 102 F (38.9 C). His entire buttock was red and swollen with red streaks. The patient’s mother immediately took him to the emergency department (ED). Intensive care unit staff members performed deep tissue debridement of the lesion because the patient was not stable enough to go the OR. Despite debridement and antibiotics, on day three, the patient developed acute renal failure, necessitating peritoneal dialysis, and respiratory failure, requiring intubation. A radiograph showed extensive erosion at the femur head secondary to osteomyelitis. The original wound culture revealed CA-MRSA resistant to clindamycin. The patient was extubated on day 20, and had a left total hip replacement.
He will need management for his physical and emotional issues for the rest of his life.
Discussion: This healthy young man developed a CA-MRSA infection that progressed from soft-tissue infection to femoral head osteomyelitis requiring total hip replacement. Genetically distinct from health careeassociated MRSA, CA-MRSA often is resistant to many noneb-lactam antibiotics (eg, doxycycline, clindamycin). In patients presenting with purulent skin and soft-tissue infections (SSTIs) in 11 EDs throughout the United States in 2008, MRSA was identified in 59% of the cases.1 Emergency department visits for SSTIs increased almost threefold from 1993 to 2005, from 1.2 million visits (1.35% of all ED visits) to 3.4 million visits (2.98% of all ED visits), concurrent with widespread emergence of CA-MRSA.2 Outbreaks of CA-MRSA have been reported in all patient populations, including athletes.3 In a survey of 312 high schools in Nebraska, MRSA infections in athletes increased from 4.4% to 14.4% between 2006 and 2008. During the same time frame, the incidence of MRSA per 10,000 wrestlers increased from 19.6 to 60.1.4 Outbreaks of CA-MRSA have occurred at high school, college, and professional levels for football, rugby, and wrestling.5,6 The primary site of infection is (continued on page 569)
This content is adapted from AHRQ Web M&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Catherine Liu, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Liu C. CA-MRSA skin infections: an ounce of prevention is worth a pound of cure. AHRQ Web M&M [serial online]. http://webmm.ahrq.gov/case.aspx?caseID¼281. Published October 2012. Accessed January 28, 2014.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
http://dx.doi.org/10.1016/j.aorn.2014.02.016
664 j AORN Journal
May 2014
Vol 99
No 5
Ó AORN, Inc, 2014
PERIOPERATIVE GRAND ROUNDS (continued from page 664) cutaneous, and the major mode of transmission is direct skin-to-skin contact.7 This case illustrates the need to improve infection prevention and early recognition. Early follow-up for this patient would have provided important culture results and susceptibilities to antibiotic therapy. In this case, the patient first ascribed his infection to a spider bite. One study of ED patients reporting spider bites found that the vast majority were diagnosed with SSTIs and only 3.8% had spider bites.8 Infection of actual spider bites is very rare. The critical step in management of cutaneous abscesses is incision and drainage. This patient had normal vital signs without systemic signs or symptoms. The 2011 Infectious Diseases Society of America MRSA guidelines state that patients without systemic signs should not be treated with antibiotics.9 Randomized clinical trials show no significant difference in the outcome of MRSA cure whether patients received antibiotics or placebos.10-12 It is unclear whether the use of clindamycin, to which the organism in this case was resistant, led to progression of the patient’s disease. The Infectious Diseases Society of America guidelines recommend adjunctive antibiotic therapy when patients fail to respond to incision and drainage alone, and when there is rapidly progressive disease and cellulitis.9 Good personal and environmental hygiene are key in preventing infections from spreading.13 Facilities and equipment necessary to promote good hygiene should be made available, as should appropriate cleaning supplies. As a dominant cause of SSTIs, CA-MRSA can lead to devastating consequences, such as this tragic case. A proactive approach toward infection control may minimize long-term morbidity.
Perioperative Points: n Before any surgery, perioperative nurses should
assess patients to identify any skin infections. n Education and review for CA-MRSA and health
careeassociated MRSA should be ongoing. n Perioperative nurses should work closely with in-
fection preventionists to prevent the spread of infection from community to hospital environments. n Guidelines for infection prevention should be reviewed and revised annually.
www.aornjournal.org
References 1. Talan DA, Krishnadasan A, Gorwitz RJ, et al. Comparison of Staphylococcus aureus from skin and soft-tissue infections in US emergency department patients, 2004 and 2008. Clin Infect Dis. 2011;53(2):144-149. 2. Pallin DJ, Egan DJ, Pelletier AJ, Espinola JA, Hooper DC, Camargo CA Jr. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of communityassociated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291-298. 3. David MZ, Daum RS. Community-associated methicillinresistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(3):616-687. 4. Buss BF, Mueller SW, Theis M, Keyser A, Safranek TJ. Population-based estimates of methicillin-resistant Staphylococcus aureus (MRSA) infections among high school athletesdNebraska, 2006e2008. J Sch Nurs. 2009;25(4):282-291. 5. Liu C, Graber CJ, Karr M, et al. A population-based study of the incidence and molecular epidemiology of methicillin-resistant Staphylococcus aureus disease in San Francisco, 2004-2005. Clin Infect Dis. 2008;46(11): 1637-1646. 6. Turbeville SD, Cowan LD, Greenfield RA. Infectious disease outbreaks in competitive sports: a review of the literature. Am J Sports Med. 2006;34(11):1860-1865. 7. Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med. 2005;352(5): 468-475. 8. Suchard JR. “Spider bite” lesions are usually diagnosed as skin and soft-tissue infections. J Emerg Med. 2011; 41(5):473-481. 9. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55. 10. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med. 2010;55(5):401-407. 11. Rajendran PM, Young D, Maurer T, et al. Randomized, double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant Staphylococcus aureus infection. Antimicrob Agents Chemother. 2007;51(11):4044-4048. 12. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med. 2010;56(5): 283-287. 13. MRSA information for coaches, athletic directors, and team healthcare providers. Centers for Disease Control and Prevention. http://www.cdc.gov/mrsa/community/ team-hc-providers/index.html. Updated September 10, 2013. Accessed February 4, 2014.
AORN Journal j 569
He will need management for his physical and emotional issues for the rest of his life.
Discussion: This healthy young man developed a CA-MRSA infection that progressed from soft-tissue infection to femoral head osteomyelitis requiring total hip replacement. Genetically distinct from health careeassociated MRSA, CA-MRSA often is resistant to many noneb-lactam antibiotics (eg, doxycycline, clindamycin). In patients presenting with purulent skin and soft-tissue infections (SSTIs) in 11 EDs throughout the United States in 2008, MRSA was identified in 59% of the cases.1 Emergency department visits for SSTIs increased almost threefold from 1993 to 2005, from 1.2 million visits (1.35% of all ED visits) to 3.4 million visits (2.98% of all ED visits), concurrent with widespread emergence of CA-MRSA.2 Outbreaks of CA-MRSA have been reported in all patient populations, including athletes.3 In a survey of 312 high schools in Nebraska, MRSA infections in athletes increased from 4.4% to 14.4% between 2006 and 2008. During the same time frame, the incidence of MRSA per 10,000 wrestlers increased from 19.6 to 60.1.4 Outbreaks of CA-MRSA have occurred at high school, college, and professional levels for football, rugby, and wrestling.5,6 The primary site of infection is (continued on page 569)
This content is adapted from AHRQ Web M&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Catherine Liu, MD, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/owner, Nurse Collaborations, San Antonio, TX. (Citation: Liu C. CA-MRSA skin infections: an ounce of prevention is worth a pound of cure. AHRQ Web M&M [serial online]. http://webmm.ahrq.gov/case.aspx?caseID¼281. Published October 2012. Accessed January 28, 2014.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
http://dx.doi.org/10.1016/j.aorn.2014.02.016
664 j AORN Journal
May 2014
Vol 99
No 5
Ó AORN, Inc, 2014
PERIOPERATIVE GRAND ROUNDS (continued from page 664) cutaneous, and the major mode of transmission is direct skin-to-skin contact.7 This case illustrates the need to improve infection prevention and early recognition. Early follow-up for this patient would have provided important culture results and susceptibilities to antibiotic therapy. In this case, the patient first ascribed his infection to a spider bite. One study of ED patients reporting spider bites found that the vast majority were diagnosed with SSTIs and only 3.8% had spider bites.8 Infection of actual spider bites is very rare. The critical step in management of cutaneous abscesses is incision and drainage. This patient had normal vital signs without systemic signs or symptoms. The 2011 Infectious Diseases Society of America MRSA guidelines state that patients without systemic signs should not be treated with antibiotics.9 Randomized clinical trials show no significant difference in the outcome of MRSA cure whether patients received antibiotics or placebos.10-12 It is unclear whether the use of clindamycin, to which the organism in this case was resistant, led to progression of the patient’s disease. The Infectious Diseases Society of America guidelines recommend adjunctive antibiotic therapy when patients fail to respond to incision and drainage alone, and when there is rapidly progressive disease and cellulitis.9 Good personal and environmental hygiene are key in preventing infections from spreading.13 Facilities and equipment necessary to promote good hygiene should be made available, as should appropriate cleaning supplies. As a dominant cause of SSTIs, CA-MRSA can lead to devastating consequences, such as this tragic case. A proactive approach toward infection control may minimize long-term morbidity.
Perioperative Points: n Before any surgery, perioperative nurses should
assess patients to identify any skin infections. n Education and review for CA-MRSA and health
careeassociated MRSA should be ongoing. n Perioperative nurses should work closely with in-
fection preventionists to prevent the spread of infection from community to hospital environments. n Guidelines for infection prevention should be reviewed and revised annually.
www.aornjournal.org
References 1. Talan DA, Krishnadasan A, Gorwitz RJ, et al. Comparison of Staphylococcus aureus from skin and soft-tissue infections in US emergency department patients, 2004 and 2008. Clin Infect Dis. 2011;53(2):144-149. 2. Pallin DJ, Egan DJ, Pelletier AJ, Espinola JA, Hooper DC, Camargo CA Jr. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of communityassociated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008;51(3):291-298. 3. David MZ, Daum RS. Community-associated methicillinresistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev. 2010;23(3):616-687. 4. Buss BF, Mueller SW, Theis M, Keyser A, Safranek TJ. Population-based estimates of methicillin-resistant Staphylococcus aureus (MRSA) infections among high school athletesdNebraska, 2006e2008. J Sch Nurs. 2009;25(4):282-291. 5. Liu C, Graber CJ, Karr M, et al. A population-based study of the incidence and molecular epidemiology of methicillin-resistant Staphylococcus aureus disease in San Francisco, 2004-2005. Clin Infect Dis. 2008;46(11): 1637-1646. 6. Turbeville SD, Cowan LD, Greenfield RA. Infectious disease outbreaks in competitive sports: a review of the literature. Am J Sports Med. 2006;34(11):1860-1865. 7. Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med. 2005;352(5): 468-475. 8. Suchard JR. “Spider bite” lesions are usually diagnosed as skin and soft-tissue infections. J Emerg Med. 2011; 41(5):473-481. 9. Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52(3):e18-e55. 10. Duong M, Markwell S, Peter J, Barenkamp S. Randomized, controlled trial of antibiotics in the management of community-acquired skin abscesses in the pediatric patient. Ann Emerg Med. 2010;55(5):401-407. 11. Rajendran PM, Young D, Maurer T, et al. Randomized, double-blind, placebo-controlled trial of cephalexin for treatment of uncomplicated skin abscesses in a population at risk for community-acquired methicillin-resistant Staphylococcus aureus infection. Antimicrob Agents Chemother. 2007;51(11):4044-4048. 12. Schmitz GR, Bruner D, Pitotti R, et al. Randomized controlled trial of trimethoprim-sulfamethoxazole for uncomplicated skin abscesses in patients at risk for community-associated methicillin-resistant Staphylococcus aureus infection. Ann Emerg Med. 2010;56(5): 283-287. 13. MRSA information for coaches, athletic directors, and team healthcare providers. Centers for Disease Control and Prevention. http://www.cdc.gov/mrsa/community/ team-hc-providers/index.html. Updated September 10, 2013. Accessed February 4, 2014.
AORN Journal j 569
