View Full Version : MRSA
We now have a problem on our hands with this stuff at the Jail. I have seen some nasty stuff in my lifetime but nothing like this before. It spreads very fast and just about everyone who has it has had to be taken to ER for debridement and draining of the infected areas. Surgery has had to happene in 4 cases. I have seen some big holes in people with this. I guess it starts out as a small pimple then takes off after it has erupted. The area becomes hardened, raised, and very warm with cellitis developing in all cases. What I have been told by some is to use gloves when patting people down, wash hands constantly, and take a shower before going home. Also, leave the uniform at work.
Now my question to the Docs is: I know that MRSA is found everywhere, but why all of the sudden has it spread like wildfire? Does one have to have any pre-existing diseases and/or a weakened immune sysytem for this stuff to grow and develope? Was the above given advice on staying "sterile":eek: going overboard or can I do more to keep this stuff there and not take it home?
Thanks!
jasonglh
10-27-2005, 18:38
In the hospital for a known MRSA patient we use strict contact precautions. So its pretty much gown and gloves unless they have it in their sputum then we observe droplet precautions which is a mask with eye shield.
I think it can live up to 24 hours on objects as well though.
http://www.cdc.gov/ncidod/hip/ARESIST/mrsahcw.htm
Do a google search of MRSA jail Precautions and you will see articles about outbreaks all over the country. Some places have reported fatalities as well.
I'm sure the others can provide much more info than I can.
18C/GS 0602
10-27-2005, 23:32
MRSA for all those people out there who don’t know stands for methicillin resistant staph aureus. Staph aureus is very common bacteria that typically lives on skin and can cause soft tissue infections. MRSA is a type of staph aureus that is resistant to many different antibiotics and because of that can be difficult to treat. Initially it was a bacteria that was only seen in hospitalized patients that had been exposed to many antibiotics. Unfortunately recently there have been a lot of infections in non-hospitalized people in the community. This stain looks like it is genetically different from the one seen in hospitalized patients. In terms of prevention good hand washing will help, but if you are in physical contact with people with MRSA it can be difficult not to get exposed to it. That doesn’t necessarily mean getting infected.
The Reaper
10-28-2005, 07:05
Why not hose all of the cells down with STB?
TR
A good friend of mine picked this up somewhere recently, he had to have about a 6 inch long by 1-1.5 inch deep chunk cut out of his abdomen because of it. Bad Juju! He was also on some kind of wicked bad meds for like 2 weeks.
Scary stuff
Surgicalcric
10-28-2005, 07:55
Why not hose all of the cells down with STB?
TR
And change all the mattresses.
There was a very large outbreak of it a few months back at SOPC. I dont remember the exact number of students med dropped from one class but it was in the high 30's. Thereafter all the linen and mattresses were changed and it helped. There are still a few cases here and there (damned gig-pits) but not as many as before.
Crip
Yes it is nasty stuff. I have watched about 5-6 debridemts including lancing just to relieve the pressure at the ER within the last 5 weeks. Antibiotic of choice around here is Septra. Now, is there any point during the treatment of an infected individual that they are considered no longer a threat to the rest of us.
Eagle5US
10-28-2005, 19:56
Ugg...MURRSA BAAADD...
Eagle
Kyobanim
10-28-2005, 20:03
Is this something that can be picked up in a gym?
Eagle5US
10-28-2005, 20:50
Is this something that can be picked up in a gym?
Moreso if someone brings it in.
To break it down to the most basics...
It is a Staph infection on 'roids. Staph is everywhere, on your skin, on "stuff", where you would (and would not) expect it. You wouldn't know it was MRSA until it was cultured...and it grew "the bug":eek:
Eagle
Damn. Do I have permission to print this thread and bring it to my gym? Not sure what good it will do but knowledge is power.
RockyFarr
11-23-2005, 21:17
MRA has been growing more prevalent throughout America for sometime, probably fed by our use of indescriminent antibiotics-SF shotgun medicine. It's always been common were folks were kept in close quaters, like wrestling teams, etc. Not sudden, just steady....
MRA has been growing more prevalent throughout America for sometime, probably fed by our use of indescriminent antibiotics-SF shotgun medicine. It's always been common were folks were kept in close quaters, like wrestling teams, etc. Not sudden, just steady....
Check your PM's.
Doc
18C/GS 0602
11-23-2005, 22:57
Welcome COL Farr. It is an honor to have you here.
DoctorDoom
11-28-2005, 00:20
x
It's a complicated problem -- governments and the food/pharmaceutical industries need to jump to it, and right quick, but like most things in America right now powerful lobbies are pulling for the Dark Side. There are many other multiple-drug-resistant bugs cooking in the wings right now -- the enteric bugs (campylobacter, salmonella) will make the next big splash (pardon the imagery).
A major factor in induction of resistance is the use of massive quantities of antibiotics in the poultry, aquaculture, and beef/pork industries. Couple this irresponsible use of drugs with rampant over-prescribing and a rapid dropoff in antimicrobial R&D (drugs for chronic conditions are much more profitable than those which treat acute infections) and we are looking at a return to the pre-penicillin days.
Bad juju is right. Don't even get me started on TB.
all the recent news on TV and like about the super bug and MRSA... prompted todays interview I did on a local TV news station:
http://www.kgun9.com/NewsArticle/tabid/1112/xmid/15655/Default.aspx
Here is some background...
How I managed to get a MRSA infection on my left forearm
On the Monday and Tuesday (January 15 & 16, 2007) mornings following the SHOT Show in Orlando I went to my local gym here in Tucson. I use a variety of machines, free weights and the aerobic apparatus’s there. I am sure it was on Tuesday, after I returned home I noticed on my left forearm what appeared to be a pimple. It was a small red area about ½ the size of a dime with a center that was raised and white. The white center was tender to the touch. Being the guy that I am I squeezed it.
By the mid afternoon it had swollen a bit and was really red and noticeable. Wednesday it was starting to emit puss. Same thing for Thursday and Friday and the wound site really began to grow. It was starting to freak me and my wife out. She is an RN and, God bless, always goes off the deep end on wanting to take care of us. Be, again being the typical guy, told her I would take care of this myself.
Almost immediately, I began flushing the site with hydrogen peroxide, washing with warm water and soap, then applying Neosporin antibiotic ointment and covering with a large band aide at this point, this was not helping and the wound was getting worse.
Sunday night I started to get a fever and the amount of puss coming from the wound increased. A USAF buddy of mine stopped by and when he saw the arm he immediately said that I need to go and see the Dr. I had already made an appointment but the earliest I could get in was Tuesday.
Monday night and I have a temperature of 101.5 and the amount of swelling and puss has increased dramatically. I don’t spook easily, but this was freaking me the hell out. Next morning I went to see the Dr. and my left hand has swollen during the night and I cannot close it.
I showed it to the Dr. and his eyes bulged. He gloved up, took a culture, and then said, “This may hurt a bit” and proceeded to squeeze around the wound draining it. He put me on 750 mg of Levaquin for 10 days and told me that he wanted to see me for a follow-up on Friday.
Immediately I took the first 750 mg Levaquin...and Wednesday I could see the color of the puss change from the brown tinge to more of a Bailey’s cream color. Wednesday my temperature broke and fell back down to normal.
Jump to Friday. I went in for the follow up and the Dr. was happy with the visual inspection of the wound. He pulled up the results of the culture he took from the following Tuesday and, tada! MRSA! Here is what it said:
2+ STAPH AUREUS
Note: Oxacillin resistance indicates methicillin resistance (MRSA). MRSA ORGANISMS ARE RESISTANT TO ALL BETA LACTAM AGENTS, INCLUDING CEPHALOSPORINS.
Then it listed stuff that this strain is resistant to:
Sulfa/Trimeth S (susceptible)
Tetracycline S
Clindamycin S
ERYTHROMYCIN R (Resistant)
Vancomycin S
Amoxicillin/Clavulinic Acid R
Oxacillin R
Moxifloxacin S
Rifampin S
The Dr. again gloved up, and began to squeeze out a shit load of puss. Then, he gave me a local anesthetic and then made a small incision on another part of the wound area and drained more. I was about to scream when he said, “ok, I think I got it all...” Whew.
I have six more days of Levaquin to take and I have another follow-up with the good Dr. on Wednesday.
Lessons Learned:
Gyms, common areas where large numbers of people live, meet, hang out are breeding grounds for a whole host of new and frankly dangerous new infections that start so benignly and then the end result is a MRSA 2+ Staph infection.
Future actions:
I was thinking that this could have started out as a piece of fiberglass working its way out and the site got infected, then I was thinking it was some kind of skin disorder... then it dawned on me that this similar thing happened one perhaps 2 other times but no where near the scale that this one turned into. With each case, I had either just returned from the gym or... I had just come back from training somewhere and was staying with a large group of people in one common area. So, I will definitely shower and clean up after each trip to the gym, and I will refrain from squeezing pimples.
Admin edit...Your holistic cure is not an antibiotic ointment as you advertise it to be. While it may show some premise, it has not been approved as a pharmacological treatment and will not be referred to as such here. Personal opinions on alternative medicine are fine. Advocations of such in treating potentially life threatening bacteria are another matter. This type of encouragement generally prevents people from seeking timely medical care from a qualified provider and tends to promote the belief that their local health food store substitutes for their pharmacy because "they read about it on a Special Forces Website" - Eagle
When I worked in the Jail Division I have never seen it so bad. Jeez, I didn't even know what "MRSA" was until I started doing the medical run. We had one inmate come in at the window who had advanced MRSA and we didn't take him because he was leaking so bad that it almost smelled like death. He eventually died within two days of getting to the hospital (which was that day). I personally took around 15-18 people to the hospital, one of which had to have his arm amputated.
The neat thing to watch however was the ER doctor's do a radial nerve block, incise, pull out the mucous plug, and in most cases debride the open would. Then it was the drugs they started them all on, Septra/Bactera and Augmentin (note sure it was this one as I cannot remember off hand. Mugwump, need some help here.).
Out of all the things you can pick-up working in a Jail or Prison, MRSA was the most feared. And would you believe there were still Deputies that would never wear gloves when patting a person down or searching through their belongings. I use to tell them that if you patted someone down that had it and you didn't know it and afterwards you had a bad itch on your neck from shaving and you scratched it to death, you would be in a very serious situation if it elected (MRSA) to start eating away on your neck
LeapingGnome
10-20-2007, 04:47
Crip is right, it's nasty stuff as witnessed at the old(er) school SOPC training location. I've read the recent news scares and listened to the talking heads spew panic but the one thing i haven't heard mentioned is the importance of properly taking your antibiotics. If you have a 5(7,9) day cycle...take the whole damn cycle. A lot of people will feel better on day 3 and stop taking their meds. Without going into the pharmacology, if you don't take the whole cycle you are helping create antibiotic resistant strains like MRSA. I heard a woman on the news last night saying that her doctor told her to stop taking her antibiotics so she wouldn't get MRSA. Wrong answer. The other issue is docs prescribing antibiotics for viral infections because mom wants the kid to have them. Also wrong answer. Antibiotics are for bacterial infections. Period. A QP I know was recently given antibiotics for an infection and the doc didn't culture the drainage. Once again, with out going into details, the doc needs to know what kind of infection it is in order to properly prescribe drugs. You can go ahead and make a guess and start treating, but if the culture comes back you can always change the drug regimen based on the culture. If antibiotics are properly prescribed and properly taken the risk is cut way down. Another fun MRSA fact is that it tends to live in the nose of the person who has it and can live there for months or years. As with anything, your mom was right. Don't pick your nose, keep yourself clean, always wash your hands, don't scratch scabs and wounds and if it looks bad go see a doctor...or your friendly neighborhood 18D. The whole MRSA thing is an evolving community health issue that is worth discussing and sharing information about. I would be interested in hearing other guys recent MRSA experiences.
Yasnevo
Many individuals are carriers of MRSA (usually on the skin) but it causes no problems unless it gets into a skin breach (on the carrier) or is transferred to the respiratory system of a person who is susceptible or otherwise vulnerable to that infection. In terms of infection control, the spread of the organism is by contact, but you still need a vulnerability for the infection to take hold. I advise that you check for some underlying skin breach or similar vulnerability because it is not usual for a person to develop those symptoms simply by coming into contact with another person who has the MRSA organisms on his/her skin. If that was the case, we would be inundated with non-iatrogenic infections and we would grind to a halt as a hospital.
At our hospital we have recently had to shut down an entire Intensive Therapy Unit because the MRSA and C. Diff. infection rates were unacceptably high. The unit was steamed and refitted and it was sealed over a period of 4 days and flooded with a toxic gas. There is a national campaign to nail the spread of MRSA here in the UK and there are various projects underway (some of which have been developed in partnership with US organisations):
1) The use of elemental silver in paints for new ward refits
2) The use of silver alloy threads for patients' ward clothing
3) The replacement of human IT interfaces with easier to clean alternatives. One example of this is flexible rubber keyboards for ITU.
(Silver is known to retard or prevent the spread of MRSA. The exact mechanism by which it does this is not clear.)
If you are in an organisation such as a hospital where you are experiencing recurrent MRSA infections in your patients or 'customers' then you need to look into the pathways of infection, ie your infection control policies. Staff and (to a lesser extent) asymptomatic visitors who are carrying the organism are the main cause of the spread of this infection. If it keeps happening, a blanket test of all critical staff who may have been in contact with that patient may be ordered. It has happened here: an entire department was forced to undergo nasal swabs for the detection of MRSA and if these were positive then the staff were reassigned while appropriate remedies were put in place.
The other thing they have done here is make infection control mandatory training for all hospital staff, not just those in direct day to day contact with high risk patients. It now joins manual handling, basic life support, fire training and child protection on the list of mandatories.
Divemaster
10-24-2007, 01:36
Just another bump to get this thread to the head of the line. When I started reading this, I was shocked to see this thread started 2 + years ago. Well, that was until I realized this was an SF medical thread. 18D's rock! (testimonial provided by a stunt team guy NOT on an STD closed course). Silver bullet? What silver bullet?
Seriously, admins how about giving the panic media a clue as to how our guys were all over this in 2005?
I am not in any way an expert in the field of MRSA...I did hower have it and dealt with it.
Here in Tucson, for the last week or two, on the evening news, there has been a MRSA altert.
Amazing.
Y-
incarcerated
09-12-2009, 23:21
A good friend at work got the pulmonary version. Watch your dust.
http://www.bloomberg.com/apps/news?pid=20601124&sid=aAkcxmCaOfKc
Infectious Bacteria Found on Northwest Beaches, Scientists Say
By David Olmos
Sept. 12 (Bloomberg) -- Drug-resistant bacteria that causes serious infections and is most commonly spread in hospitals was found on nine beaches in Washington state, scientists said.
Samples from water and sand collected from 11 public beaches near Puget Sound near Seattle and in California were tested for a germ known as methicillin-resistant Staphylococcus aureus, or MRSA, and a closely related drug-resistant organism, according to a study reported today at a meeting of infectious disease doctors in San Francisco.
MRSA is found in about 5 percent of hospital patients, and accounts for almost two-thirds of skin infections in emergency rooms, up from just 2 percent 35 years ago, according to the Rockville, Maryland-based U.S. Agency for Healthcare Research and Quality. Scientists are studying how the bacteria spread away from hospitals, nursing homes and kidney dialysis centers.
“We were interested in answering where in the community, outside the health care system, could the average American pick this up,” said Marilyn Roberts, the study’s lead author, in a telephone interview. “We found MRSA in a lot more places than we thought we would.”
Roberts, a researcher at the University of Washington’s School of Public Health in Seattle, presented the findings today at the Interscience Conference on Antimicrobial Agents and Chemotherapy in San Francisco.
Strain of Staph Infections
Staphyloccus aureous is a strain of so-called staph infections that are typically carried on the skin or in the nose of healthy people. The first U.S. MRSA infection was reported in 1968, according to the National Institutes of Health. The bacteria are resistant to common first-line antibiotics, such as penicillin and amoxicillin, and can lead to a serious form of pneumonia and death. The most vulnerable patients are those with weakened immune systems and those undergoing surgery, Roberts said.
Scientists have known that staph can spread in water, such as in swimming pools, Roberts said. And previous studies have found MRSA present in warmer waters, such as South Florida.
The study by University of Washington researchers was the first to look at the presence of MRSA in the water and the sand at beaches, Roberts said. MRSA or the closely related germ, called Methicillin-resistant coagulase-negative Staphylococci, were found at all nine of the Washington sites. The bacteria weren’t discovered at the two California beaches. The germs may not have been found at the California sites because the samples were collected on a single day and the sample size was “skimpy,” Roberts said.
Question of Transmission
The study didn’t attempt to determine how MRSA was getting into the water or sand, Roberts said. Possible explanations include beachgoers shedding the bacteria from their bodies, transmission from birds and animals and run-off from hospital locations, although none of the sampling sites was near a hospital, she said.
“When we started the study, we didn’t necessarily think we’d find MRSA at all,” Roberts said. “The findings suggest that there’s probably a lot more out there than what we were able to detect” considering the relatively small samples taken, she said.
Further studies may analyze where people with MRSA infections were exposed to the bacteria, she said.
To contact the reporter on this story: David Olmos in San Francisco at dolmos@bloomberg.net.
Last Updated: September 12, 2009 12:45 EDT
swatsurgeon
09-13-2009, 14:21
Just be aware...despite being a "resistant" bacteria, there are medications available to use to treat it and kill it.
ss
CivieAttorney
01-18-2010, 21:51
A question for the docs and medicos on this forum:
While doing some pro bono stuff, I shook hands with a guy who then said "so I got MRSA from my job."
The thing is, I have open wounds on my hand from dry skin, and it was several hours before I could apply alcohol (though I washed my hands right after the interview).
I'm kind of worried, and web searches are giving me conflicting symptom info.
Then I found this thread. Is there an extended incubation period for this, or should I expect symptons within 24 hrs. / No worries if nothing in that time?
Thanks,
Benjamin
Doczilla
01-19-2010, 21:02
Everybody gets MRSA these days. The majority of cutaneous abscesses in urban centers are due to MRSA, and they rarely result in a life-threatening infection, particularly in immunocompetent active individuals.
The infection, if you got it (unlikely), would probably begin with localized redness of the skin around the open wound or point of entry. The redness may spread, or result in red streaks up the arm, or collect as an abscess at the point of infection. Fever would be a concerning sign. A systemic, life threatening infection would be very rare.
Because of the open wounds on your skin, this could be a portal of entry for the bacteria at any time. This exposure to your client really means nothing to you, as we are surrounded by MRSA constantly. Observe good hand hygiene, treat the dry skin, and observe for any signs of infection such as redness.
'zilla
A question for the docs and medicos on this forum:
While doing some pro bono stuff, I shook hands with a guy who then said "so I got MRSA from my job."
The thing is, I have open wounds on my hand from dry skin, and it was several hours before I could apply alcohol (though I washed my hands right after the interview).
I'm kind of worried, and web searches are giving me conflicting symptom info.
Then I found this thread. Is there an extended incubation period for this, or should I expect symptons within 24 hrs. / No worries if nothing in that time?
Thanks,
Benjamin
PedOncoDoc
01-20-2010, 05:48
What Doczilla said. Also, we are all colonized with bacteria on our skin, in our guts (from cheek to cheek) and elsewhere. Staph aureus (the SA in MRSA) is one of the most common bacteria on our skin and rarely causes infection with appropriate hand/wound hygiene. MRSA is no different that regular Staph in this aspect; it just responds to fewer antibiotics when it does cause an infection.A large percent of us in this country are colonized with MRSA. It used to be that MRSA was almost exclusively encountered in hospital-acquired infections, but this is no more. Now most of the MRSA infections occur in the cummunity.
On a side note - the over-use of antibiotics has added to this problem, but the fault lies in the patients just as much as with the doctors. Patients often come in expecting/demanding antibiotics for illnesses/symptoms which do not require therapy. The culpable doctors, out of fear of losing patients or being sued when they miss the rare infection requiring antibiotics and don't see the patient in close follow-up, prescribe the antibiotics. Some also feel it's much easier to prescribe the drugs to avoid a lengthy discussion/argument about why the antibiotics aren't needed so they can see the 30-40 patients per day they need in order to support their family, pay their bills and astronomical malpractice insurance and pay off their medical school debt. They don't think about the downstream effect of adding to antibiotic resistance. (Rant off.)
I am a minimalist when I prescribe medications in general. More specifcaly related to antibiotics, I don't prescribe them to immunocompetent individuals without clear evidence of a bacterial infection that their immune system is not containing and clearing on its own. Yes, that often means a quick follow-up appointment in 1-3 days, but it saves them the cost of a drug copay, the risk of a reaction to antibiotics, and does not add to the growing problem of drug resistant bacteria.
It has been shown in some drug-resistant bacterial strains that the survival advantage of the resistant bugs is only in the setting of rampant antibiotic use, and that with appropriate prescribing practices and time the infection rates don't change but much fewer instances of multi-drug resistant bacterial infections are seen.
MOO for most, scientific literature references for the last paragraph.
CivieAttorney
01-20-2010, 08:43
Thanks for the info. It's more concise and to the point thabn I've found anywhere, even from the CDC. So far my hands are healing up without problem, so I'm going to start breathing again.
I've treated/referred maybe two dozen Marines/Sailors with MRSA. Every damn one of them said it was a "spider bite." http://www.medscape.com/content/2004/00/48/28/482893/art-jabfp482893.fig3.jpg This is what it looked like in the field. Pics available on Google seemed to be way further progressed then what it looks like at the casual "Hey Doc, have a look at this?" stage.
Is just a Marineism, or have y'all heard the same description of 'spider bite'?
PedOncoDoc
01-21-2010, 06:38
Is just a Marineism, or have y'all heard the same description of 'spider bite'?
It's a regional thing - people from most regions call these abscesses (pockets of pus) "spider bites" but in the deserts of the southwest - particularly on the reservations - abscesses, along with a variety of other maladies, are blamed on scorpions.
If you've never seen a brown recluse bite, they can appear similar early in the process. One way to tell the difference is that in later stages there will be necrosis in the pocket of the spider bite which leads to an indent in the skin. The abscesses over time will grow and can show pus at the surface. The recluse bites will not have pus in them unless they get infected.
I had such an abcessing infection a couple of years ago - medially on the posterior of my left calf - first thought it might be either an insect bite or staph infected hair follicle - within 48 hrs and non-responsive to a normal Rx regimen, knew it was different but did not initially equate it to MRSA - I then treated it as a GSW - kept it open and drained, irrigated it 4xd and packed with polysporin and watched for signs of systemic infection - healed within a couple of weeks and now looks like an old .22-sized GSW - MRSA was less well known then and it wasn't until later that I realized what had happened.
Richard
I had such an abcessing infection a couple of years ago - medially on the posterior of my left calf - first thought it might be either an insect bite or staph infected hair follicle - within 48 hrs and non-responsive to a normal Rx regimen, knew it was different but did not initially equate it to MRSA - I then treated it as a GSW - kept it open and drained, irrigated it 4xd and packed with polysporin and watched for signs of systemic infection - healed within a couple of weeks and now looks like an old .22-sized GSW - MRSA was less well known then and it wasn't until later that I realized what had happened.
Richard
Interesting thread.
Same thing here, Richard. I too had a similar infection on the upper inner thigh. I didn't know what to call it so I assumed it was a spider bite. Started off as a red spot, which bulged and then grew to an abcess, which I popped and then continued to squeeze out drainage. It turned into a small "hole" and looked gnarly enough for me to actually get concerned enough to keep it cleaned out and repeatedly doused with hydrogen peroxide and bacitracin/neosporin (what I had around the house). I had one foot in the starting blocks to run to the ER if I saw infection spreading. IIRC, that thing persisted for many weeks but eventually closed up and healed leaving a little indentation.
rltipton
01-21-2010, 20:16
I had an adventure with this stuff just this September. I got a little zit on my right thigh about 3" above my knee, so I popped it...no big deal. Then I went out nd worked in my yard and got sweaty and dirty... The next day the zit was the size of a quarter and very painful, so I cleaned it well and put neosporin and a bandaid on it. The next morning I went to the ER because it was very angry and red, extremely painful to the point is hurt to walk, about the size of an orange. The doc sliced it open and drained it, bandaged it and sent me home, but he did not get in deep enough.
When I woke up the following morning I knew I had something bad. My leg was red and VERY hot from mid-thigh to mid-knee, 90% of the circumference of my leg, with a knot the size of a large grapefruit over my knee. I went back to the ER and they admitted me right away, did surgery on it again, packed almost a foot of gauze in it, put me on IV antibiotics and some very powerful pain killers. They gave me, my wife, and my kid a bottle of body wash and some ointment to put in our noses for a week afterwards, had to pretty much sterilize the whole house.
The doc said if I had waited 24-36 hours longer I could have lost my leg or died. It sure as hell hurt and made me feel like I was going to die from it...made me sick as hell. At one point I could put the whole tip of my thumb in the hole between packings. It looks like about a .38 or 9mm GSW scar.
Incidentally, I saw a discovery channel show about the top 10 deadliest 'bugs' on Earth and MRSA was #3 or 4 I think. It's scary stuff.
Doczilla
01-22-2010, 23:21
I've treated/referred maybe two dozen Marines/Sailors with MRSA. Every damn one of them said it was a "spider bite." http://www.medscape.com/content/2004/00/48/28/482893/art-jabfp482893.fig3.jpg This is what it looked like in the field. Pics available on Google seemed to be way further progressed then what it looks like at the casual "Hey Doc, have a look at this?" stage.
Is just a Marineism, or have y'all heard the same description of 'spider bite'?
Virtually every patient I see with a cutaneous abscess says it was a "spider bite", yet virtually none of them have actually seen the spider that supposedly caused the abscess. It comes from the progression of the infection from a small wheal and localized redness, which often resembles a mosquito bite. As it worsens, the patient has locked onto the "bug bite" theory and assumes that it, being more serious, came from a spider. It then progresses to an abscess with or without a head. Sometimes there can be some necrosis or scab in the middle of the abscess, which can resemble pictures the patient has seen of brown recluse bites.
The brown recluse gets blamed by a lot of folks for these things when it really doesn't deserve it. There is one case of a BRS bite in Minnesota, where they are not endemic, that occurred after someone was bitten by a BRS that had hidden away in a shipping container from Texas. BRS are shy (hence, recluse), so unless you're digging around in wood piles or outhouses, you're not that likely to get bitten by one. Most BRS bites heal with no significant adverse effect. <10% cause the identifiable necrotic lesion.
Hallmarks of MRSA related abscess include multiple abscesses that are not contiguous, recurrent abscesses, and abscesses that appear after another person in close contact has had one, i.e., household member.
For a simple abscess with little or no surrounding cellulitis, surgical drainage and packing are all that are required, and antibiotics should be reserved for those with a large amount of cellulitis or systemic signs of illness such as fever (I'm with PedOncoDoc about prescribing practices, though I admit I have been guilty of it myself from time to time). Antibiotics which cover MRSA include Bactrim (very effective against MRSA, cheap and generic), Doxycycline (also cheap and generic), and Clindamycin (generic, but not cheap). Levaquin (expensive) will cover about 70-80%. If you're going to treat with Bactrim, keep in mind that a large number of skin infections are caused by S. epidermidis and GABH Strep, which are not well covered by Bactrim, so consider double coverage with amoxicillin or something else. I am not a fan of Keflex for skin infections, since the skin concentrations are not great, and almost all treatment failures for cellulitis I have seen in the ER are in patients put on Keflex or single-coverage with Bactrim.
'zilla
PedOncoDoc
01-23-2010, 13:07
Good concise info, Doczilla.
I would only add that there is a significant subset of MRSA that has inducible resistance to clindamycin (between this and the cost, it's a wonder we still use it for MRSA.) I was not aware of the poor tissue concentrations of skin with Keflex. My typical practice for patients with cellulitis without systemic symptoms was to prescribe them Keflex and have a 1-2 day follow-up phone call. If things were improving I had them complete their course. If not, I would call in Bactrim for presumed MRSA. I had a good success rate with this treatment plan, but I might reconsider now. I see fewer cases of cellulitis in my current patient population, and they tend to be admitted and placed on Cefepime and Vancomycin as they are likely neutropenic at the time of infection.
Reading about the overuse of antibiotics reminds me of an advertisement I overheard at a local grocery story/pharmacy a month ago:
"Just in time for the cold and flu season, we are proud to offer free antibiotics to anyone with a valid prescription."
I am guessing the marketing director had the final say about that ad.
While working a short stint at a student health clinic, Bactrim was the drug of choice for non complicated cellulitis / abscess post I+D. (No one left without a prescription of some kind). Bactrim to Keflex prescriptions were at least 5:1 (for SSTI). Of course these are students all using common equipment in a gym, common areas for gathering, common restrooms. Can't say for sure if we had seen more clinically documented MRSA than other outpatient facilities away from the dorms, but due to the way we were treating, I would assume so.
Regarding clindamycin, I've seen it used in patients with "sulfa and penicillin" allergy. Although, for the most part, cephalosporins can be used safely unless a true anaphylactic reaction to penicillin exists. At the local hospital here, we had 69% susceptibility of S. aureus to clindamycin (compared to 94% for Bactrim). However, inducible resistance as PedOncoDoc mentioned is common and must be tested for if the bacteria tests resistant to Macrolides (erythromycin), and there is 70% resistance to erythromycin here. Unfortunately, "inducible resistance" means that the clindamycin will test susceptible in vitro on the microbiologic report but will be resistant in vivo.
The quinolones may or may not work depending on geographic location. We found good susceptibility to moxifloxacin in hospital here, but some outpatient clinics in the Pittsburgh area were seeing a lot of resistance, and we do not generally use it.
I was unaware of that Keflex information. Thank you. Do you typically use dicloxacillin, or move to another cephalosporin?
SR
Doczilla
01-25-2010, 23:41
I don't know if there is any evidence to support it, but in theory, since Clinda shuts down bacterial protein synthesis, it could shut down production of some of the inflammatory "stuff" put out by the bacteria, and theoretically may lead to rapid improvement in the pain and redness of the infection subsequently. I have observed this in the ER when I've given IV clinda, but who knows if they would have gotten to feeling better in the same amount of time if I gave them something else. They also usually received an NSAID, tylenol, and possibly a steroid or IV fluid during the stay as well, so my observation may not be worth much. We are seeing some community acquired c. diff here, so I don't prescribe clinda lightly. Bactrim is probably the least likely of all the antibiotics to precipitate c. diff, at least according to our ID folks.
I agree on the penicillin/cephalosporin cross-reactivity issue. It dates back to when the two classes of antibiotics were produced on the same equipment, so there was some cross contamination, and cross-reactivity was reported to be about 10%. The first and second generation cephalosporins (like Keflex or Ancef) are more likely to produce an allergic reaction in someone allergic to PCN than the third generation (Rocephin, ceftazidime, cefpodoxime) and fourth generation (Maxipime) cephalosporins. If they get anaphylaxis to PCN or something like it, I won't take the chance of administering a cephalosporin, but otherwise I don't really worry about it. I just came across this article from 2006 Journal of Family Practice, which seems a decent review of available evidence.
http://findarticles.com/p/articles/mi_m0689/is_2_55/ai_n16084680/
Several other articles I found in Pubmed seem to support the assertion that cross reactivity is rare.
Our ID guys really don't like Keflex for skin and soft tissue infections, which is what changed my practice from prescribing it for cellulitis or abscess. It's great for UTIs in pregnant patients, and it's fine for preventing infection in a wound which is not yet infected (stateside. Different bugs than you would find in a combat wound in the sandbox.) such as a laceration with significant tissue damage, contamination, or for ex-fix pins and such, but that's about it. I usually go with amoxicillin just because it's something I use often, and it's cheap and generic ($4 at many pharmacies, and free at some. 500mg or suspension form, but not the 875mg), and I know the dosing without looking it up. Diclox would be fine but it's not on the $4 list at Wal Mart.
Amox/clav I reserve for the dog bites, cat bites, and fight bites (knuckle lacerations overlying the extensor tendons of the hand, when it is suspected that these are from hitting someone's teeth) because it is expensive, but is DOC for pasteurella (dog and cat) or eikenella (human). For these, I also give the first dose in the ER because I don't really know when they'll go to the pharmacy, and any delay can be problematic. I'll give it PO, or give a dose of Unasyn IV during their stay if they're too drunk to swallow early on. Amoxicillin is rapidly absorbed from the gut based on what I've looked at recently, so I will probably be giving less Unasyn in the future.
Most of the patients I see are uninsured, so I and the physicians and PAs I work with have gotten to know what the drugs cost since the patient will be paying out of pocket. Otherwise, the only thing they can manage to afford somehow is the percocet. If they would just sell some of the percocet (which many do I'm sure), they could afford the antibiotics too. :rolleyes:
'zilla
mlawacko
01-26-2010, 19:33
Daughter had MRSA. Bad JUJU. Started out what looked like a boil. She squeezed it and bam. The hospital removed a chunk of her leg. We had to clean out the open wound a few times a day and had a nurse visit our home for a few weeks. CDC was very interested in what happened. Wash your hands and don't pick your nose. The disease doc told us that basically we all carry some sort of MRSA in our noses. Got real interesting when grandson went to the hospital with bad ear infection. We mentioned mom had MRSA and he got a private room with lots of tests. This was before it got famous. Very bad stuff. Needs hard core antibiodics. Real bad.