MRSA

Methicillin Resistant Staphylococcus Aureus infections

Marion Mae Pernia MD

Level II IM Resident
01 Objectives

1. Discuss brief background about MRSA its pathophysiology and

epidemiology in the Philippines
2. Familiarize on categories of MRSA and its risk factors
3. Understand the colonization and transmission of MRSA
4. Identify management of MRSA associated infections based on the
2011 IDSA guidelines in the management of MRSA
 MRSA:
INTRODUCTION
● Methicillin-resistant S. aureus
● S. aureus is a gram positive bacterium that colonizes the skin and is present in
the anterior nares in 25-30% of healthy people
● Methicillin is a semisynthetic beta-lactamase-resistant penicillin
● MRSA is an antimicrobial-resistant type of S. aureus resistant to currently
available beta-lactam antibiotics
● Methicillin resistance requires the presence of mecA gene
● Defined as an oxacillin MIC >4 mcg/mL (CLSI)
EPIDEMIOLOGY

Antimicrobial Resistance Surveillance Program, 2018 Annual Report of DOH

EPIDEMIOLOGY

3,794
53%
43% CUTANEOUS
58% 42%

21% BLOOD

Antimicrobial Resistance Surveillance Program, 2018 Annual Report of DOH

 CATEGORIES

HA- MRSA
Healthcare-associated MRSA

CA- MRSA
Community-associated
MRSA

Reference: Harrisons Principles of Internal Medicine 20th ed

 HA- MRSA Risk Factors
● Defined as MRSA
● Antibiotic
that occurs >48 hours following hospitalization or occurs
use
outside the hospital within 12 months of exposre to health care
● Prolonged hospitalization
● Severe, invasive disease (SSTI, BSI and pneumonia)
● type II and IIIcare
● Carry SCCmecIntensive
● Hemodialysis
● Worldwide, prevalence varies from <1% in Scandinavia to 40% in Japan, Israel
● MRSA
and elsewhere in Europecolonization
● Proximity
● Capacity to form biofilm on to others
invasive, withdevices
foreign MRSA (ET infection
tubes, IFC,
endovascular●catheters)
Post discharge (nursing home, chronic
wound, CVC or other invasive device)
 Risk
CA- MRSA Factors
● Defined as MRSA that occurs in the absence of healthcare
Community outbreaks (native and aboriginal communities, sports
exposure
teams, child care centers, military personnel and prison inmates and
 Most
guards)often associated with SSTI in young healthy individuals
● Sensitive
Skin traumato(lacerations,
non-betaabrasions, tattoos, injection drug use)
lactam antibiotics
● Cosmetic body shaving
● Carry SCCmec type IV or V
Incarceration
● Most
Sharingfrequent
equipmentcause of skin
not cleaned and soft between
or laundered tissue infections
users (SSTI)
● Can
Closealso cause invasive, severe disease (necrotizing pneumonia,
contact
● Animals
osteomyelitis, UTI, infective endocarditis and sepsis)
● Many patients have no risk factors
Other RISK FACTORS:
Antibiotic use
 Antibiotic use particularly cephalosporin and fluoroquinolone
use strongly correlates with risk of MRSA colonization and
infection
 Risk for MRSA increased with the number of antimicrobial agents
(>4)
 Cephalosporin use for >5 days were 3 times more likely to
acquire MRSA than those without antibiotic use
Other RISK FACTORS:
HIV

• Primary sites of these infections were skin and soft tissue

• Risk factors:
CD4 count <50cells/microL
Plasma HIV RNA (>100,000 copies/ microL) and lack of
antiretroviral therapy
 Other RISK FACTORS:

Injection drug users

 Injection drug users were 16 times more likely to develop invasive MRSA
infection (bacteremia, endocarditis and osteomyelitis

INDWELLING HEMODIALYSIS CATHETER

Incidence of invasive MRSA infection was 100 times higher among dialysis
patients than in general population
Other RISK FACTORS:
Long term care
 HA-MRSA is prevalent among residents of long term care
facilities
 MRSA-colonized residents are frequently transferred between
hospitals and long term care facilities
TRANSMISSION
 COLONIZATION
 Individuals colonized with MRSA serve as a
reservoir for transmission
 Can colonize the skin and nares of hospitalized
patients, HCW and healthy individuals
 Can occur in following ways:
 Contact with contaminated wounds or dressings
of
 infected patients
 Contact with another individual’s colonized intact
skin
 Contact with contaminated inanimate objects
 Inhalation of aerosolized droplets from chronic
nasal carriers
SITES OF COLONIZATION
Anterior nares and oropharynx
• Intact skin(including the hands, axillae,perineum and
umbilicus)
• Surgical wounds
• Decubitusulcers
• Intravascularcathetersitesandotherinvasivedevices
• Throat
• Sputumstool
• Genitourinarytract
Both a commensal and an opportunistic pathogen
20-40% of healthy persons are colonized with Staphylococcus aureus
Rate of colonization is ELEVATED among:

1. Insulin-dependent diabetics
2. HIV-infected patients
3. Hemodialysis patients
4. Injection drug users
5. Individuals with skin damage
 INFECTIONS CAUSED BY MRSA

Infected
Skin & soft tissue infection Bacteremia Endocarditis

Bone and joint

Pneumonia CNS infections
infections
SKIN AND TISSUE INFECTION
Manifestations Treatment Comment
1. Cutaneous For simple
abscess, Incision and abscesses or
furuncles and drainage boils, I&D alone
carbuncles likely adequate
2. Minor skin infections
(impetigo) and
secondarily infected Mupirocin ointment on
skin lesions (eczema, affected areas
ulcers or lacerations)
Conditions in which Antimicrobial Therapy is recommended after
I&D due to CA-MRSA
IDSA Guidelines in Methicillin Resistant Staphylococcus Aureus in Adults and Children 2011
IDSA Guidelines in Methicillin Resistant Staphylococcus Aureus in Adults and Children 2011
 RECURRENT MRSA SSTI
 Defined as 2 or more discrete SSTI episodes at different sites
over a 6-month period
 Pathogenesis is unclear but likely a complex interplay between
the pathogen, host colonization, patient behavior, and
environmental exposures
 The initial approach is the same as for patients with a first
episode
 Panel suggests a multifaceted approach that actively engages the
patient in personal and environmental hygiene measures
 PREVENTION OF RECURRENT
SSTI
PERSONAL  Keep draining wounds
HYGIENE AND covered with clean, dry ENVIRONMENTAL
WOUND CARE bandages
 Maintain good personal • Focus cleaning efforts on high-
hygiene such as touch surfaces that may contact
handwashing, regular bathing bare skin or uncovered infections
 Avoid reusing or sharing • Commercially available cleaner or
personal items (disposable detergents appropriate for routine
razors, lines and towels) cleaning of surfaces
 PREVENTION OF RECURRENT
SSTI
DECOLONIZATION
strategies:
Should be considered in cases if:
 Nasal decolonization with mupirocin twice daily for
• Patient develops a recurrent SSTI despite 5-10 days
optimizing wound care and hygiene  Nasal decolonization with mupirocin twice daily for
measures 5– 10 days and topical body decolonization regimens
• Ongoing transmission occurring among with a skin antiseptic solution (eg, chlorhexidine) for
household members or other close contacts 5–14 days or dilute bleach baths.
 Consider dilute bleach baths: 1⁄4 cup per 1⁄4 tub (13
gallons) of water for 15 min, 2x/week for 3 months
 PREVENTION OF RECURRENT
SSTI
ROLE OF ANTIBIOTICS
 Recommended for the treatment of active infection ONLY
and is NOT routinely recommended for decolonization
• Oral agent (TMP-SMX or Doxycycline) in combination with
Rifampin
• Short courses of 5-10 days to decrease development of
resistance
 Bacteremia, Sepsis, and Infective Endocarditis

MRSA BACTEREMIA
Manifestations Treatment Comment
 Identify source and extent of infection; eliminate and
debride other sites of infection Vancomycin
Daptomycin Duration of at least 2
 Repeat blood cultures 2-4 days after initial positive weeks
Uncomplicated 4-6 weeks is
as needed thereafter15-20
cultures and Bacteremia mkd IV q 8-12
to document clearance
recommended for
6 mkd IV OD
of bacteremia 8 mkd (complicated) complicated
 Echocardiography recommended for all patients with bacteremia
bacteremia. TEE is preferred over TTE.

CPG BY IDSA GUIDELINES ON MRSA 2011

 MRSA AND INFECTIVE
ENDOCARDITIS
• S. aureus one of the more
common causes of prosthetic-
valve endocarditis which requires
urgent valve replacement is
necessary

• Infective endocarditis is associated

with MRSA bacteremia and should
be ruled out in any patient with
MRSA in the bloodstream.
 MRSA AND INFECTIVE
ENDOCARDITIS
PROSTHETIC DEVICE-RELATED INFECTIONS

S.aureus accounts for a large proportion of prosthetic device-related infections

Intravascular catheters, pacemakers, prosthetic valves, orthopedic devices, peritoneal
catheters, pacemakers, left ventricular-assist devices, or vascular grafts
More Acute, have both local and systemic manifestations and tend to progress more
rapidly
Occur more commonly soon after implantation unless the device is used for access (IV
and HD catheters)
 MRSA AND INFECTIVE
ENDOCARDITIS
EVALUATE FOR VALVE REPLACEMENT SURGERY

• Vegetation > 10 mm
• ≥ 1 embolic event during the first 2 weeks of therapy
• Severe valvular insufficiency, valvular perforation or dehiscence •
Decompensated heart failure
• Perivalvular/ myocardial abscess
• New heart block
• Persistent fevers or bacteremia are present
 MRSA PNEUMONIA

 Preceding or concurrent influenza-like illness

 Empirical therapy for MRSA should be considered in patients with
severe CAP defined by any one of the following:
• Requirement for ICU admission
• Necrotizing or cavitaryinfiltrates
• Empyema

 Empirical coverage for MRSA should be discontinued if sputum or

blood cultures do not grow the organism.
MRSA BONE AND JOINT INFECTIONS

Arise from:
• Hematogenousseeding
• Contiguousfocusofinfection
• Directinoculationfromtraumaormedicalprocedure
• Surgical debridement is the mainstay of therap
MRSA BONE AND JOINT INFECTIONS
MRSA BONE AND JOINT INFECTIONS:
Device related osteoarticular infections
MRSA BONE AND JOINT INFECTIONS:
Device related osteoarticular infections
 MRSA CNS INFECTIONS

Occur as:
• Complicationofneurosurgicalprocedures
• Contiguousfocusofinfection
• Complicationofbacteremiaorinfectiveendocarditis
• Treatment is difficult because of the location of the infection and BBB
• Surgical drainage of focal abscesses and removal of foreign body (infected shunt) should
be performed
MRSA CNS INFECTIONS
 VANCOMYCIN DOSING

 IV vancomycin 15-20  In seriously ill patients with  Continuous infusion

mg/kg (actual body suspected MRSA infection, a vancomycin is unlikely to
weight) q 8-12 hrs, not loading dose of 25-30 mg/kg substantially improve patient
to exceed 2 g per dose. (actual body weight) may be outcome, compared with
considered. intermittent dosing.
 VANCOMYCIN or DAPTOMYCIN
● recommended as the drug of choice for the treatment of invasive
MRSA infections
● It is important to note that Vancomycin is less effective than SPRPs
for the treatment of infections due to methicillin susceptible strains
● In patients with beta-lactam allergies, alternatives to SPRPs for the
treatment of invasive infections should be used only after careful
consideration
● Desensitization to Beta-lactams remains an option for life-
threatening infections
• IV vancomycin 15-20 mg/kg (actual body weight) q 8-12 hrs, not to exceed
2 g per dose.
• In seriously ill patients with suspected MRSA infection, a loading dose of
25-30 mg/kg (actual body weight) may be considered.
• Given risk of red man syndrome and possible anaphylaxis associated with
large doses, consider prolonging infusion time 2 h and pre-medication with
antihistamine .
• Continuous infusion vancomycin is unlikely to substantially improve patient
outcome, compared with intermittent dosing .
VANCOMYCIN DOSIN
 VANCOMYCIN THERAPEUTIC DRUG
MONITORING
 Obtain serum troughs at steady state(b/f4thor5thdose).
 Monitoring of peak vancomycin concentrations is not recommended
 For serious infections
(e.g.bacteremia,endocarditis,osteomyelitis,pneumonia,severe SSTI
[nec fasc]), target vancomycin trough concentrations of 15-20
mcg/mL.
 For most patients with SSTI with normal renal function and not
obese, traditional doses of 1 g Q12 are adequate and trough
monitoring is not required.
 Trough vancomycin monitoring is recommended for serious
infections and patients who are morbidly obese, have renal
dysfunction (including those receiving dialysis), or have fluctuating
volumes of distribution
● recommended as the drug of choice for the treatment of invasive MRSA
infections
● It is important to note that Vancomycin is less effective than SPRPs for the
treatment of infections due to methicillin-susceptible strains
● In patients with beta-lactam allergies, alternatives to SPRPs for the
treatment of invasive infections should be used only after careful
consideration
● Desensitization to Beta-lactams remains an option for life-threatening
infections
● your reference websites or publications
● You can list here your reference websites or publications
Resources
● 2011 Clinical Practice Guidelines by the Infectious Diseases
Society of America for the Treatment of Methicillin-
Resistant Staphylococcus aureus Infections in Adults and
Children
● •Antimicrobial Resistance Surveillance Program, 2018
Annual Report of DOH
 Thank
You!
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