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           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 Society–USA
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                                    Slide 2



                                                      USA 100            USA 300
             Where                                    Hospital          Community
              When                                          1983           2000
                 PVL                                    Absent            Present
    MR element                                        Mec I-III           Mec IV
      Active Abx                                Vanc, Lin,               TMP-SMX,
                                                  Dapto                 Doxy, Clind.
       Infections                               Wound VAP                SSS, CAP
                                               Plastic/metal             Necrosis

From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
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From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
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From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 5

 METHICILLIN-RESISTANT S. AUREUS
INFECTIONS AMONG PATIENTS IN THE
     EMERGENCY DEPARTMENTS
    (Moran GJ. NEJM 2006;355:66)

   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) > 18 yrs, lesion <1 wk, Aug 2004
    3) S. aureus isolates – CDC
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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%

From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 8


                                      CONCLUSIONS

   1. MRSA epidemic in the community

   2. Differed from nosocomial MRSA

   3. Diverse and often unique pathology




From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
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From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 10




From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 11




                     PFGE TYPING OF MRSA


                                                HA HCA CA TOTAL
   USA 100                                      74% 62% 23% 58%
   USA 300                                      16% 22% 67% 29%




From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                                 Slide 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

From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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


From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                                   Slide 16


                  ANTIBIOTICS FOR MRSA

             Agent                                           ADR        Comment
     Vancomycin                                             Renal         Levels

          Linezolid                                      Marrow         Lung static
                                                          optic
     Daptomycin                                           CPK             Dose
                                                                         Not lung
         TMP-SMX                                             Rash       Resistance

     Clindamycin                                    C. difficile        Resistance
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 17


                                     EPIDEMIOLOGY
   Source: Nose, skin, objects
   • Nose: MSSA – 30%
            MRSA – 2-5%
   • St. Louis Rams – Objects
   • MSM – Genital source
     (CID 2007;44:410)
   Intervention: Barrier precautions
   • Nose: Muperocin
   • Body: Hebiclens, Phisohex
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                         Slide 18

                    MRSA (USA 300) in MSM
       (Diep BA. Ann Intern Med 2008;148:249)

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


 From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 19




From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                         Slide 20


 UNIVERSAL SURVEILANCE FOR MRSA
     IN 3 AFFILIATED HOSPITALS
(Robicsek A et al. Ann Intern Medicine 2008;148:409)

    Goal: To determine the effect
     of two expanded surveillance
     methods on rates of MRSA
     infection



 From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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%


From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.
                                                                        Slide 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
From J. G. Bartlett, MD, at 11th RW Program Clinical Update, IAS–USA.

				
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