MRSA TREATMENT MANAGEMENT RECOMMENDATIONS



LINCOLN MEDICAL AND MENTAL HEALTH CENTER

MRSA TREATMENT MANAGEMENT;

P&T RECOMMENDATIONS FOR LINCOLN MEDICAL CENTER

References:

1. Borlaug G. Community associated methicillin resistant staphylococcus aureus. Guidelines for clinical management. Winsconsin Division of public health. October 2005.

2. CDC. Strategies for clinical management of MRSA in the community: Summary of an experts meeting convened by the center for disease control and prevention. March 2006.

3. Wallin TR, Hern HG, Frazee BW. Community-Associated Methicillin-Resistant Staphylococcus aureus. Emerg med clin N Am. 2008; 26:431-455.

4. Moran GJ, Krishnadasan A, Gorwitz RJ, etal. Methicillin Resistant S. aureus Infections among patients in the emergency department. N Engl j Med . 2006;355:666-74

Frank Piacenti PharmD 8/08

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Clinical Presentation

1. Spider bit appearance

2. Folliculitis, pustular lesions

3. Furuncle, carbuncle (boils)

4. Cellulitis, impetigo

5. Infected wound

History/ risk factors for MRSA

1. Previous MRSA infection/colonization

2. History of (within 12 months): recent admissions, surgery, nursing home, indwelling catheter, dialysis

3. Intravenous drug abuse

4. Close contact with someone known to have MRSA

TREATMENT

1. The best treatment for most abscesses is local care and Incision and Drainage (I&D). Empiric antibiotics are not indicated unless patient has MRSA risk factors AND the wound appears aggressive.

2. If antibiotics are necessary and sensitivity is pending, begin IV vancomycin or PO antibiotics based on clinical severity.

a. EMPIRIC:

Oral Antibiotic choices to cover MRSA

i. Cephalexin to cover Group A Streptococcus or if penicillin allergic use clindamycin.

+

ii. Bactrim 10mg/kg divided 2-3 times daily.

- The dose is based on the trimethoprim 160mg component in one double strength tablet. 70kg patient = 2 tablets twice daily.

a. Do not use in children < 2months of age and women in their 3rd trimester

- + Rifampin 600mg once daily. Rifampin Cannot be used alone, must be used in combination with another agent.

OR

iii. Doxycycline or minocyline 100mg twice daily + Rifampin 600mg.

- Do not use in children < 12 years of age and in women who are pregnant.

3. Adjust antibiotics based on culture and sensitivity

i. Clindamycin 300-450mg 4 times daily. If the sensitivity panel reads resistant to erythromycin and sensitive to clindamycin or if clindamycin sensitivity is not displayed, a D-test must be performed by microbiology before using this agent.

ii. Bactrim, doxycycline, rifampin or minocycline (as above)

iii. Moxifloxacin 400mg (only as a last option)

- May be used if sensitivity panel indicates sensitive to fluoroquinolones (cipro, levofloxacin).

- Moxifloxacin can only be used in patients who require a short course of therapy, no longer than 5-7 days for skin and soft tissue infections.

- No other quinolones are recommended.

- MRSA may develop fluoroquinolone resistance if used for an extended period of time. (>7 days).

If patient has signs and symptoms of a gram positive infection: skin, lungs, blood, or chronic indwelling catheters

MRSA Colonization

(Nasal swab positive)

*Contact Precautions*

Cellulitis / Impetigo

(No focal lesion AND no purulent drainage)

Skin Abscess+cellulitis

(Lesions, furuncle, carbuncle, boils)

* Contact Precautions*

(Wear gloves and wash hands in and out of patient rooms)

Most likely MSSA or Streptococcus species. Typically treat with Beta-lactam antibiotics (cephalexin)

Perform incision and drainage of abscess and other lesions when possible and send an I&D sample for culture. Draw 2 sets of blood cultures(BEFORE STARTING ANTIBIOTICS) if a systemic infection is suspected

No treatment necessary if patient does not have signs and symptoms of an infection or history of MRSA

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