MRSA: the ER, and the ER/ICU interface

Report
Skin and Soft Tissue Emergencies
Dennis Djogovic MD, FRCPC
Financial Disclosures
 None to declare
Objectives
 When should skin infections be of special
concern?
 Differential?
 Treatment priorities?
Case 1
 23 previously healthy male presents to the ED
with “spider bites” to his left lower leg
 Clinically stable vitals and appearance
 Medical Hx: benign
 Social Hx: lives at home. Competitive wrestler
 Non systemic cellulitis
 PO Abx
 Evidence based choices are poor
 Retrospective analyses
 O/E:
 Chest/abd exam normal
 Lower left leg
 Normal pulses, sensation, strength
 10-20 small pustules (<1mm in size), mild surrounding
redness, non painful
 Make sure you cover for Strep and Staph
 Staph
 Do you need to worry about MSSA or MRSA?
PO Abx Choices
 Keflex
 Strep and MSSA
 Clinda
 Strep, MSSA, MRSA
 Amoxicillin
 Strep

But not staph
 Septra, Doxycycline
 Staph (MSSA and MRSA)

But not strep
 Linezolid
MRSA background
 Methicillin (B lactamase) in use since 1959
 Outbreaks of MRSA since the 1960s
 Hospital acquired
 Far more virulent
 Community acquired
 Less virulent (usually)
 Community prevalence increasing
Incidence of MRSA in Different
Settings
MRSA per Ward, MSSA (N=818); MRSA (N=295)
CAN-WARD
WARD TYPE
% OF ALL S. aureus
ICU
15.7%
Surgical Ward
9.2%
Medical Ward
27.8%
ER
24.2%
Outpatient Clinic
23.1%
Overall
26.5%
MRSA tips
 Age <2
 First nations
 Close proximity to many people
 Athletes
 Prisons
 Military
 Hospital
 Skin breaks
 IVDU
 Skin disorders
 Known colonizers
Case 2
 23 previously healthy male presents to the ED
with “spider bites” to his left lower leg
 Treated with clindamycin, swab grew MRSA
 5 days later, lesions not healing, and appears to
have more cellulitis
 Appears clinically unwell
 HR 115, 125/70, 38.9C
 Erythema of lower leg
 Although not rapidly progressive
What is the ideal parenteral
therapy?
Vancomycin
 Inhibits cell wall synthesis
 Fairly safe
 Very effective
 For now
 Greatest level of experience and knowledge
 Achieving ideal dose levels not easy
 MSSA cleared faster with B lactams than Vanc
 Tissue penetration variable
 Bone, CSF
Linezolid
 Bacteriostatic
 Inhibits at ribosomal level
 Excellent tissue bioavailability
 IV or PO
Linezolid
 Adverse effects
 Thrombocytopenia
 Anemia
 Lactic acidosis
 Above mostly in the prolonged use setting
 Serotonin syndrome
 Reversibly binds MOA, if added to serotonin agent
Vanco vs Linezolid
 Linezolid versus vancomycin for the treatment of methicillin-resistant
Staphylococcus aureus infections. Stevens DL, Herr D, Lampiris H, Hunt JL,
Batts DH, Hafkin. Clin Infect Dis. 2002;34(11):1481
 hospitalized adults with known or suspected methicillin-resistant
Staphylococcus aureus (MRSA) infections
 linezolid (600 mg twice daily; n=240) or vancomycin (1 g twice daily;
n=220) for 7-28 days.
 S. aureus was isolated from 53% of patients; 93% of these isolates were
MRSA. Skin and soft-tissue infection was the most common diagnosis,
 15-21 days after the end of therapy, no statistical difference between the
2 treatment groups
 clinical cure rates (73.2% of linezolid group and 73.1% in vancomycin
group)
 microbiological success rates (58.9% linezolid group, 63.2% vancomycin
group)
 similar rates of adverse event
Case 3
 62 yr old female presents with triage
complaint of “blisters”
 Groan…
Case 3
 62 yr old female
 2 day duration
 Now also in her mouth
 Rapidly worsening
 HR 120, BP 105/50, 38.4C, RR 26/min
Blisters- Bad or just gross?
 Acuity?
 Sick?
 Localized or widespread?
 Mucus membranes?
 Patient
 Sick?
 Immunocompromised?
 Age?
 New meds?
 Blisters: tough or fragile?
Mucous Membranes?
 HSV
 SJS/TENS
 Pemphigus vulgaris
 Pemphigus paraneoplastic
 Mucus membrane pemhigoid
 type of Bullous Pemphigoid
Stevens-Johnson Syndrome/ Toxic
Epidermal Necrolysis Syndrome
(SJS/TENS)
 An acute, immunologically mediated desquamation
disorder secondary to infectious or environmental
exposure.
 Very uncommon. (1/500000)
 BUT it can lead to disastrous sequelae akin to a major
burn.
 Mortality SJS – 10%
 Mortality TENS – 30%
Risk Factors
 Any viral infection prior to triggering exposure,
notably HIV+
 Medication exposures
 Active malignancy
 Southeast Asian Ethnicity
Early Prognostic Markers
 Age >40
 Active Malignancy
 Tachycardia (>120) at presentation
 % TBSA desquamated
 Serum Bicarbonate <20mmol/L at presentation
 Uremia at presentation (>10mmol/L)
 Hyperglycemia at presentation (>14mmol/L)
SCORTEN Prognostic Score
SCORTEN Score
Mortality
0-1
3.20%
2
12.10%
3
35.30%
4
58.30%
5 or more
90%
Management
 Prompt identification and withdrawal of
trigger.
 General principles of burn care.
 Appropriate fluid resuscitation
 Wound care/Debridement
 Steroids**
 IVIG**
 Mucosal / Ophthalmological involvement
require appropriate specialist involvement.
UAH Burn Unit-Suspected Trigger
-
Cefazolin
Diltazem
TMP-SMX
Phenytoin
Vancomycin
Atorvastatin
Lamogtridine
Allopurinol
Mycoplasma
pneumonia
2
1
3
1
1
2
1
1
1
**Viral serology was sought on all patients with a diagnosis of SJS/TENS and was all
non-contributory.
Observations on Triggers
 The average time from onset of rash to stopping
of medication was 10 days (range 2-30)
Case 4
 86 yr old male
 Dementia
 2 week onset of blisters on arms, legs (creases)
 A few have popped/leaked over past day
Bullous Pemphigoid versus
Pemphigous Vulgaris
 PemphigoiD = Deep
 VulgariS = Superficial
 OR
 Vulgaris = vulgar = ugly = sick and bad!
 Refer early
 Not many acute therapies in the ED
 Maybe IV steroids?
 Make sure you are not missing infection!!
 If on a recent abx, use a different class (TENS?!)
Case 5
 Healthy 32 yr female
 Gardening yesterday, scratched left arm on
fence
 Nightime fever
 Awoke with painful red rash on left arm
 Spreading
 HR 130, BP 90/50, O2 sat 91%
 VBG: 40/26/7.18/lactate 9
Necrotizing skin infections
 Necrotizing
 Fasciitis
 Myositis
 Cellulitis
 In common
 all of these patients are SICK
 Only the OR can really tell the difference
Imaging?
 Ultrasound
 Not too helpful
 Can find abscess
 MRI
 Obtained from the ER??
 May overexaggerate soft tissue involvment
Imaging?
 Non contrast CT
 Looking for air
 If you see air, you have necrotizing infection
 If you don’t see air, this could still be necrotizing
infection
 Get your surgeon to look
 Ideally in the OR!
Treatment
 OR
 Antibiotics
 Pen G and Clindamycin
 +/-IVIG
Take home points
 A few ideas on antibiotic choices
 Blisters, rashes, lesions
 Quick?
 Sick?
 Tick, tick, tick!!
Thanks for your time!
 [email protected]

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