MRSA: the ER, and the ER/ICU interface
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Transcript MRSA: the ER, and the ER/ICU interface
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!
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