[NP-Clinical] Derm/MRSA question

Tue Aug 21 22:22:38 PDT 2007

First, it sounds as if she has not been drained adequately, just based on
the description. A one-cm stab incision for something that is at least 4 cm
deep is rarely-I'd argue NEVER-adequate for proper drainage. Better would be
to consult surgery, do conscious sedation or OR incision and drainage, and
then abx according to the C&S.which in this case appears to be Cipro. She
needs an incision-elliptical preferred--that goes from end-to-end of the
induration and that is large enough to get a sterile-gloved finger into to
really probe the wound, explore its true extent, and break up loculations.
The problem with MRSA wounds is that they often are honeycombed and
difficult to drain well without an adequate opening. Also, being in the
gluteal/inguinal fold area, these things can really tunnel with a much more
extensive infection than suspected by surface appearance.

Second, the first physician should be re-educated that Keflex is no longer
considered first-line treatment for abscess/cellulitis.

Some strains of MRSA are still susceptible to Cipro. The top three oral abx
that are most likely (at least in my area of the country, the Midwest) to
work for MRSA are Bactrim, Clinda and Cipro (pretty much in that order).

If it's really looking bad (and it sounds as if she definitely needs further
intervention, given her pain level), call surgery consult and consider
admitting her under observation status for 23 hours of IV abx and pain meds.
Sometimes we add Vanc to jump-start treatment. If not improving dramatically
with proper I&D and IV abx after 23 hours, she warrants a full admission.

I think you're right to be concerned about her.

Diane Dito

  _____  

From: np-clinical-bounces at nurse.net [mailto:np-clinical-bounces at nurse.net]
On Behalf Of Kimberly Spering
Sent: Tuesday, August 21, 2007 10:35 PM
To: NP Clinical
Subject: [NP-Clinical] Derm/MRSA question

I have a question about HOSPITAL-acquired MRSA.  I'm hoping that someone can
point me in the right direction.

My chief medical assistant had a bad folliculitis in the gluteal/inguinal
fold last Friday; our one physician did an I & D and put her on Keflex.  She
came into the ER on Sunday with severe pain and swelling of the area.  The
same on-call doctor ended up packing it--a 1 cm opening and 4 CM DEEP--and
finally did a culture--it grew out MRSA (as I had suspected from the
description).  Another physician ended up packing it with iodoform gauze
this afternoon.  Here's the puzzling part:  the sensitivity was done and it
was MOST sensitive to Cipro (MIC < 0.25), then Levaquin and Gatifloxin (both
< 0.5).  The D-test (I think that was what it was called) showed no
clindamycin resistance, but Clinda had a higher MIC (can't remember the
number); Bactrim was <0.5/9.5 MIC.

Now, the kicker is that she had surgery in May (transvaginal taping,
cystocele/rectocele repair, and a hemorrhoidectomy).  Per the CDC website,
any MRSA infection that occurs within 12 months should be considered
hospital-acquired, NOT community-acquired.  I have saved and re-read
Christine's former posts from January about Bactrim treatment.  I have also
read some information about hospital-acquired MRSA treatment.  However, with
these sensitivities, I am unsure if we should lean toward the Cipro (scant
literature exists about this treatment option) or stick with the usual
Bactrim, especially since Cipro has the better sensitivity.  The literature
is very vague about treatment options, other than to check with local health
bureaus about sensitivity.  I have researched everywhere I could think of
(and was rather disappointed with the CDC website), but I am at a
cross-roads.

The second doc changed her meds to Bactrim and Cipro for the moment.  I told
him that I would recommend consulting ID--at least by phone.  We've had two
pregnant patients with MRSA in the past few years--one is an OR nurse, and
the other worked in a nursing home...both initially asymptomatic colonizers,
apparently.  They both had consultations, and both were given different
treatments.

I saw the area tonight when he repacked the wound--it is just awful, with
about 3 inches of extended redness beyond the stab site.  She is on Percocet
and Toradol for the pain, and it is barely holding her.

Any thoughts, advise, and medication suggestions would be most welcome until
I speak with the ID physician tomorrow.

Thanks in advance~

Kim Spering, NP

OB-GYN

(copy of Christine's email from Jan.)

----- Original Message ----- 

From: Christine <mailto:chrisbsmith at mindspring.com>  Smith 

To: NP Clinical <mailto:np-clinical at nurse.net>  

Sent: Thursday, January 25, 2007 6:34 PM

Subject: Re: [NP-Clinical] Derm/MRSA question

Yes.  There are several recommendations found in the literature advocating
two Bactrim DS BID. I have not find specifics beyond considering it if
"worse" or if the patient is "big."  In any case I have prescribed two but
not routinely.  It's a good idea to make that notation on the RX for the
pharmacists not familiar with this change otherwise you will get call backs
from the pharmacy. I have literature at work recommending this with 56
references and will try to get it tonight. I always only opt to do 2 tabs
BID to TID with recurrent infections. 

First-line treatments include: 

1.  Bactrim DS 1 to 2 BID to TID x 10 d

2.  Minocycline 100 mg BID x 10 d

3.  Doxycycline 100 mg BID x 10 d 

4.  Clindamycin 300 mg to 450 mg QID x 10 d

Also:

Hibiclens daily for three days in a row  then three times weekly for
recurrent infection.  (no reference to time frame. ?For one month? Forever?)

Note:  Reserve vancomycin, Zyvox, etc.  for severe cases.  They are not
first-line treatment.

Christine Smith, NP

Antioch, CA

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