在美國治療 MRSA SSTI 的新指引

 

Treating MRSA Skin and Soft Tissue Infections -- New Guidelines

John G. Bartlett, MD

Posted: 04/29/2011

Treating MRSA Skin and Soft Tissue Infections

Early this year, the Infectious Diseases Society of America published its first-ever recommendations for the treatment of infections caused by methicillin-resistant Staphylococcus aureus (MRSA).^[1] The guidelines appeared in the February 2011 issue of Clinical Infectious Diseases. The stated purpose of the MRSA treatment guidelines was to provide recommendations on the management of the most common clinical syndromes encountered in both adult and pediatric patients with MRSA infection. One of the most common of these is the MRSA skin and soft tissue infection (STTI).

Basic Treatment

The primary treatment of the focal STTI caused by community-associated MRSA is incision and drainage when mature (eg, fluctuant).

Antibiotic Treatment

Indications. The need for antibiotics is often a judgment call with the following considerations favoring antibiotics:

Severe or extensive disease involving multiple sites;

• Rapid progression with cellulitis;


• Signs and symptoms of systemic disease;


• Comorbidities: immunosuppression, age extremes;


• Abscess in an area that is hard to drain -- face, hand, or genitalia; and


• Failure to respond to incision and drainage.

Antibiotic Selection

Outpatient. Clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX), tetracycline, doxycycline, monocycline, and linezolid are considered equally effective. To cover both group A Streptococcus and MRSA ("nonpurulent cellulitis") use:

1.      Clindamycin;

2.      Amoxicillin plus either TMP/SMX or a tetracycline; or

3.      Linezolid.

The presence of pus suggests S aureus; cellulitis without pus suggests group A Streptococcus.

Hospitalized patient. For the hospitalized patient with SSTI (major abscess, wound infection, infected ulcer, etc.), the infected tissue should be debrided and cultured, and an empiric antibiotic initiated pending the results of the culture. Antibiotic treatment is outlined in the Table.

Table. Antibiotic Therapy for STTI in Hospitalized Patient

Drug	Dose	Duration
Vancomycin	Dose to target trough level	7-14 days
Linezolid	600 mg twice daily, PO or IV	7-14 days
Daptomycin	4 mg/kg once daily	7-14 days
Telavancin	10 mg/kg once daily	7-14 days
Clindamycin	600 mg IV or 300 mg PO 3 times daily	7-14 days

PO = orally; IV = intravenous

Recurrent SSTIs

Patient instructions should include the following:

• Cover wounds;


• Use good personal hygiene with bathing and frequent handwashing using soap or alcohol-based gel;


• Avoid reusing or sharing razors, towels, and other items that touch infected skin;


• Consider environmental hygiene with a focus on high skin contact areas (door knobs, counters, tubs, toilet seats); and


• Use standard detergents.

Role of Decolonization in Recurrent STTI

Decolonization should be considered if the preceding measures are inadequate:

• Nasal decolonization with mupirocin twice daily for 5-10 days.


• Nasal decolonization plus body decolonization with chlorhexidine for 5-14 days. An alternative is dilute bleach baths (1 teaspoon bleach per gallon water or one quarter cup bleach per one quarter tub or 13 gallons of water) and bathe 15 minutes twice weekly for about 3 months.


• Oral antibiotics are recommended for treatment of active lesions and not routinely recommended for decolonization unless the preceding measures are failing. Consider an oral agent based on sensitivity of colonizing or infecting strain in combination with rifampin.

Suspected household or interpersonal spread. Contacts should be evaluated; if they have evidence of S aureus, treat them and consider nasal and body decolonization as described above.

Role of cultures. The usefulness of culturing recurrent STTIs is limited. Screening cultures prior to decolonization is not recommended if there is at least 1 documented MRSA infection; surveillance cultures after decolonization are not routinely recommended.

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References

1.      Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:e18-e55. Available at: http://cid.oxfordjournals.org/content/early/2011/01/04/cid.ciq146.full Accessed April 19, 2011.

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