We avoid the knee-jerk vanco or linezolid response for CA-MRSA, since most of what we see is soft tissue and responds to the Tetracycline family, sulfa, or clindamycin.
And we don’t try to decolonize anyone because they just get recolonized, and we’d like to avoid breeding further resistance by decolonizing with rifampin, bactroban, and other stuff.
CA-MRSA is here to stay; we just hope it doesn’t exchange plasmids with HA-MRSA and develop into a supervirulent pathogen that needs IV vancomycin. That would be bad.
I read the report and found it interesting, but a couple of questions. One, what do you mean by ‘decolonize?’ Treat the infection enough for the body to take care of things, but not wiping out the staph on the patient? Two, how quickly are resistances evolving? You speak with a bit of dread over CA mixing with HA-MRSA, but to me (uneducated, of course), this seems like a ‘when,’ not an ‘if.’
(The jokes made me groan, but I liked the one about an un-MRSA-ful god. )
About 10% of patients will have CA-MRSA living passively on their bodies, usually in their nostrils, or armpits, or groin, after the active infection is knocked out. One school of thought says that recurrences may be prevented by wiping out these colonies of staph on the skin. Another school of thought says that exposing the CA-MRSA to decolonizing agents just breeds more resistance, and that if the person still lives in a place where they’re likely to get exposed to it again (like NFL training camps, military barracks, or prisons), they’ll just get recolonized anyway. I suspect the latter is the typical experience, based on what I’ve seen at work.
Remember, some sort of bacteria is always going to thrive on skin, without causing infection or disease. Staph Aureus’ cousin, Staph Epidermidis usually fills this role.
It probably is a ‘when’, and resistances evolve fast. But the particulars of the genomes involved with HA-MRSA and CR-MRSA carry their own challenges, and thus far don’t appear to be readily exchangeable, at least not in a way that produces a virulent super-resistant organism.
I’ve seen VRSA that was sensitive to other things (linezolid, tigecycline, gentamicin, teicoplanin). The issue actually wasn’t so much the infectious organism itself, it was the fact that the infection was on a prosthetic heart valve and the patient just wasn’t fit enough for a valve replacement procedure.
The hard-core antibiotics were a time-buying measure rather than a cure for the endocarditis, and the patient lived another 3 months before eventually dying from the chronic obstructive airways dsiease that made her unfit for surgery.
You CAN eradicate VRSA, VRE and MRSA, you just have to hit it hard with antibiotics you know will kill it (which means IV, expensive and new).
All of this is why I usually have a rant at patients who either a) request antibiotics for self-limiting viral illnesses, or b) stop a course of antibiotics for a genuine bacterial illness mid-way through.
I don’t hand out antibiotics for coughs without radiological or clinical evidence of pneumonia, I don’t give out antibitics for middle ear infections unless the kid has pus pouring out from the ear. Also I won’t give antibitocs for sore throat unless you meet the criteria ( 3 out of 4 of: fever, swollen lymph nodes, pus on your tonsils and no cough), and even then the idea is to prevent rheumatic fever, not to fix your throat faster.
You can imagine that this approach, no matter how common-sense and evidence based, didn’t always go down well with the parents who had been waiting to see a doctor for 2 hours in the kiddy ER a with their feverish toddler . Getting told “yup, it’s an ear infection, probably viral, carry on with the pain relief you’ve been giving” is generally not what they wanted to hear.
Actually, I find that spending 2-3 minutes discuss why antibiotics aren’t needed satisfies most parents. Either that or they just don’t want to argue and they know they can call the pediatrician and get a Rx the next day. I can’t tell you how many times I’ve had to explain why Sally didn’t get any better after taking that Amoxil for a ‘head cold’ that her doctor gave her 2 days ago!
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