Abstract
Among pediatric and adult providers, 70% preferred trimethoprim-sulfamethoxazole for directed treatment of community-associated methicillin-resistant Staphylcoccus aureus skin and soft-tissue infections, although a higher proportion of pediatric compared to adult providers favored clindamycin (36% vs. 8%, p<0.0001). For recurrent infections, 88% of providers employed at least one topical decolonization strategy.
Keywords: Methicillin-Resistant Staphylococcus aureus, Skin infections, Soft-tissue infections, Questionnaire
Introduction
Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause of skin and soft-tissue infections (SSTIs) in the community, with incidence rates as high as 19.8 per 100,000.1,2 Recurrent infections are common, with rates ranging from 9-18%.1,3 While the epidemiology of CA-MRSA SSTIs is well-described,2 management strategies, especially for recurrent infections, remain undefined. Although SSTI treatment guidelines exist,4,5 recommendations specifically for CA-MRSA are vague, and uncertainties remain regarding optimal antimicrobial regimens, requirement for antibiotics following incision and drainage (I&D), and utility of decolonization. Two recent surveys among practicing physicians regarding management of CA-MRSA SSTIs demonstrated a lack of consensus in favored treatment strategies6,7; however, one study surveyed only pediatric infectious disease (ID) providers6 while the other addressed only the question of the need for antibiotics in addition to I&D.7
In this study, we surveyed both adult and pediatric outpatient providers from multiple medical specialties to determine preferred treatment and prevention strategies used in clinical practice for primary and recurrent CA-MRSA SSTIs.
Methods
An internet-based survey was conducted in January 2009 at the University of Pennsylvania Health System (UPHS) and the Children's Hospital of Philadelphia (CHOP). Eligible individuals were all adult and pediatric providers at UPHS and CHOP within the divisions/departments of emergency medicine (ED), ID, dermatology, and primary care (family medicine, internal medicine, and general pediatrics) with an MD, DO, CRNP, or PA-C degree and a functional email address, who have ever seen an outpatient with recurrent skin or soft tissue infections. All study subjects were sent an introductory email with a hyperlink to an on-line questionnaire with 23 questions regarding provider demographics, number of recurrent CA-MRSA SSTIs seen monthly, approaches to treatment and prevention of these infections, and overall impressions of the burden of disease for patients. Recurrent CA-MRSA SSTIs were defined as furuncles, folliculitis, and/or skin and soft-tissue abscesses known or presumed to be caused by CA-MRSA that occur on more than one occasion. Differences in responses were assessed using Fishers exact test. All statistical calculations were performed using STATA v10.0 (Stata Corp, College Station, TX).
Results
Of 575 healthcare providers surveyed, 192 (32%) responded (Table 1). Ninety-four percent of respondents were physicians. A higher proportion of ID specialists compared to those in other specialties responded (72% vs. 30%, p<0.0001).
Table 1.
Treatment strategies for acute community-associated methicillin-resistant Staphyloccus aureus skin and soft-tissue infections (CA-MRSA SSTIs) reported by survey respondents
| All Adult and Pediatric Providers (n=192) |
Adult Providers | Pediatric Providers | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| ED (n=17) |
Internal Medicine (n=27) |
Family Medicine (n=18) |
Infectious Disease (n=25) |
Dermatology (n=8) |
All Adults (n=95) |
ED (n=20) |
General Pediatrics (n=71) |
Infectious Disease (n=6) |
All Pediatrics (n=97) |
||
|
Do you prescribe antibiotics following I&D? |
|||||||||||
| Yes, always | 60% | 12% | 58% | 62% | 32% | 75% | 45% | 78% | 75% | 60% | 74% |
| No | 4% | 18% | 4% | -- | 4% | 12% | 6% | -- | 1% | -- | 1% |
| Depends on size/location | 34% | 65% | 31% | 38% | 64% | 12% | 46% | 22% | 23% | 40% | 23% |
| Other | 2% | 6% | 8% | -- | -- | -- | 3% | -- | 1% | -- | 1% |
|
Preferred empiric antibiotic choice for acute infectionsa |
|||||||||||
| Amoxicillin/clavulanate | 2% | -- | 4% | -- | -- | -- | 1% | -- | 4% | -- | 3% |
| Cephalexin | 3% | -- | 12% | 6% | 12% | -- | 8% | -- | 3% | -- | 2% |
| Ciprofloxacin | 2% | -- | -- | -- | -- | 12% | 1% | 5% | 1% | -- | 2% |
| Clindamycin | 29% | 12% | 12% | -- | 4% | 12% | 8% | 79% | 39% | 80% | 50% |
| Doxycycline | 2% | -- | -- | -- | 4% | 25% | 3% | -- | -- | -- | -- |
| TMP/SMX | 57% | 88% | 69% | 88% | 72% | 50% | 75% | 16% | 48% | 20% | 40% |
| Other | 5% | -- | 4% | 6% | 8% | -- | 4% | -- | 4% | -- | 3% |
|
Preferred directedb antibiotic choice for acute infectionsa |
|||||||||||
| Ciprofloxacin | 3% | -- | -- | -- | -- | 12% | 1% | 6% | 4% | -- | 4% |
| Clindamycin | 22% | 12% | 12% | 6% | -- | 12% | 8% | 56% | 30% | 60% | 36% |
| Doxycycline | 1% | -- | -- | -- | 4% | -- | 1% | -- | -- | -- | -- |
| Linezolid | 1% | -- | -- | -- | -- | -- | -- | -- | -- | 20% | 1% |
| Minocycline | 1% | -- | -- | -- | -- | 12% | 1% | -- | -- | -- | -- |
| TMP/SMX | 70% | 82% | 77% | 88% | 96% | 62% | 84% | 39% | 66% | 20% | 59% |
| Other | 4% | 6% | 12% | 6% | -- | -- | 5% | -- | -- | -- | -- |
|
Preferred duration of antibiotics for acute infections |
|||||||||||
| <7 days | 4% | -- | 8% | 6% | 12% | 12% | 8% | 6% | -- | -- | 1% |
| 7-10 days | 76% | 100% | 50% | 62% | 52% | 12% | 59% | 94% | 93% | 100% | 94% |
| 11-14 days | 15% | -- | 35% | 19% | 32% | 50% | 26% | -- | 6% | -- | 4% |
| >14 days | 3% | -- | 4% | 6% | 4% | 25% | 5% | -- | 1% | -- | 1% |
| Other | 1% | -- | 4% | 6% | -- | -- | 2% | -- | -- | -- | -- |
ED=emergency department, I&D=incision and drainage, TMP/SMX=trimethoprim/sulfamethoxazole
Only antibiotic agents chosen by at least one respondent are shown
“Directed” is defined as an antibiotic choice made based on culture results, when available
Treatment strategies reported by respondents are described in Table 1. Of responding ED and primary care providers (PCPs), 97% reported managing patients with recurrent CA-MRSA SSTIs in their own practice (vs. referring to a specialist). A greater proportion of adult compared to pediatric providers favored trimethoprim-sulfamethoxazole for empiric (75% vs. 40%, p<0.0001) and directed (84% vs. 59%, p<0.0001) treatment of acute CA-MRSA SSTIs. A higher proportion of pediatric compared to adult providers favored clindamycin for empiric (50% vs. 8%, p<0.0001) and directed (36% vs. 8%, p<0.0001) therapy. When prescribing antibiotics for acute CA-MRSA SSTIs, most respondents reported having culture data in less than a quarter of cases. In cases of recurrent infection, 53% of respondents reported treating recurrences with the same antibiotic for the same duration as prior infections, 14% used the same antibiotic for a longer duration, 14% used a different antibiotic for the same duration, and 6% used a different antibiotic for a longer duration.
Decolonization strategies reported by respondents are described in Table 2. Eighty-nine percent of providers who attempted decolonization used a combination of strategies, with the most popular combination being topical mupirocin with antiseptic bodywash which was used by 38%. ED providers were less likely than other providers to decolonize patients with recurrent CA-MRSA SSTIs (63% vs. 84%, p=0.004). Adult providers were less likely than pediatric providers to decolonize household members of patients with recurrent CA-MRSA SSTIs (46% vs. 80%, p<0.0001). Overall, 10% of respondents attempted decolonization of household pets of patients with recurrent CA-MRSA SSTIs. Considering the timing of decolonization, 81% of ID providers who attempted decolonization did so after the acute infection resolved, while 66% of non-ID providers did so while treating the active infection (p<0.0001). Overall, 53% of respondents thought their decolonization regimens were somewhat or very effective at preventing recurrent CA-MRSA SSTIs.
Table 2.
Decolonization strategies for recurrent CA-MRSA SSTIs reported by survey respondents
| All Adult and Pediatric Providers (n=192) |
Adult Providers | Pediatric Providers | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| ED (n=17) |
Internal Medicine (n=27) |
Family Medicine (n=18) |
Infectious Disease (n=25) |
Dermatology (n=8) |
All Adults (n=95) |
ED (n=20) |
General Pediatrics (n=71) |
Infectious Disease (n=6) |
All Pediatrics (n=97) |
||
|
Do you decolonize patients with recurrent infections? |
|||||||||||
| Yes | 80% | 53% | 73% | 60% | 92% | 88% | 73% | 72% | 90% | 100% | 87% |
| No | 20% | 47% | 27% | 40% | 8% | 12% | 27% | 28% | 10% | -- | 13% |
|
Do you decolonize the household of patients with recurrent infections? |
|||||||||||
| Yes, always | 28% | 12% | 12% | 7% | 17% | 38% | 15% | 44% | 43% | -- | 41% |
| Yes, if family has SSTI | 35% | 18% | 19% | 36% | 54% | 25% | 31% | 28% | 39% | 100% | 39% |
| No | 37% | 71% | 69% | 57% | 29% | 38% | 54% | 28% | 19% | -- | 20% |
| Timing of decolonization | |||||||||||
| During treatment of the acute infection | 57% | 89% | 58% | 50% | 23% | 75% | 52% | 54% | 68% | -- | 62% |
| After the acute infection is resolved | 43% | 11% | 42% | 50% | 77% | 25% | 48% | 46% | 32% | 100% | 38% |
|
Preferred decolonization regimens for patients with recurrent infectionsa |
|||||||||||
| Oral TMP/SMX | 9% | 11% | 21% | 22% | 32% | 29% | 24% | -- | 9% | -- | 8% |
| Oral rifampin | 6% | -- | 10% | 11% | 23% | 29% | 15% | -- | 2% | -- | 1% |
| Topical mupirocin | 88% | 100% | 100% | 100% | 82% | 57% | 89% | 100% | 94% | 100% | 96% |
| Antiseptic bodywash | 73% | 100% | 79% | 78% | 100% | 57% | 89% | 77% | 67% | 100% | 71% |
| Bleach baths | 34% | 22% | -- | -- | 29% | 6% | 92% | 55% | 75% | 62% | |
| Other | 10% | 11% | 5% | -- | 18% | 14% | 8% | 15% | 8% | 25% | 10% |
ED=emergency department, SSTI=skin and soft-tissue infection, TMP/SMX=trimethoprim/sulfamethoxazole
Providers could select more than one favored decolonization regimen
The most commonly reported behavioral modifications recommended by providers were: avoiding towel sharing (62%), laundering linens in hot water (54%), avoiding nose or skin picking (51%), avoiding intimate contact during active lesions (45%), long-term use of bodywash (31%), and long-term use of bleach baths (14%).
More than half of respondents reported that recurrent CA-MRSA SSTIs significantly impact patient quality of life due to missed work or school, inconvenience of medical treatment, or emotional distress and/or embarrassment.
Discussion
We found that CA-MRSA SSTIs are a challenging problem treated by both PCPs and specialists. There is considerable variation, especially between adult and pediatric providers, in preferred management strategies, including choice of antimicrobials, administration of antibiotics following I&D, and decolonization strategies for patients and households.
Most PCPs and ED providers manage patients with recurrent CA-MRSA SSTIs in their own practice without referring to a specialist. This “decentralized’ nature of CA-MRSA SSTI care creates challenges for studying the epidemiology of these infections, and suggests that newer treatment guidelines should target a broad range of clinicians.
When considering the need for antimicrobials after I&D, most providers prescribe antibiotics in addition to such drainage, mirroring results from a recent survey.7 A large majority prefer trimethoprim-sulfamethoxazole as both empiric and directed therapy, which may reflect high trimethoprim-sulfamethoxazole susceptibility rates among CA-MRSA isolates and/or lower perceived risk for Clostridium difficile infection as compared to clindamycin. Interestingly, the observed reliance by most providers on trimethoprim-sulfamethoxazole as empiric therapy for purulent SSTIs may have unintended negative consequences if generalized to the treatment of nonpurulent infections such as erysipelas or cellulitis, which are frequently caused by Streptococcus species. This could lead to inadequate treatment of such infections due to the limited activity of trimethoprim-sulfamethoxazole against these organisms.8
Higher rates of clindamycin use among pediatricians mirror observations from a recent pediatric survey6 and may result from limited published data describing clindamycin use in children with CA-MRSA infections. It was interesting to observe that clindamycin remains a preferred empirical agent among many pediatric providers despite the recent emergence of clindamycin resistance in certain geographical areas.9
Decolonization is commonly used by most providers in cases of recurrent CA-MRSA SSTIs. Of note, mupirocin is used most frequently, despite debate regarding the role of nasal colonization in CA-MRSA dynamics.10 Antiseptic bodywash, bleach baths, and environmental hygiene strategies are also common, likely reflecting recognition of the importance of nonnasal colonization and fomites in the spread of CA-MRSA.10 Decolonization of household members is less common, suggesting either a reluctance of providers to treat individuals who are not their patients, or that consideration of the household as a reservoir for CA-MRSA is an emerging concept.
Our overall response rate was low; however, by the inclusive design of our study we surveyed all providers in the targeted divisions/departments without knowledge of their clinical activities. We, thus, expected a priori that many surveyed individuals would not care for patients with CA-MRSA SSTIs and would be unable to answer our questionnaire. Additionally, our study is limited by its conduct within a single academic health system, which may limit generalizability, and by the voluntary, self-reported nature of the questionnaire, which may lead to recall and/or reporting bias. Also, a majority of respondents were physicians, making the generalizability of our findings to non-physician providers limited. Regardless, our study is the first, to our knowledge, to report practice patterns for recurrent CA-MRSA SSTIs among a broad range of adult and pediatric providers.
In summary, recurrent CA-MRSA SSTIs are a challenging problem encountered by both PCPs and specialists. There is considerable variability in treatment and prevention strategies used in clinical practice, highlighting a lack of available clinical data. Comparative studies are needed regarding optimal antimicrobial regimens, necessity of antibiotics following incision and drainage (I&D), and the effectiveness of decolonization strategies among patients and households.
Acknowledgements
Financial support. None.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Potential conflicts of interest. E.L. has received research funding from Merck, OrthoMcNeil, AstraZeneca, and Cubist pharmaceuticals. All other authors: no conflicts.
References
- 1.Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005;352:1436–1444. doi: 10.1056/NEJMoa043252. [DOI] [PubMed] [Google Scholar]
- 2.Gorwitz RJ. A review of community-associated methicillin-resistant Staphylococcus aureus skin and soft tissue infections. Pediatr Infect Dis J. 2008;27:1–7. doi: 10.1097/INF.0b013e31815819bb. [DOI] [PubMed] [Google Scholar]
- 3.Miller LG, Quan C, Shay A, et al. A prospective investigation of outcomes after hospital discharge for endemic, community-acquired methicillin-resistant and -susceptible Staphylococcus aureus skin infection. Clin Infect Dis. 2007;44:483–492. doi: 10.1086/511041. [DOI] [PubMed] [Google Scholar]
- 4.Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41:1373–1406. doi: 10.1086/497143. [DOI] [PubMed] [Google Scholar]
- 5.Gorwitz RJ, Jernigan DB, Powers JH, et al. Strategies for clinical management of MRSA in the community: Summary of an experts' meeting convened by the Centers for Disease Control and Prevention. 2006 Available at http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html.
- 6.Creech CB, Beekmann SE, Chen Y, et al. Variability among pediatric infectious diseases specialists in the treatment and prevention of methicillin-resistant Staphylococcus aureus skin and soft tissue infections. Pediatr Infect Dis J. 2008;27:270–272. doi: 10.1097/INF.0b013e31815c9068. [DOI] [PubMed] [Google Scholar]
- 7.Hammond SP, Baden LR. Clinical decisions. Management of skin and soft-tissue infection--polling results. N Engl J Med. 2008;359:e20. doi: 10.1056/NEJMclde0806337. [DOI] [PubMed] [Google Scholar]
- 8.Elliott DJ, Zaoutis TE, Troxel AB, et al. Empiric Antimicrobial Therapy for Pediatric Skin and Soft-Tissue Infections in the Era of Methicillin-Resistant Staphylococcus aureus. Pediatrics. 2009;123:e959–e966. doi: 10.1542/peds.2008-2428. [DOI] [PubMed] [Google Scholar]
- 9.Diep BA, Chambers HF, Graber CJ, et al. Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men. Ann Intern Med. 2008;148:249–257. doi: 10.7326/0003-4819-148-4-200802190-00204. [DOI] [PubMed] [Google Scholar]
- 10.Miller LG, Diep BA. Clinical practice: colonization, fomites, and virulence: rethinking the pathogenesis of community-associated methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46:752–760. doi: 10.1086/526773. [DOI] [PubMed] [Google Scholar]