MRSA - Anbx choice

Q: 62 years old male with previous history of sick sinus syndrome and subcutaneous implanted permanent pacemaker (PPM) has been recovering in ICU from knee replacement surgery. Patient was admitted to ICU after more than-expected blood loss during surgery. The patient is now stable and designated as "Ready to Move" to ward by bedside nurse. On admission to ICU two days back, the admitting intern noted mild skin redness over the PPM site and sent culture from the skin area, which is now reported as Methicillin resistance Staphylococcus aureus (MRSA). Patient has no other clinical signs of infection. In fact, cardiology advised transferring patient to rehab directly from the ICU as there is no other inpatient need. Your choice of antibiotic? (select one)

A) Oral trimethoprim-sulfamethoxazole 

B) Oral doxycycline

C) Oral minocycline

D) Oral clindamycin

E) Intravenous (IV) Vancomycin

Answer: E

Although it is true that in mild MRSA skin and soft tissue infections (localized involvement with no systemic symptoms), an oral antibiotic may suffice. But, there are few instances when IV antibiotics should be used, as an extension of infections may become life-threatening. 

When soft tissues are in close proximity to any life or limb-saving indwelling device such as PPM, defibrillator, prosthetic joint, or a vascular graft, soft tissue infection should be considered a manifestation of device infection if it originates on the skin directly overlying the device. 

IV antibiotic for skin and soft tissues MRSA should always be considered when there is:

• extensive soft tissue involvement
• signs of systemic toxicity
• rapid progression of clinical manifestations
• persistence or progression of symptoms after 48 to 72 hours of oral therapy
• immunocompromise status
• proximity of soft tissue infection to an indwelling device

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References:

1. Ruhe JJ, Smith N, Bradsher RW, Menon A. Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome. Clin Infect Dis 2007; 44:777.

2. Drugs for MRSA skin and soft-tissue infections. Med Lett Drugs Ther 2014; 56:39.

3. Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med 2007; 357:380.