Options for empiric outpatient MRSA is typicallY spread by: antimicrobial treatment of SSTIs when MRSA is a consideration* > Having direct contact with another Drug name Considerations Precautions** person’s information about n FDA-approved to n Clostridium difficile > Sharing personal items, such as towels or treat serious infec- infection, while MRSA skin . tions due to S. aureus uncommon, may occur razors, that have touched infected skin n D-zone test should more frequently in be performed to association with identify inducible clindamycin compared > Touching surfaces or items, such as used clindamycin resis- to other agents tance in erythromy- bandages, contaminated with MRSA cin-resistant isolates

Tetracyclines n is n Not recommended during n Doxycycline FDA-approved to treat S. aureus n n Not recommended for skin infections children under the age of 8 n Activity against group A , a common © Bernard Cohen, MD Dermatlas; www.dermatlas.org cause of , unknown

Trimethop- n Not FDA-approved n May not provide coverage rim- to treat any for group A streptococcus, Sulfamethox- staphylococcal a common cause of cellulitis azole infection n Not recommended for women in the third trimester of pregnancy n Not recommended for infants less than 2 months © Gregory Moran, MD http://phil.cdc.gov n Use only in n Drug-drug interactions Rifampin combination with are common. other agents

n Consultation with n Has been associated an infectious with myelosuppression, disease specialist neuropathy and lactic is suggested acidosis during prolonged n FDA-approved to therapy treat complicated skin infections, including those © Bernard Cohen, MD Dermatlas; www.dermatlas.org caused by MRSA

n MRSA is resistant to all currently available beta-lactam agents ( and cephalosporins) n Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) and (, , azithromycine) are not optimal for treatment of MRSA SSTIs because resistance is common or may Chances are, you’ll need it. develop rapidly.

Role of decolonization Regimens intended to eliminate MRSA colonization should not be used in patients with active infections. Decolonization regimens may have a role in preventing recurrent infections, but more data are needed to establish their efficacy and to identify optimal regi- mens for use in community settings. After treating active infections and reinforcing hygiene and appropriate wound care, consider consultation with an infectious disease specialist regarding use of Developed with support from the CDC Foundation through an decolonization when there are recurrent infections in an individual educational grant from Pfizer Inc. patient or members of a household. When a patient has a be warranted in addition to incision and drainage Outpatient1 management of based on clinical assessment (e.g., presence of skin and soft tissue infections skin infection, it may systemic symptoms, severe local symptoms, immune suppression, extremes of patient age, Patient presents with signs/symptoms of skin infection: very likely be MRSA. infections in a difficult to drain area, or lack of n Redness n Swelling n Warmth response to incision and drainage alone). For n Pain/tenderness n Complaint of “spider bite” Recent data suggest that MRSA in the com- severe infections, consider consulting with an munity is increasing. The spectrum of disease infectious disease specialist. Obtaining specimens YES caused by MRSA appears to be similar to that of for culture and susceptibility testing is useful to in the community. Skin guide therapy, particularly for those who fail to Is the lesion purulent (i.e., are ANY of the following signs present)? and soft tissue infections (SSTIs), specifically respond adequately to initial management. n Fluctuance – palpable n Central point or “head” furuncles (abscessed hair follicles or “boils”), fluid-filled cavity, n Draining pus carbuncles (coalesced masses of furuncles), and MRSA skin infections can develop into more serious movable, compressible n Possible to aspirate pus n Yellow or white center with needle and syringe , are the most frequently reported infections. It is important to discuss a follow-up clinical manifestations. The role of MRSA in plan with your patients in case they develop YES NO cellulitis without or purulent drainage is systemic symptoms or worsening local symptoms, less clear since cultures are rarely obtained. or if symptoms do not improve within 48 hours. 1. Drain the lesion Possible cellulitis 2. Send wound drainage without abscess: The Centers for Disease Control and Prevention What is MRSA? for culture and n Provide antimicrobial susceptibility testing therapy with coverage (CDC) encourages you to consider MRSA in the Methicillin-resistant Staphylococcus aureus (MRSA) 3. Advise patient on for Streptococcus spp. differential diagnosis of SSTIs compatible with is an antimicrobial-resistant type of S. aureus that is wound care and hygiene and/or other suspected S. aureus infections, especially those that are resistant to currently available beta-lactam 4. Discuss follow-up plan with patient n Maintain close purulent (fluctuant or palpable fluid-filled including penicillins (e.g., , ), follow-up cavity, yellow or white center, central point or “anti-staphylococcal” penicillins (e.g., methicillin, n Consider adding coverage for MRSA “head,” draining pus, or possible to aspirate oxacillin), and cephalosporins (e.g., cephalexin). (if not provided initially), pus with needle or syringe). A patient’s If systemic symptoms, if patient does not respond presenting complaint of “spider bite” should Educate Patients to Prevent Spread severe local symptoms, immunosuppression, or raise suspicion of an S. aureus infection. Patient education is a critical component of MRSA failure to respond to I&D, case management. Healthcare professionals should consider antimicrobial Abbreviations therapy with coverage for I&D: incision and drainage Incision and drainage constitutes the primary educate patients, caretakers and, when possible, MRSA in addition to I&D MRSA: methicillin-resistant Staphylococcus aureus therapy for these purulent skin infections. household members on methods to avoid MRSA (See reverse for options) SSTI: skin and soft tissue Empiric antimicrobial coverage for MRSA may transmission to close contacts. infection

1 For severe infections requiring inpatient management, consider consulting an infectious disease specialist. * Data from controlled clinical trials are needed to establish the Additional materials for healthcare professionals and patients are available comparative efficacy of these agents in treating MRSA SSTIs. Patients with signs and symptoms of severe illness should be treated as inpatients. at www.cdc.gov/MRSA or by calling 1-800-CDC-INFO. ** Consult product labeling for a complete list of potential adverse effects associated with each agent.

Algorithm co-developed by CDC, American Medical Association, and Infectious Diseases Society of America