February 1, 2008

EIN: Decolonize MRSA Patients or Not?


An Emerging Infections Network (EIN) member in Saudi Arabia asked whether he should attempt to decolonize a 53-year-old male patient with psoriasis carrying methicillin-resistant Staphylococcus aureus (MRSA). MRSA had once before been eradicated from the patient. His wife and five children were screened and also found to be carrying MRSA in their noses, although none had invasive disease. “Should we attempt to eradicate MRSA in everyone in the family?” the EIN member asked.

In general, respondents agreed eradication should not be attempted in this situation. Additional comments from respondents included:

Florida: I would not eradicate the MRSA from the patient or the family unless they are having an invasive procedure that compromises skin integrity…. The patient with psoriasis will likely be colonized as long as his skin disease is active since the numerous skin squames allow for a great niche for MRSA or MSSA colonization.

Also, if there are no active infections then decolonization is unnecessary since 25 percent of the world at any one time has MSSA colonization and 1 percent may have MRSA colonization. Over 50 percent of patients with psoriasis and chronic skin diseases will be colonized with MSSA or MRSA.

Minnesota: I would not. MRSA is quickly becoming part of the human mucosal niche just like MSSA is now. If you screen the family and eradicate the bug from them, what about their neighbors? School mates? Co-workers? The cat is out of the bag.

Tennessee: Mupirocin resistance is [a more] likely outcome than eradication of MRSA…. Hand washing and standard hygienic precautions are the watch words.

Quebec: Decolonization should only be considered in circumstances of recurrent CA-MRSA skin infections defined as two or more in 6 months.

If you choose to decolonize them, go all the way, with two sensitive oral systemic agents, 4 percent chlorhexidine baths daily, and nasal mupirocin tid for 7 days. Remember that pets (dogs/cats) may also carry MRSA in their nares as well. In the community setting, nothing assures you that the initial carrier will not bring it back from school or work in the future.

In my opinion, I think we have arrived in an era when we all have to live with MRSA and not worry about it so much unless we start showing signs of infection. I think that you should reassure him and only try to decolonize him and his family if they start to have symptomatic disease. For now they should just be aware of their status and should inform physicians when they present for infections.

Kentucky: I am using a skin survey after daily bathing on the patient and any household member with [skin and soft tissue infection (SSTI)] history. To any new "lesion" of any kind, topical triple antibiotic cream or ointment [over-the-counter] Neosporin in the US) is applied BID for three days or until all signs are resolved. The trick is getting them to bathe daily and take the time to comply with the survey and topical application, so I [give them] a diagram of the human [body] and ask them to mark the place(s) [with a lesion] on the diagram, put it up in the bathroom, and make a check by it each time they apply the topical. Only two have recurrent lesions and they admit to non-compliance with the survey until the lesions are quite painful. The series is not large enough for statistical significance yet, so please know it is more anecdotal experience currently; however, it has made my call backs from this population much better!

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