February 1, 2008

Multidrug-resistant Staph Reported among MSM

MRSAThe Annals of Internal Medicine last month reported an outbreak of a multi-drug resistant strain of virulent Staphylococcus aureus among men who have sex with men (MSM) in San Francisco and Boston. This USA300 strain is resistant to β-lactams, fluoroquinolones, tetracycline, macrolide,clindamycin, and mupirocin. The authors suggest the infection might have been transmitted sexually among MSM because it often was located on the buttocks, genitals, or perineum.

The authors acknowledge, however, they did not document specific sexual behaviors associated with the infection and note that MRSA infections in these regions also have been reported among heterosexuals. The key point regarding sexual transmission, said study co-author Kenneth Mayer, MD, FIDSA, is that this strain of multidrug-resistant USA300 “is being spread within a subgroup of the population who are likely to have the type of contact with each other that could disseminate it.” Isolated cases of this multidrug-resistant strain have been reported among heterosexuals, but the potential to spread more widely beyond MSM is currently unknown, he said. “The challenge is to get better data to give people a realistic sense of what are the necessary and sufficient conditions to amplify and spread the infection,” he added.

Regarding treatment, an editorial accompanying the article by authors at the Centers for Disease Control and Prevention, notes clinicians may opt for antibiotics based on a patient’s age, immunosuppression, severity of symptoms, or presence of fever, but “most uncomplicated MRSA skin infections respond well to drainage alone. It has not been established through controlled studies whether certain patients benefit from ancillary antimicrobial therapy.” The authors advise clinicians who opt for antimicrobials that this strain usually responds to trimethoprim-sulfamethoxazole; and even tetracycline-resistant strains usually respond to minocycline and doxycycline. However, clinicians should be aware of resistance to these and other agents since the strain contains a plasmid that can acquire additional resistance traits easily.

For clinicians, what’s important is “having the index of suspicion,” said Dr. Mayer. “Since not everyone volunteers their sexual history, and this infection is not limited to MSM, it’s important to remember there is more nasty staph out in the community. That means that if you start a more conventional antibiotic, just be sure to instruct the patient that if it’s not getting better between 24 and 48 hours to come back sooner rather than later.”

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