I&D and MRSA

Trauma Columnist · Nov 17, 2009

For MRSA, if they aren't PCN-allergic, I use bactrim and keflex. If PCN allergic, clindamycin and bactrim.

The ER where I work has low (

meandragonbrett · Nov 17, 2009

I'm afraid I don't understand why they would be wanting you to cut back on the abx. If a patient has MRSA they need abx!

Bactroban once WEEKLY for a year? Yeah...right....nobody is going to be compliant with that.

JDCitizen · Nov 17, 2009

for mrsa, if they aren't pcn-allergic, i use bactrim and keflex. if pcn allergic, clindamycin and bactrim.
the er where i work has low (
i almost never go with two antibiotics if it's nasty i will give a dose of rocephin x 1 and bactrim for a week.
(of course i have been crawled for giving rocephin)
i only use clindamycin on rare occasions because i have seen too many induced resistance.
i have seen multiple, multiple cultures with multiple resistances. more than a few times i have had to choose between rocephin as the only local antibiotic or admission for the big guys. i would say 40% of mine are resistant to pcn.
if i have to work on a site i do a culture and in my early days it didn't take me long to discover everything that looks like it probably is mrsa is not... iv reviewed results with my doctors and they haven't ever seen some of the bugs i treat.

i have seen the little pimple on a leg go crazy within 5 days and need surgery.

JDCitizen · Nov 17, 2009

i'm afraid i don't understand why they would be wanting you to cut back on the abx. if a patient has mrsa they need abx!
bactroban once weekly for a year? yeah...right....nobody is going to be compliant with that.

sometimes i don't even fathom this doctor's train of thought, especially since i have her treatment of mrsa. don't get me wrong this doctor is sharp but sometimes i do walk out the office bewildered.

as for nasal pcrs and bactroban: when in rome do what the romans tell you j

life as a midlevel: danged if you do and danged if you don't.

tracelane, DNP, NP · Nov 18, 2009

I do lots of I&D's. I often think fondly of myself and the abscess queen!

I always give antibiotics. It has been something of an argument among the docs I've worked with about whether to give Bactrim DS 2 bid or one BID for 10 days. Some infectious disease providers prefer 2 BID so I usually go with this.

One of the docs I work with always gives Cipro but I haven't found this to be effective.

I remember way back people were using Bactroban but nothing recently.

T

Advanced Practice Columnist / Guide · Nov 19, 2009

I don't do I&D's and don't see office patients either but it looks like MRSA in the community setting is treated with either single agent Co-trimoxazole or Clindamycin. There are reports of Doxycycline being used.

I've heard of Bactroban used in nursing home settings but these places tend to make a big deal of colonized MRSA because of fear that it would spread and infect other nursing home residents. Don't know any data on results though.

TraumaRUs, is it possible that double coverage is a Nephrology-specific protocol being that you are dealing with ESRD patients who have dialysis catheters?

For the rest of the NP's, if the sensitivity result already identified the Staph organism as Methicillin-resistant, wouldn't you just treat with whatever antibiotic the sensitivity panel showed?

meandragonbrett · Nov 19, 2009

TraumaRUs, is it possible that double coverage is a Nephrology-specific protocol being that you are dealing with ESRD patients who have dialysis catheters?

Pretty sure double coverage is not nephro specific. I've seen it in the community setting personally. I've had a nasty MRSA that I've been unable to get rid of. It was only susceptible to vancomycin, linezolid, bactrim, and rifampin. It was a mess!

Trauma Columnist · Nov 19, 2009

Nope - this is in my prn job in an ER. We don't treat MRSA the same way in renal pts at all - we use Vanco almost exclusively for my usual pt population.

I was referring to the community pts that I see in the ER.

JDCitizen · Nov 20, 2009

i don't do i&d's and don't see office patients either but it looks like mrsa in the community setting is treated with either single agent co-trimoxazole or clindamycin. there are reports of doxycycline being used.
i've heard of bactroban used in nursing home settings but these places tend to make a big deal of colonized mrsa because of fear that it would spread and infect other nursing home residents. don't know any data on results though.
traumarus, is it possible that double coverage is a nephrology-specific protocol being that you are dealing with esrd patients who have dialysis catheters?
for the rest of the np's, if the sensitivity result already identified the staph organism as methicillin-resistant, wouldn't you just treat with whatever antibiotic the sensitivity panel showed?

i don't wait on the c&s to start my antibiotics i depend on my c&s to tell me i am using the right antibiotic. i have seen too many patients with multiple resistances and have seen more than a few with multiple co-infections

fun is treating a patient with multiple resistant mrsa and multiple resistant e-coli. i have been on the phone more than a few time with our id doctors for their input.

i love bactrim but i have seen resistance to it or the patient has an allergy to sulfur.

we don't use clindamycin first line due to the number of induced resistance we have seen.

Advanced Practice Columnist / Guide · Nov 20, 2009

i don't wait on the c&s to start my antibiotics i depend on my c&s to tell me i am using the right antibiotic. i have seen too many patients with multiple resistances and have seen more than a few with multiple co-infections.
fun is treating a patient with multiple resistant mrsa and multiple resistant e-coli. i have been on the phone more than a few time with our id doctors for their input.
i love bactrim but i have seen resistance to it or the patient has an allergy to sulfur.
we don't use clindamycin first line due to the number of induced resistance we have seen.

so, it sounds like you're covering them under the presumption that the pus will grow mrsa. what do you do if the cultures turn out to be mssa? i can somehow relate to that though, we always cover gram positives with vancomycin and gram negatives with cefepime (aztreonam, if pcn allergic) in the critical care setting empirically. however, we always de-escalate once the sensitivities come out.

JDCitizen · Nov 20, 2009

so, it sounds like you're covering them under the presumption that the pus will grow mrsa. what do you do if the cultures turn out to be mssa? i can somehow relate to that though, we always cover gram positives with vancomycin and gram negatives with cefepime (aztreonam, if pcn allergic) in the critical care setting empirically. however, we always de-escalate once the sensitivities come out.

also about 95% of results are mrsa. i was finding so much mrsa the state health department took notice. ok this is not inpatient..... this is a clinic. the bugs that we can't cover with po meds have to go to the hospital or infirmary.

unfortunately one of the local hospitals we are forced to use we send a patient to them the patient comes back and we have to redirect the patient elsewhere for needed treatment (i.e. this hospital is near worthless) what's worse at time the patient comes back with no documentation .

i concur with your inpatient regiments one of the practices i worked with we always treated hard and fast and if necessary de-escalated the treatment when necessary (many times though the need to de-escalate was not necessary). bad thing to have to use high power antibiotics on so many different patients; pretty scary over the long term especially when the sensitivities are coming back with many more r's than s's.....