Do You Find MDs Often Miss MRSA Diagnosis?

[VivaLasViejas, ASN, RN]

OK, I haven't been a nurse forever, but it sure feels like it. Especially when a new resident comes to me complaining about a "rash" she's had for over a year despite multiple trips to her primary care physician, a pharmacy's worth of ointments and pills and anti-itch creams, and now a referral to a dermatologist whom she can't even get in to see until May. She even saw her PCP last Tuesday, and he apparently told her she has to "live with it" till she can get in to the skin doc.

I took one look at it and went She has, literally, at least fifty "spider-bite" lesions in various stages all over her legs, arms, back, and abdomen. Several of them have yellowish exudate and look infected, while others are obviously older and have the characteristic reddish-black craters in the middle..........and if it's not MRSA, I'll eat my nursing cap!! This poor woman is 96 years old, still fairly sharp mentally but she's no bigger than a minute.........what I don't understand is why her PCP hasn't been able to diagnose it when I, a 'mere' nurse, can glance at it and know immediately what it is. I've seen way too much of this stuff not to recognize it; heck, I've had a couple of bouts with MRSA myself. How could an MD NOT catch this??

Luckily, the PCP was receptive to my urgent fax describing my findings ("please schedule an appointment ASAP"), but MRSA is so prevalent in the community now, it blows my mind that a medical doctor can miss it. So now I wonder: is it common for physicians not to recognize this infection? And if so, does this mean that community-based nurses need to start stripping new move-ins down to their skivvies and doing complete skin examinations?

I already know the answer to that last question........but I'm still shocked. And after fifteen years in health care, I'd thought I was pretty much un-shockable.:uhoh21:

[everthesame, LPN, LVN]

I don't think a physician can or should diagnose MRSA by appearance alone. IMO, the PCP should have cultured one or two of the lesions and alerted the facility where the patient lives of the potential for MRSA. It is possible the lesions were caused by a non MRSA staph infection.

I am not sure how nurses in the community handle MRSA or potential MRSA infections but I will find out soon. I just accepted a home health nursing position. Currently at the hospital where I work, any patient with any history of MRSA is automatically placed in isolation. At the rate we are going, I wouldn't be surprised if ten years from now most of our patients are in isolation for a history of MRSA.

[mianders, RN]

It has been my experience that MOST boils are MRSA, and the physicians in our area usually treat it as such without culturing.

[Larry77, RN]

"I think it's a spider-bite"....lol

famous quotes heard daily in the ED.

We, as nurses, are here to be the eyes and ears of the MD's, just like the CNA's should be the eyes and ears of the RN's...sounds like you noticed and addressed an issue that the doc may have overlooked---our job.

Remember at that age I'm sure your patient has numerous disease processes and a million meds to manage--which all probably took precedence over a rash on her legs.

[Elvish, BSN, DNP, RN, NP]

When I worked at the community health center, it got so bad one summer, that anytime anyone came in with anything remotely resembling a bite, we cultured it & started them on Bactrim. 100% of those cultures popped up MRSA+. People of all ages, infant to geris. Scary stuff.

[CritterLover, BSN, RN]

the community where i work has an mrsa pandemic.

our er doesn't culture -- just assumes that it is mrsa and treats accordingly.

is that best practice?

arguments can be made against it.

however, trying to follow up with patients with mrsa+ cultures would be very difficult, if not impossible, given that we often arn't given accurate phone numbers/addresses. even if we had the manpower to call/try to track down all of those patients, it would be very hit-or-miss.

(interestingly, i've noticed that the urgent care centers in the area do send cultures and follow up. my thought is that this is due to urgent care centers having a mostly +insurance patient population, making them easier to track down).

important to note, though is that community-acquired mrsa is very different than hospital-acquired mrsa. i review an awful lot of c/s reports at work, and lately mrsa is often resistent only to the oxacillin, and sensitive to everything else; esp when the patient comes into the facility with it.

acinetobacter (and pseudomonas, to a lesser extent) is the organism that tends to be resistant to everything.

[CHATSDALE]

it has been my opinion that most mds are quick to do cultures, at ltc there is frequently a standing order to culture any wound which is open mds do the throat swab

however i have seen some pretty bad mds and equal number of bad nurses so this lady probably fell through the cracks

i too, don't believe that you can dx a infection through sight or smell though some nurses swear they can do it

[Elvish, BSN, DNP, RN, NP]

I could smell pseudomonas in my sleep.

[walkingon, CNA, LPN]

I am only a fairly new CNA home health aide, but had a funky feeling about the rash on one of our clients that I had to sponge bathe several days a week. The family was inattentive, and it took us several weeks of begging, but we finally got her to her family MD who sent her home with a RX for amoxycillin and corticosteroid cream. She continued to decline after her dr. visit despite meds, rash getting worse and progressively weaker. After more begging and finally a rather nasty phone call to the family, got her admitted to the hospital. Soon after found out it was a combination of MRSA and scabies, family doc missed both diagnoses, and believe me, this is a lesson I will NOT forget. Scrutinizing any anomaly on every bit of every client's skin that I can see has become second nature, and I'm not shy about speaking up about it.

[Apollorn]

Do you think they'll ever stop screening for MRSA in hospitals what with its prevelance in the community?

[Simplepleasures]

http://www.abcnews.go.com/Health/Germs/story?id=4431562&page=1

http://www.abcnews.go.com/Health/Germs/story?id=3759700

Some interesting reports, says it is common to present with "spider bite like" wound.

[TiredMD]

A rash you've had for over a year is unlikely to be MRSA.

Of course, you could get a MRSA abscess over a pre-existing skin condition (eczema, cellulitis, fungal infection, and on and on and on). But those are two seperate things.