Otolaryngologic Community Acquired Methicillin Resistant Staph Aureus Infections in a Suburban Private Practice

CA MRSA refers to a MRSA infection occurring in the community in an individual without the established risk factors seen in Hospital Acquired MRSA (HA MRSA). CA MRSA sporadically began to appear in the early 1980’s. Originally felt to be spread from HA MRSA strains, it has subsequently been determined CA MRSA is microbiologically distinct. These isolates generally carry unique chromosomal alleles including the SCCmecIV and V and the Panton-Valentine leukocidin.. CA MRSA has a propensity for superficial soft tissue infection including abscess formation, necrotizing fasciitis,and necrotizing pneumonia . PVL is considered to be the etiologic component in these aggressive CA MRSA infections. CA MRSA colonization has skyrocketed from virtually nonexistent to as high as 50% of all Staph aureus infections and to over 2% in the healthy U.S. population. There have been several reports in the literature of CA MRSA infections involving the head and neck with inappropriate antibiotic treatment underscoring the need for greater recognition and understanding in the management of CA MRSA. We present a series of patients with head and neck CA MRSA encountered in a 12 month period in the senior author’s private suburban practice. Infection characteristics, management techniques and outcomes are discussed. METHODS AND MATERIALS 10 subjects were identified with head and neck CA MRSA infections in a 12 month period from 3/2008 to 3/2009. Patients were included in this study if they had culture proven MRSA without any of the criteria of HA MRSA. All patients with abscesses (7/10) underwent incision and drainage (within 24hrs) When localization was in doubt due to excessive edema, ultrasound was performed utilizing a portable ultrasound. Whenever possible incisions were created in a cosmetically acceptable area. Patient #6 required an open deep biopsy. All patients underwent culture utilizing sterile technique. All abscess cavities were irrigated with Vancomycin solution (2mg/cc) (Baxter Healthcare Corporation, Deerfield, IL) then packed with 1⁄4” gauze soaked in Vancomycin. This packing was changed on a daily basis until the cavity volume had significantly reduced. All patients then received appropriate antibiotics based on sensitivities. The patients with paranasal sinus infections were started on topical nebulized antibiotics. All patents were seen as an out patient 1 day, 1week and 1 month post drainage. RESULTS (Tables I – IV) (Figures 1 -3) Ten subjects were included, 8 males and 2 females. Average age 42.3y (mean 44y; range 21y-75y). No patient met the classic criteria for hospital acquired MRSA . Three patients with CA MRSA infections were predominantly nasal soft tissue (#2,4, and 5); 3 subjects had lower lip involvement (#1,7, and 10); 2 had chronic paranasal sinus infections (#8 and 9); one subject (#6) had diffuse involvement of his entire right lower face and another (#3) had a submental abscess. Only patient (#3) had been cultured prior to referral via an attempted intraoral aspiration performed elsewhere. 4 subjects received empiric therapy prior to referral (#1,2,3, and 7). Of these only half received antibiotics generally considered effective against CA MRSA in our locale (#3 and 7). All subjects with soft tissue abscess (#1-5, 7, and 10) underwent formal operative incision and drainage (I and D) using sterile technique in the operating suite within 24 hours. Four of these subjects (#3,4,7,and 10) had such significant associated edema that a portable ultrasound was employed to help localize the abscess cavity fig. a-d). Antibiotic sensitivities are seen in table 3. All of the patients that underwent soft tissue I and D had packing placed. The packing was to be changed daily. The mean time packing was required was 1 week (range 4 – 21d) . One patient (#7) did not perform daily packing changes. This same individual was the only subject who required a second I and D one week after the first. One patient (#6 with diffuse hemi facial skin involvement with necrosis(fig3a-b)) was initially evaluated by a dermatologic oncologist for suspected skin cancer. When referred to us he underwent deep facial soft tissue biopsy with culture of the biopsied material which was positive for MRSA. All patients received sensitivity directed antibiotics. Most subjects ( #3,4,5,6,7,and 10) received oral Doxycycline . These oral antibiotics were employed for an average of 26 days. Two patients received TMP/SMX (#1 and 6 for 10d and 5wks respectively). The latter received both Doxycycline and TMP/SMX. Both paranasal sinusitis patients underwent topical culture directed nebulized therapy ( #8 and 9 received gentamycin and TMP/SMX respectively). At one month follow up no subject had recurrent infection and all incisions had healed well except #3 who began to have evidence of a depressed scar on her submental drainage site requiring a minor scar revision . DISCUSSION It is likely that Staphylococcus Aureus has been present since the human specie evolved acting as both a commensal and pathologic organism. I There exists a repeating pattern of ingenious human intervention to combat this infective agent followed by equally ingenious modification of the bacterium to resist. reported. Originally sporadic cases, the prevalence of Methicillin Resistant S. Aureus has increased exponentially predominately in the hospital or chronic care setting. In 1975 2.4 % of all hospital S. Aureus cultures were MRSA, this rose to 29% in 1991 and climbed to 40% in 1996. MRSA infections outside of the hospital or chronic care setting were rare. Most of these individuals had prosthetic devices , chronic intravenous drug abusers or frequent antibiotic use. However beginning in the late 1980’s increasing reports of community acquired MRSA infections in patients without any associated risk factors began to appear by the mid 1990’s CA MRSA was reported to have increased 26 fold and has continued to increase at alarming rate while the incidence of HA MRSA has remained relatively stable. CA MRSA was originally felt to be spread from nosocomial strains of MRSA, however its’ disease pattern differed from HA MRSA pathology. A predilectation to superficial soft tissue infection, fasciitis, and abscess formation including life threatening necrotizing pneumonia characterized severe CA MRSA.3-5 Antibiotic resistance pattern also significantly differed. HA MRSA generally was resistant to most antibiotics except vancomycin. CA MRSA tended to be sensitive to many antibiotics. Gottleib et al (1992) who reported the first series otolaryngologic patients with MRSA who did not have nosocomial risk factors. Park et al. noted that the prevalence of CA MRSA in chronic suppurative otitis media rose from 0.7 % in 1998 to 11.4% in 2006 while the proportion of HA MRSA remained stable. Manarey et al reported a 9.22% MRSA infection rate in chronic rhinosinusitis in an outpatient setting.[ A 2.7% MRSA infection rate in acute rhinosinusitis was reported by Huang. Other reports of ENT related community acquired MRSA infections include series on pediatric neck abscesses, facial abscesses, and post rhytidectomy patients. Our small series adds to this growing accumulation of head and neck CA MRSA infections. Despite our series small size several important features are evident. In our series all patients with soft tissue infections started with a red mark and swelling which rapidly increased in size. This is frequently confused with a spider bite. The CDC warns that this presentation should alert the health care professional to possible CA MRSA particularly in an endemic area. Prompt I and D is critical for both therapeutic and diagnostic reasons. We have found the judicious use of ultrasound to be beneficial in helping to direct incision location and discovery of hidden loculations. The head and neck surgeon should drain the abscess in an area to minimize an untoward scar. A through attempt to break all loculations should be performed followed by appropriate antibiotics and packing. Generally continued until all signs of the infection have disappeared, typically around 14 days to 21 days. Standard infection control measures should be employed for all CA MRSA infected patients in outpatient and inpatient healthcare settings. Hand washing with soap and water or alcohol gel even if gloves are employed after contacting contaminated patients. Change gloves when moving from a contaminated site to a clean site in the same patient. Wearing gown and eye protection if there is any chance of body fluid risk. When an inpatient strong consideration should be given to room isolation or at the very least, a private room. Upon discharge counseling should be given to close contacts and household members regarding hand hygiene and wound contact.