Ca - Mrsa Current Perceptions On Treatment

CA- MRSA CURRENT PERCEPTIONS ON TREATMENT
Dr.T.V.Rao MD
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a major
public health threat. Every hospital using Diagnostic Microbiology services find
few reports with MRSA reported. The challenge to the clinical microbiology
laboratory is how to respond to the MRSA problem, in particular to CA-MRSA.
Yet in our laboratories with poor infrastructure we will mark isolate as just
MRSA, and without putting much thought on CA-MRSA, as there is upraise of
Community associated MRSA ( CA-MRSA,) By the CDCs definition, CA- MRSA
infection is classified as community-associated in individuals who have not
been hospitalized or undergone a medical procedure within the past 12
months. Previously, infection with MRSA typically occurred in hospitalized
patients, known as health care-associated MRSA infection (HA-MRSA). As we
all know that in the late 1990s, dramatic increases in the frequency of
community-acquired methicillin-resistant Staphylococcus aureus (MRSA)
infections were noted among children without established risk factors for
MRSA infections other differences between HA-MRSA and CA-MRSA exist.
Fortunately, CA-MRSA isolates are usually susceptible to more antibiotic agents
than HA-MRSA isolates, which tend to be resistant to multiple antibiotics. CA-
MRSA isolates are more likely to produce specific virulence factors or
exotoxins. An important virulence factor produced by many MRSA strains is
Panton-Valentine leukocidin (PVL), a cytotoxin. Infection with a PVL-producing
strain can result in serious clinical illness, such as osteomyelitis or
haemorrhagic necrotizing pneumonia. In the recent past at our hospital we are
getting at least 3-5 isolates as MRSA with simple marker of identification being
resistant to Cefoxitin, many times we are all limited by using human blood
however I find when you wish to test MRSA we should prefer to use mannitol
salt agar was added to the inoculation media for the detection of MRSA
.Genotypes of CA-MRSA strains are distinct from HA-MRSA isolates. The mecA
gene in staphylococci is responsible for resistance to beta-lactam antibiotics.
The mecA gene is transported on a mobile genetic element known as a
staphylococcal cassette chromosome (SCC). Five SCCmec complex types have
been found for Staphylococcus aureus. Another important characteristic
differentiating CA-MRSA strains from HA-MRSA strains is the production of
unique toxins and virulence factors. Analyses have revealed differing genes and
toxins isolated from CA-MRSA strains that have not been found in HA-MRSA
isolates. A clinically significant virulence factor unique to CA-MRSA strains is
the PVL toxin. This cytotoxin damages human leukocytes and can produce
severe tissue necrosis. Case reports of previously healthy children and adults
affected with CA-MRSA infection and the resulting necrotic clinical
manifestations, Although the true prevalence of PVL toxin production in CA-
MRSA is not known, some reports indicate that the majority of CA-MRSA
isolates are able to secrete this highly potent toxin. The most common CA-
MRSA clone circulating in the United States, USA300, carries the genes
encoding PVL. However, the USA 300 CA-MRSA clone is being increasing
recognized as a nosocomial pathogen and so the molecular characteristics of
CA-MRSA and HA-MRSA strains are becoming blurred.
Antibiotic treatment of CA-MRSA Due to the genotypic differences described
above, CA-MRSA isolates are primarily resistant to beta-lactam antibiotics
(penicillins, cephalosporins, and carbapenems) and macrolides. Thus,
additional treatment options are available to clinicians treating CA-MRSA
infection. Many clinicians jump to use Vancomycin the best for use in MRSA
well reviewed studies indicate, Oral antibiotic choices most likely to be used by
paediatric clinicians include clindamycin, trimethoprim-sulfamethoxazole,
doxycycline, minocycline, rifampin and linezolid. Data describing the
effectiveness of these agents in children with CA-MRSA. Documentation of the
effectiveness of TMP-SMX comes from case reports and anecdotal
recommendations. Sensitivity studies documenting the susceptibility of CA-
MRSA to TMP-SMX should be obtained with its use. Because TMP-SMX
contains a sulphonamide antibiotic, it should not be used in children with a
history of a documented true allergic reaction to previous sulphonamide use.
As CA-MRSA infection may also occur in new-borns, caution should be used
when prescribing TMP-SMX in these patients. As TMP-SMX may displace
bilirubin from albumin binding sites, this antibiotic should not be used in new-
borns with increased bilirubin, next option being Clindamycin is another
antibiotic frequently recommended as an initial therapeutic option. Most CA-
MRSA isolates are susceptible to clindamycin. However, it is important that
inducible resistance be tested for when using clindamycin, Clindamycin should
not be used if the D-test is positive, which indicates inducible resistance.
Clindamycin is a viable option for infants aged younger than 2 months with CA-
MRSA infection, Vancomycin is generally considered the drug of choice for
severe CA-MRSA infections. Although MRSA is usually sensitive to vancomycin,
strains with intermediate susceptibility, or, more rarely, resistant strains have
been reported. Linezolid is a unique antibiotic, a member of the oxazolidinone
class. Linezolid provides good in vitro activity toward MRSA, although
resistance has been reported. Data on its use and effectiveness in treating CA-
MRSA are limited, Doxycycline and minocycline have been reported in a small
number of adult case reports to be effective therapy for MRSA infection,
including skin and soft tissue infections caused by CA-MRSA. In conclusion we
are many treating the cases of CA-MRSA without much rationalism we all
should know CA-MRSA has more possibilities to produce the toxin which needs
more proof, an important theoretical but unproven beneficial effect of
linezolid and clindamycin may be the ability of these agents to modify CA-
MRSA toxin production. A case report published in 2005 (Micek) described four
adults with severe respiratory CA-MRSA infection, in which all the isolates
were positive for PVL. Three patients failed therapy with vancomycin but
responded to linezolid or clindamycin. As linezolid and clindamycin both
function to inhibit protein synthesis, this mechanism may be valuable in
modifying exotoxin production. Rifampin may possess good in vitro activity
toward CA-MRSA. Case reports have been published describing the use of
rifampin in combination with another antibiotic, such as TMP-SMX,
clindamycin, or doxycycline/minocycline.it is important to know when the
clinicians find their patients not responding to Vancomycin and Linezolid they
should consider the lesser tested and prescribed drugs as Clindamycin and
TMP-SMX as in most laboratories we do not have facilities to differentiate HA-
MRSA from CA-MRSA by Molecular methods. Unless we establish better
facilities in our Departments our reports many not serve the true purpose of
optimal treatments in cases of MRSA.
Ref (Web resources from CDC)
Dr.T.V.Rao MD Professor of Microbiology Freelance write

Ca - Mrsa Current Perceptions On Treatment

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