CA-MRSA Treatment

[njac]

Has anyone found/seen any evidence for the use of >1 antimicrobial agent in the outpatient treatment of CA-MRSA? Depending on your region, Bactrim, Clindamycin, and Doxycycline are often options for CA-MRSA. I was trying to find any evidence that using more the one of these has any effect on outcomes.

I couldn't find anything that really addressed that issue. Just mention that if you want to use Bactrim but if there is any suspicion of nec fasc you need to add on Clinda for Group A Strep coverage until that is ruled out.

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[npage148]

BACTRIM is more than one agent!

 

[njac]

you know what I meant! I think the SMZ is the more active agent (although some people call in SMX... I know SMZ from the horse world) against MRSA.

 

[ItsOverZyvox]

I don't think you'll find any reference for dual therapy for CA-MRSA... at least I haven't seen it.

Why do you think we need dual coverage?

 

[WVUPharm2007]

Why do you think we need dual coverage?

Because it's MRSA!!! Quickly, run before it grows the size of the Stay-Puff Marshmallow man and consumes us all!

 

[ItsOverZyvox]

Because it's MRSA!!! Quickly, run before it grows the size of the Stay-Puff Marshmallow man and consumes us all!

Dude..... first, it's community acquired.. (doesn't mean it's less virulent) and when and where did anyone ever teach you to treat MRSA with synergism?

 

[firefighter9015]

Dude..... first, it's community acquired.. (doesn't mean it's less virulent) and when and where did anyone ever teach you to treat MRSA with synergism?

Technically CA-MRSA is more virulent and less resistent than hospital-acquired MRSA. At least that is what they teach us.

Dual coverage just add to the resistance problem, or at least I think that it would.....but I am just a lowly pharmacy student whose brain has been fried for 4 weeks now with ID in therapeutics.

 

[WVUPharm2007]

Dude..... first, it's community acquired.. (doesn't mean it's less virulent) and when and where did anyone ever teach you to treat MRSA with synergism?

Clearly, you're sarcasm detector is broken...

 

[Moxxie]

Technically CA-MRSA is more virulent and less resistent than hospital-acquired MRSA. At least that is what they teach us.

Dual coverage just add to the resistance problem, or at least I think that it would.....but I am just a lowly pharmacy student whose brain has been fried for 4 weeks now with ID in therapeutics.

No! Throw Daptomycin and Pip/tazo and Vanco at it 🙂 Mix in some Rifampin for pretty colors 😛

On a more serious note, one of our profs was telling us that she's seen several daptomycin-resistant MRSA cases come through one of our local hospitals. That scares me.

 

[njac]

I don't think you'll find any reference for dual therapy for CA-MRSA... at least I haven't seen it.

Why do you think we need dual coverage?

I don't. I'm trying to build an argument against it.

 

[njac]

No! Throw Daptomycin and Pip/tazo and Vanco at it 🙂 Mix in some Rifampin for pretty colors 😛

On a more serious note, one of our profs was telling us that she's seen several daptomycin-resistant MRSA cases come through one of our local hospitals. That scares me.

In Idaho? damn. no bueno.

we've had some VISA (dialysis pts) but if you withhold vanco for awhile the MICs creep back down.

 

[RxWildcat]

Theres no reason for dual coverage if its CA MRSA, its a lot more susceptible to ABs than HA-MRSA (and in most all cases you'd likely only need one agent for HA-MRSA). Necrotizing fasciitis is a lot more likely a result of group A strep or anaerobes, so I doubt you'd emperically cover with 2 MRSA drugs, more likely if you didn't know the bug you'd treat with a carbapenem + vanc.

 

[njac]

empirically with a carbapenem???

overuse of carbapenems is a bit scary - a friend of mine is doing a specialty residency at a place that has carbapenemase resistance. ick.

but starting out with empiric clinda (covers CA MRSA, anaerobes and group A strep) is not a bad idea - I saw the mention of that on top of bactrim just until diagnosis in some EM articles. Isn't clinda po pretty $$? Could that be the rationale why bactrim was the "base" drug?

 

[JerryPharmD]

In our ID elective they talk about HA eventually acquiring PVL. Anyone think this might happen?😕

 

[Moxxie]

This might be a helpful study (see table 5 in particular):

http://jama.ama-assn.org/cgi/conten...&stored_search=&FIRSTINDEX=0&journalcode=jama

 

[Moxxie]

In our ID elective they talk about HA eventually acquiring PVL. Anyone think this might happen?😕

Here's an article about CAMRSA and PVL - I bet that HAMRSA will obtain PVL, if many of the strains don't already have it.

http://www.cdc.gov/ncidod/Eid/vol9no8/pdfs/03-0089.pdf

Oh, and here's more info: http://en.wikipedia.org/wiki/Panton-Valentine_leukocidin (wikipedia, yeah, I know... 🙄)

 

[RxWildcat]

empirically with a carbapenem???

yeah my ID professors would probably choke if they saw me suggest that, if you don't want to use the carbapenem and cover it all, you could do pip/tazo + vanc or cefepime + vanc + metro

 

[Trancelucent1]

I can tell you that in practice we do not double cover. Usually they start empirically on IV abx and then as we transition them out they're on PO meds. It depends on the susceptibilities but bactrim, clinda, or doxy are all options that we've used. So far I've yet to see it double-covered.