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StaphAseptic™ News
Warning: MRSA risks rise following derm surgery
July 9, 2009
By Ilya Petrou, M.D.
Methicillin-Resistant Staphylococcus Aureus(MRSA) infections seen in dermatologic surgery may be on the rise. According to one expert, physicians need to be wary of MRSA infections in post-surgical wounds and maintain a high level of suspicion, particularly in those infected wounds that do not respond to standard antibiotic therapies post-surgery.
"MRSA has been on the radar for some time now; however, dermatologic surgeons in particular need to have a heightened awareness of this challenging to treat infection as skin and soft tissue are the most commonly infected organs. Post-surgical infections that do not respond to standard therapies need to be quickly assessed for the possibility of MRSA infection and treated appropriately," says Emily J. Fisher, M.D., department of dermatology, Lahey Clinic, Burlington, Mass.
In a recent study, Dr. Fisher assessed the occurrence of MRSA infections following dermatologic surgical procedures, including Mohs surgical procedures and standard excisional surgical procedures, using a large survey-based study. Surveys were mailed to all US-based members of the American College of Mohs Surgery asking participants to retrospectively quantify the number of Mohs and standard excisions performed in the preceding year including body location and type of closure and record the number of MRSA infections seen.
The study also quantified the use of antibiotics following dermatologic surgery and the relationship between the use of antibiotics and the rate of MRSA infection.
The response rate of sent surveys was 11 percent. Results showed that the rate of MRSA infection following Mohs surgery and standard excisional surgery was 0.27 and 0.30 percent, respectively. The survey showed that prophylactic antibiotic therapy (defined as>50 percent of the time) is more frequently prescribed to patients post-Mohs surgery compared to post-standard surgical excision.
There was no difference in infection rate following Mohs surgery in practices prescribing prophylactic antibiotics less than 50 percent of the time compared to more than 50 percent of the time. However, lower infection rates were seen when prophylactic antibiotics were prescribed more than 50 percent of the time following standard excisions.
The study also found that the most common infection sites following Mohs surgery were on the face, leg and trunk; however, according to Dr. Fisher, the higher number of infections in these areas likely correlates to the higher number of surgeries done in those areas.
"We know from many studies in the past that the rate of post-surgical infection in dermatologic surgery is very low, ranging from 0.4 percent to 2.29 percent.
Nevertheless, MRSA can be difficult to treat and the data indicates that its occurrence in post-surgical infections may be on the rise. In the context of post-surgical MRSA, I think that the concern is there but fortunately it is relatively low," Dr. Fisher tells Dermatology Times.
Staphylococcus aureus is the most common infection seen in post-dermatologic surgery. The beta-lactams such as the penicillins and cephalosporins are commonly used in the treatment of post-surgical wound infections and can be given prophylactically to thwart any possible wound infection; however, MRSA is notoriously resistant to these classes of antibiotics.
In surgical wounds that do not respond to these standard antibiotic regimens and MRSA is suspected, Dr. Fisher drains the wound and follows up with a course of tetracycline. If this proves to be ineffective, trimethoprim-sulfamethoxazole could also be used. However, due to the higher adverse event profile with this drug, Dr. Fisher prefers to reserve it as a second line of therapy for MRSA wound infection.
"In those surgical wounds where MRSA infection is suspected, it would be prudent for the physician to start the patient on a course of antibiotics that would cover MRSA without necessarily waiting for laboratory culture confirmation. Incision and drainage of the wound should also be done to avoid any subsequent sequelae from MRSA.
"These therapeutic measures are even more important in cases of rapid progression, larger sites, systemic manifestations and in immuno-compromised patients," Dr. Fisher says.
The precautions that are already being taken peri-operatively in dermatologic surgery are extensive and likely explain why the incidence of infections is so low, however some bacteria do get through, including MRSA.
According to Dr. Fisher, surgeons should be more wary of their geriatric surgical patients as this patient population is more likely to have recent hospital stays or be living in nursing homes where nosocomial infections such as MRSA can be more of an issue. DT
http://www.modernmedicine.com
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