10. Community-acquired MRSA is on the rise.
In the last 5 years in the United States, there has been a steady increase in MRSA infections in patients without traditional risk factors (9,10). Historically, clinicians have been concerned about MRSA in nursing home patients, patients in other long-term care facilities, injection drug users, and hospitalized patients. In the last 5 years there have been increasing numbers of patients with MRSA with none of these risk factors. Often these patients present with a serious life-threatening S. aureus infection. It is now appropriate to give vancomycin empirically for patients who have serious illnesses due to suspected S. aureus even if they don’t have traditional risk factors for MRSA. As ID practitioners, we do not want to encourage overuse of vancomycin, and clinicians should quickly switch to other agents if the patient proves not to be infected with MRSA. While vancomycin is a useful drug, it is considered inferior to the beta-lactams for many infections, such as bone or joint infections, and should only be used in patients with documented or suspected MRSA, or patients intolerant of beta-lactams. Several new drugs provide alternatives to vancomycin for MRSA, including linezolid and daptomycin. Both of these agents are more expensive and have not proven in clinical trials to be superior (with the possible exception of linezolid for MRSA pneumonia). Linezolid offers the advantage of having excellent oral availability; however, oral linezolid use is complicated by its high cost. Oral linezolid costs approximately $100 a day, and in almost all cases the use of this drug must be preapproved before an insurance company will pay for it. Insurance companies will almost always approve oral linezolid if the only alternative is continued hospitalization, skilled nursing home placement, or home IV antibiotic therapy. Trimethoprim/sulfa is a much less expensive alternative to oral linezolid for MRSA, and is very useful for less serious MRSA infections such as UTIs. About 85% of MRSA strains are sensitive to trimethoprim/sulfa. Many community-acquired MRSA strains are clindamycin susceptible, and minocycline and doxycycline have activity against many MRSA strains.
So these are 10 things ID physicians wish all hospitalists knew. The 11th is that we enjoy working with our hospitalist colleagues, so please call when you think you need us.
Dr. Armitage may be reached at [email protected].
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