MRSA: treating people with infection.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) has a gene that makes it resistant to methicillin as well as to other beta-lactam antibiotics including flucloxacillin, beta-lactam/beta-lactamase inhibitor combinations, cephalosporins, and carbapenems. MRSA can be part of the normal body flora (colonisation), especially in the nose, but it can cause infection, especially in people with prolonged hospital admissions, with underlying disease, or after antibiotic use. About 20% of S aureus in blood cultures in England, Wales, and Northern Ireland is resistant to methicillin. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatment for MRSA infections at any body site? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 11 systematic reviews, RCTs, or observational studies that met our inclusion criteria. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: clindamycin, daptomycin, fusidic acid, glycopeptides (teicoplanin, vancomycin), linezolid, macrolides (azithromycin, clarithromycin, erythromycin), quinolones (ciprofloxacin, levofloxacin, moxifloxacin), quinupristin-dalfopristin, pristinamycin, rifampicin, tetracyclines (doxycycline, minocycline, oxytetracycline), tigecycline, trimethoprim, and trimethoprim-sulfamethoxazole (co-trimoxazole).

Risk factors for recurrent lower extremity cellulitis in a U.S. Veterans Medical Center population.

BACKGROUND: Despite the frequency of recurrent acute cellulitis of the lower extremities, factors associated with this infection have not been previously assessed in a case-control study among patients admitted to U.S. hospitals. METHODS: We compared the clinical characteristics of 47 patients with those of 94 age- and sex-matched control subjects admitted to the Miami Veterans Affairs Medical Center. RESULTS: In a multivariate analysis, two physical factors, lower extremity edema and body mass index, one behavioral factor, smoking, and one demographic factor, homelessness, were significantly and independently associated with recurrent cellulitis. The latter two factors have not previously been reported to be independently associated with cellulitis. CONCLUSIONS: Our results suggest that increased emphasis on weight loss, smoking cessation, and improved foot hygiene in the homeless might decrease recurrences of lower extremity cellulitis.

Differences in presentation and outcome of invasive pneumococcal disease among patients with and without HIV infection in the pre-HAART era.

Invasive pneumococcal disease (PD) occurs frequently among HIV-infected patients, but it is unclear whether its manifestations and outcome are different compared to those observed among patients without HIV-1 infection. Because the immune reconstitution that accompanies antiretroviral therapy may change some of these features and because most cases of HIV- 1 infection occur in resource-poor settings of the world where access to antiretroviral agents is limited, we compared PD among patients with and without HIV-1 infection in a North American population before the introduction of highly active antiretroviral therapy (HAART). The records of all pneumococcal cultures processed at this medical center over a period of 20 months were used to identify patients with invasive PD. Hospital records were reviewed for 103 of these patients (52 with and 51 without HIV-1 infection) and demographic, clinical, laboratory, radiographic, and microbiologic information was abstracted and subsequently analyzed. Despite similarities in presenting signs and symptoms, we found a higher incidence of bacteremia but a more favorable outcome with less frequent requirements for intubation and admission to intensive care units and better survival among individuals with HIV infection. Factors such as less advanced age, the presence of fewer comorbid conditions, or a less florid inflammatory response among HIV-infected individuals may account for differences in outcome of invasive PD.

Diagnosis of strep throat in adults: are clinical criteria really good enough?

The clinical manifestations of group A streptococcal and nonstreptococcal pharyngitis overlap quite broadly. For this reason, the updated Infectious Diseases Society of America practice guideline for group A streptococcal pharyngitis, published in this issue of Clinical Infectious Diseases, recommends laboratory confirmation of the clinical diagnosis by means of either throat culture or a rapid antigen detection test. However, a recently published guideline, developed by a subcommittee of the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) in collaboration with the Centers for Disease Control and Prevention, advocates use of a clinical algorithm alone, in lieu of microbiologic testing, for confirmation of the diagnosis in adults for whom the suspicion of streptococcal infection is high. In this discussion, we examine the assumptions of the ACP-ASIM guideline, question whether its recommendations will achieve the stated objective of dramatically decreasing excess antibiotic use, and suggest that its recommendations be confirmed by clinical trials before clinicians abandon long-held teachings regarding diagnosis and management of group A streptococcal pharyngitis.