Tuesday, July 10, 2007

Mercy MRSA

It's officially an epidemic. As the junior surgeon at the hospitals where I staff, I tend to get more than my share of perianal abscesses, "butt pus", and other consults for various subcutaneous abscesses needing incisional debridement. It used to be, you'd drain them in the ED, tell them remove the packing in 24 hours and start three times a day sitz baths subsequent to that. We'd see them in 7 or 10 days and all evidence of sepsis had resolved. Not any more. I had a lady about 6 months ago, a PR vice president, who came to see me about a buttuck abscess. I drained it. The induration and erythema persisted. She got another one on the other butt cheek, and the beginnings of one on her medial thigh. I took her to the OR, opened everything up and placed a penrose drain. Final cultures: Methicillin Resistant Stapholococcus Aureas (MRSA). She ended up going home with six weeks of doxycycline. This was an upper middle class lady who was absolutely traumatized. MRSA used to be the bane of ICU's, the so called nosocomially acquired infections. Now, it's become a widespread community acquired infection. Why is this a problem? It's an aggressive little sucker, for one. You can't eradicate it simply by doing an I&D (incision and drainage). It comes back. Always. And not necessarily in the same place. Antibiotics must complement the I&D. And penicillin derivatives don't work. Or Levofloxacin. Or Clindamycin or anything else except for IV Vancomycin, doxycycline, Linezolid (if you feel like dipping into your IRA), and occasionally Bactrim.

I changed my practice after that lady. I culture all abscesses now. If the preliminary reading from the lab demonstrates gram positive cocci in clusters, I call in a prescription for Doxycycline. Patients that look septic get admitted for IV vanco. Often, I refer them to an Infectious Disease specialist. Sometimes I can even tell if it's going to be MRSA or not clinically. MRSA infections tend not to have the foul smelling, purulent pus that you see with a typical E Coli perianal abscess. There's a lot of induration and erythema, but a strange absence of white pus. It's almost a brownish, necrotic purulence. Those people I start on Doxycycline right away.

The last 15 subcutaneous abscesses I've had to drain, 14 of the cultures came back MRSA. (I've kept track). And all patients were young, relatively healthy people who were admitted from the community. Not one was a chronic ICU lingerer. So the next time you notice a boil or persistently reddened, painful mosquito bite, don't blow it off. Go see your FP.

12 comments:

Anonymous said...

I had an abcess June 23rd seen by a GP. He didn't culture, and he put me on Augmentin.After six days, I developed pnuemonia and spent five days in the hospital. They had me on steroids, which made me diabetic for the duration,and IV antibiotics, plus Levaquin. Afterword I was on Levaquin.Three days later,Monday, July 3rd, I had a painful pimple, and I remarked to my husband that I was sure I was getting another abcess in the same spot.Couldn't go to the GP until Thursday July 5th, by which time it was the size of a marble. He cultured it this time, and remarked he thought it was a MRSA. He put me on Bactrim(2 tabs twice a day) I had 4 tabs, and went in to the hospital at 2am, July 6th. At that point my chin met my chest, and I had red streaks. I developed a golf ball sized thing in my neck, plus the marble-shooter size in my chin, plus a nice case of blood poisioning.Sent two days more in the hospital on IV antibiotics and Linezolid. I have three more days on Linezolid and the site is almost gone. Also, my husband and I have spent almost fourteen days in decolonization with Hibiclens and a nasal ointment as well. The infectious disease doctor was an important factor in good recovery, the GP missed too much, especially as follow-up.
You have to have good insurance, because even with insurance this has cost thousands of dollars of bills and medication, and 4 weeks out of work.( Linezolid for 14 days without insurance is $2,200)

buckeye surgeon said...

Anon-
Sounds like you had a rough go of it. Glad someone finally figured out what the hell was going on. I've had good results with doxycycline(much cheaper) but with established bacteremia sometimes linezolid or IV vancomycin are your only options.

Anonymous said...

I think with the cellulitis extending down my neck the way it did, plus the antibiotics I had been on, plus the IV antibiotics they had already given me, they went to the first thing that would stop it.
I also made an error in my first entry. The first abscess was treated on June 15th. I went into the hosp. June 23 with the pneumonia.(So, my addition stinks.)
I never knew that an infection could be so much work to be rid of.

Anonymous said...

Buckeye Surgeon,
I'v been fighting a MRSA infection, (breast abscess resulting from a clogged duct due to nursing). I was admitted to the hospital for 5 days, given IV Vanco and sent home with Bactrim. Bactrim didn't work. I was then put on Doxycycline which seems to have done the trick. I'm just about to finish up my first 10 course of Doxy and feel great. The doctor had written the Rx with 2 refills. Is there a 'standard' of how many courses of Doxy are required to eradicate the MRSA? (I've been 'pumping/dumping' my milk as the cyclines typically aren't breastfeeding friendly. I'd love to resume breastfeeding my son, but not sure I have the energy to go through much more pumping/dumping if another course is required.)

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Anonymous said...

Hi. I had gone to my Gyno in Oct of 2009 for an abcess in my right breast. I asked for a culture and antibiotice because it ruptured, was red, and warm to touch. I had a fever and generally didn't feel well. She refused. She ordered a mammo and an ultrasound of the breast. My mammo came back normal so they didn't feel the need to do the ultrasound. A month later I went back in worse shape and she repeated the orders for mammo/ultrasound. Mammo came back normal again. I demanded they do the ultrasound. They lost the records between taking them and my follow up apt. So I went to a different doctor. I ended up having surgery on my right boob. Only to find out it was MRSA. I had MRSA and didn't know it until yesterday. NOV to late March I had this and wasn't treated for it. Seriously. I am so very angry about this. I could have been given Bactrim and could have avoided the surgery. I am very dissapointed in the doctors.

Anonymous said...

My daughter is currently in the hospital and has been there since Monday, May 10. She went to the FP on the previous Friday with a breast infection. He told her to use warm compresses and gave her an antibiotic. By Monday morning she was in so much pain and the site had become larger. He went to the ER. They admitted her, started a round of antibiotics, and scheduled her for surgery Tuesday morning. She is still in a great deal of pain. She has drain tubes in her left breast and they changed out 25 yards of packing this morning. They don't expect to send her home until next week. She is still on morphine which causes her O2 to drop as well as her heart rate so she is also on oxygen. They have tried 4-5 antibiotics so far. It is MRSA. This bug is one VERY nasty one!

Anonymous said...

I had a severe MRSA breast abscess 5 1/2 years ago from breastfeeding. Hospitalized for 6 days- vancomycin, clindamycin and rifampin, then pic line of vanc for 10 more days. Since then, have had persistent myalgia in arms and legs. Have you ever heard of anyone else having this after mrsa? Have seen many docs with no solutions...

Heidi W said...

MRSA in my R breast abscess. I've had the abscess for five years and someone finally cultures it. I'm supposed to start 10 days of lecaquin and if that doesn't work just leave it. This doesn't sound quite right to me.....

Mama Terry said...

Hi, My daughter gave birth 5 weeks ago 8 weeks early. She developed mastitis in her Right breast the first week and was told to put hot compresses on it and take ibuprofen which she did. A couple days later she has a lump the size of a walnut on the inside of her breast, she is feverish and lathargic and it is red and swollen. I take her to the er and they tell her it is mastitis and give her amoxycillin and vicodin and send her home. That night we are back at the er because her joints ache and she is not feeling right at all. We are all more than worried at this point, we sit in a room for 7 hours waiting for a breast surgeon that doesn't know her name and comes in and says Oh its just mastitis. By this time she had already had an ultrasound and I knew she had a 3 cm abcess inside her breast. I told him so and he said he better go have a look at her chart. He told us there was nothing at that point he could do as he didn't think it was anything to be concerned about. The er dac ordered a byopsy on it and the next morning she had one. It came back as MRSA, in hospital kind. She is allergic to Morphine and Sulpha drugs and we found out that the top med for Mrsa contains a derivative of sulpha so she was put on Clendomyacin, given more vicodin and Ibuprofen and sent home, no instructions on side affects or reactions at all. By the next morning she looked like the girl in charlie and the choclate factory that eats the candy that swells her up, Heer eyes were swollen shut, she looked like she had ben in a fight with Mike Tyson and lost. She was covered in hives from her head to her toe, back to the er, they tell us she is having an a llergic reaction to the antibiotic and give her benadryl and Levaquin and send her home. Two days later we are back at the er because now her joints are hurting so bad that she can hardly move. They tell us that she is having a type 2 reaction to the Levaquin and is allergic to it also. They give her an enormous amount of benadryl Prednisone and zanac and send her home with perscriptions for all and no antibiotic. She sees the breast sugeon at his office and he gives her something else for the mrsa and says he doesn't think surgery is warranted at that time. She calls me yesterday and says that the scab came off the injection site and black pus is coming out of it by the buckets. She stays up all night trying to not get this on anything as she has 3 other children and the premie to take care of. Today April 23 she saw the surgeon again, he now says surgery is the only option and that she is going in on Wednesday, she doesn't know what to expect, nothing was explained, the wic lady actually told her to keep nursing the baby, thank god for good sense because if she had he would be extremely ill or worse by now. She is scared to death and we are both finding out that there is not any easy access information out there. I would not wish this on anyone, it is horrible to see someone go through this I can not even imagine the pain and emotional strain this causes. My daughter was a very vibrant 31 year old before this disease and now it is everything she can do just to get up. What do they do when your allergic to all the antibiotics that treat it? Has anybody got any answers out there we are running out of options.

Anonymous said...

I got a perianal abscess drained today morning. I did not have any fever past few days. But now this evening I am having low grade fever (100 F) .
The surgeon did not do a culture.
What should I keep watching so that I can tell early enough if it's msra ?
Higher fever?
Increased erythema diameter?
Increased induration diameter?

Anonymous said...

I am a registered nurse who works with an infectious disease doctor all the time. am in contact with MRSA often and I do believe it has worked it's way into my own system.
So when I decided to go to the doctor for a very recurrent bout of breast mastitis I mentioned this article to the doctor there.

Sadly, there is not much information out there for nursing mothers to go off of. I am pumping and dumping by a schedule, had to lance a blocked milk duct on the tip of my nipple(how's that for a piercing?) which created large amounts of exudate that I now flush hot water over and literally milk out. Then I have to put medihoney on my nipple to prevent closure of the blocked duct. One thing is for sure...after this bout of antibiotics and once the infection clears I am weaning completely. I do not want it returning and the easiest way to rid an infection is to get to the bottom of it's food source... My milk. Sadly, I will have to finish. Thank god my little guy can do solids finally.