Community-acquired methicillin-resistant Staphylococcus aureus in nasal vestibular abscess.код для вставкиСкачать
ORIGINAL ARTICLE Community-acquired methicillin-resistant Staphylococcus aureus in nasal vestibular abscess Marisa A. Earley, MD1 , Mark E. Friedel, MD, MPH1 , Satish Govindaraj, MD2 , Belachew Tessema, MD3 , Jean Anderson Eloy, MD1,4 Background: Community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is a recognized entity that is increasingly responsible for skin and so tissue infections. However, it is not the usual pathogen isolated in nasal vestibular abscess. dominance in nasal vestibular abscess. Clinicians should obtain cultures, modify antibiotic therapy as warranted, and initiate empiric therapy to include MRSA coverage for nasal C 2011 ARS-AAOA, LLC. vestibular abscess. Methods: We present a series of 13 consecutive patients presenting to a tertiary care center with nasal vestibular abscess over a 2.5-year period. Key Words: Results: All abscesses were cultured and 100% (13/13) grew S. aureus. Of the S. aureus isolates, 92% (12/13) were MRSA. Antibiotic susceptibilities of the MRSA isolates were as follows: 100% were susceptible to rifampin, trimethoprimsulfamethoxazole, and tetracycline, 75% to clindamycin, 58% to ﬂuoroquinolones, and 17% to erythromycin. Conclusion: MRSA is an important pathogen in the community. It is therefore critical to appreciate its potential pre- C ommunity-acquired methicillin-resistant Staphylococcus aureus (MRSA) is a recognized entity of increasing frequency for skin and soft tissue infections.1,2 Over the past decade, it has been demonstrated to be a growing concern in pediatric head and neck infections,3–5 adult head and neck abscesses,6,7 rhinosinusitis,7–11 periorbital cellulitis,12,13 and nasal septal abscess and facial cellulitis.14 1 Department of Otolaryngology–Head and Neck Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ; 2 Department of Otolaryngology–Head and Neck Surgery, Mount Sinai Medical Center, New York, NY; 3 Connecticut Sinus Institute, University of Connecticut, Farmington, CT; 4 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ Correspondence to: Jean Anderson Eloy, MD, FACS, Assistant Professor and Vice Chairman, Director of Rhinology and Sinus Surgery, Department of Otolaryngology–Head and Neck Surgery, UMDNJ-New Jersey Medical School, 90 Bergen Street, Suite 8100, Newark, NJ 07103; e-mail: email@example.com Potential conflict of interest: None provided. Presented at the 56th Annual Meeting of the American Rhinologic Society, Boston, MA, September 25, 2010. Received: 15 January 2011; Revised: 22 February 2011; Accepted: 1 March 2011 DOI: 10.1002/alr.20061 View this article online at wileyonlinelibrary.com. 379 methicillin-resistant Staphylococcus aureus; MRSA; nasal abscess; nasal vestibule; community-acquired Staphylococcus aureus; Staphylococcus aureus infection; vestibular abscess How to Cite this Article: Earley MA, Friedel ME, Govindaraj S, Tessema B, Eloy JA. Community-acquired methicillin-resistant Staphylococcus aureus in nasal vestibular abscess. Int Forum Allergy Rhinol, 2011; 1:379–381 Historically, S. aureus is the most common pathogen isolated in nasal septal abscess15–19 ; however, the incidence of MRSA in nasal vestibular abscess is unknown. We present a series of patients presenting to a tertiary care center with nasal vestibular abscess that yielded an unusually high incidence of MRSA-positive cultures without traditional risk factors for MRSA infection. Patients and methods After approval of our protocol by our Institutional Review Board, a retrospective chart review of all nasal vestibular infections presenting to our tertiary care institution over a 2.5-year period from January 2008 to June 2010 was performed. Patients were identified based on their admission to the otolaryngology service and current procedural terminology codes 30000 and 30020. Thirteen patients met inclusion criteria based on location of infection. History, physical exam findings, culture results, and antibiotic sensitivities were reviewed. Results Age, gender, and traditional risk factors for MRSA infection are listed in Table 1. All patients underwent incision International Forum of Allergy & Rhinology, Vol. 1, No. 5, September/October 2011 Earley et al. Discussion TABLE 1. Distribution of cases Case Age, Risk Methicillin number years Sex factors sensitivity 1 31 M None Resistant 2 49 F Abx Resistant 3 43 M None Resistant 4 60 F DM Resistant 5 40 M None Resistant 6 41 M None Resistant 7 37 F HIV Resistant 8 55 F HIV, IVDA Sensitive 9 44 M None Resistant 10 37 M None Resistant 11 53 M None Resistant 12 53 M None Resistant 13 6 F None Resistant Abx = recent prior antibiotic usage; DM = diabetes mellitus; F = female; HIV = human immunodeficiency virus infection; IVDA = intravenous drug abuse; M = male. and drainage of abscess for therapeutic reasons and to obtain specimens for culture. After incision and drainage, patients were treated with intravenous antibiotics, which were later changed to oral antibiotic after significant clinical improvement was noted. All cultures (13/13) grew S. aureus. Of the S. aureus isolates, 92% (12/13) were MRSA. All MRSA isolates were resistant to penicillins and cephalosporins with additional antibiotic susceptibilities of the MRSA isolates listed in Table 2. Of the 13 patients, 61.5% were male and 38.5% were female. The mean age was 42.2 years (range, 6–60 years). A total of 31% (4/13) of the patients had significant risk factors for MRSA. TABLE 2. Antibiotic sensitivities in MRSA isolates Number of Total number sensitive MRSA of MRSA isolates isolates Rifampin 11 11 Trimethoprim- 12 12 Tetracycline 12 12 Clindamycin 9 12 Fluoroqinolones 7 12 Erythromycin 2 12 Antibiotics sulfamethoxazole MRSA = methicillin-resistant Staphylococcus aureus. The number of cases of community-acquired MRSA across the country is increasing.1,2 It is therefore important to consider how to manage patients presenting with soft tissue infections, including nasal vestibular abscess. In a review by Daum,1 community-associated MRSA infections were suggested to be highly susceptible to clindamycin. Moran et al.2 also found 95% of MRSA isolates in patients presenting to the emergency department with skin and soft tissue infections to be sensitive to clindamycin. However, in our series only 75% were sensitive to clindamycin. In an extensive review of MRSA in head and neck infections, Brook6 discusses treatment options, with the mostutilized treatment method being surgical drainage followed by antibiotic treatment based on culture sensitivity. Studies focusing on MRSA rhinosinusitis8–11 found oral antibiotics based on culture sensitivities combined with nasal irrigations with mupirocin to be effective, with a low rate of recurrence. There are no review articles to our knowledge dealing specifically with the outpatient management of MRSA in nasal vestibular abscess. Based on the prevalence of MRSA in our case series, it seems appropriate that emphasis be placed for clinicians to obtain cultures and initiate empiric therapy to include MRSA coverage for nasal vestibular abscess. In our series, trimethoprim-sulfamethoxazole, rifampin, or tetracycline with or without topical antibiotics would be an appropriate regimen. Studies suggest initiating contact precautions in patients hospitalized with skin and soft tissue infections until culture results determine if MRSA is present.20 Our finding that 92% of patients presenting with nasal vestibular abscess were MRSA-positive strongly supports initiating contact precautions immediately in order to decrease contamination of health care providers. It seems reasonable to consider traditional risk factors for MRSA when deciding on patients’ treatment regimen prior to having culture sensitivity results. The review by Daum1 suggests that risk factors associated with community-acquired MRSA include household contacts with MRSA, children, soldiers, incarcerated persons, athletes, Native Americans, Pacific Islanders, persons with previous community-acquired MRSA infection, and intravenous drug users. However, a prospective study by Miller et al.20 demonstrated that there are no reliable epidemiologic or clinical risk factors that could distinguish patients infected with community-associated MRSA from those with methicillin-sensitive S. aureus (MSSA). This study had stringent inclusion criteria and involved statistical analysis of results from an extensive survey given to patients with cultures positive for S. aureus. Our series was a retrospective chart review and therefore, a thorough survey as performed by Miller et al.20 was not employed. However, the risk factors we did screen for included recent hospitalization or antibiotic use, diabetes mellitus, human immunodeficiency virus (HIV) infection or other International Forum of Allergy & Rhinology, Vol. 1, No. 5, September/October 2011 380 MRSA in nasal vestibular abscess immunocompromised state, and intravenous drug use. The only patient with MSSA had 2 of these risk factors, and of the remaining 12 patients, 3 had 1 risk factor each. These findings, although from a small sample, question the presumption that well-defined risk factors exist for S. aureus infection. Various case reports and series suggest that MRSA infections progress more rapidly and with more devastating complications than MSSA.7,13,14 Severity or rapidity of symptom progression might be a tool that clinicians may use when treating patients with presumed S. aureus infections. Conclusion Community-acquired MRSA is prevalent in nasal vestibular abscess in the outpatient setting. Although there are limited reviews and prospective studies to assess incidence of MRSA in nasal vestibular abscess, clinicians should consider data such as those presented in this cases series when initiating empiric antibiotic therapy. Larger reviews as well as prospective studies are necessary to critically analyze trends in nasal vestibular abscess and to assess for statistically significant risk factors associated with communityacquired MRSA. References 1. 2. 3. 4. 5. 6. 7. 381 Daum RS. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357:380–390. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355:666–674. Inman JC, Row M, Ghostine M, Fleck T. Pediatric neck abscesses-changing organisms and empiric therapies. Laryngoscope. 2008;118:2111– 2114. Guss J, Kazahaya K. Antibiotic-resistant Staphylococcus aureus in community-acquired pediatric neck abscesses. Int J Pediatr Otorhinolaryngol. 2007;71:943– 948. Naseri I, Jerris RC, Sobol SE. Nationwide trends in pediatric Staphylococcus aureus head and neck infections. Arch Otolaryngol Head Neck Surg. 2009;135:14–16. Brook I. Role methicillin-resistant Staphyococcus aureus in head and neck infections. J Laryngol Otol. 2009;123:1301–1307. Bothwell NE, Shvidler J, Cable BB. Acute rise in methicillin-resistant Staphylococcus aureus infections in a coastal community. Otolaryngol Head Neck Surg. 2007;137:942–946. 8. 9. 10. 11. 12. 13. Rutar T, Zwick OM, Cockerham KP, Horton JC. Bilateral blindness from orbital cellulitis caused by community-acquired methicillin-resistant Staphylococcus aureus. Am J Ophthalmol. 2005;140:740– 742. Huang WH, Hung PK. Methicillin-resistant Staphylococcus aureus infections in acute rhinosinusitis. Laryngoscope. 2006;116:288–291. Solares CA, Batra PS, Hall GS, Citardi MJ. Treatment of chronic rhinosinusitis exacerbations due to methicillin-resistant Staphylococcus aureus with mupirocin irrigations. Am J Otolaryngol. 2006;27:161–165. Gerencer RZ. Successful outpatient treatment of sinusitis exacerbations caused by communityacquired methicillin-resistant Staphylococcus aureus. Otolaryngol Head Neck Surg. 2005;132:828– 833. Huang SF, Lee TJ, Lin KL. Concomitant bilateral orbital and brain abscesses—unusual complications of pediatric rhinosinusitis. Chang Gung Med J. 2005;28:51–55. Boden JH, Ainibinder DJ. Methicillin-resistant ascending facial and orbital cellulitis in an Operation Iraqi Freedom troop population. Ophthal Plast Reconstr Surg. 2007;23:397–399. International Forum of Allergy & Rhinology, Vol. 1, No. 5, September/October 2011 14. Cheng LH, Kang BH. Nasal septal abscess and facial cellulitis caused by community-acquired methicillinresistant Staphylococcus aureus. J Laryngol Otol. 2010;124:1014–1016. 15. Ambrus PS, Eavey RD, Baker AS, Wilson WR, Kelly JH. Management of nasal septal abscess. Laryngoscope. 1981;91:575–582. 16. Shapiro RS. Nasal septal abscess. Can Med Assoc J. 1978;119:1321–1323. 17. Huang PH, Chiang YC, Yang TH, Chao PZ, Lee FP. Nasal septal abscess. Otolaryngol Head Neck Surg. 2006;135:335–336. 18. Jalaludin MA. Nasal septal abscess—restrospective analysis of 14 cases from University Hospital, Kuala Lumpur. Singapore Med J. 1993;34:435–437. 19. Sandel HD, Davison SP. Three spontaneous occurrences of nasal septal abscess in patients with chronic asymptomatic HIV—the need for early intervention and reconstruction. Ear Nose Throat J. 2009;88:1058–1066. 20. Miller LG, Perdreau-Remingon F, Bayer AS, et al. Clinical and epidemiological characteristics cannot distinguish community associated methicillin-resistant Staphylococcus aureus infection from methicillinsusceptible S. aureus infection: a prospective investigation. Clin Infect Dis. 2007;44:471–482.