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Community-acquired methicillin-resistant Staphylococcus aureus in nasal vestibular abscess.

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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:
jean.anderson.eloy@gmail.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.
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