MRSA: An evolving, high-risk area for the ED
Can treatment choices get you sued?
Editor's Note: This is a two-part series on liability risks regarding antibiotic choice in the emergency department. This month, we report on liability risks involving methicillin-resistant Staphylococcus aureus.
The issues involved with treating community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in the ED are complex, says John Burton, MD, residency program director for the Department of Emergency Medicine at Albany (NY) Medical Center.
"There are a great deal of public fears and misconceptions about this bug and its subsequent infections that create near panic in some communities," he says.
This makes caring for a MRSA patient ripe for "confusion, failed expectations, and uncertain causes and effects," says Burton. In other words, it's a perfect combination of factors to provoke legal action against treating physicians. To make things more difficult, "the treatment of these infections is a moving target," adds Burton.
Five years ago, skin abscess infections weren't very common, and the general consensus was that uncomplicated infections did not require antibiotic coverage in an immunocompetent patient. If antibiotics were given, cephalexin was a typical choice.
"As MRSA began appearing in our communities and ED wound cultures, this management view began to come apart at the seams," says Burton. Initially, there were recommendations to culture all wounds, and subsequent opinions ranged from treating all wound patients with antibiotics to treating only those with larger and more inflamed wounds.
Current antibiotic coverage for these patients has increasingly emphasized trimethoprim/sulfamethoxazole as a first-line agent, says Burton, with doxycycline or minocycline as an alternate for sulfa-allergic patients.
"Physicians should certainly be aware of the sensitivities of this bug, as well as prevalence, in their treatment populations," says Burton.
How to cover for MRSA?
Regarding community-acquired MRSA, the most likely scenario for an ED physician to be sued is if antibiotics such as keflex are used that do not cover it, and MRSA has been well-documented in the area, according to James R. Miner, MD, FACEP, associate professor of emergency medicine at University of Minnesota Medical School and faculty physician in the ED at Hennepin County Medical Center, both in Minneapolis.
"The clinical presentation of MRSA is not different from other staph strains, so it's no more likely to be missed than any other infection," adds Miner. "Adding bactrim to keflex or using clindamycin covers the MRSA in most communities to account for this."
But community-acquired MRSA is now common enough in many areas that standard medications like keflex may not be suitable first-line agents anymore. "A lot of community-acquired MRSA is sensitive to bactrim or clindamycin. Local susceptibilities are important to know," says Miner. "We cover for MRSA in anybody with sepsis, no defined source, those who are at risk for MRSA, and ill pneumonia patients. The overwhelming majority of these patients are being admitted."
Inpatients should be covered with vancomycin for 24 to 48 hours until the source or organism is identified, adds Miner.
David A. Talan, MD, FACEP, chairman of the department of emergency medicine and faculty in the Division of Infectious Diseases at Olive View-UCLA Medical Center, says he is aware of lawsuits that have come forward contending negligence regarding choice of antibiotic for skin and soft tissue infections that progressed to sepsis because antibiotics active against MRSA were not given. "This is an evolving high-risk area for docs," says Talan.
Even with MRSA now recognized as the leading cause of skin and soft tissue infections, many doctors still prescribe cephalexin despite the fact that it lacks in vitro activity. Since this is still a widespread practice and there is a lack of clinical trials proving this is ineffective, however, it could be contended that this practice is within the standard of care, says Talan.
"On the other hand, for a patient who appears sick and may be infected with MRSA, I think most emergency medicine docs would give empirical coverage with vancomycin or another MRSA-active parenteral drug," he says.
Incision and drainage may be adequate for simple uncomplicated abscesses, but antibiotics should be given for ill patients and those with cellulitis or deeper infections, says Talan.
"I think prescribing keflex for likely MRSA skin infection at this point is still 'defensible,' as in a defense can be made. But of course, it all comes down to a jury's decision," says Talan. "There are plenty of guidelines now that say this is frankly wrong, but there continues to be use of keflex despite these guidelines."
No clinical outcomes "proof" on keflex yet
At present, there is no clinical trial "proof" that keflex is inferior to MRSA-active drugs in terms of clinical outcome. "We are conducting a $10 million NIH study to answer this question," says Talan. The results of the NIH study are expected to be available in about three years. "The wheels of progress turn slowly," says Talan. "However, it will be the largest randomized clinical trial of uncomplicated skin and soft tissue infections conducted that will evaluate off-patent antibiotics active against MRSA."
"Of course, there are a boatload of examples in infectious disease that substantiate that if you use a drug that kills the bug in the test tube, then the patient will do better than using one that does not. Even juries get that," Talan says.
Physicians should routinely culture wounds that undergo incision and drainage in the ED to contribute to the monitoring of drug-sensitivities for this bug, recommends Burton.
"There is little evidence to guide one's understanding and practice in these patients," says Burton. "Despite approximately half a decade of a startling increase in prevalence of this bug in ED patient populations, we have very little definitive data that clarify the effect on outcomes for either end of the spectrum no antibiotic coverage with emphasis on wound care, versus aggressive, comprehensive antibiotic coverage in all patients."
The concept of "double coverage" is a confusing in itself, adds Burton. "If the prevalence of community-acquired MRSA in these wounds ranges from 35-70% in our patients, do we ignore the potential coverage of methicillin-sensitive bugs?" he asks. "This is further confused by the view that we typically were not utilizing antibiotic coverage in the pre-MRSA era of skin abscess patients."
Clear and documented wound care instructions are essential for MRSA patients. The plan should include advising the patient to follow-up with a physician for wound assessment or, in some settings in which access to a primary care physician is limited or absent, a plan for a "wound check" in the ED, advises Burton.
"Culture of debrided wounds has now evolved to be a routine, advised practice in these patients," says Burton. "This is a clear departure from a historical practice that viewed pus cultures as nonessential and noncontributory to any meaningful patient outcome. The landscape has changed. These wounds should be routinely cultured."
Burton recommends having an agreed-upon wound care plan for patients in your community. "This will close the gaps between opinions of treating physicians, and thereby reduce the risk inherent to disparate practice plans if patient outcomes worsen instead of improve," he says.
Incorporate infectious disease expertise into this strategic planning, to formulate treatment strategies based on local prevalence and sensitivity data, says Burton.
Be wary of medical experts who advocate that this issue is simple and that there are clear standards of care, warns Burton. "It's a fast moving and evolving issue that requires formulation of a treatment plan specific to each wound and patient, with recognition of local practice patterns based on the prevalence and sensitivities of this bug," he says.
Sources
For more information, contact:
- John Burton, MD, Residency Program Director, Department of Emergency Medicine, Albany Medical Center, 47 New Scotland Ave., MC 139, Albany, NY 12208. Phone: (518) 262-4050. Fax: (518) 262-3236. E-mail: [email protected]
- James R. Miner, MD, FACEP, Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Ave., South Minneapolis, MN 55415. Phone: (612) 873-7586. Fax: (612) 904-4241. E-mail: [email protected]
- David A. Talan, MD, FACEP, FAAEM, FIDSA, Chairman, Department of Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View DriveNorth Annex, Sylmar, CA 91342. Phone: (818) 364-3107. Fax: (818) 364-3268. E-mail: [email protected]
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