For my book SUPERBUG: The Fatal Menace of MRSA (came out last March; paperback will be out in February), I spent several years talking to about 100 victims of antibiotic-resistant staph, and family members of victims who did not survive their infections. There were some striking things about their stories.
One was the variability of the bug, which can cause anything from mild one-time skin infections to lethal necrotizing pneumonia, adding up to almost 19,000 deaths, 369,000 hospitalizations and possibly 7 million medical office visits a year. The other was the variability of the patients’ treatment. Some had the good luck to find physicians who knew about the bug, understood the layers of testing needed to determine the best antibiotics to use, and were sensitive to the possibilities of over- and under-treatment. Others were not so lucky: They went to doctors who didn’t recognize the infection, didn’t prescribe drugs that worked, didn’t have anything to offer when the infection recurred — a whole panoply of errors.
It was a lesson for me in how long it can take news of a new medical development to percolate through the clinical community, especially to primary-care practitioners — people who don’t have a channel for new news because they don’t work for an academic medical center or belong to a specialty society that puts out a journal or at least a substantial newsletter. But it was also a lesson on how few agreed-upon standards of practice there were for treating MRSA. For many presentations, there was no evidence refer to; clinicians were thrown back onto poring through the literature, or on making educated guesses based on their past experience.
As of this week, that should change. The Infectious Diseases Society of America has publshed the first-ever clinical practice guidelines for treating MRSA in adults and children. It’s a substantial document, 38 pages (in the advance access section of Clinical Infectious Diseases) and should be a tremendous resource for patients and their physicians. (I know of one patient who printed it out yesterday and took it to an office visit — only to find the physician had just downloaded a copy himself.)
In a statement released by IDSA, lead author Dr. Catherine Liu of the University of California, San Francisco said:
MRSA has become a huge public health problem and physicians often struggle with how to treat it… The guidelines establish a framework to help physicians determine how to evaluate and treat uncomplicated as well as invasive infections. It’s designed to be a living document, meaning the recommendations will evolve as new information and antibiotics become available.
Up to this point, those seeking guidance on MRSA could look only to a flowchart constructed several years ago by the CDC that covered recognition of skin and soft-tissue infections and provided guidance on which of the few remaining working antibiotics to choose or avoid.
The new guidelines are much more comprehensive. They cover skin and soft tissue infections, bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system infections, down to the preferred drugs (including old generics) and optimal dosing, both adult and pediatric. (The guidelines are endorsed by the Pediatric Infectious Diseases Society and the American Academy of Pediatrics, along with the American College of Emergency Physicians.)
They also take up the problematic issue that we are losing one of the last-resort drugs, vancomycin, to resistance; they cover dosing of vancomycin and monitoring; management of vanco-resistant infections; and, the thing no one wants to contemplate, infections so resistant to vancomycin that they are untreatable.
Two important issues in the guidelines:
They explicitly state what many clinicians have been talking about for several years: That for uncomplicated abscesses, antibiotics may not be necessary, and simply opening up the abscess and draining it may do just as much good. Important caveats: Antibiotics should still be used if there are multiple abscesses, or an abscess in a difficult place (on the face, in the groin); or if cellulitis is present; or if the patient is immune-compromised or has additional systemic disease.
They also endorse the set of practices, collectively called “decolonization,” that people undertake when they are bedeviled by recurrent MRSA infections: antibiotic nasal gel, antiseptic washes, dilute bleach baths, and aggressive cleaning of surfaces in the person’s home. They even take up the possibility of decolonizing not just the infected person, but other people in the household where the recurrent infections are happening. (As far as I can see, they don’t mention decolonizing pets.) Decolonization has been controversial; there has been good evidentiary support for it only in hospitals, in patients about to undergo surgery, and the CDC was reluctant to recommend anything beyond that. That didn’t stop frustrated doctors and desperate patients, who tried their own home-brewed combinations of those practices, varying the things they did and the length they did them for and hoping the infections would not recur.
As many, many people told me when I was working on Superbug, MRSA by itself is a lonely and isolating infection. Finding out that medicine couldn’t say with surety what to do for you was worse, and trying multiple regimens, not knowing which would work, was the worst of all. These guidelines will provide decision support and a shared body of knowledge for physicians, which is crucial. But they also give patients some reassurance that the quixotic behavior of the bacterium, and the potential complexities of their treatment, have been thought through.
