Staph infections

I had a patient ask about her father who I was treating for a sternal wound infection after a coronary bypass operation. She asked what MRSA was as she'd been told her father was infected with it and she was concerned over stories she'd heard on TV.

MRSA is methicillin-resistant Staphylococcus (staph) aureus bacteria that's become an increasingly prevalent issues in society. Previously mostly confined to hospitals & nursing homes, we've now seen rapid changes in community infection patterns to where in some areas, drug-resistant staph infections are the rule rather then the exception. I'm usually surprised now when it's not a resistant infection that shows up in the ER or wards.

Some recent well-publicized infections from football fields and neonatal units have made headlines. Predictably, the lawyers are also now advertising this as a new tort for class action lawsuits.

What's driving this emergence of MRSA? A lot of things are being implicated.

- Inappropriate antibiotic use in the outpatient setting (think getting antibiotics from your internist or pediatrician for the common cold, a viral process not sensitive to antibiotics)

- Inappropriate antibiotic use in the inpatient setting (prolonged prophylactic antibiotic use for surgery, unnecessary broad spectrum coverage, failure to change prescribing patterns to hospital bacteria sensitivity profiles)

- The rise since the early 1980's of powerful new Penicillin-class (Unasyn,Zosyn,Fortaz) antibiotics followed by other new class of antibiotics like the Quinolones (Cipro,Levaquin,Tequin) which put tremendous tools in our hands for fighting infection, but also produced "social Darwinism" among bacterial strains that resulted in resistant species

- Massive use of antibiotics given to livestock, which result in larger feed animals

- Consumer products that now contain anti-biotic material (mouthwash, soaps)

- Breakdowns in universal precautions (gowns, hand-washing) to avoid patient to patient spread (which isn't really causing MRSA but facilitates it's transfer)

What's this got to do with Plastic Surgery? Well, many of us do in fact treat some of the worst soft tissue infections you'll see. In addition, antibiotics have historically been given indiscriminately after many elective cosmetic procedures. Despite a lot of evidence not supporting antibiotic use beyond the peri-operative period (or possibly at most 24 hours), you see a lot of people continue to give 5-7 days of oral cephalosporins (eg. Keflex).

What drives this? Defensive medicine & patient's expectations. Many people have rationalized that if a infection develops & they did not have someone on antibiotics that there will be both medical liability & upset patients. You may not be able to avoid the latter, but there is increasing data that we may in fact be causing more problems (on a system-wide perspective) then we are avoiding. Unrequired antibiotics will result in more cases of anti-biotic colitis & drug-resistant infections.


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