Preferred Treatment and Prevention Strategies for Recurrent Community-Associated Methicillin-resistant Staphylococcus aureus (CA-MRSA) Skin and Soft-Tissue Infections (SSTIs): A Survey of Adult and Pediatric Providers

Background: CA-MRSA is a frequent cause of SSTIs. Recurrent infections occur in up to 20% of patients. Management strategies, especially for recurrent infections, remain undefined. 

Objective: To survey both adult and pediatric outpatient providers from multiple medical specialties to determine preferred treatment and prevention strategies used in clinical practice for primary and recurrent CA-MRSA SSTIs. 

 Methods: An internet-based survey was conducted in January 2009 at the University of Pennsylvania Health System and the Children’s Hospital of Philadelphia.  Eligible individuals were all adult and pediatric providers within the emergency department (ED), infectious diseases (ID), dermatology, and primary care (family medicine, internal medicine, and general pediatrics).
 Results: A total of 192 healthcare providers responded. A greater proportion of adult compared to pediatric providers favored trimethoprim-sulfamethoxazole for empiric (75% vs. 40%, p<0.0001) and directed (84% vs. 59%, p<0.0001) treatment of acute CA-MRSA SSTIs.  A higher proportion of pediatric compared to adult providers favored clindamycin for empiric (50% vs. 8%, p<0.0001) and directed (36% vs. 8%, p<0.0001) therapy.  When prescribing antibiotics for acute MRSA SSTIs, most respondents reported having culture data in less than a quarter of cases.  In cases of recurrent infection, 53% of respondents reported treating recurrences with the same antibiotic for the same duration as prior infections, 14% used the same antibiotic for a longer duration, 14% used a different antibiotic for the same duration, and 6% used a different antibiotic for a longer duration. ED providers were less likely than other providers to decolonize patients with recurrent CA-MRSA SSTIs (63% vs. 84%, p=0.004).  Adult providers were less likely than pediatric providers to decolonize household members of patients with recurrent MRSA SSTIs (46% vs. 80%, p<0.0001).  Overall, 10% of respondents attempted decolonization of household pets of patients with recurrent CA-MRSA SSTIs.  Considering the timing of decolonization, 81% of ID providers who attempted decolonization did so after the acute infection resolved, while 66% of non-ID providers did so while treating the active infection (p<0.0001). 

Conclusions: CA-MRSA SSTIs are a challenging problem treated by both PCPs and specialists.  There is considerable variation, especially between adult and pediatric providers, in preferred management strategies, including choice of antimicrobials, administration of antibiotics, and decolonization strategies for patients and households. Comparative studies are needed regarding optimal antimicrobial regimens, and the effectiveness of decolonization strategies among patients and households.