Family Medicine, Internal Medicine and Surgery Case 3

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Case 03 - Owen, 58 years old

Owen is a 58 y/o who underwent ORIF L tibia and fibula following a closed ankle fracture. He is readmitted 6 days post-op with wound dehiscence, drainage and surrounding cellulitis

Blood cultures are negative but wound cultures show PMN and gm + cocci on gm stain and grow MRSA

Questions

1) What isolation precautions should be taken to prevent spread of MRSA in the hospital?

  • Should staff wear masks to enter?
  • Should staff or other patients be cultured?

Answers

Measures to be taken = Contact Precautions

  • Masks do not need to be worn; MRSA is spread by contact by hands (less likely objects or clothing) but not by airborne/droplet route
  • The most likely source of MRSA is patient colonization (found in 6 - 8% of general population). No culturing of staff is indicated unless this is part of a cluster of infections epidemiologically associated with a staff member


Questions

2) The patient undergoes debridement with removal of hardware and placement of external fixator; he is responding to iv vancomycin. Because of pre-existing DJD, a R total knee replacement is scheduled in 6 months. The patient, his family and doctors have several questions.

  • Does MRSA pose a risk to his family/friends?
  • What are the criteria for discontinuation of contact precautions?
  • What measures can be undertaken to decrease risk of MRSA infection at TKA site?

Answers

  • Generally MRSA does not pose a risk to family/friends
    - Low risk of transmission to healthy individuals with intact skin; even if were transmitted, generally would result in colonization rather than infection; so patients can socialize normally with a reminder for good hand hygiene
  • Criteria for discontinuation of contact precautions (can be found on intranet site)
    - Negative nares culture x 2 and negative culture of previous positive site with patient off antibiotics
    - If re-admitted, should re-institute contact precautions and obtain nares culture x 1; if negative, can stop contact precautions;
    - IF OPEN WOUNDS PRESENT, contact precautions should be continued as risk of persistent colonization is high and screening cultures not fully sensitive
  • For elective knee replacement
    - Use vancomycin as peri-operative antibiotic in place of or in addition of standard (cefazoline)
    - Some centers use de-colonization regimen pre-operatively:
    - chlorhexidine skin cleansing + mupirocin nasal cream x 5 days

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