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MRSA Infections:

- Discussion: (see MSSA)
    - true methicillin resistance involves the production of enzymes which are able to maintain cell-wall integrity during growth and division even when beta lactams have inactivated penicillin-binding proteins (ie resistant to penicillins and cephalosporins);  
    - MSRA of are now present in both large and small non-teaching hospitals and in community nursing homes;
           - approximately 15% of all nosocomial staph aureus isolates are methicillin resistant;
           - approximately 75 % of staph. epidermidis strains are resitant and 80% staph haemolyticus strains are resistant; 
    - osteomyelitis:
           - Comparative Severity of Pediatric Osteomyelitis Attributable to Methicillin-Resistant Versus Methicillin-Sensitive Staphylococcus aureus 

    - Panton-Valentine leucocidin: 
           - pore-forming toxin secreted by community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) and with the often-lethal necrotizing pneumonia;
           - genes encoding for Panton-Valentine leucocidin may be a primary reason for aggressive prevalance in the community;
           - references:
                   - Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. 
                   - Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence.
                   - Association between Staphyloccocus aureus strains carrying gene for Panton-Valentine leukocidin and lethal necrotising pneumonia in immunocompetent patients.
                   - Is Panton-Valentine leukocidin the major virulence determinant in community-associated methicillin-resistant Staphylococcus aureus disease?
                   - Staphylococcus aureus Panton-Valentine Leukocidin Causes Necrotizing Pneumonia

    - treatment:
           - prevention:
                   - the best treatment is prevention:
                   - hospital personel should wash hands after every patient contact; 
                   - ref: The role of MRSA screening in joint-replacement surgery.
           - antibiotic choices:
                   - vancomycin
                   - zyvox 
                   - septra and rifampin (for chronic suppression) 
                          - The bactericidal effects of anti-MRSA agents with rifampicin and sulfamethoxazole-trimethoprim against intracellular phagocytized MRSA

                   - clindamycin
                          - inducible resistance (appears sensitive on petri dish but is not)
                          - D-test: an erythromycin disk is placed near a clindamycin disk on a Kirby-Bauer plate;
                                 - w/ inducible resistance, zone of inhibition around clinda will be flattened in direction of erythromycin disc and will resemble letter D;
                   - minocycline
                   - rifampin
                          - Rifampicin as an adjunct to vancomycin therapy in MRSA septicaemia in burns
                   - teicoplanin
                   - daptomycin
                   - bacitracin (topical)
                          - Eradication of colonization by methicillin-resistant Staphylococcus aureus by using oral minocycline-rifampin and topical mupirocin
                          - Contemporary antimicrobial activity of triple antibiotic ointment: a multiphased study of recent clinical isolates in the United States and Australia.

    - references: 
           - Intramedullary Fixation of Long Bones--Basic Science and Pathology: Orthopedic Experience with methicillin-resistant Staphylococcus aureus during a Hospital Epidemic.
           - Comparison of levofloxacin, alatrofloxacin, and vancomycin for prophylaxis and treatment of experimental foreign-body-associated infection by methicillin-resistant Staphylococcus aureus.
           - Teicoplanin alone or combined with rifampin compared with vancomycin for prophylaxis and treatment of experimental foreign body infection by methicillin-resistant Staphylococcus aureaus. 
           - Necrotizing Fasciitis Caused by methicillin-resistant Staphylococcus aureus Resulting in Death. A report of three cases.
           - Natural history of community-acquired methicillin-resistant Staphylococcus aureus colonization and infection in soldiers.
           - Bactericidal activity of orally available agents against methicillin-resistant Staphylococcus aureus.

No mercy for MRSA: treatment alternatives to vancomycin and linezolid

MRSA colonisation and subsequent risk of infection despite effective eradication in orthopaedic elective surgery