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Treatment and Prevention of Methicillin Resistant Staphylococcus aureus

Dermatologic Infection among Traveler

Sunardi Radiono

Department of Dermatology and Venereology

Faculty of Medicine Universitas Gadjah Mada

Introduction

Traveling either internationally or locally have been reported to cause any kinds of skin

problem. Importing an uncommon infectious disease by returning traveler from other part of the

world to their home land are common. Skin problem represent one of the 10 most common

problem found in travel clinic or traveler health problem visiting in general practitioner clinic in

several country, the number were varied from 5% (OBrienet al. 2006 around 11% (Caumes et al.2008). Traveler health problem might be a big problem for Indonesian since the number ofIndonesian traveling abroad increase steadily. Take as an example, around 200,000 and more

Indonesian do their haj to Saudi Arabia for a month period every year. So far no official report

about the size of skin problem arousing from the people returning of doing their haj in Saudi

Arabia. In the current time in Saudi Arabia the role of Staphylococcus aureus as community

pathogen were also emerging (Bukharie et al., 2001) as it happen in other part of the world since

the past 30 years. The evidence of Methicillin Resistant Staphylococcus aureus (MRSA) were also

increasing in Saudi Arabia in the continuing periods (Bukharie, 2010). MRSA is an important

cause of nosocomial infections world wide. However the epidemiology of MRSA is changing asthe isolation of MRSA is no longer limited to hospitalized patients or persons with

predisposing risk factors. Outbreaks of community-associated MRSA (CA-MRSA) have been

reported worldwide in divers community populations (Carleton et al., 2004, Charlebois et al.,

2002, Kluytmans-Vandenberg, 2006). CA-MRSA now recognized as distinct clonal entities that

differs from traditional Hospital acquired MRSA (HA-MRSA). By definition both HA-MRSA

and CA-MRSA are resistant to methicillin (and including all betalactam antibiotics), but

important differences exist in epidemiology, microbiologic characteristics, clinical aspect of

infection and management strategies between the two. Resistant to all betalactam antibiotics is

mediated by the mecA gene which code for penicillin binding protein PBP2A. The mecA gene

located in the genetic island called staphylococcal cassette chromosome mec (SCC-mec).

Differences in the type of SCC-mec differentiate the HA-MRSA and CA-MRSA. The

HA-MRSA tend to be multi-resistant, whereas CA-MRSA tend to be susceptible to narrow-

spectrum non-beta-lactam such as clindamycin, trimethoprim-sulfamethoxazole and tetracycline.

High percentage of CA-MRSA strain carry gene for Panton-Valentine leucocidin (PVL), an

exotoxin that is lethal for leucocytes, whereas such a gene are mostly absent on HA-MRSA.

Furthermore HA-MRSA usually considered as an opportunistic agent, CA-MRSA causes

infections in healthy, mostly young host without any predisposing co morbidities. Returning

back to example of the highest Indonesian destination of Saudi Arabia, the prevalence of MRSA

isolate from several part of the country indicate the mark increment time by time. MRSA isolate

increase from 2% in 1999 to 8% in 2003, 62% represent CA-MRSA infection (Al-Tawfiq, 2006).


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The proportion of CA-MRSA isolate increase from 42% in 1999 to 66% in 2002 in Riyadh

(Moussa and Sibl, 2009). Nearly equal findings also reported from other part of the world

including North and South America, Australia, Europe, Africa and Asian countries. Further

study indicate that higher the prevalence rate of isolate on the population correlate with higher

prevalence rate of the infections. A study done on surgical discharge from three referral Hospital

East Java and Bali Indonesia showed that among 2500 patients underwent surgical operation

433/2500 (17%) patients carried S. aureusand 67 (3%) carried MRSA isolate (Santosaningsih et

al., 2008). Discharge MRSA screening of surgical patients in Indonesia. Proceeding International

Symposium on Staphylococci and Staphylococcal Infection, Australia). Furthermore study on

clinical sample for bacterial culture from wider part of Indonesia indicate that MRSA was 30%

of total S.aureusisolate (Santosaningsih et al., 2008). Methicillin resistant Staphylococcus aureus

(MRSA) among clinical isolate in Indonesia Proceeding International Symposium on

Staphylococci and Staphylococcal Infection, Australia). A multi centre study. This evidence maycorrelate with the fact that 52% of refuge of Merapi volcano in Yogyakarta in 2010 who suffer

pyoderma carried S. aureus (Triasari et al., 2011) as suggested by VandenBergh and Verbrugh

(1999). So far no accurate data indicate the prevalence of CA-MRSA reservoir among Indonesian

population.

MRSA Dermatologic infections in traveler

Clinical infections of MRSA basically were similar with methicillin-sensitive Staphylococcus

aureus (MSSA) infections, but typically difference with the HA-MRSA. HA-MRSA commonlycause blood stream and respiratory system infections, whereas CA-MRSA isolated from skin

and soft tissue infections(SSTIs) (Enright, 2006). As usual CA-MRSA causes mild infections,

but they may also be severe which need hospitalization or end in subsequence mortality (Moussa

and Sibl, 2009, US-Centers for Disease Control and Prevention, 1999). Some study reported

that population at risk for CA-MRSA infections are young children, daycare attendees, prison

inmates, indigenous populations, men who have sex with men, HIV infection, members of

football teams, wrestlers, fencing teams, injection drug users, homeless, tattoo recipients, military

recruits (Byers and Decker, 2008). A study done by Thind et al. (2010) in India reported the

clinicobacterial relationship pyoderma and MRSA (table 1)

(cited from: Thind et al., 2010)


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Other study done by Li and Zhang (2010) in China also indicate the equal result (tabel 2).

Table.2. Number of bacterial isolate from difference dermatosis in out patient department in

Beijing.

Primary skin diseases

Patients,

n

Types of bacteria

isolatedNo

growthMRSA MSSA Other

Dermatitis and eczema 54 2 22 19 15

Unclassified eczema 35 1 13 15 10

Atopic dermatitis 2 2

Contact dermatitis 11 1 3 3 4

Seborrhoeic

dermatitis

2 1 1

Photosensitivity 2 2

Autosensitization 1 1

Prurigo 1 1

Suspected S. aureus

infection

15 7 7 1

Impetigo 10 6 3 1Furuncle 3 1 2

Folliculitis 1 1

Abscesses 1 1

Others* 35 6 17 10

MRSA, methicillin-resistantStaphylococcus aureus;MSSA, methicillin-

susceptileS. aureus;*Includes several kinds of nonbacterial infectious

skin diseases such as papular urticaria, erythema multiforme, bullous

pemphigus,tinea pedis and burns, with suspected secondary bacterial

infections. Cited from Li and Zhang, 2010.

The study result indicate the high percentage of SA as causative agent of community-acquired

pyodermas, therefore the presence of MRSA isolate was only 9%. Among the MRSA isolate theresistancy profile were shown on table 3.

The occurrence of MRSA in population which probably induce the dermatologic infection

(SSTI) has been reported differently between the HA-MRSA and CA-MRSA. HA-MRSA

infection more related to intestinal colonization (Bhalla et al., 2007), while CA-MRSA infections

suggested relate with narres carriage of CA-MRSA (VandenBergh and Verbrugh, 1999).

Cutaneous colonization therefore anecdotically reported as depend on competition between

MSSA and MRSA in nares (DalAntonia et al., 2005), and innate immune response difference

against SA and S epidermidis in skinwhich indicate that SA were less competitive to colonized in

normal skin (Holland et al., 2009). Thus such a conditions may have implication on prevention

efforts.

Prevention of MRSA dermatologic infection for traveler

In order to set a preventive action of MRSA skin and soft tissue infection (SSTI) in traveler,

several consideration should be taken into account. Understanding of the risk factors concerning


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to SSTI such as : previous history of MRSA infection, antibiotic therapy in the previous 8 weeks,

intra venous drugs use, abscess, hospitals admission or surgery in the previous year and diabetes

mellitus (Stentrom et al., 2009). Specific action targeted to prevent infection in persons who are

going to travel could be arranged as:

1. Education, focusing in hygiene in the perspective of personal, organization, health careworkers mainly in time of an out break or visiting. (Table 4)

2. Strengthening effort on life style changes to both person or care giver such as:enforcement of 5 steps hand wash.

Table 4.

Personal and caregiver hygiene measuresShower daily using soap and hot waterWash hands frequently and/or use sanitation gelsCover wounds with dry, clean dressings

Avoid contact with wound drainage (use gloves)

Avoid sharing towels, razors, clothing, personal itemsClean cuts and abrasions with soap and water

Environmental and organizational control measures

Routinely clean shared equipment (eg, wrestling mats, benches,athletic equipment, whirlpools)

Clean and disinfect contaminated surfacesLaunder contaminated clothes and/or linens in hot water with

detergent or bleach

Limit participation in contact sports unless adequate wound coveragecan be obtained

Use a barrier (eg, clothes, towels) to bare skin when in contact withshared equipment or surfaces (eg, sauna benches, exercise

machines, massage tables)Health careinitiated measures

Use antimicrobials judiciouslyRecognize and treat CA-MRSA lesions early

Educate and counsel patients and caregivers about appropriate woundcareConsider decolonization strategies for recurrent disease or in localized

outbreaks in consultation with infectious disease physicians

Treatment of MRSA skin and soft tissue infection (SSTI)

Management of cases with SSTI may consist of: 1) surgical treatment 2) systemic medical therapy

(either for critical (severely ill patient) and non critical patient condition) and 3) topical treatment.

The surgical treatment may be the only choice in case the lesion is an abscess. While the use of

systemic medication consider the patient condition, as an example for non critical patients could

be seen in table 5. The topical treatment in general may use gentamycin or fusidic acid or

mupirocin preparation, though several report indicate the presence of gentamycine resistant

MRSA. The usage of bathing with antiseptic is also advised as additional management in MRSA

SSTI.


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Table 5. Potential antibiotic for non-critical Skin and Soft Tissue MRSA infection (cited from

Cohen 2009)

Antibacterial Adult dosage Child dosage Comments

TMP/SMX 1 DS tablet q12hb 610 mg/kg/d (TMP), in divided Not recommended for patients with sulfa allergies,

(cotrimoxazole) [DS]a doses q12hc women who are in their third trimester of pregnancy or

newborns aged


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Refference

1. O Brien et al., 2006: Illness in returned travelers and immigrants/refugees: The six yearexperience of two Australian Infectious Diseases Units. J Travel Med 2006; 13: 145152.

2. Caumes et al., 2008: Health Problems in returning travelers consulting generalpractitioners. J Travel Med; 15: 457459.

3. Bukharie HA., 2010: A review of community-acquired methicillin resistantStaphylococcus aureus for primary care physicians. JFam Com Med.17;3: 117-120.

4. Santosaningsih et al., 2008: Discharge MRSA screening of surgical patients in Indonesia.Proceeding International Symposium on Staphylococci and Staphylococcal Infection,

Australia

5. Oktavriana T, Trisnowati N and Sri Siswati A.,2011: Bacterial profile and its antibioticsensitivity pattern among pyoderma of Merapi victims in refuge barrack of Maguwoharjo

Yogyakarta. Proceeding of National Dermatology and venereology conferenceManado,Indonesia

6.VandenBergh MFQ and Verbrugh HA., 1999: Carriagge of Staphylococcus aureus:Epidemiology and Clinical relevance. JLab Clin Med 123,6; 525-33.

7. Byers DK and Decker CF.,2008: The changing epidemiology of Methicillin ResitantStaphylococcus aureus.Dis Mon; 54:756-762.

8.Thind P,Prakash SK, Wadhwa A, Garg VA and Pati B, 2010: Bacterial profile ofcommunity-acquired pyodermas with special reference to methicillin-resistant

Staphylococcus aureus. Ind J Dermatol-Venereol. And Leprol 76,5: 572-74.9. Bhalla A, Aron DC and Donskey CJ., 2007: Staphylococcus aureus intestinal colonization is

associated with increased frequency of S. aureus on skin of hospitalized patients. Bmc

Infect Dis.7:105.

10. DalAntonia M, Coen PG, Wilks M et al., 2005: Competition between methicillin-sensitiveand -resistant S. aureusin the anterior nares. J Hosp.Infec 61: 6267.

11. Holland DB, Bojar RA, FarrarMD et al., 2009: Diferential innate immune responses of aliving skin equivalent model colonized by S. epidermidis or Staphylococcu aureus FEMS

Microbiol Lett 290: 149155.

12. Stenstrom et al., 2009: Prevalence of and risk factors for methicillin-resistantStaphylococcus aureus skin and soft tissue infection in a Canadian emergency

department. CJEM., 11,5: 430-8.

13. Cohen P.R., 2007: Community-Acquired Methicillin-Resistant Staphylococcus Aureus SkinInfections Implications for Patients and Practitioners. Am J Clin Dermatol; 8 (5):

259-270.

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