1 – Failure to recognize MRSA soft-tissue infection. Conventional teaching is to treat skin and soft-tissue infections with agents such as cephalexin or its intravenous counterpart, cefazolin. Patients who fail to respond require either or both a culture and switch in treatment to include an agent that covers MRSA such as vancomycin, trimethoprim-sulfa, or linezolid. Failure to do so or delay in doing so can lead to necrotizing fasciitis, osteomyelitis and other life-threatening complications and death.

2 – Patient with history of MRSA and recurrent soft-tissue infection is assumed to have MRSA until proven otherwise. To treat such a patient with a wound infection with an agent such as cephalexin delays appropriate therapy and subjects the patient to unnecessary complications.

3 – Failure to appropriately screen for MRSA. Preoperative patients who undergo hardware or prosthesis material placement including vascular grafts are now recommended to be screened preop for MRSA. If screen is positive, the options are decolonization (which can take several days to a week) or use of prophylactic vancomycin preoperatively. Failure to take either of these steps can lead to hardware and wound infection.

4 – Delays in recognition and treatment of MRSA bloodstream infections still occur, often with devastating results. No bacteremia with S. aureus, MRSA or MSSA is ever considered a “skin contaminant” (such thinking was common years ago but has been shown to be incorrect).

5 – Failure to appreciate that a deep space infection requires drainage. This occurs with MRSA or MSSA but is more likely to be more devastating with MRSA.

6 – Failure to appreciate side effects and limitations of therapies such as vancomycin.

Dr. SB