reducción de mortalidad en pacientes con Diabetes Mellitus tipo 2

PRÁCTICA FAMILIAR RURAL │Vol 1 │ No. 7 │Marzo 2018 www.saludrural.org

 

MRSA infected wounds in a community hospital in rural tropical Ecuador


David Gaus, Diego Herrera, Danny Larco

 

 

Abstract

Introduction:  Although community acquired MRSA has been well described in many areas around the globe, little information is available about the prevalence of MRSA infections in rural areas of the Andean Region of South America.  This study characterizes wound infections from a rural community hospital in Ecuador.

Methods: A retrospective review of 235 bacterial isolates from infected wounds that included wound type, site, gender, etc...  

Results: Ninety-two (39.1%) isolates were Staphylococcus aureus.  Of these, forty-two (44.7%) were methicillin resistant S. aureus (MRSA). 

Conclusion: community acquired MRSA wound infections rates appear to warrant the use of empiric antibiotics that cover MRSA infections.  If wound infections reflect a bacterial epidemiology similar to that of skin and soft tissues infections, empiric anti-MRSA antibiotic coverage is also warranted.  In Ecuador, national antibiotic guidelines do not provide for such empiric coverage. 

 

Background

Staphylococcus aureus is a bacterium that causes life-threatening infections in healthcare and in the community.  Historically associates with hospital settings, in 1999 an outbreak of Methicillin resistant Staph aureus (MRSA) associated with the USA300 clone in a state prison in Mississippi, USA, marked the beginning of the community acquired MRSA outbreak  (1).   By 2004, MRSA became the major cause of skin and soft tissue infections (SSTI) in the United Sates (2). 

The USA300 Latin American variant (USA300-LV) was first identified in 2005, disseminating through communities and hospitals in Colombia, Ecuador and Venezuela (3) (4) (5).  Interestingly, it has been demonstrated that the South American epidemic is not an extension of the North American epidemic, but rather were concurrent, with the two variants showing a common ancestor (6).  Of note, a different MRSA isolate was identified in Uruguay during a community-associated MRSA outbreak in 2003  (7).

This study reviews the bacterial epidemiology of wound infections at a rural hospital in a poor community in rural, tropical Ecuador

 

Methodology

Bacterial isolates and their resistance patterns from wound cultures from 2014-2017 were reviewed retrospectively with no knowledge of patient identification.  S. aureus isolates were studied to determine rates of MRSA and their specific resistance patterns. 

 

Results

235 bacterial isolates were reviewed from various wound sources. (tabla 1)    

Tabla 1. Anatomic distribution of bacterial isolates

UBICACIÓN
ANATOMICA
NUMERO DE AISLAMIENTOS
PORCENTAJE
%
PIES
56
23.8
PIERNAS
55
23.4
MANOS
20
8.5
QUIRURGICA ABDOMINAL
18
7.7
NO ESPECIFICA
14
6.0
CABEZA
13
5.5
GLUTEO
10
4.3
SURCO BALANO PREPUCIAL
9
3.8
BRAZO
5
2.1
ESPALDA
5
2.1
PELVIS
5
2.1
TORAX
5
2.1
AXILA
4
1.7
QUEMADURA
4
1.7
PERIANAL
3
1.3
ESCROTO
2
0.9
MAMA
2
0.9
QUIRUGICA EXTREMIDADES
2
0.9
CUELLO
1
0.4
GLANDULA BARTOLINO
1
0.4
PERIODONTAL
1
0.4
TOTAL
235
100.0

92 of these isolates were S. aureus. (table 2)  42 were identified as MRSA with their respective resistance patterns. (table 3)  

Tabla 2. Resultados de pruebas de sensibilidad en S. aureus en heridas

ANTIBIOTICO
CONCENTRACION
(mg/dL)
AISLADOS SENSIBLES
AISLADOS INTERMEDIOS
AISLADOS RESISTENTES
PORCENTAJE DE
 RESISTENCIA
AMPICILINA
10
11
0
83
88.3
OXACILINA
1
52
0
42
44.7
CEFOXITIN
30
52
0
42
44.7
ERITROMICINA
15
68
1
25
26.6
AZITROMICINA
15
68
1
25
26.6
TRIMETOPRIM-SULFAMETOXAZOL
25
70
1
23
24.5
DOXICICLINA
30
77
0
17
18.1
CLINDAMICINA
2
79
0
15
16.0
CIPROFLOXACINA
5
87
0
7
7.4
LEVOFLOXACINA
5
87
0
7
7.4
RIFAMPICINA
5
91
0
3
3.2
GENTAMICINA
10
91
1
2
2.1
NETILMICINA
30
91
1
2
2.1
LINEZOLID
30
94
0
0
0.0
VANCOMICINA
30
94
0
0
0.0
 
TOTAL
1112
5
293
20.8

Tabla 3.  Patron de resistencia de 42 aislamientos de MRSA de heridas

MRSA RESISTENCIA
42 AISLAMIENTOS
ANTIBIOTICO
NUMERO DE CASOS
PORCENTAJE
 ENCONTRADO
%
AMPICILINA
42
100.0
TRIMETOPRIM-SULFAMETOXAZOL
21
50.0
DOXICICLINA
17
40.5
AZITROMICINA
13
31.0
ERITROMICINA
13
31.0
CLINDAMICINA
7
16.7
CIPROFLOXACINA
5
11.9
GENTAMICINA
2
4.8
VANCOMICINA
0
0.0
LINEZOLID
0
0.0

 

Discussion

These results reveal that MRSA is an important pathogen responsible for wound infections in this rural community.  Further studies are required to determine how this pathogen has become widely disseminated in this area.  This resistant bacteria requires attention when discussing treatment options, as the usual antibiotics used for wound infections of the skin include first generation cephalosporins and antistaphylococcal penicillins such as dicloxacillin.  In this region of Ecuador,  anecdotally, amoxicillin is also used considerably.  Most wound infections are not cultured, so informed empiric therapeutic decisions are critical.

In other areas of the world, such as the USA, there is significant sensibility to TMP-Sulfa and to Doxicycline, however this small report suggests that with a 50% and 40% resistance rate respectively, these antibiotics might not be appropriate.  Conversely, inducible Clindamycin resistance in other parts of the world  is growing, but this study shows a smaller percentage of MRSA resistance to Clindamycin than to TMP-Sulfa and Doxicycline.

Ecuador's National Health Council's (CONASA)  National Table of Basic Medications and National Therapeutic Registry (Cuadro Nacional de Medicamentos Basicos), ninth revision, 2014, does not expressly recommend the use of certain oral antibiotics, known to be more effective against MRSA skin and soft tissue infections (8).  This study would suggest that these recommendations might require updating.

 

Conclusiones

MRSA is an important causes of wound infections in a small rural tropical community in Ecuador.  Further studies are required to determine the role of this concerning bacteria in skin and wound infections, and to determine what antibiotics demonstrate utility against MRSA in this community.  Current ministry of public health recommendations for treating skin and soft tissue infections might require updating to take into account this worrisome bacteria.

 

References

1.

(CDC) CfDCaP. Methicillin-resistant Staphylococcus aureus skin or soft tissue infections in a state prison--Mississippi, 2000. MMWR. Morbidity and mortality weekly report. 2001; 50(42).

2.

Talan DA, Krishnadasan A, Gorwitz RJ, Fosheim GE, Limbago B, Albrecht V, et al. Comparison of Staphylococcus aureus from skin and soft-tissue infections in US emergency department patients, 2004 and 2008. Clinical Infectious Diseases. 2011 July; 53(2).

3.

Reyes J, Rincón S, Díaz L, Panesso D, Contreras GA, Zurita J, et al. Dissemination of methicillin-resistant Staphylococcus aureus USA300 sequence type 8 lineage in Latin America. Clinical infectious diseases. 2009 December; 49(12).

4.

Arias CA, Rincón S, Chowdhury , Martínez E, Coronell W, Reyes , et al. MRSA USA300 clone and VREF—a US–Colombian connection?. New England Journal of Medicine. 2008 November; 359(20).

5.

Alvarez CA, Barrientes OJ, Leal AL, Contreras GA, Barrero L, Rincón S, et al. Community-associated methicillin-resistant Staphylococcus aureus, Colombia. Emerging infectious diseases. 2006 December; 12(12).

6.

Planet PJ, Díaz L, Kolokotronis SO, Narechania A, Reyes J, Xing G, et al. Parallel epidemics of community-associated methicillin-resistant staphylococcus aureus USA300 infection in North and South America. The Journal of infectious diseases. 2015 December; 212(12).

7.

Ma XX, Galiana A, Pedreira W, Mowszowicz M, Christophersen I, Machiavello S, et al. Community-acquired Methicillin-resistant Staphylococcus aureus, Uruguay. Emerging infectious diseases. 2005 June; 11(6).

8.

Comisión Nacional de Medicamentos e Insumos. Cuadro Nacional de Medicamentos Básicos. 9th ed. Quito: Registro Terapeutico Nacional; 2014.

 

 

 

 

 

 



DOI: http://dx.doi.org/10.23936/pfr.v0i7.199.g258

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