What is the risk of a patient developing Methicillin-resistant Staphylococcus aureus (MRSA) infection in a rash while on long-term triamcinolone (Kenalog) therapy?

From the Guidelines

For a patient on long-term triamcinolone who has developed MRSA in one of their rashes, I strongly recommend discontinuing the topical steroid in the affected area and initiating treatment with vancomycin or linezolid, as these antibiotics have activity against MRSA, according to the most recent guidelines 1.

Treatment Approach

The patient should be treated with oral antibiotics effective against MRSA, such as vancomycin or linezolid, for 7-10 days.

• The choice of antibiotic should be based on the severity of the infection and the patient's risk factors for MRSA infection.
• If the infection is severe, with extensive involvement, systemic symptoms, or immunocompromise, the patient should be evaluated promptly for possible intravenous antibiotic therapy.

Management of the Affected Area

• The patient should cover the infected area with a clean bandage and practice good hand hygiene to prevent spread.
• Long-term triamcinolone use can suppress local immune function and alter skin barrier integrity, creating conditions favorable for bacterial infections including MRSA.

Reintroduction of Topical Steroid

• The steroid may be cautiously reintroduced to unaffected areas once the infection resolves, but should be used at the lowest effective dose for the shortest duration possible.

Considerations

• The patient's infection should be closely monitored, and the treatment regimen should be adjusted as needed based on the patient's response to therapy and the results of any culture or susceptibility testing 2.
• It is essential to consider the potential for antibiotic resistance and to choose an antibiotic that is likely to be effective against the patient's specific infection.

From the Research

Treatment Options for MRSA Infection

The patient's development of MRSA in one of their rashes while on long-term triamcinolone requires careful consideration of treatment options. The following points summarize the available evidence:

• Vancomycin, linezolid, and daptomycin are commonly used antibiotics for treating MRSA infections 3, 4, 5, 6.
• The efficacy of vancomycin has become questionable due to the emergence of MRSA isolates with reduced susceptibility 3.
• Linezolid has shown superiority in clinical and microbiological success compared to vancomycin in treating MRSA-caused skin and soft tissue infections 5.
• Daptomycin appears to be equally efficacious as vancomycin for MRSA bacteremia, while linezolid therapy was associated with higher mortality 4.
• The timing of antibiotic therapy is crucial in treating life-threatening infections, including sepsis and septic shock, and early empiric antibiotic administration can influence survival 7.

Antibiotic Susceptibility Patterns

The susceptibility patterns of MRSA isolates to different antibiotics are as follows:

• Vancomycin: while all isolates were sensitive, the MIC 90 increased from 1.5 μg/ml to 2 μg/ml over a 2-year period, and the percentage of isolates with vancomycin MIC >2 μg/ml doubled 3.
• Linezolid: MIC 90 remained steady, but the geometric mean MIC increased, and more than 40% of isolates showed MIC 3 μg/ml, which may herald the future development of resistance 3.
• Daptomycin: showed good sensitivity against MRSA isolates, with decreasing MIC 90 and geometric mean MIC over time 3.

Considerations for Treatment

When considering treatment options for the patient's MRSA infection, the following points should be taken into account:

• The patient's long-term use of triamcinolone may affect their immune response and increase their risk of developing resistant infections.
• The choice of antibiotic should be based on the susceptibility pattern of the MRSA isolate, as well as the patient's clinical condition and medical history.
• The timing of antibiotic therapy is critical, and early empiric treatment may be necessary to improve outcomes 7.