Methicillin Resistant Staphylococcus Aureus (MRSA)


Article Author:
Abdul Siddiqui


Article Editor:
Janak Koirala


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
10/27/2018 12:31:43 PM

Introduction

Based on the antibiotic susceptibilities, Staphylococcus aureus is divided into two types: methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA), also known as oxacillin-resistant Staphylococcus aureus. Methicillin resistance in S. aureus is defined as an oxacillin minimum inhibitory concentration (MIC) of greater than or equal to 4 micrograms/mL. MRSA infection is one of the leading causes of hospital-acquired infections and is commonly associated with significant morbidity, mortality, length of stay, and cost burden. MRSA infections can be further divided into hospital-associated (HA-MRSA) infections and community-associated (CA-MRSA) infections. They differ not only in respect to their clinical features and molecular biology but also to their antibiotic susceptibility and treatment.[1][2][3]

Etiology

Methicillin resistance has occurred in S. aureus by mutation of a penicillin-binding protein, a chromosome-encoded protein. This type of resistance is transferred between S. aureus organisms by bacteriophages. This is one of the only medically relevant examples of chromosome-mediated drug resistance by phage transduction.[4]

Epidemiology

The history of MRSA infection goes back to 1961 when it was first described. Since then, the incidence and prevalence of MRSA infection have been increasing dramatically across the United States. Recently, some population studies have hinted at reducing HA-MRSA incidences in the United States but at the expense of a growing prevalence of CA-MRSA. The reported incidence of MRSA-related hospitalizations ranges from 11.5% to 60%.[5][3]

Risk Factors

The commonly associated risk factors for MRSA infection are prolonged hospitalization, intensive care admission, recent hospitalization, recent antibiotic use, MRSA colonization, invasive procedures, HIV infection, admission to nursing homes, open wounds, hemodialysis, and discharge with long-term central venous access or long-term indwelling urinary catheter. A higher incidence of MRSA infection is also seen among healthcare workers who come in direct contact with patients infected with this organism.

Although advancing age by itself is not considered a risk factor for MRSA infection, age more than 65 years is a significant risk factor for hospitalization. Hence, advancing age is indirectly linked to MRSA acquisition. Living in an area with a high prevalence of CA-MRSA or admission to a hospital with a high prevalence of HA-MRSA also is considered a significant risk factor for MRSA colonization.

Pathophysiology

The key reason for MRSA resistance to beta-lactam antibiotics is due to the presence of the mecA gene sequence, which is known to generate transpeptidase PB2a that lowers the affinity of the organism to bind to beta-lactam antibiotics.[6]

History and Physical

MRSA can cause a range of organ-specific infections, the most common being the skin and subcutaneous tissues, followed by invasive infections like osteomyelitis, meningitis, pneumonia, lung abscess, and empyema. Infective endocarditis caused by MRSA is associated with an increased morbidity and mortality compared to any other organism and is linked to intravenous drug abuse.

Skin and soft tissue infections (SSTI): CA-MRSA is a predominant organism associated with SSTIs like cellulitis, necrotizing fasciitis, and diabetic foot ulcers. It also is increasingly associated with more invasive disease than those due to non-MRSA. More frequently these infections are multidrug-resistant leading to frequent recurrence, increased hospitalization, and mortality.

Bone and joint infection: Staphylococci are the most common cause of bone and joint infections. Oxacillin resistance has become increasingly common among these patients. MRSA can cause osteomyelitis of spine, long bones of upper and lower extremities by extension of local infection from a wound or as a part of hematogenous infection. Similarly, MRSA can cause septic arthritis of both native and prosthetic joints.   

Pneumonia: Staphylococcal pneumonia, historically known, as post-influenza pneumonia, was a distinct clinical entity with a dramatic onset of respiratory symptoms and mortality ranging from 80% to 90% in the pre-antibiotic era. It carried specific radiological features including cavitary lesions, empyema, and pyopneumothorax and pathological features such as pulmonary hemorrhage and microabscess formation. In the post-antibiotic period, the course has been less explosive, not always associated with viral influenza, associated with other risk factors for S. aureus infections, and carries a mortality of around 30% to 40%. Nevertheless, CA-MRSA causing life-threatening necrotizing pneumonia in otherwise healthy individuals has been reported across the United States recently. It is characterized by severe respiratory symptoms, high fevers, hemoptysis, and hypotension. It rapidly progresses to sepsis and septic shock with leukopenia and elevated C-reactive protein (greater than 350 mg/dL). Multilobar cavitating alveolar infiltrates in a clinical setting like this is consistent with CA-MRSA infection.

MRSA is also a leading cause of hospital-acquired and ventilator-associated pneumonia. Hospital-acquired pneumonia (HAP), or nosocomial pneumonia, is characterized as pneumonia developing 48 hours or more after hospital admission, indicating that it was not incubating at the time of admission. Ventilator-associated pneumonia (VAP) is defined as pneumonia developing 48 hours or more after implementation of endotracheal intubation and mechanical ventilation and was not present before intubation. The microbiological etiology of these two conditions is similar and carries grave prognosis associated with poor overall outcomes.

Bacteremia: Bacteremia due to S. aureus has been reported to be associated with mortality rates of 15% to 60%. MRSA bacteremia is commonly seen in intensive care unit patients with central line insertions. Infective endocarditis is associated with MRSA bacteremia and should be ruled out in any patient with MRSA in the bloodstream. The outcomes related to MRSA bacteremia are worse than other MRSA infections because of the decreased response to vancomycin in these patients.

Endocarditis: MRSA is an important cause of bacterial endocarditis which can cause mortality in about a third of the infected patients (30-37%). Right-sided MRSA endocarditis is commonly associated with intravenous drug use and intravenous catheters. Patients with tricuspid valve vegetations may have septic pulmonary emboli causing nodular infiltrates and cavitating lesions in the lungs. Similarly, patients with involvement of mitral and aortic valves may have secondary infections in distant foci such as bones and joints, kidneys, brain, and other organs. It is important to take history and perform a thorough examination of these patients combined with necessary labs and radiological tests.[7] 

Evaluation

Clinical suspicion in patients with risk factors related to MRSA infection is crucial in diagnostic and therapeutic intervention. Confirmation of MRSA infection should not delay treatment with empiric antibiotics against MRSA. Clinicians should send samples from suspected sources of infection for analysis including blood, sputum, urine, or wound scraping.[8][9][10]

A positive Gram stain with cocci in clusters is suggestive of S. aureus. DNA polymerase chain reaction (PCR) of MRSA is the most sensitive test and gold standard test if cultures are inconclusive.

DNA PCR of MRSA from nares is a frequently employed diagnostic test to rule out MRSA colonization. It is not a confirmatory test of MRSA infection, but a negative test is highly sensitive to rule out MRSA infection.

Sputum cultures are not very specific or sensitive to diagnose MRSA pneumonia, therefore bronchoalveolar lavage or a deep tracheal aspirate for intubated or tracked patients can be performed to identify the organism in patients with HAP or VAP.

Treatment / Management

The selection of empiric antibiotic therapy for the treatment of MRSA infection depends on the type of disease, local S. aureus resistance patterns, availability of the drug, side effect profile, and individual patient profile.[11][12][13]

SSTIs: For most uncomplicated SSTIs suspected of MRSA infection, empirical treatment is with oral antibiotics like trimethoprim/sulfamethoxazole, tetracyclines, such as doxycycline or minocycline, and clindamycin. Higher doses of trimethoprim/sulfamethoxazole (160/800mg, one tablet three times daily or 2 tablets twice daily in adults) is recommended for MRSA in patients with normal renal function. Newer agents, such as linezolid and tedizolid, and delafloxacin also can be used as alternative oral regimens if available and deemed cost-effective.

Parenteral antibiotics are indicated for invasive SSTIs or with signs of systemic involvement, inadequate response to oral therapy, or if an SSTI occurs adjacent to an indwelling device.

Intravenous vancomycin is the drug of choice for most MRSA infections seen in hospitalized patients. It can be used both as empiric and definitive therapy as most MRSA infections are susceptible to vancomycin. There are sporadic cases of vancomycin-resistant MRSA. The dosage depends upon the type and severity of the infection. Vancomycin trough is obtained just before the fourth dose to ascertain a therapeutic level. The goal trough range typically is between 10 and 20 micrograms/mL. For complicated infections, the goal is between 15 and 20 micrograms/mL. The dose should be adjusted based on trough levels in the serum and according to renal function.

Daptomycin is a suitable parenteral alternative when vancomycin is not available or not being tolerated. Other short-acting options include ceftaroline and telavancin. Long-acting treatment options include dalbavancin and oritavancin. Regardless of the initial empiric antibiotic choice, subsequent therapy should be tailored based on the careful review of culture and susceptibility data.

The duration of therapy for treatment of MRSA SSTIs may range from 5 to 14 days depending on the extent of infection and response to treatment.

Bacteremia: Source control is a significant part of the treatment for MRSA bacteremia along with empiric MRSA coverage until the susceptibility results are available.[14][15]

Vancomycin and daptomycin are considered adequate empiric therapy according to the Infectious Diseases Society of America guidelines of 2011. MRSA isolates in the bloodstream with vancomycin MIC greater than or equal to 2 micrograms/mL may not respond adequately to vancomycin. Therefore, in these cases, daptomycin is a better option. If either vancomycin or daptomycin could not be used secondary to allergy, toxicity or resistance, telavancin and ceftaroline are also used as alternative antibiotics for treatment of bacteremia. In difficult to treat cases, a combination of parenteral antibiotic drug regimen have also been used, such as the following: daptomycin plus ceftaroline, vancomycin plus ceftaroline, daptomycin plus trimethoprim-sulfamethoxazole, ceftaroline plus trimethoprim-sulfamethoxazole.

Teicoplanin is a bacteriostatic glycopeptide with a similar spectrum of activity and efficacy as vancomycin and is better tolerated than vancomycin. However, it is used less commonly due to its limited availability. Teicoplanin is not FDA approved and is not available in the USA. There is no role for the use of linezolid, quinupristin-dalfopristin, tigecycline, or fluoroquinolones for treatment of S. aureus bacteremia. Linezolid has been found to be inferior compared to vancomycin in clinical trials. 

Follow-up cultures should be repeated to document clearance of the infection from the bloodstream. Persistent, positive cultures after 48 hours of treatment should prompt further evaluation related to drug susceptibility and source control.

Endocarditis: The 2015 American Heart Association (AHA) guidelines recommend intravenous vancomycin as the first line treatment for endocarditis. For patients who cannot tolerate vancomycin, intravenous daptomycin should be used. Recommended duration of treatment for native valve endocarditis is six weeks. Prosthetic valve endocarditis secondary to MRSA should be treated with intravenous vancomycin and rifampin for 6 weeks and gentamicin should be given in the first 2 weeks of therapy. However, there is no evidence of additional benefit of combining rifampin or gentamicin with vancomycin or daptomycin for native valve endocarditis. Telavancin, ceftaroline and quinupristin-dalfopritin have been used successfully as a salvage therapy in select group of patients. Clindamycin or linezolid should not be used to treat endocarditis because of their poor outcome compared to cell wall active agents such as vancomycin and daptomycin.[7]     

Consultations

Infectious Disease specialists should be consulted when managing serious MRSA infections such as endocarditis and bone and joint infections.

For MRSA with reduced susceptibility to vancomycin (VISA or VRSA), in addition to obtaining Infectious Disease consultation, hospital infection control should also be alerted.   

Pearls and Other Issues

Prevention and control of MRSA infections include necessary infection-control steps like strict hand hygiene and adequate contact precautions. Hand hygiene means washing hands with soap and water or an alcohol-based cleanser before and after contact with patients who have MRSA infection. Contact precautions include the use of gowns, gloves, and possibly masks during clinical encounters with patients with MRSA infection. Infection control also may include keeping patients in isolated rooms or the same rooms of other patients who have an MRSA infection.

Other measures include active surveillance to screen for MRSA colonization by testing for PCR MRSA or cultures of nares, oropharynx, or perineum. If found positive, contact precautions can be instituted for these patients to prevent transmission of MRSA as colonization is considered to be a significant risk factor for MRSA infection.

Enhancing Healthcare Team Outcomes

The key to managing MRSA infections is to prevent them in the first place. Over the years many guidelines have been issued, and most hospitals have a team of infectious disease experts who perform surveillance and monitor for outbreaks of MRSA. Besides the standard precautions, the CDC recommends contact precautions. The patient should be in an isolated room if available; everyone should gown and glove when coming into contact with the patient.  The transport of MRSA patients should be minimized and dedicated medicated equipment should be used on them. Further, environmental measures like cleaning and disinfecting the room are important. In addition, the hospital must have a surveillance policy, when to remove a patient from isolation and report the infection to the state. Many states now make it mandatory to report all new MRSA cases. Finally, there should be a hospital committee that oversees the prescription of antibiotics and their indications and who can prescribe them. [16][17](Level V)

Outcomes

The majority of data indicate that MRSA increases mortality and morbidity in seniors, nursing home patients and those with organ dysfunction. Individuals with end-stage liver disease, renal insufficiency and those admitted to the ICU have high mortality rates when there is an associated MRSA infection. The mortality rates vary from 5-60%, depending on the patient population and site of infection. More important, more patients with MRSA are now undergoing surgery, and in at least 40% of patients, a central line was the cause of the infection. Finally, about 60% of patients do acquire MRSA within 48 hours despite having no healthcare risks. [2][12][18](Level V)


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Methicillin Resistant Staphylococcus Aureus (MRSA) - Questions

Take a quiz of the questions on this article.

Take Quiz
A 71 year old is admitted to the hospital and found to have MRSA pneumonia. He is unable to receive vancomycin because of allergy. What is the best drug for him?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the drug of choice for the treatment of methicillin-resistant staphylococcus aureus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the mechanism of resistance seen in methicillin-resistant Staphylococcus aureus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What drug can be used to treat an ICU patient with MRSA when there is no vancomycin available?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A healthy adult male develops cellulitis of his leg. A Gram stain shows gram-positive cocci in clusters. Which of the following is true?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
For adults, what is the best drug for treating healthcare-associated methicillin-resistant Staphylococcus aureus bacteremia?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 37-year-old patient who lives at home develops methicillin-resistant Staphylococcus aureus, nonpurulent cellulitis. Which of the following is an appropriate treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which is NOT a risk factor for MRSA infection?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
An otherwise healthy female develops cellulitis of her arm. The gram stain reveals gram-positive cocci in clusters. What is the next best step in her treatment?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is necessary in the transfer of drug resistance to methicillin between S. aureus organisms?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Select the correct statement about methicillin-resistant S. aureus (MRSA).



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What should be used to treat osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA)?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient in the ICU has developed MRSA. It is decided to treat the patient, but there is no vancomycin available. Which of the following may be effective?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A patient has methicillin-resistant Staphylococcus aureus (MRSA). Select the correct statement.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is the drug of choice for treatment of serious methicillin-resistant Staphylococcus aureus?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents to his clinician with red, painful pustules on his back. These started developing 2 days ago and have increased in number and size. On lab evaluation, it is found to be caused by a gram-positive, catalase positive, and coagulase positive bacteria that grow in clusters. A course of penicillin is started but there is no change in symptoms. What is the mechanism by which this bacteria acquires resistance?

(Move Mouse on Image to Enlarge)
  • Image 428 Not availableImage 428 Not available
    Contributed by Scott Jones, MD
Attributed To: Contributed by Scott Jones, MD



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A client is seen in the emergency department for a methicillin-resistant Staphylococcus aureus skin abscess. The abscess is incised and drained, appropriately dressed, and the client is prescribed antibiotics. Which of the following is appropriate when providing the client with discharge instructions? Select all that apply.



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Methicillin Resistant Staphylococcus Aureus (MRSA) - References

References

Xiao G,Chen Z,Lv X, Chlorhexidine-based body washing for colonization and infection of methicillin-resistant {i}Staphylococcus aureus{/i} and vancomycin-resistant {i}Enterococcus{/i}: an updated meta-analysis. Infection and drug resistance. 2018     [PubMed]
Khan TM,Kok YL,Bukhsh A,Lee LH,Chan KG,Goh BH, Incidence of methicillin resistant {i}Staphylococcus aureus{/i} (MRSA) in burn intensive care unit: a systematic review. Germs. 2018 Sep     [PubMed]
Lakhundi S,Zhang K, Methicillin-Resistant Staphylococcus aureus: Molecular Characterization, Evolution, and Epidemiology. Clinical microbiology reviews. 2018 Oct     [PubMed]
Sabbagh P,Riahi SM,Gamble HR,Rostami A, The global and regional prevalence, burden, and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV-infected people: A systematic review and meta-analysis. American journal of infection control. 2018 Aug 28     [PubMed]
Miao J,Wang W,Xu W,Su J,Li L,Li B,Zhang X,Xu Z, The fingerprint mapping and genotyping systems application on methicillin-resistant Staphylococcus aureus. Microbial pathogenesis. 2018 Sep 19     [PubMed]
Shahkarami F,Rashki A,Rashki Ghalehnoo Z, Microbial Susceptibility and Plasmid Profiles of Methicillin-Resistant Staphylococcus aureus and Methicillin-Susceptible S. aureus. Jundishapur journal of microbiology. 2014 Jul     [PubMed]
Lee J,Austin JM,Kim J,Miralles PD,Kaafarani HMA,Pronovost PJ,Ghimire V,Berenholtz SM,Donelan K,Martinez E, Developing and Testing a Chart Abstraction Tool for ICU Quality Measurement. American journal of medical quality : the official journal of the American College of Medical Quality. 2018 Sep 28     [PubMed]
Ko JH,Moon SM, Evaluation of Methicillin-Resistance Rates among Community-associated {i}Staphylococcus aureus{/i} Infections in Korean Military Personnel. Journal of Korean medical science. 2018 Sep 24     [PubMed]
Clebak KT,Malone MA, Skin Infections. Primary care. 2018 Sep     [PubMed]
Huang DB,Magnet S,De Angelis S,Holland TL,File TM Jr,Dryden M,Corey GR,Torres A,Wilcox MH, Surveillance of iclaprim activity: in vitro susceptibility of Gram-positive skin infection pathogens collected from 2015 to 2016 from North America and Europe. Diagnostic microbiology and infectious disease. 2018 Sep 10     [PubMed]
Kavanagh KT,Abusalem S,Calderon LE, View point: gaps in the current guidelines for the prevention of Methicillin-resistant {i}Staphylococcus aureus{/i} surgical site infections. Antimicrobial resistance and infection control. 2018     [PubMed]
Lewis PO,Heil EL,Covert KL,Cluck DB, Treatment strategies for persistent methicillin-resistant Staphylococcus aureus bacteraemia. Journal of clinical pharmacy and therapeutics. 2018 Oct     [PubMed]
Eisenschenk M, A concern with the clinical consensus guidelines on meticillin-resistant staphylococci. Veterinary dermatology. 2018 Apr     [PubMed]
Sirijatuphat R,Sripanidkulchai K,Boonyasiri A,Rattanaumpawan P,Supapueng O,Kiratisin P,Thamlikitkul V, Implementation of global antimicrobial resistance surveillance system (GLASS) in patients with bacteremia. PloS one. 2018     [PubMed]
Remschmidt C,Schneider S,Meyer E,Schroeren-Boersch B,Gastmeier P,Schwab F, Surveillance of Antibiotic Use and Resistance in Intensive Care Units (SARI). Deutsches Arzteblatt international. 2017 Dec 15     [PubMed]
Zayyad H,Eliakim-Raz N,Leibovici L,Paul M, Revival of old antibiotics: needs, the state of evidence and expectations. International journal of antimicrobial agents. 2017 May     [PubMed]
Kengen R,Thoonen E,Daveson K,Loong B,Rodgers H,Beckingham W,Kennedy K,Suwandarathne R,van Haren F, Chlorhexidine washing in intensive care does not reduce bloodstream infections, blood culture contamination and drug-resistant microorganism acquisition: an interrupted time series analysis. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 2018 Sep     [PubMed]
Baddour LM,Wilson WR,Bayer AS,Fowler VG Jr,Tleyjeh IM,Rybak MJ,Barsic B,Lockhart PB,Gewitz MH,Levison ME,Bolger AF,Steckelberg JM,Baltimore RS,Fink AM,O'Gara P,Taubert KA, Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015 Oct 13     [PubMed]
Elward AM,McAndrews JM,Young VL, Methicillin-sensitive and methicillin-resistant Staphylococcus aureus: preventing surgical site infections following plastic surgery. Aesthetic surgery journal. 2009 May-Jun;     [PubMed]
National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 through June 2004, issued October 2004. American journal of infection control. 2004 Dec;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Corrections (CCN). The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Corrections (CCN), it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Corrections (CCN), you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Corrections (CCN). When it is time for the Nurse-Corrections (CCN) board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Corrections (CCN).