question and answer
How to decolonize MRSA
June 2009

I have a patient who suffers repeat episodes (every 1-2 months) of multiple boils and folliculitis. Recent swabs came back growing methicillin-resistant Staph aureus. This man is in his 30s and active in the community. Should I continue to manage each infection with incision, drainage and antibiotics or should I attempt to decolonize him with trimethoprim-sulfamethoxazole, rifampin and fucidic acid or some other regime?
RON CURTIS, MD, Newmarket, ON

Approximately 1/3 of people will be chronic asymptomatic carriers of Staphylococcus aureus (either methicillin-resistant or methicillin-sensitive) in the nares and skin and this may then serve as a source for clinical infections. In patients with recurrent skin infections due to S. aureus, clearance of the carrier state may reduce the incidence of infections. Clearance of the carrier state is usually successful at least in the short term in otherwise healthy people, although it will often recur. Decolonizing patients with multiple co-morbid illnesses and those with chronic wounds is rarely successful. A regimen of intranasal mupirocin ointment applied twice daily and showering with chlorhexidine 1% for 10 days is usually effective. If unsuccessful or in higher risk patients, systemic therapy can be added to this regimen and usually consists of either trimethoprim-sulfamethoxazole (MRSA) or cloxacillin (MSSA) plus rifampin for 10 days. Environmental decontamination of the home and decolonization of family contacts will help to minimize the risk of re-colonization with MRSA.
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