The Top 10 Things ID Specialists Wish Every Hospitalist Knew

10. Community-acquired MRSA is on the rise.

In the last 5 years in the United States, there has been a steady increase in MRSA infections in patients without traditional risk factors (9,10). Historically, clinicians have been concerned about MRSA in nursing home patients, patients in other long-term care facilities, injection drug users, and hospitalized patients. In the last 5 years there have been increasing numbers of patients with MRSA with none of these risk factors. Often these patients present with a serious life-threatening S. aureus infection. It is now appropriate to give vancomycin empirically for patients who have serious illnesses due to suspected S. aureus even if they don’t have traditional risk factors for MRSA. As ID practitioners, we do not want to encourage overuse of vancomycin, and clinicians should quickly switch to other agents if the patient proves not to be infected with MRSA. While vancomycin is a useful drug, it is considered inferior to the beta-lactams for many infections, such as bone or joint infections, and should only be used in patients with documented or suspected MRSA, or patients intolerant of beta-lactams. Several new drugs provide alternatives to vancomycin for MRSA, including linezolid and daptomycin. Both of these agents are more expensive and have not proven in clinical trials to be superior (with the possible exception of linezolid for MRSA pneumonia). Linezolid offers the advantage of having excellent oral availability; however, oral linezolid use is complicated by its high cost. Oral linezolid costs approximately $100 a day, and in almost all cases the use of this drug must be preapproved before an insurance company will pay for it. Insurance companies will almost always approve oral linezolid if the only alternative is continued hospitalization, skilled nursing home placement, or home IV antibiotic therapy. Trimethoprim/sulfa is a much less expensive alternative to oral linezolid for MRSA, and is very useful for less serious MRSA infections such as UTIs. About 85% of MRSA strains are sensitive to trimethoprim/sulfa. Many community-acquired MRSA strains are clindamycin susceptible, and minocycline and doxycycline have activity against many MRSA strains.

So these are 10 things ID physicians wish all hospitalists knew. The 11th is that we enjoy working with our hospitalist colleagues, so please call when you think you need us.

Dr. Armitage may be reached at [email protected].

References

1. Young M. Plosker GL. Piperacillin/tazobactam: a pharmacoeconomic review of its use in moderate to severe bacterial infections. Pharmacoeconomics. 2001;19:1135-75.
2. Fowler VG Jr., Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia according to compliance with recommendations of infectious diseases specialists: experience with 244 patients. Clinical Infect Dis. 1998;27:478-86.
3. Pepin J, Valiquette L, Alary ME, et al. Clostridium difficile-associated diarrhea in a region of Quebec 1991 to 2003: a changing pattern of disease severity. CMAJ. 2004:171:466-72.
4. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea [see comment]. N Engl J Med. 2002;346:334-9.
5. Chitkara YK, McCasland KA, Kenefic L. Development and implementation of cost-effective guidelines in the laboratory investigation of diarrhea in a community hospital. Arch Intern Med. 1996;156:1445-8.
6. Bulusu M, Narayan S, Shetler K, Triadafilopoulos G. Leukocytosis as a harbinger and surrogate marker of Clostridium difficile infection in hospitalized patients with diarrhea. Am J Gastroenterol. 2000;95:3137-41.
7. Neuhauser MM, Weinstein RA, Rydman R; Danziger LH, Karam G, Quinn JP. Antibiotic resistance among gramnegative bacilli in US intensive care units: implications for fluoroquinolone use. JAMA. 2003;289:885-8.
8. Cizman M. The use and resistance to antibiotics in the community. Int J Antimicrob Agents. 2003;21:297-307.
9. Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J. Comparison of community- and health care–associated methicillin-resistant Staphylococcus aureus infection JAMA. 2003;290:2976-84.
10. Chambers HF. Community-associated MRSA—resistance and virulence converge. N Engl J Med. 2005;352:1485-7.