Managing skin and soft-tissue infection and nosocomial pneumonia caused by MRSA: a 2014 follow-up survey

Abstract

As a follow-up to our 2009 survey, in order to explore opinion and practice on the epidemiology and management of meticillin-resistant Staphylococcus aureus (MRSA) in Europe, we conducted a second survey to elicit current opinions on this topic, particularly around antibiotic choice, dose, duration and route of administration. We also aimed to further understand how the management of MRSA has evolved in Europe during the past 5 years. Members of an expert panel of infectious diseases specialists convened in London (UK) in January 2014 to identify and discuss key issues in the management of MRSA. Following this meeting, a survey was developed comprising 36 questions covering a wide range of topics on MRSA complicated skin and soft-tissue infection and nosocomial pneumonia management. The survey instrument, a web-based questionnaire, was sent to the International Society of Chemotherapy for distribution to registered European infection societies and their members. This article reports the survey results from the European respondents. At the time of the original survey, the epidemiology of MRSA varied significantly across Europe and there were differing views on best practice. The current findings suggest that the epidemiology of healthcare-associated MRSA in Europe is, if anything, even more polarised, whilst community-acquired MRSA has become much more common. However, there now appears to be a much greater knowledge of current treatment/management options, and antimicrobial stewardship has moved forward considerably in the 5 years since the last survey.

Introduction

In 2009, we surveyed European physicians about their opinions and practice on the epidemiology and management of meticillin-resistant Staphylococcus aureus (MRSA) infections [1]. The epidemiology of MRSA varied significantly across Europe at that time and there were differing views on treatment and the role of the limited novel antibiotics, namely linezolid, tigecycline and daptomycin.

Five years ago, the incidence of healthcare-associated MRSA (HA-MRSA) was very high; however, there was evidence to suggest that the epidemiology of HA-MRSA was changing [2]. At that time, community-acquired MRSA (CA-MRSA) was very rare in Europe, unlike in North America where it was the most common cause of community-acquired skin and soft-tissue infection [3, 4, 5]. Following the dramatic rise in community-acquired cases across North America, there was concern that Europe might experience the same phenomenon. If this did occur, the survey respondents felt that there would be a considerable shift in community antibiotic use in Europe.

Today, the epidemiology of HA-MRSA in Europe is, if anything, even more polarised, with significant reductions in HA-MRSA in some European countries [6] and persisting high levels of HA-MRSA in others [7]. The incidence is also directly proportional to the volume of antibiotic usage across the continent [8], providing potent support for the development of effective pan-European antimicrobial stewardship programmes.

Although CA-MRSA played only a minor role in Europe 5 years ago, it has become more common, as originally feared [9]. Many strains may persist and cause recurrent infection, as well as being highly pathogenic by virtue of eliciting the Panton–Valentine leukocidin (PVL) cytotoxin. These strains may exhibit some interesting and challenging epidemiology, with some strains emerging in livestock [10] and others dispersing widely around the world.

Treatment of MRSA has largely focused on the use of glycopeptides, with many older antibiotics, such as doxycycline, trimethoprim/sulfamethoxazole (SXT), clindamycin, fusidic acid and rifampicin being used for outpatients and those with minor infections. However, there is now a wealth of knowledge regarding the use of linezolid [7] and daptomycin in MRSA [11], whilst our knowledge of tigecycline is gradually increasing [12, 13, 14, 15], and many other novel antibiotics will soon become available or are currently under development, i.e. ceftaroline, tedizolid, dalbavancin and oritavancin.

The objectives of this survey were: (i) to explore current opinion and practice on MRSA complicated skin and soft-tissue infections (cSSTIs) and MRSA nosocomial pneumonia (NP) in Europe and, where possible, to compare the results with the findings of the survey 5 years ago; (ii) to review current physician opinion on practical and controversial questions around antibiotic choice, dose, duration and route of administration; (iii) to try and understand any developments and evolution in the management of MRSA infections in Europe over the past 5 years; and (iv) to support antibiotic stewardship.