{"id":1312,"date":"2013-05-01T16:21:36","date_gmt":"2013-05-01T16:21:36","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1312"},"modified":"2022-02-17T19:08:27","modified_gmt":"2022-02-17T19:08:27","slug":"methicillin-resistant-staphylococcal-infections-recent-developments","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/clinical-pathology\/methicillin-resistant-staphylococcal-infections-recent-developments\/","title":{"rendered":"Methicillin-Resistant Staphylococcal Infections: Recent Developments"},"content":{"rendered":"<p class=\"p1\"><em><span class=\"s1\">Christine L. Cain, DVM, Diplomate ACVD<\/span><\/em><\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\">The increasing prevalence of staphylococcal antimicrobial resistance, particularly methicillin resistance, presents a challenge to veterinary practitioners treating clinical infections. Failure to recognize staphylococcal antimicrobial resistance frequently results in ineffective empiric therapeutic choices and protracted clinical disease. In addition, concern is developing regarding potential transmission of antimicrobial-resistant strains from humans to animals and vice versa.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\">METHICILLIN RESISTANCE<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Methicillin-resistant staphylococci possess the <b><i>mecA<\/i><\/b> <b>gene<\/b>, carried on the mobile genetic element <b>staphylococcal chromosome cassette<\/b> <b><i>mec<\/i><\/b> (SCCmec), which encodes for an altered <b>penicillin-binding protein<\/b> (PBP2a).<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Production of this low-affinity, penicillin-binding protein renders resistance to virtually all beta-lactam derivatives, including:<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">Carbapenems (eg, imipenem, meropenem)<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Cephalosporins (eg, cephalexin, cefpodoxime, cefovecin)<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Penicillins (eg, penicillin, amoxicillin)<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Potentiated penicillins (eg, amoxicillin and clavulanic acid).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Although references to methicillin resistance are commonplace in the medical literature, oxacillin is often used by veterinary microbiology laboratories as the correlate for testing antimicrobial resistance. Both methicillin and oxacillin are semisynthetic penicillinase-resistant penicillins, but oxacillin is more stable <i>in vitro<\/i>.<\/span><span class=\"s2\"><sup>2,3<\/sup><\/span><span class=\"s1\"> Cefoxitin susceptibility testing is also used by human microbiology laboratories to screen for methicillin resistance in <i>Staphylococcus aureus<\/i> isolates, but may not reliably detect methicillin resistance in <i>S pseudintermedius<\/i>.<\/span><span class=\"s2\"><sup>2<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">More recently, a <b><i>mecA<\/i><\/b> homologue\u2014<b><i>mecC<\/i><\/b>\u2014has been identified in some European staphylococcal isolates from humans and animals that exhibit methicillin resistance but lack the <b><i>mecA<\/i><\/b> gene.<\/span><span class=\"s2\"><sup>4-6<\/sup><\/span><span class=\"s1\"> The prevalence of this gene in staphylococci is currently unknown.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\">MULTIDRUG RESISTANCE<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Although methicillin-resistant staphylococci are not necessarily more virulent than methicillin-susceptible staphylococci,<\/span><span class=\"s2\"><sup>7<\/sup><\/span><span class=\"s1\"> treatment options are often severely limited by multidrug resistance. This is particularly true for infections caused by methicillin-resistant <i>S pseudintermedius<\/i> (MRSP); MRSP isolates are increasingly multidrug resistant.<\/span><span class=\"s2\"><sup>2,8-11<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Resistance to non\u2013beta-lactam antimicrobials is common and conveyed by genetic mechanisms other than the <i>mecA<\/i> gene;<\/span><span class=\"s2\"><sup>2,8-11<\/sup><\/span><span class=\"s1\"> these antimicrobials include:<\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">Fluoroquinolones <\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Lincosamides<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Macrolides<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Potentiated sulfonamides<\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">Tetracyclines.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Due to the prevalence of multidrug resistance in methicillin-resistant strains, empirical switching of antimicrobial classes when treating staphylococcal infections that fail to respond to first-line antimicrobials (particularly beta-lactams) is NOT recommended. <b>Treatment choices should be based on culture and susceptibility testing.<\/b><\/span><\/p>\n<div class=\"orange-box\">\n<h2 class=\"p3\"><span class=\"s1\">METHICILLIN-RESISTANT STAPHYLOCOCCI<\/span><\/h2>\n<h3 class=\"p4\"><span class=\"s1\"><b><i>Staphylococcus pseudintermedius<\/i><\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><i>S pseudintermedius<\/i> colonizes the skin and mucosa of healthy dogs and is the most common cause of canine pyoderma.<\/span><span class=\"s2\"><sup>12<\/sup><\/span><span class=\"s1\"> MRSP has been recognized as a cause of pyoderma, surgical site infections (particularly following orthopedic procedures), and urinary tract infections, among others.<\/span><span class=\"s2\"><sup>9,13<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Classification<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Investigators have recently used molecular techniques to classify 3 closely related staphylococcal species\u2014<i>S intermedius<\/i>, <i>S pseudintermedius<\/i>, and <em>S<\/em><i> delphini<\/i>\u2014as the <i>S intermedius<\/i> group. It appears correct to assume that all previously classified <i>S intermedius<\/i> isolates from dogs, cats, and humans were actually <i>S pseudintermedius<\/i> isolates.<\/span><span class=\"s2\"><sup>12-15<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Prevalence<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The prevalence of MRSP infections in veterinary patients has increased substantially over the past decade. Although reported sporadically in the 1990s.<\/span><span class=\"s2\"><sup>16,17<\/sup><\/span><span class=\"s1\"> MRSP infections are now commonly reported in the veterinary literature and increasingly isolated by veterinary microbiology laboratories.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Colonization<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">MRSP has also been isolated from carriage sites (skin and mucous membranes, including nares, oral mucosa, and rectal mucosa) of healthy dogs and cats.<\/span><span class=\"s2\"><sup>17,18<\/sup><\/span><span class=\"s1\"> Several studies support a carriage rate of:<\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\">1.5% to 3% in healthy dogs<\/span><span class=\"s2\"><sup>19-21<\/sup><\/span><\/li>\n<li class=\"p1\"><span class=\"s1\">0% to 4% in healthy cats.<\/span><span class=\"s2\"><sup>18,22<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Overall, the literature suggests that MRSP isolation rates from clinical specimens may significantly exceed the prevalence of MRSP colonization in healthy animals, although prevalence may vary by sampled population and geographic area.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b><i>Staphylococcus schleiferi<\/i><\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><i>S schleiferi<\/i> is an emerging cause of infections in veterinary patients.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Classification<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Two variants have been described based on coagulase production: <\/span><\/p>\n<ul>\n<li class=\"p1\"><span class=\"s1\"><i>S schleiferi<\/i> subspecies <i>schleiferi<\/i> (coagulase negative) <\/span><\/li>\n<li class=\"p1\"><span class=\"s1\"><i>S schleiferi<\/i> subspecies <i>coagulans<\/i> (coagulase positive). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Recent studies suggest the 2 subspecies are not distinct by genotype or clinical behavior; therefore, both should be considered important pathogens.<\/span><span class=\"s2\"><sup>23,24<\/sup><\/span><span class=\"s1\"> Coagulase-positive and coagulase-negative <i>S schleiferi<\/i> are associated with pyoderma (especially recurrent pyoderma) and otitis in dogs with allergic dermatitis, although infections of other body sites in nonallergic dogs have also been reported.<\/span><span class=\"s2\"><sup>24<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Prevalence<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Methicillin resistance is particularly prevalent in clinical isolates of <i>S schleiferi<\/i>, with reported rates often exceeding 50%.<\/span><span class=\"s2\"><sup>1,22-26<\/sup><\/span><span class=\"s1\"> Fluoroquinolone resistance is also common in methicillin-resistant <i>S schleiferi<\/i> (MRSS) isolates.<\/span><span class=\"s2\"><sup>9,23,24,27-29<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">MRSS has been isolated from:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Dogs and cats with inflammatory skin disease<\/span><span class=\"s2\"><sup>18-20,30-32<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Carriage sites (skin or mucosal) of healthy dogs and cats.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b><i>Staphylococcus aureus<\/i><\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Human Prevalence<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><i>S aureus<\/i> colonizes approximately 30% of the human population worldwide and is a major cause of skin and soft tissue infections in humans.<\/span><span class=\"s2\"><sup>33<\/sup><\/span><span class=\"s1\"> The number of human infections caused by methicillin-resistant <i>S aureus<\/i> (MRSA) has increased dramatically since the 1960s.<\/span><span class=\"s2\"><sup>34<\/sup><\/span><span class=\"s1\"> While human MRSA infections were once primarily nosocomial, community-associated MRSA infections of healthy individuals are being diagnosed more frequently.<\/span><span class=\"s2\"><sup>34,35<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Veterinary Prevalence<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">MRSA infections have also been reported in a variety of companion and exotic animal species.<\/span><span class=\"s2\"><sup>9,36-41<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">In dogs, prevalence of <em>S aureus<\/em> colonization appears to be substantially lower than that of <i>S pseudintermedius<\/i>.<\/span><span class=\"s2\"><sup>42<\/sup><\/span><span class=\"s1\"> In addition, <em>S aureus<\/em> infections are far less common than <i>S pseudintermedius<\/i> infections.<\/span><span class=\"s2\"><sup>9<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In cats, reports conflict as to whether <i>S pseudintermedius<\/i> or S aureus is the primary colonizing coagulase-positive staphylococcal species.<\/span><span class=\"s2\"><sup>43-46<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Healthy dogs and cats may be colonized by MRSA, although this colonization is likely transient.<\/span><span class=\"s2\"><sup>47,48<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">As is the case with MRSP, MRSA isolates are often resistant to non\u2013beta-lactam antibiotics, especially:<\/span><span class=\"s2\"><sup>9<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Fluoroquinolones <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Lincosamides<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Macrolides.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><b>Zoonotic Potential<\/b><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">MRSA infections in companion and exotic animals are often associated with human hospital- or community-acquired clonal strains, suggesting, but not proving, human-to-animal transmission.<\/span><span class=\"s2\"><sup>38,39,49<\/sup><\/span><span class=\"s1\"> Although the possibility of MRSA transmission from colonized or infected humans to animals, or vice versa, has frequently been suggested, the true direction of transmission is difficult to prove.<\/span><span class=\"s2\"><sup>30,49,50<\/sup><\/span><span class=\"s1\"> While human-to-animal transmission is usually assumed, the infected or colonized human in the household may not be identified as the MRSA source for the pet.<\/span><span class=\"s2\"><sup>48<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Coagulase-Negative Staphylococci<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">The clinical importance of coagulase-negative staphylococci (CoNS), other than the coagulase-negative variant of <i>S schleiferi<\/i>, has not been well elucidated in veterinary patients. Historically, CoNS were considered commensal organisms or contaminants with limited pathogenic potential; however, they are becoming more frequently associated with nosocomial infections in humans.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">CoNS are frequently methicillin resistant and may produce a number of virulence factors.<\/span><span class=\"s2\"><sup>51,52<\/sup><\/span><span class=\"s1\"> When CoNS are isolated from clinical specimens, practitioners are encouraged to interpret results in light of culture technique: CoNS isolated from culture samples of closed sites, such as intact pustules or joints, are more likely to be true pathogens than those obtained by swabbing the skin&#8217;s surface.<\/span><\/p>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\">RISK FACTORS<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\"><strong>Recent antimicrobial exposure appears to be the most critical risk factor for acquisition of methicillin-resistant staphylococci<\/strong>.<\/span><span class=\"s2\"><sup>13<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">In a recent prospective study, Beck and colleagues demonstrated that, following antimicrobial therapy, isolation of MRSP from the skin and mucosal sites of dogs with pyoderma caused by methicillin-susceptible <i>S pseudintermedius<\/i> (MSSP) is common.<\/span><span class=\"s2\"><sup>13<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Similarly, in a large retrospective study, recent administration of beta-lactam antimicrobials was found to be a risk factor for dogs with MRSS clinical isolates.<\/span><span class=\"s2\"><sup>24<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Recent administration of beta-lactams or fluoroquinolones is a risk factor for MRSA infection in dogs and cats.<\/span><span class=\"s2\"><sup>37,53<\/sup><\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Additional risk factors for MRSA infection include:<\/span><span class=\"s2\"><sup>37,53<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Contact with ill or hospitalized human <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Intravenous catheterization<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Multiple antimicrobial courses<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Prolonged hospitalization<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Surgical implants.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">It is likely that alteration of commensal staphylococcal flora by systemic antimicrobial treatment, particularly beta-lactam antibiotics, allows for subsequent colonization by methicillin-resistant strains. With the increasing prevalence of antimicrobial resistant strains, practitioners are encouraged to consider the potential for infection associated with methicillin-resistant staphylococci even in the absence of risk factors, such as recent antimicrobial administration or hospitalization.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\">CULTURE &amp; SUSCEPTIBILITY<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Given the increasing prevalence of methicillin- and multidrug-resistant staphylococci, culture and susceptibility testing (<b>Figure 1<\/b>) is likely an underutilized tool, particularly in the management of pyoderma, urinary tract infections, wounds, and surgical site infections.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Clinical indications for performing culture and susceptibility testing include:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Clinical lesions consistent with deep pyoderma, such as furuncles, nodules, and draining tracts<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Any surgical site infection, particularly those associated with orthopedic procedures<\/span><span class=\"s2\"><sup>13,54<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Presence of a nonhealing wound<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Cytologic evidence of mixed or nonstaphylococcal infection (eg, intracellular bacterial rods)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">History of prior antimicrobial-resistant staphylococcal infection<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">History of recent antimicrobial therapy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Lack of response to appropriate empiric antimicrobial therapy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Recurrent or relapsing infection.<\/span><\/li>\n<\/ul>\n<div id=\"attachment_3163\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-1.jpg\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-3163\" class=\"wp-image-3163 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-1-300x200.jpg\" alt=\"Cain_figure 1\" width=\"300\" height=\"200\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-1-300x200.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-1.jpg 451w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3163\" class=\"wp-caption-text\">Figure 1. Collection of a sample for culture and susceptibility testing using a culturette swab; taken from a dog with superficial pyoderma.<\/p><\/div>\n<div class=\"orange-box\">\n<h2><span class=\"s1\">Inducible Resistance &amp; Clindamycin<\/span><\/h2>\n<ul class=\"ul1\">\n<li class=\"li1\"><b><\/b><span class=\"s5\"><b>Inducible resistance<\/b><\/span><span class=\"s1\">, in which the presence of an inducing agent, such as erythromycin, promotes expression of a resistant phenotype, has been reported in MRSA isolates from humans and animals and some MRSP isolates.<\/span><span class=\"s2\"><sup>56,57<\/sup><\/span><\/li>\n<li class=\"li1\"><b><\/b><span class=\"s5\"><b>Clindamycin<\/b><\/span><span class=\"s1\"> use in infections caused by isolates exhibiting inducible resistance may result in treatment failure.<\/span><span class=\"s2\"><sup>56,57<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Microbiology laboratories can test for <\/span><span class=\"s5\"><b>inducible clindamycin resistance<\/b><\/span><span class=\"s1\"> using a double disk diffusion test (D-test) with adjacent erythromycin and clindamycin disks (<b>Figure 2<\/b>). <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In the absence of this test, clinicians may predict inducible resistance based on susceptibility results, indicating <\/span><span class=\"s5\"><b>erythromycin resistance<\/b><\/span><span class=\"s1\"> and <\/span><span class=\"s5\"><b>clindamycin susceptibility<\/b><\/span><span class=\"s1\">.<\/span><span class=\"s2\"><sup>56<\/sup><\/span><\/li>\n<\/ul>\n<div id=\"attachment_3164\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-2.jpg\"><img decoding=\"async\" aria-describedby=\"caption-attachment-3164\" class=\"wp-image-3164 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-2-300x200.jpg\" alt=\"Cain_figure 2\" width=\"300\" height=\"200\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-2-300x200.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-2.jpg 451w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3164\" class=\"wp-caption-text\">Figure 2. Double disk diffusion test (D-test) for detection of inducible clindamycin resistance; note the D-shaped zone around the clindamycin disk (CC) due to its close proximity to the erythromycin disc (E) <em>Courtesy Dr. David A. Bemis, University of Tennessee Veterinary Bacteriology Laboratory<\/em><\/p><\/div>\n<\/div>\n<h2><span class=\"s1\">EMPIRIC THERAPY<\/span><\/h2>\n<p class=\"p3\"><span class=\"s1\">Despite the importance of culture and susceptibility testing in management of staphylococcal infections, empiric antimicrobial therapy remains common practice for first-time infections or treatment-na\u00efve patients, especially patients with pyoderma.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Beta-lactam derivatives, especially <b>cephalosporins<\/b>, are frequently considered first-line choices in treatment of pyoderma due to their bactericidal activity, tissue penetration, and low incidence of adverse effects.<\/span><span class=\"s2\"><sup>55<\/sup><\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Preferential selection of other antimicrobials, such as <b>macrolides, lincosamides, or potentiated sulfonamides<\/b>, as first-line therapies for staphylococcal infections has been suggested due to concerns regarding potential colonization with methicillin-resistant strains due to beta-lactam antimicrobial use.<\/span><span class=\"s2\"><sup>24<\/sup><\/span><span class=\"s1\"> Due to frequent resistance in methicillin-resistant strains, especially MRSP, practitioners should be aware for the potential of empiric failure with these antimicrobials; changes in therapy should be based on culture and susceptibility results. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Use of systemic <strong>fluoroquinolones<\/strong> for treatment of staphylococcal infections should be reserved for cases in which:<\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\"><em>In vitro<\/em> susceptibility is demonstrated<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">A fluoroquinolone is considered the most appropriate antimicrobial choice for the patient.<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Empiric use of fluoroquinolones is NOT recommended due to the potential for therapeutic failure if the infection is caused by methicillin-resistant strains, which frequently exhibit coresistance to fluoroquinolones.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Due to the connection between systemic antimicrobial therapy and acquisition of methicillin-resistant strains, topical antimicrobial or antiseptic therapy for the treatment of canine pyoderma, especially for first-time, mild, or localized infections, is recommended.<\/span><span class=\"s2\"><sup>31<\/sup><\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\">RESISTANT INFECTION THERAPY<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\"><b>Table 1<\/b> lists antimicrobial options and dosing regimens for methicillin-resistant staphylococcal pyoderma, based on culture and susceptibility.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.01.21-PM.png\"><img decoding=\"async\" class=\"wp-image-4294 size-full aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.01.21-PM-e1456521232580.png\" alt=\"Screen Shot 2015-06-04 at 3.01.21 PM\" width=\"312\" height=\"467\" \/><\/a><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\">Treatment Duration<\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Recommended treatment duration for methicillin-resistant staphylococcal infections does not necessarily exceed that recommended for methicillin-susceptible infections, which is the case, for example, for methicillin-susceptible staphylococcal pyoderma:<\/span><span class=\"s2\"><sup>58<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Superficial infections<\/strong> should be treated for a minimum of 3 to 4 weeks; then 1 week past clinical resolution<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Deep infections<\/strong> should be treated for a minimum of 6 to 8 weeks; then 2 weeks past clinical resolution.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Clinical resolution of MRSP-associated pyoderma may take longer than resolution of MSSP-associated pyoderma, but this is more likely due to empiric treatment failure, infection chronicity, or secondary pathologic changes to the skin rather than increased virulence of methicillin-resistant strains.<\/span><span class=\"s2\"><sup>59<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\">Systemic Therapy<\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Systemic antimicrobial options for treatment of methicillin- and multidrug-resistant staphylococcal infections are often limited to:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Aminoglycosides, particularly amikacin<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Chloramphenicol<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Rifampin. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">When prescribed for extended therapy, potential adverse effects of these medications must be considered (see <b>Table 2<\/b>).<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.01.34-PM.png\"><img loading=\"lazy\" decoding=\"async\" class=\"wp-image-4295 size-medium aligncenter\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Screen-Shot-2015-06-04-at-3.01.34-PM-e1456521328358-300x181.png\" alt=\"Screen Shot 2015-06-04 at 3.01.34 PM\" width=\"300\" height=\"181\" \/><\/a><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Despite good <i>in vitro<\/i> susceptibility,<\/span><span class=\"s2\"><sup>8<\/sup><\/span><span class=\"s1\"> administration of antimicrobials used in humans for serious MRSA infections, such as linezolid and vancomycin,<\/span><span class=\"s2\"><sup>60<\/sup><\/span><span class=\"s1\"> should be avoided in veterinary patients due to ethical concerns (these drugs are reserved for use in humans with MRSA infections); cost of these medications is also prohibitive.<\/span><span class=\"s2\"><sup>61,62<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\">Topical Therapy<\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Topical antimicrobial therapy for resistant staphylococcal infections has increased due to:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Limited options for systemic therapy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Potential for adverse drug effects <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Rise of multidrug resistance.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Topical therapy alone has been found to be effective for treatment of pyoderma associated with methicillin-resistant staphylococci (<b>Figures 3 and 4<\/b>).<\/span><span class=\"s2\"><sup>59<\/sup><\/span><span class=\"s1\"> Therapeutic options for sole or adjunctive therapy include:<\/span><span class=\"s2\"><sup>63<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Hypochlorous acid and sodium hypochlorite based products (including dilute bleach baths)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Mupirocin (2%) ointment<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Shampoos, conditioners, sprays, and wipes containing chlorhexidine (2%\u20134%), benzoyl peroxide, or ethyl lactate<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Wipes containing nisin, an antimicrobial protein.<\/span><\/li>\n<\/ul>\n<div id=\"attachment_3165\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-3.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3165\" class=\"wp-image-3165 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-3-300x199.jpg\" alt=\"Cain_figure 3\" width=\"300\" height=\"199\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-3-300x199.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-3.jpg 452w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3165\" class=\"wp-caption-text\">Figure 3. Superficial pyoderma in a dog; note the large epidermal collarettes and crusts on the ventral abdomen. Multi drug-resistant, methicillin-resistant S pseudintermedius was isolated on skin culture.<\/p><\/div>\n<p>&nbsp;<\/p>\n<div id=\"attachment_3166\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-4.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3166\" class=\"wp-image-3166 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-4-300x200.jpg\" alt=\"Cain_figure 4\" width=\"300\" height=\"200\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-4-300x200.jpg 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Cain_figure-4.jpg 451w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-3166\" class=\"wp-caption-text\">Figure 4. Same dog from Figure 3 after 4 weeks of twice weekly bathing with 4% chlorhexidine-based shampoo and daily treatment with 3% chlorhexidine-based spray; no systemic antimicrobial therapy was administered<\/p><\/div>\n<h2><span class=\"s1\">IN SUMMARY<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Methicillin- and multidrug-resistant staphylococcal infections are becoming increasingly common in veterinary patients.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Empiric antimicrobial selection<\/strong> is difficult and treatment failure is common. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Culture and susceptibility testing<\/strong> is indicated for management of staphylococcal infections, particularly canine pyoderma and surgical site infections. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Topical antimicrobial therapy<\/strong> may be useful for infection treatment and prevention in cases of limited systemic antimicrobial options or adverse drug effects. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Stri<span class=\"s1\">St<\/span>ct hygiene practices<\/strong> should be observed to limit bacterial transmission.<\/span><\/li>\n<\/ul>\n<div class=\"orange-box\">\n<h2 class=\"p3\"><span class=\"s1\">INFECTION PREVENTION<\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Strict hygiene practices are critical to limit transmission of methicillin-resistant staphylococci. Prudent hygiene practices include:<\/span><span class=\"s2\"><sup>7,48,64-67<\/sup><\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Barrier precautions, such as disposable gloves, when working with infected patients <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Covering open or draining wounds<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Frequent cleaning of dishes, washing of bedding, and environmental disinfection<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Regular hand washing, especially after handling infected patients and between patients<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Restricting infected pets from sleeping in bed with humans (or vice versa) and preventing pets from licking humans.<\/span><\/li>\n<\/ul>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\">To learn more about preventing spread of infection, read <\/span><a href=\"https:\/\/todaysveterinarypractice.com\/todays-technician-assisting-the-surgeon-practical-strategies-for-preventing-nosocomial-infections\/\"><span class=\"s5\">Practical Strategies for Preventing Nosocomial Infections<\/span><\/a><span class=\"s1\"> (March\/April 2013 issue of <i>Today&#8217;s Veterinary Practice<\/i>)<\/span><span class=\"s1\">.<\/span><\/p>\n<\/div>\n<p class=\"p1\"><span class=\"s1\">CoNS = coagulase-negative staphylococci; MRSA = methicillin-resistant <i>Staphylococcus aureus<\/i>; MRSP = methicillin-resistant <i>Staphylococcus pseudintermedius<\/i>; MRSS = methicillin-resistant <i>Staphylococcus<\/i> schleiferi; MSSP = methicillin-susceptible <i>Staphylococcus pseudintermedius<\/i><\/span><\/p>\n<p class=\"p5\"><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Christine-L.-Cain.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignleft size-full wp-image-9241\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/05\/Christine-L.-Cain.png\" alt=\"Christine L. Cain\" width=\"100\" height=\"112\" \/><\/a>Christine L. Cain<\/strong>, DVM, Diplomate ACVD, is assistant professor of dermatology and allergy at the University of Pennsylvania School of Veterinary Medicine. Dr. Cain&#8217;s clinical interests include management of allergic, immune-mediated, and infectious skin diseases. Her research is primarily focused on infectious disease and antimicrobial resistance, particularly staphylococcal antimicrobial resistance. Dr. Cain received her DVM from Ohio State University and completed an internship in small animal medicine and surgery at Red Bank Veterinary Hospital in Tinton Falls, New Jersey, followed by a residency in dermatology at University of Pennsylvania.<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Christine L.<\/p>\n","protected":false},"author":1,"featured_media":2746,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":1231,"footnotes":""},"categories":[374],"tags":[13],"class_list":["post-1312","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-may-june-2013","tag-peer-reviewed","column-features","clinical_topics-clinical-pathology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - 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