CDC Investigates First Case Of VRSA

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By Brian McCurdy, Associate Editor

Researchers at the Centers for Disease Control and Prevention (CDC) recently discovered the first reported case of vancomycin-resistant Staphylococcus aureus (VRSA) in the world. The organism was identified in a patient in Michigan, had not spread to anyone else and is susceptible to other antibiotics, according to the CDC Web site.
The 40-year-old woman was treated on an outpatient basis, has complicated diabetes and peripheral vascular disease, and undergoes hemodialysis on a regular basis, according to Dr. David Johnson, Deputy Director and Chief Medical Executive of the Michigan Department of Community Health. The VRSA is susceptible to trimethoprim-sulfamethoxazole and linezolid (ph), notes Dr. Steve Solomon, the CDC’s Acting Director of the Division of Health Care Quality Promotion, in a CDC release.

Guy Pupp, DPM, Director of the Diabetic Foot Clinic at Kern Hospital and Medical Center in Warren, Mich., treated the woman after the CDC contacted him. He says she is doing well and doctors are close to getting the last of three negative cultures for her VRSA.
“This is a big deal. Our fears (over increasing resistant strains) have been realized,” says Dr. Pupp, who is also the Clinic Director at the Sinai Grace Diabetic Foot Center in Detroit. However, he notes that identifying the resistant strain has also been “a big victory.”
Dr. Pupp treated the woman on an outpatient basis and says the CDC cordoned off areas in the Michigan hospital, had medical personnel wear special suits with hoods and took other precautions so the woman’s infection would not spread. He says the CDC was “efficient” to work with and took 500 cultures during its investigation of everyone who had contact with the patient. Dr. Pupp says his aggressive debridement was successful.

Was It The Result Of Rising Nosocomial Infections?
Adam Landsman, DPM, PhD, says the increase in Staph infections and shift from gram negative to gram positive bacteria over the past few years is a fact that can’t be ignored.
“The emergence of Staph resistance to vancomycin is of great concern because it symbolizes the fact that bacteria are going to do what we expect them to do ... become resistant to even the strongest antibiotics,” says Dr. Landsman, Director of Research and Adjunct Professor of Biologic Sciences at Dr. William A. Scholl College of Podiatric Medicine at Finch University.
Dr. Landsman attributes the discovery to the prevalence of nosocomial infections, noting the CDC recently released a series of guidelines that should be followed to help reduce these infections. The CDC feels the discovery of the Staph poses an insignificant risk to the general public. “This case does serve to reinforce for those of us in health care the absolute necessity of adhering to strict infection control precautions, as has been done in this case, and to continue to use antibiotics wisely and judiciously,” notes Dr. Solomon.
As Dr. Landsman suggests, one way of combating these infections is reducing the frequency of hospital admissions when outpatient management is possible. He says podiatrists often admit patients with serious infections for surgical treatment (i.e., incision and drainage), followed by a course of intravenous antibiotics for seven to 10 days in the hospital. This “gives patients great exposure to resistant bacteria and may cause colonization or full infection,” explains Dr. Landsman.
As a result, he is trying to minimize hospital and IV exposure when possible by using strong oral medications, such as linezolid (Zyvox, Pharmacia), to treat his diabetic patients who have serious infections. Linezolid has tissue penetration equal to IV medications without the IV-associated side effects, according to Dr. Landsman. He emphasizes that linezolid is indicated for both methicillin-resistant Staph aureus and vancomycin-resistant Staph.

What Does The Future Hold?
Dr. Pupp says the woman is “very close to being healed,” adding that the woman is fortunate because the infection was not systemic and did not involve deep tissue. If another VRSA arises in a patient systemically, Dr. Pupp says investigative medications may be needed. If the VRSA involves deep tissue, a below the knee amputation might be warranted to avoid sepsis.
“In the future, we will continue to see resistant strains of bacteria and will certainly see new antibiotics developed to meet these future needs,” comments Dr. Landsman. “I feel that podiatrists will continue to render surgical treatment for infection, but will take steps to get patients out of the hospital more quickly, whenever this can be done safely.
“I believe that as the newest generation of oral medications improve, there will be a shift away from IVs in favor of orals. I hope that the insurance carriers will not limit coverage to IVs when the best option may be an oral.”

Update: What Are The Best Treatments For Scars?
Scarring can have a lasting psychological effect on many patients and some previously accepted medications may have side effects or make the scarring worse.
A 1999 study revealed that in 90 percent of the study cases, using the oft-recommended topical Vitamin E to treat scarring had either no effect or made the condition worse. However, more recent therapeutic approaches have had an impact.
Leslie Baumman, MD, currently uses a combination of Retin A, Curad Scar Therapy and the 940 Dornier laser on her patients. Dr. Baumann, the Director of Cosmetic Dermatology at the University of Miami, treats “all types” of scars ranging from C-section scars to keloids.
While patients may initially want to see a dermatologist for scars, there are a variety of lower extremity scars that DPMs can treat as well. Gary Dockery, DPM, a Fellow of the American Society of Podiatric Dermatology, says he treats all lower extremity scars such as keloids, burn scars and hypertrophic scars. His preferred treatment methods include using Mederma for “very small scars and scars in areas where manipulation and motion are easily performed.” Mederma Skin Care for Scars was recently named as the most-often recommended modality by pharmacists for scar reduction, according to Pharmacy Times.
For keloids and hypertrophic scars, Dr. Dockery opts for Cica-Care and Oleeva Clear. Both doctors agree that pathological keloid scars are the most difficult to treat and patients with a family history of scarring are at an increased risk. Dr. Baumann has seen better treatment results with scars that are less than six months old. Dr. Dockery agrees that scars less than a year old are receptive to most treatments.
Both doctors administer treatment to fairly new scars frequently, from every few weeks to once a month. Dr. Dockery has encouraging words for people with older or difficult scars, adding that “all scars appear to respond sooner or later.” He notes that even older scars or more serious scars take three to twelve months to reduce.
– Gina DiGironimo
Production Editor

Texas DPMs Win Legal Battle Over The Ankle
Texas podiatrists have been treating ankles for decades but a recent decision by the Texas Board of Podiatric Medical Examiners caused a bit of controversy and a legal battle between podiatrists and orthopedists.
Samuel Mendicino, DPM, says after the board of examiners received requests to clarify what specifically is in the scope of practice of DPMs, it sought to clarify the definition of foot (and ankle) as historically treated by podiatrists.

“Podiatrists have been treating the functional foot for decades in Texas. This hasn’t enhanced our scope of practice,” explains Dr. Mendicino, who practices in Houston and is Chairman of the Texas Podiatric Medical Association’s Scope of Practice committee.
The Texas Orthopedic Association asked for an opinion from the state attorney general’s office on the ankle issue and Attorney General John Cornyn decided the board of podiatric medical examiners had extended its scope of practice. Attorney generals’ opinions are not legally binding in Texas and Dr. Mendicino points out the misconception that the board had expanded a scope of practice, since podiatrists had always treated ankles. He believes the board of podiatric examiners had clarified what had been going on for decades with ankles and other structures that affect the foot’s function.
“When (the attorney general’s opinion came out), some podiatrists had lost privileges at local hospitals that they had for years,” says Dr. Mendicino. He says the Texas Podiatric Medical Association became involved in the dispute because it believed the examiners’ move affected the association’s membership.
In a unique twist, the Texas Podiatric Medical Association sued the Texas Board of Podiatric Medical Examiners. When the dust settled, it was decided that the attorney general’s opinion did not supercede the examiners’ definition of the ankle. District Judge Pete Lowry recently refused to throw out the results of that lawsuit, as the Texas Orthopedic Association requested.
Richard Pollak, DPM, favors letting podiatrists treat ankles. Dr. Pollak, who practices in San Antonio, Texas, thinks those podiatrists who are qualified to work on ankles should be permitted to do so.
“If you can show documentation and expertise of doing a certain procedure … regardless of your degree, then you should be able to perform this procedure,” says Dr. Pollak, who is on the credentials committees of several hospitals.
Dr. Pollak says the legal decision regarding ankles cleared up “gray areas” which had been in podiatry the 25 years he has been practicing. He says he is capable of working on ankles but the previous standards “seemed to limit certain procedures I felt I was capable of doing.”
Had the standard of practice for podiatrists always included the ankle, Dr. Pollak says his practice would be “slightly different” than it is today. “I feel that I’ve been hurt from a professional standpoint by not being able to perform all the procedures that I’ve been trained to perform,” claims Dr. Pollak.
The Texas Medical Association, which joined with the orthopedists in the suit, is reviewing its options, according to the association Web site.
— B.M.

Aquacel AG Garners FDA Approval
The Food and Drug Administration (FDA) recently granted approval to Aquacel Ag, a new antimicrobial wound dressing that is indicated for chronic and acute wounds, ranging from surgical wounds and diabetic foot ulcers to leg and pressure ulcers and partial thickness wounds.
According to the manufacturer ConvaTec, the dressing is a combination of sodium carboxymethylcellulose with ionic silver 1.2% and features Hydrofiber technology that allows it to “absorb up to 20 times its weight in fluid.”
Alan Cantor, DPM, began using the Aquacel Ag three months ago and hails it as a “unique and revolutionary wound dressing.” Dr. Cantor, who practices privately and is an Attending Surgeon at the Nassau University Medical Center in East Meadow, N.Y., praises the dressing’s “superb absorption coupled with the antimicrobial ionic silver” and the gel’s “controlled, sustained release of silver,” which makes it dose dependent for patients.
In his clinical experience, Dr. Cantor has found that the dressing’s “unique combination retains drainage and bacteria-critical to enhanced anti-microbial activity.” He believes the dressing’s ability to absorb and retain moisture “is better than enhanced alginates” and its “science and delivery of silver” differentiates it from other wound dressings.
— G.D.

Clarification
Stacey Stefansky, DPM, was the lead author for the article, “Win The Battle Against Postoperative Infections,” which appeared in the August 2002 issue of Podiatry Today.

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