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S. lugdunensis osteoarticular infection often linked to orthopedic devices
SAN DIEGO – Bone and joint infections caused by Staphylococcus lugdunensis are an underestimated hospital-acquired infection often associated with orthopedic devices, according to a multicenter study.
“Consider potential relapse even after 1 year of the end of antibiotic treatment and follow patients with bone and joint infections caused by S. lugdunensis for a minimum 2 years after the end of treatment,” lead study author Dr. Piseth Seng said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
S. lugdunensis is a virulent coagulase-negative staphylococcus which behaves like S. aureus. Prior to the current study, only 47 cases are believed to be published in the medical literature, according to Dr. Seng of the department of internal medicine at Assistance Publique des Hôpitaux de Marseille (France). The purpose of the current study was to report a series of 138 cases of S. lugdunensis osteoarticular infection managed in nine hospital centers and three private clinics in France from January 1995 to December 2014.
The mean age of patients was 61 years, and 68% were male. Of the 138 cases, 113 (82%) were associated with an orthopedic device, including 2 cases of infection after anterior cruciate ligament reconstruction, 66 cases of prosthetic joint infection, and 3 cases of vertebral orthopedic device infection. The majority of orthopedic device infections (88%) occurred more than 1 month after implantation, while the remaining 12% occurred within the first month of implantation.
The researchers identified 30 cases (22%) of bone and joint infection that occurred in the absence of an orthopedic device, including 7 cases of arthritis, 21 cases of osteitis, and 2 cases of vertebral osteomyelitis.
The majority of patients (91%) received a combination of antibiotic and surgical treatment, including amputation (6%), orthopedic prosthesis removal (14%), internal orthopedic device removal (23%), and surgical debridement and retention of the orthopedic device (41%). The proportion of S. lugdunensis strains with reduced susceptibility to antistaphylococcal agents was low. Resistant strains included five to oxacillin, four to fosfomycin, two to fusidic acid, two to co-trimoxazole, one to rifampicin, and one to clindamycin.
To date, relapses have occurred in 19% of the 123 patients in whom researchers have complete follow-up data. The readmission rate among these patients was 76%, and four (3%) died of their infection. “These relapses were not associated with risk factor or comorbidity or polymicrobial infection,” noted Dr. Seng, who characterized the incidence of bone and joint infections caused by S. lugdunensis as being under reported. “S. lugdunensis is known as an organism forming biofilms, but treatment options (surgical debridement or prosthesis removal) did not influence clinical outcomes.”
The mean time to relapse was 305 days and no risk factor or comorbidity was associated with relapse.
Dr. Seng acknowledged that the study was limited by its retrospective design. He and his associates reported having no financial disclosures.
SAN DIEGO – Bone and joint infections caused by Staphylococcus lugdunensis are an underestimated hospital-acquired infection often associated with orthopedic devices, according to a multicenter study.
“Consider potential relapse even after 1 year of the end of antibiotic treatment and follow patients with bone and joint infections caused by S. lugdunensis for a minimum 2 years after the end of treatment,” lead study author Dr. Piseth Seng said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
S. lugdunensis is a virulent coagulase-negative staphylococcus which behaves like S. aureus. Prior to the current study, only 47 cases are believed to be published in the medical literature, according to Dr. Seng of the department of internal medicine at Assistance Publique des Hôpitaux de Marseille (France). The purpose of the current study was to report a series of 138 cases of S. lugdunensis osteoarticular infection managed in nine hospital centers and three private clinics in France from January 1995 to December 2014.
The mean age of patients was 61 years, and 68% were male. Of the 138 cases, 113 (82%) were associated with an orthopedic device, including 2 cases of infection after anterior cruciate ligament reconstruction, 66 cases of prosthetic joint infection, and 3 cases of vertebral orthopedic device infection. The majority of orthopedic device infections (88%) occurred more than 1 month after implantation, while the remaining 12% occurred within the first month of implantation.
The researchers identified 30 cases (22%) of bone and joint infection that occurred in the absence of an orthopedic device, including 7 cases of arthritis, 21 cases of osteitis, and 2 cases of vertebral osteomyelitis.
The majority of patients (91%) received a combination of antibiotic and surgical treatment, including amputation (6%), orthopedic prosthesis removal (14%), internal orthopedic device removal (23%), and surgical debridement and retention of the orthopedic device (41%). The proportion of S. lugdunensis strains with reduced susceptibility to antistaphylococcal agents was low. Resistant strains included five to oxacillin, four to fosfomycin, two to fusidic acid, two to co-trimoxazole, one to rifampicin, and one to clindamycin.
To date, relapses have occurred in 19% of the 123 patients in whom researchers have complete follow-up data. The readmission rate among these patients was 76%, and four (3%) died of their infection. “These relapses were not associated with risk factor or comorbidity or polymicrobial infection,” noted Dr. Seng, who characterized the incidence of bone and joint infections caused by S. lugdunensis as being under reported. “S. lugdunensis is known as an organism forming biofilms, but treatment options (surgical debridement or prosthesis removal) did not influence clinical outcomes.”
The mean time to relapse was 305 days and no risk factor or comorbidity was associated with relapse.
Dr. Seng acknowledged that the study was limited by its retrospective design. He and his associates reported having no financial disclosures.
SAN DIEGO – Bone and joint infections caused by Staphylococcus lugdunensis are an underestimated hospital-acquired infection often associated with orthopedic devices, according to a multicenter study.
“Consider potential relapse even after 1 year of the end of antibiotic treatment and follow patients with bone and joint infections caused by S. lugdunensis for a minimum 2 years after the end of treatment,” lead study author Dr. Piseth Seng said in an interview at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.
S. lugdunensis is a virulent coagulase-negative staphylococcus which behaves like S. aureus. Prior to the current study, only 47 cases are believed to be published in the medical literature, according to Dr. Seng of the department of internal medicine at Assistance Publique des Hôpitaux de Marseille (France). The purpose of the current study was to report a series of 138 cases of S. lugdunensis osteoarticular infection managed in nine hospital centers and three private clinics in France from January 1995 to December 2014.
The mean age of patients was 61 years, and 68% were male. Of the 138 cases, 113 (82%) were associated with an orthopedic device, including 2 cases of infection after anterior cruciate ligament reconstruction, 66 cases of prosthetic joint infection, and 3 cases of vertebral orthopedic device infection. The majority of orthopedic device infections (88%) occurred more than 1 month after implantation, while the remaining 12% occurred within the first month of implantation.
The researchers identified 30 cases (22%) of bone and joint infection that occurred in the absence of an orthopedic device, including 7 cases of arthritis, 21 cases of osteitis, and 2 cases of vertebral osteomyelitis.
The majority of patients (91%) received a combination of antibiotic and surgical treatment, including amputation (6%), orthopedic prosthesis removal (14%), internal orthopedic device removal (23%), and surgical debridement and retention of the orthopedic device (41%). The proportion of S. lugdunensis strains with reduced susceptibility to antistaphylococcal agents was low. Resistant strains included five to oxacillin, four to fosfomycin, two to fusidic acid, two to co-trimoxazole, one to rifampicin, and one to clindamycin.
To date, relapses have occurred in 19% of the 123 patients in whom researchers have complete follow-up data. The readmission rate among these patients was 76%, and four (3%) died of their infection. “These relapses were not associated with risk factor or comorbidity or polymicrobial infection,” noted Dr. Seng, who characterized the incidence of bone and joint infections caused by S. lugdunensis as being under reported. “S. lugdunensis is known as an organism forming biofilms, but treatment options (surgical debridement or prosthesis removal) did not influence clinical outcomes.”
The mean time to relapse was 305 days and no risk factor or comorbidity was associated with relapse.
Dr. Seng acknowledged that the study was limited by its retrospective design. He and his associates reported having no financial disclosures.
AT ICAAC 2015
Key clinical point: S. lugdunensis infections are often associated with orthopedic devices.
Major finding: Of 138 cases of S. lugdunensis osteoarticular infection, 113 (82%) were associated with an orthopedic device.
Data source: A retrospective study of 138 cases of S. lugdunensis osteoarticular infection managed in nine hospitals and three private clinics in France.
Disclosures: The researchers reported having no financial disclosures.
VIDEO: Hospitalized heart failure patients susceptible to C. difficile
LONDON – U.S. patients hospitalized for heart failure and treated with antibiotics during their hospital stay had an increased rate both for developing Clostridium difficile infection and dying from it, based on nationwide data collected from nearly six million patients.
“Heart failure was an independent risk factor” in multivariate analyses that controlled for demographic factors as well as for several comorbidities of heart failure, Dr. Petra Mamic said in a video interview at the annual congress of the European Society of Cardiology.
She and her associates used data collected by the National Inpatient Sample during 2012 in more than 5.8 million U.S. hospitalized patients who received antibiotic treatment for a urinary tract infection, pneumonia, or sepsis. They compared the rate of subsequent infection with C. difficile in the roughly 1.4 million of these patients who had heart failure and the nearly 4.5 million without heart failure. In a multivariate analysis heart failure patients were 13% more likely to develop C. difficile infection compared with patients without heart failure. In a second multivariate analysis that focused just on patients with heart failure those who had become infected by C. difficile were 81% more likely to die in hospital compared with heart failure patients without this type of infection.
“Heart failure patients are frequently hospitalized and have a lot of bacterial infections, and so receive treatment with a lot of antibiotics,” said Dr. Mamic, an internal medicine physician at Stanford (Calif.) University. “What is important is that C. difficile infection is preventable. Our ultimate goal is to prevent C. difficile in these patients who have such high morbidity and mortality,”
Dr. Mamic had no disclosures.
On Twitter @mitchelzoler
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LONDON – U.S. patients hospitalized for heart failure and treated with antibiotics during their hospital stay had an increased rate both for developing Clostridium difficile infection and dying from it, based on nationwide data collected from nearly six million patients.
“Heart failure was an independent risk factor” in multivariate analyses that controlled for demographic factors as well as for several comorbidities of heart failure, Dr. Petra Mamic said in a video interview at the annual congress of the European Society of Cardiology.
She and her associates used data collected by the National Inpatient Sample during 2012 in more than 5.8 million U.S. hospitalized patients who received antibiotic treatment for a urinary tract infection, pneumonia, or sepsis. They compared the rate of subsequent infection with C. difficile in the roughly 1.4 million of these patients who had heart failure and the nearly 4.5 million without heart failure. In a multivariate analysis heart failure patients were 13% more likely to develop C. difficile infection compared with patients without heart failure. In a second multivariate analysis that focused just on patients with heart failure those who had become infected by C. difficile were 81% more likely to die in hospital compared with heart failure patients without this type of infection.
“Heart failure patients are frequently hospitalized and have a lot of bacterial infections, and so receive treatment with a lot of antibiotics,” said Dr. Mamic, an internal medicine physician at Stanford (Calif.) University. “What is important is that C. difficile infection is preventable. Our ultimate goal is to prevent C. difficile in these patients who have such high morbidity and mortality,”
Dr. Mamic had no disclosures.
On Twitter @mitchelzoler
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LONDON – U.S. patients hospitalized for heart failure and treated with antibiotics during their hospital stay had an increased rate both for developing Clostridium difficile infection and dying from it, based on nationwide data collected from nearly six million patients.
“Heart failure was an independent risk factor” in multivariate analyses that controlled for demographic factors as well as for several comorbidities of heart failure, Dr. Petra Mamic said in a video interview at the annual congress of the European Society of Cardiology.
She and her associates used data collected by the National Inpatient Sample during 2012 in more than 5.8 million U.S. hospitalized patients who received antibiotic treatment for a urinary tract infection, pneumonia, or sepsis. They compared the rate of subsequent infection with C. difficile in the roughly 1.4 million of these patients who had heart failure and the nearly 4.5 million without heart failure. In a multivariate analysis heart failure patients were 13% more likely to develop C. difficile infection compared with patients without heart failure. In a second multivariate analysis that focused just on patients with heart failure those who had become infected by C. difficile were 81% more likely to die in hospital compared with heart failure patients without this type of infection.
“Heart failure patients are frequently hospitalized and have a lot of bacterial infections, and so receive treatment with a lot of antibiotics,” said Dr. Mamic, an internal medicine physician at Stanford (Calif.) University. “What is important is that C. difficile infection is preventable. Our ultimate goal is to prevent C. difficile in these patients who have such high morbidity and mortality,”
Dr. Mamic had no disclosures.
On Twitter @mitchelzoler
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE ESC CONGRESS 2015
MRSA coverage in cellulitis treatment
A 57-year-old man presents with pain and swelling in his leg. He has had low-grade fevers. He has a history of type 2 diabetes. On exam, his right lower extremity is warm, erythematous, and swollen to the midcalf. There is no purulence, fluctuance, or weeping skin. Labs are: WBC, 12,000; Na, 134; K, 5.2; BUN, 20; creatinine, 1.4.
What therapy would you recommend?
A) Ciprofloxacin.
B) Cefazolin.
C) Vancomycin.
D) Trimethoprim-sulfamethoxazole.
Myth: Cellulitis treatment should include MRSA coverage.
Cellulitis is almost always caused by group A streptococcus. There are exceptional circumstances where other organisms must be considered; but for the most part, those situations are rare. With the growing concern for community-associated methicillin-resistant Staphylococcus aureus infection (MRSA), more and more patients are receiving empiric coverage for MRSA for all skin infections. Is this coverage for MRSA in patients with cellulitis a new myth in evolution?
In a study by Dr. Arthur Jeng and colleagues, all patients admitted to one hospital over a 3-year period with diffuse cellulitis were studied (Medicine 2010;89:217-26). A total of 179 patients were enrolled in the study; all patients had serologic studies for exposure to streptococci and what antibiotics they received, and outcomes were recorded.
Almost all patients with positive antibodies to streptococci responded to beta-lactam antibiotics (97%). But 91% of the patients who did not develop streptococcal antibodies also responded to beta-lactam antibiotics, for an overall response rate of 95% for treatment with beta-lactam antibiotics.
The most recent clinical practice guidelines published by the Infectious Diseases Society of America recommend treatment for infection with beta-hemolytic streptococci for outpatients with nonpurulent cellulitis (Clin. Infect. Dis. 2011;52:285-92). The addition of vancomycin is reserved for patients with purulence/evidence of abscess or exudate.
How common is it to prescribe antibiotics that cover MRSA in patients with cellulitis?
In a 2013 study, 61% of patients treated for cellulitis received antibiotics that included community-acquired MRSA coverage (Am. J. Med. 2013;126:1099-106).
A recent study looked at whether additional community-associated MRSA coverage with trimethoprim-sulfamethoxazole in addition to beta-lactam therapy for cellulitis showed any benefit over therapy with only a beta-lactam (Clin. Infect. Dis. 2013;56:1754-62). The study was a randomized, double-blind, placebo-controlled trial. The experimental group received trimethoprim-sulfamethoxazole and cephalexin, while the control group received cephalexin plus placebo.
There was no difference in outcome between the two groups, with the conclusion that addition of trimethoprim-sulfamethoxazole to cephalexin did not lead to a better outcome than cephalexin alone in patients with nonpurulent cellulitis.
A study by Dr. Thana Khawcharoenporn and Dr. Alan Tice looked at whether cephalexin, trimethoprim-sulfamethoxazole, or clindamycin was superior for the treatment of outpatient cellulitis (Am. J. Med. 2010;123:942-50). They concluded that trimethoprim-sulfamethoxazole and clindamycin were better than cephalexin. However, more than 50% of patients in this study had abscesses or ulcers – clinical criteria that increase the possibility of MRSA.
The most commonly used oral antibiotic for the coverage of community-associated MRSA is trimethoprim-sulfamethoxazole. This increasing use of TMP-sulfa has its risks, especially in elderly populations (Ann. Emerg. Med. 2014; 63:783-4). Trimethoprim-sulfamethoxazole can cause serious skin reactions and hyperkalemia (especially in the elderly and those with renal impairment), and the drug has a marked drug interaction with warfarin, leading to high risk of excessive anticoagulation.
These risks of TMP-sulfa use make it extremely important to have clear and worthwhile indications for its use.
The best evidence right now is that for simple cellulitis (no purulence, abscess, or exudate), treatment with a beta-lactam antibiotic is the best option. There is no need to add MRSA coverage to beta-lactam therapy.
If there is no response to treatment, then broadening coverage to include MRSA would be appropriate.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
A 57-year-old man presents with pain and swelling in his leg. He has had low-grade fevers. He has a history of type 2 diabetes. On exam, his right lower extremity is warm, erythematous, and swollen to the midcalf. There is no purulence, fluctuance, or weeping skin. Labs are: WBC, 12,000; Na, 134; K, 5.2; BUN, 20; creatinine, 1.4.
What therapy would you recommend?
A) Ciprofloxacin.
B) Cefazolin.
C) Vancomycin.
D) Trimethoprim-sulfamethoxazole.
Myth: Cellulitis treatment should include MRSA coverage.
Cellulitis is almost always caused by group A streptococcus. There are exceptional circumstances where other organisms must be considered; but for the most part, those situations are rare. With the growing concern for community-associated methicillin-resistant Staphylococcus aureus infection (MRSA), more and more patients are receiving empiric coverage for MRSA for all skin infections. Is this coverage for MRSA in patients with cellulitis a new myth in evolution?
In a study by Dr. Arthur Jeng and colleagues, all patients admitted to one hospital over a 3-year period with diffuse cellulitis were studied (Medicine 2010;89:217-26). A total of 179 patients were enrolled in the study; all patients had serologic studies for exposure to streptococci and what antibiotics they received, and outcomes were recorded.
Almost all patients with positive antibodies to streptococci responded to beta-lactam antibiotics (97%). But 91% of the patients who did not develop streptococcal antibodies also responded to beta-lactam antibiotics, for an overall response rate of 95% for treatment with beta-lactam antibiotics.
The most recent clinical practice guidelines published by the Infectious Diseases Society of America recommend treatment for infection with beta-hemolytic streptococci for outpatients with nonpurulent cellulitis (Clin. Infect. Dis. 2011;52:285-92). The addition of vancomycin is reserved for patients with purulence/evidence of abscess or exudate.
How common is it to prescribe antibiotics that cover MRSA in patients with cellulitis?
In a 2013 study, 61% of patients treated for cellulitis received antibiotics that included community-acquired MRSA coverage (Am. J. Med. 2013;126:1099-106).
A recent study looked at whether additional community-associated MRSA coverage with trimethoprim-sulfamethoxazole in addition to beta-lactam therapy for cellulitis showed any benefit over therapy with only a beta-lactam (Clin. Infect. Dis. 2013;56:1754-62). The study was a randomized, double-blind, placebo-controlled trial. The experimental group received trimethoprim-sulfamethoxazole and cephalexin, while the control group received cephalexin plus placebo.
There was no difference in outcome between the two groups, with the conclusion that addition of trimethoprim-sulfamethoxazole to cephalexin did not lead to a better outcome than cephalexin alone in patients with nonpurulent cellulitis.
A study by Dr. Thana Khawcharoenporn and Dr. Alan Tice looked at whether cephalexin, trimethoprim-sulfamethoxazole, or clindamycin was superior for the treatment of outpatient cellulitis (Am. J. Med. 2010;123:942-50). They concluded that trimethoprim-sulfamethoxazole and clindamycin were better than cephalexin. However, more than 50% of patients in this study had abscesses or ulcers – clinical criteria that increase the possibility of MRSA.
The most commonly used oral antibiotic for the coverage of community-associated MRSA is trimethoprim-sulfamethoxazole. This increasing use of TMP-sulfa has its risks, especially in elderly populations (Ann. Emerg. Med. 2014; 63:783-4). Trimethoprim-sulfamethoxazole can cause serious skin reactions and hyperkalemia (especially in the elderly and those with renal impairment), and the drug has a marked drug interaction with warfarin, leading to high risk of excessive anticoagulation.
These risks of TMP-sulfa use make it extremely important to have clear and worthwhile indications for its use.
The best evidence right now is that for simple cellulitis (no purulence, abscess, or exudate), treatment with a beta-lactam antibiotic is the best option. There is no need to add MRSA coverage to beta-lactam therapy.
If there is no response to treatment, then broadening coverage to include MRSA would be appropriate.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
A 57-year-old man presents with pain and swelling in his leg. He has had low-grade fevers. He has a history of type 2 diabetes. On exam, his right lower extremity is warm, erythematous, and swollen to the midcalf. There is no purulence, fluctuance, or weeping skin. Labs are: WBC, 12,000; Na, 134; K, 5.2; BUN, 20; creatinine, 1.4.
What therapy would you recommend?
A) Ciprofloxacin.
B) Cefazolin.
C) Vancomycin.
D) Trimethoprim-sulfamethoxazole.
Myth: Cellulitis treatment should include MRSA coverage.
Cellulitis is almost always caused by group A streptococcus. There are exceptional circumstances where other organisms must be considered; but for the most part, those situations are rare. With the growing concern for community-associated methicillin-resistant Staphylococcus aureus infection (MRSA), more and more patients are receiving empiric coverage for MRSA for all skin infections. Is this coverage for MRSA in patients with cellulitis a new myth in evolution?
In a study by Dr. Arthur Jeng and colleagues, all patients admitted to one hospital over a 3-year period with diffuse cellulitis were studied (Medicine 2010;89:217-26). A total of 179 patients were enrolled in the study; all patients had serologic studies for exposure to streptococci and what antibiotics they received, and outcomes were recorded.
Almost all patients with positive antibodies to streptococci responded to beta-lactam antibiotics (97%). But 91% of the patients who did not develop streptococcal antibodies also responded to beta-lactam antibiotics, for an overall response rate of 95% for treatment with beta-lactam antibiotics.
The most recent clinical practice guidelines published by the Infectious Diseases Society of America recommend treatment for infection with beta-hemolytic streptococci for outpatients with nonpurulent cellulitis (Clin. Infect. Dis. 2011;52:285-92). The addition of vancomycin is reserved for patients with purulence/evidence of abscess or exudate.
How common is it to prescribe antibiotics that cover MRSA in patients with cellulitis?
In a 2013 study, 61% of patients treated for cellulitis received antibiotics that included community-acquired MRSA coverage (Am. J. Med. 2013;126:1099-106).
A recent study looked at whether additional community-associated MRSA coverage with trimethoprim-sulfamethoxazole in addition to beta-lactam therapy for cellulitis showed any benefit over therapy with only a beta-lactam (Clin. Infect. Dis. 2013;56:1754-62). The study was a randomized, double-blind, placebo-controlled trial. The experimental group received trimethoprim-sulfamethoxazole and cephalexin, while the control group received cephalexin plus placebo.
There was no difference in outcome between the two groups, with the conclusion that addition of trimethoprim-sulfamethoxazole to cephalexin did not lead to a better outcome than cephalexin alone in patients with nonpurulent cellulitis.
A study by Dr. Thana Khawcharoenporn and Dr. Alan Tice looked at whether cephalexin, trimethoprim-sulfamethoxazole, or clindamycin was superior for the treatment of outpatient cellulitis (Am. J. Med. 2010;123:942-50). They concluded that trimethoprim-sulfamethoxazole and clindamycin were better than cephalexin. However, more than 50% of patients in this study had abscesses or ulcers – clinical criteria that increase the possibility of MRSA.
The most commonly used oral antibiotic for the coverage of community-associated MRSA is trimethoprim-sulfamethoxazole. This increasing use of TMP-sulfa has its risks, especially in elderly populations (Ann. Emerg. Med. 2014; 63:783-4). Trimethoprim-sulfamethoxazole can cause serious skin reactions and hyperkalemia (especially in the elderly and those with renal impairment), and the drug has a marked drug interaction with warfarin, leading to high risk of excessive anticoagulation.
These risks of TMP-sulfa use make it extremely important to have clear and worthwhile indications for its use.
The best evidence right now is that for simple cellulitis (no purulence, abscess, or exudate), treatment with a beta-lactam antibiotic is the best option. There is no need to add MRSA coverage to beta-lactam therapy.
If there is no response to treatment, then broadening coverage to include MRSA would be appropriate.
Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].
