Chronic foot ulcers set stage for VRSA

Vancomycin, other drugs given for a year

The Centers for Disease Control and Prevention (CDC) provided the following clinical profile of the first reported case of vancomycin-resistant Staphylococcus aureus.

In June 2002, VRSA was isolated from a swab obtained from a catheter exit site from a Michigan resident age 40 with diabetes, peripheral vascular disease, and chronic renal failure. The patient received dialysis at an outpatient facility. Since April 2001, the patient had been treated for chronic foot ulcerations with multiple courses of antimicrobial therapy, some of which included vancomycin.

In April 2002, the patient underwent amputation of a gangrenous toe and subsequently developed methicillin-resistant S. aureus bacteremia caused by an infected arteriovenous hemodialysis graft. The infection was treated with vancomycin, rifampin, and removal of the infected graft.

In June 2002, the patient developed a suspected catheter exit-site infection, and the temporary dialysis catheter was removed; cultures of the exit site and catheter tip subsequently grew S. aureus resistant to oxacillin (MIC >16 µg/mL) and vancomycin (MIC >128 µg/mL). A week after catheter removal, the exit site appeared healed; however, the patient’s chronic foot ulcer appeared infected. VRSA, vancomycin-resistant Enterococcus faecalis (VRE), and Klebsiella oxytoca also were recovered from a culture of the ulcer. Swab cultures of the patient’s healed catheter exit site and anterior nares did not grow VRSA.

As of this report, the patient is clinically stable, and the infection is responding to outpatient treatment consisting of aggressive wound care and systemic antimicrobial therapy with trimethoprim/ sulfamethoxazole. The VRSA isolate recovered from the catheter exit site was identified initially at a local hospital laboratory using commercial MIC testing and was confirmed by the Michigan Department of Community Health in Lansing and the CDC.

Reference

1. Centers for Disease Control and Prevention. Staphylococcus aureus resistant to vancomycin, United States, 2002. MMWR 2002; 51:565-567.