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David M. Young, MD; Hobart W. Harris, MD, MPH; Edwin D. Charlebois, MPH, PhD; Henry Chambers, MD; Andre Campbell, MD; Françoise Perdreau-Remington, PhD; Chen Lee, MD; Mahesh Mankani, MD; Robert Mackersie, MD; William P. Schecter, MD

Arch Surg. 2004;139:947-953.

Hypothesis  A high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in soft tissue infections presents a treatment challenge.

Design  Retrospective analysis.

Setting  The San Francisco General Hospital Integrated Soft Tissue Infection (ISIS) Clinic.

Patients  Patients treated at the ISIS Clinic from July 1, 2000, to June 30, 2003.

Main Outcome Measures  Information on patient demographics, surgical procedures, microbiologic studies, and antibiotic treatments was obtained for all patients treated in the ISIS Clinic. Microbial data and antibiotic susceptibility pattern of S aureus, treatment outcome, and antibiotic prescribed were analyzed for all evaluable patients.

Results  The ISIS Clinic treated 6156 unique patients for 12 012 episodes of infection. In this cohort, 5164 (84%) were either homeless or had no health insurance. More than half of the patients (58%) were injection drug users, but most had only 1 prior visit to the clinic (62%). Patients underwent a surgical procedure 7707 times (64%). Of the 837 positive cultures obtained, S aureus was recovered 695 times (83%), and 525 (63%) of the cultures contained MRSA. Therefore, a full 76% of all S aureus isolated was MRSA. In a subset analysis of 622 cultures collected prospectively from consecutive patients, 282 (45%) grew organisms, of which 256 (91%) were S aureus. MRSA represented 59% of all S aureus isolated. Homelessness and injection drug use were risk factors for infection by S aureus and MRSA. In another subgroup of patients with soft tissue infections that required admission to the hospital, MRSA was recovered from the cultures in 149 patients. In these patients with MRSA, 44 (30%) only received a -lactam antibiotic, inactive against MRSA, and had full resolution of their infection.

Conclusions  The prevalence of MRSA soft tissue infections in the medically underserved ISIS Clinic cohort is extremely high. The transmission of the MRSA seems to be in the community. Antibiotic therapy directed at MRSA may not be needed in a large number of patients with these soft tissue infections. Studies to identify the source and cause of this MRSA outbreak are urgently needed. Clinical trials to examine the need for antibiotic therapy in soft tissue infections should be conducted.

From the Department of Surgery, San Francisco General Hospital, University of California, San Francisco (Drs Young, Harris, Campbell, Mankani, Mackersie, and Schecter); Department of Medicine, Division of Infectious Diseases, Epidemiology, and Prevention, Interventions Center, San Francisco General Hospital, University of California, San Francisco (Drs Charlebois, Chambers, and Perdreau-Remington); and Department of Surgery, McGill University School of Medicine, Montreal, Quebec (Dr Lee).

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