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abscessSm1 cellulitisSm1 folliculitisSm1
furunculosisSm2 impetigoSm1  
     

MRSA
MRSA pictures and disease information have been excerpted from VisualDx visual diagnostic decision support system as a public health service.

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Diagnosis Synopsis
Skin and soft tissue infections (SSTIs) including cellulitis, abscesses, impetigo, folliculitis, and furunculosis can all be caused by infection with Staphylococcus aureus, including methicillin-resistant Staphylococcus aureus (MRSA). Recent studies report the increasing incidence of MRSA within the community (community-associated MRSA, or CA-MRSA) as compared to 10 years ago when MRSA was primarily limited to hospital-acquired infections. In most parts of the United States, over 50% of community-associated S. aureus are MRSA. Hence, S. aureus infections and MRSA are becoming synonymous.

MRSA was first identified in 1961, shortly after the introduction of methicillin. Since that time, MRSA has widely been recognized as an important agent of disease in hospitals, nursing homes, and other long-term care facilities. Beginning in the 1990s, however, outbreaks of MRSA were recognized among healthy children, athletes, prisoners, military recruits, and intravenous drug users in the community at large. Most of those with MRSA infections lacked "traditional" MRSA risk factors, such as exposure to the health care system.

The most common manifestation of CA-MRSA infections are skin and subcutaneous infections. Many infections are attributed by patients as spider bites, although an exposure to a spider is typically not recalled by patients. MRSA skin infections occur in patients of all ages and among people with no "traditional" risk factors, or even recently described risk factors. Clearly, any person, regardless of background or exposures, can acquire a CA-MRSA infection.

Virtually all CA-MRSA isolates retain susceptibility to vancomycin, linezolid, daptomycin, and trimethoprim-sulfamethoxazole (TMP-SMX). Most isolates are susceptible to clindamycin and tetracyclines, although susceptibility can vary by geography. While CA-MRSA has a propensity for causing skin and soft tissue infections, it can also cause more severe and invasive disease syndromes including necrotizing pneumonia, empyema, necrotizing fasciitis, pyomyositis, septic thrombophlebitis with pulmonary embolization, osteomyelitis, and severe sepsis syndrome, among other manifestations. "Spider bite"-like skin infections and the more severe syndromes may be due in large part to a specific exotoxin present in many strains of CA-MRSA, Panton-Valentine leukocidin (PVL). PVL, a virulence factor that is lethal to neutrophils, has also been implicated in cases of invasive CA-MRSA infections such as necrotizing pneumonia.

Look For

  • Abscesses
  • Follicular pustules
  • Furuncles (boils)
  • Bullous impetigo - pus or fluid-filled bullae and vesicles
  • Non-bullous impetigo - crusted plaques and erosions
  • Cellulitis - circumscribed erythema and/or edema, tissue warmth, and tenderness

To a great extent, MRSA skin infections present similarly as any bacterial skin infections with the exception of severity. Skin abscesses caused by MRSA can often appear larger and more severe that the typical methicillin-sensitive abscess.

(See individual synopses of abscess, folliculitis, impetigo, and cellulitis within the VisualDx system.)

Medical Disclaimer:
The information contained in this Web page is intended to be an adjunct to traditional medical information sources. It is not intended to be a substitute for professional medical judgment.

Authors and Editors:
Loren G. Miller, MD, MPH
Noah Craft MD, PhD, DTM&H