0071643192.pdf

INFECTIOUS DISEASE

In addition to Td vaccination,

give tetanus immunoglobulin

(TIG) for high-risk wounds

with uncertain or <3 prior

immunizations.

MRSA biochemistry:

mecA––a gene that conveys

methicillin resistance found in

all MRSA

Panton-Valentine leukocidin

(PVL)—a virulence factor

found in CA-MRSA

TABLE 8.10. Tetanus Prophylaxis

LOW-RISKWOUND

PRIORIMMUNIZATION (CLEAN/MINOR)HIGH-RISKWOUNDa

≥ 3 dT (if >10 yr since last dose) dT (if >5 yr since last dose)

Uncertain or < 3 dT dT and TIG (250 units IM)

aHigh risk is defined as >6 hours old; contaminated (eg, dirt, saliva, feces); puncture, crush

wounds, or avulsions; foreign bodies, burns, frostbite.

■ Intubation and long-term neuromuscular blockade with vecuronium if

necessary

■ Succinylcholine safe for RSI

■ Tetanus immune globulin (TIG)

■ 3000–5000 units IM

■ Neutralizes circulating tetanospasmin

■ Does not affect toxin already absorbed by CNS

■ Significantly reduces mortality (but not acute symptoms)

■ Tetanus immunization (give opposite site of TIG)

■ Wound treatment

■ Delay wound debridement and irrigation until after TIG (additional

toxin may be released during procedure).

■ Antibiotics

■ Metronidazole

■ Penicillin theoretically contraindicated (may potentate neurotoxin

effects)

WOUNDPROPHYLAXIS

For prophylaxis in the absence of clinical tetanus, see Table 8.10.

Methicillin-ResistantStaphylococcus aureus

■ Began as a hospital-acquired disease (HA-MRSA), but now the community-

acquired form of MRSA (CA-MRSA) is becoming more prevalent and the

two forms are becoming epidemiologically blurred.

■ Resistance to methicillin in both CA-MRSA and HA-MRSA is through the

presence of the mecAgene, which is not found in MSSA.

■ CA-MRSA is more likely to encode the putative virulence factor, Panton-

Valentine leukocidin.

■ CA-MRSA infections should be considered in all patients with soft-tissue

infections. Populations at increased risk include: children at day care cen-

ters, athletic team members, military personnel, prisoners, IVDU patients,

HIV+patients, and Native Americans. Additional risk factors include

skintrauma, contact sports, shaving, higher body mass index, and poor

hygiene.

■ HA-MRSA is most commonly spread from one patient to another by

health care workers whose hands or gloves have become transiently conta-

minated with MRSA. Three major reservoirs of HA-MRSA are patients,

health care workers, and the inanimate environment. The disease is com-

monly found in ICUs.