Community-Acquired Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections: Management and Prevention

  • Luke F. ChenEmail author
  • Cody Chastain
  • Deverick J. Anderson


Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) was a rare phenomenon until the past decade; now CA-MRSA is endemic in many communities and is the most common cause of skin and soft tissue infections presenting to emergency rooms. CA-MRSA is distinct from its hospital-acquired counterpart, and has caused devastating infections in many healthy individuals. The epidemiology of CA-MRSA continues to evolve, and the challenge is to use the most appropriate and effective therapeutic and preventative strategies against this pathogen. This article reviews the current epidemiology of CA-MRSA, its definitions, and common clinical manifestations in the community. The article also summarizes current therapeutic options for CA-MRSA as well as strategies to reduce the transmission and the impact of CA-MRSA in both community and health care settings.


Methicillin-resistant Staphylococcus aureus MRSA, Community-acquired CA-MRSA Skin and soft tissue infection Decolonization Management Prevention Treatment 



No potential conflicts of interest relevant to this article were reported.


Papers of particular interest, published recently, have been highlighted as:•Of importance••Of major importance

  1. 1.
    Chambers HF, Deleo FR. Waves of resistance: Staphylococcus aureus in the antibiotic era. Nat Rev Microbiol. 2009;7:629–41.PubMedCrossRefGoogle Scholar
  2. 2.
    Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355:666–74.PubMedCrossRefGoogle Scholar
  3. 3.
    Udo EE, Pearman JW, Grubb WB. Genetic analysis of community isolates of methicillin-resistant Staphylococcus aureus in Western Australia. J Hosp Infect. 1993;25:97–108.PubMedCrossRefGoogle Scholar
  4. 4.
    Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA. 1998;279:593–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Daum RS, Ito T, Hiramatsu K, et al. A novel methicillin-resistance cassette in community-acquired methicillin-resistant Staphylococcus aureus isolates of diverse genetic backgrounds. J Infect Dis. 2002;186:1344–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Klevens RM, Morrison MA, Fridkin SK, et al. Community-associated methicillin-resistant Staphylococcus aureus and healthcare risk factors. Emerg Infect Dis. 2006;12:1991–3.PubMedGoogle Scholar
  7. 7.
    Francois P, Harbarth S, Huyghe A, et al. Methicillin-resistant Staphylococcus aureus, Geneva, Switzerland, 1993–2005. Emerg Infect Dis. 2008;14:304–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Coombs GW, Nimmo GR, Pearson JC, et al. Prevalence of MRSA strains among Staphylococcus aureus isolated from outpatients, 2006. Commun Dis Intell. 2009;33:10–20.PubMedGoogle Scholar
  9. 9.
    Munckhof WJ, Nimmo GR, Carney J, et al. Methicillin-susceptible, non-multiresistant methicillin-resistant and multiresistant methicillin-resistant Staphylococcus aureus infections: a clinical, epidemiological and microbiological comparative study. Eur J Clin Microbiol Infect Dis. 2008;27:355–64.PubMedCrossRefGoogle Scholar
  10. 10.
    Popovich K, Hota B, Rice T, et al. Phenotypic prediction rule for community-associated methicillin-resistant Staphylococcus aureus. J Clin Microbiol. 2007;45:2293–5.PubMedCrossRefGoogle Scholar
  11. 11.
    Diep BA, Chambers HF, Graber CJ, et al. Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men. Ann Intern Med. 2008;148:249–57.PubMedGoogle Scholar
  12. 12.
    Centers for Disease Control and Prevention: Diagnosis and Testing of MRSA Infections. Available at: Accessed 04/19/2011.
  13. 13.
    Seybold U, Kourbatova EV, Johnson JG, et al. Emergence of community-associated methicillin-resistant Staphylococcus aureus USA300 genotype as a major cause of health care-associated blood stream infections. Clin Infect Dis. 2006;42:647–56.PubMedCrossRefGoogle Scholar
  14. 14.
    Maree CL, Daum RS, Boyle-Vavra S, et al. Community-associated methicillin-resistant Staphylococcus aureus isolates causing healthcare-associated infections. Emerg Infect Dis. 2007;13:236–42.PubMedCrossRefGoogle Scholar
  15. 15.
    von Eiff C, Becker K, Machka K, et al. Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med. 2001;344:11–6.CrossRefGoogle Scholar
  16. 16.
    Kuehnert MJ, Kruszon-Moran D, Hill HA, et al. Prevalence of Staphylococcus aureus nasal colonization in the United States, 2001–2002. J Infect Dis. 2006;193:172–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Nakamura MM, Rohling KL, Shashaty M, et al. Prevalence of methicillin-resistant Staphylococcus aureus nasal carriage in the community pediatric population. Pediatr Infect Dis J. 2002;21:917–22.PubMedCrossRefGoogle Scholar
  18. 18.
    Kazakova SV, Hageman JC, Matava M, et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med. 2005;352:468–75.PubMedCrossRefGoogle Scholar
  19. 19.
    Cook HA, Furuya EY, Larson E, et al. Heterosexual transmission of community-associated methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2007;44:410–3.PubMedCrossRefGoogle Scholar
  20. 20.
    Desai R, Pannaraj PS, Agopian J, et al. Survival and transmission of community-associated methicillin-resistant Staphylococcus aureus from fomites. Am J Infect Control. 2011;39:219–25.PubMedCrossRefGoogle Scholar
  21. 21.
    Rackham DM, Ray SM, Franks AS, et al. Community-associated methicillin-resistant Staphylococcus aureus nasal carriage in a college student athlete population. Clin J Sport Med. 2010;20:185–8.PubMedCrossRefGoogle Scholar
  22. 22.
    • Golding GR, Levett PN, McDonald RR, et al.: A comparison of risk factors associated with community-associated methicillin-resistant and -susceptible Staphylococcus aureus infections in remote communities. Epidemiol Infect. 2010;138:730–7. An interesting article that compares and contrasts risk factors of infection by CA-MRSA versus CA-MSSA infections. PubMedCrossRefGoogle Scholar
  23. 23.
    Yamamoto T, Nishiyama A, Takano T, et al. Community-acquired methicillin-resistant Staphylococcus aureus: community transmission, pathogenesis, and drug resistance. J Infect Chemother. 2010;16:225–54.PubMedCrossRefGoogle Scholar
  24. 24.
    Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med. 2005;352:1436–44.PubMedCrossRefGoogle Scholar
  25. 25.
    Ruhe JJ, Smith N, Bradsher RW, Menon A. Community-onset methicillin-resistant Staphylococcus aureus skin and soft-tissue infections: impact of antimicrobial therapy on outcome. Clin Infect Dis. 2007;44:777–84.PubMedCrossRefGoogle Scholar
  26. 26.
    Miller LG, Perdreau-Remington F, Bayer AS, et al. Clinical and epidemiologic characteristics cannot distinguish community-associated methicillin-resistant Staphylococcus aureus infection from methicillin-susceptible S. aureus infection: a prospective investigation. Clin Infect Dis. 2007;44:471–82.PubMedCrossRefGoogle Scholar
  27. 27.
    Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med. 2005;352:1445–53.PubMedCrossRefGoogle Scholar
  28. 28.
    Swanson DL, Vetter RS. Bites of brown recluse spiders and suspected necrotic arachnidism. N Engl J Med. 2005;352:700–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused by community-acquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2004;23:123–7.PubMedCrossRefGoogle Scholar
  30. 30.
    ••. Liu C, Bayer A, Cosgrove SE, et al.: Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children: executive summary. Clin Infect Dis. 2011;52:285–92. This important article summarizes the current recommendations for treatment of MRSA infections from the Infectious Diseases Society of America (IDSA). PubMedCrossRefGoogle Scholar
  31. 31.
    •• Chua K, Laurent F, Coombs G, et al.: Antimicrobial resistance: Not community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA)! A clinician’s guide to community MRSA—its evolving antimicrobial resistance and implications for therapy. Clin Infect Dis. 2011;52:99–114. This is a splendid article that describes the evolution of CA-MRSA infections, current molecular epidemiology and implications for therapy. PubMedCrossRefGoogle Scholar
  32. 32.
    Kaka AS, Rueda AM, Shelburne 3rd SA, et al. Bactericidal activity of orally available agents against methicillin-resistant Staphylococcus aureus. J Antimicrob Chemother. 2006;58:680–3.PubMedCrossRefGoogle Scholar
  33. 33.
    Han LL, McDougal LK, Gorwitz RJ, et al. High frequencies of clindamycin and tetracycline resistance in methicillin-resistant Staphylococcus aureus pulsed-field type USA300 isolates collected at a Boston ambulatory health center. J Clin Microbiol. 2007;45:1350–2.PubMedCrossRefGoogle Scholar
  34. 34.
    •• Wilcox MH, Tack KJ, Bouza E, et al.: Complicated skin and skin-structure infections and catheter-related bloodstream infections: noninferiority of linezolid in a phase 3 study. Clin Infect Dis. 2009;48:203–12. This key article showed non-inferiority of linezolid compared to vancomycin for complicated skin and skin-structure infections. However, the study also found an increased failure rate of linezolid when used for Gram-negative catheter-associated bloodstream infections. PubMedCrossRefGoogle Scholar
  35. 35.
    Graber CJ, Wong MK, Carleton HA, et al. Intermediate vancomycin susceptibility in a community-associated MRSA clone. Emerg Infect Dis. 2007;13:491–3.PubMedCrossRefGoogle Scholar
  36. 36.
    •. Miller BA, Gray A, Leblanc TW, et al.: Acute eosinophilic pneumonia secondary to daptomycin: a report of three cases. Clin Infect Dis. 2010;50:e63–8. This article was one of the first descriptions of acute eosinophilic pneumonitis with daptomycin use. CrossRefGoogle Scholar
  37. 37.
    Drew RH. Emerging options for treatment of invasive, multidrug-resistant Staphylococcus aureus infections. Pharmacotherapy. 2007;27:227–49.PubMedCrossRefGoogle Scholar
  38. 38.
    Stryjewski ME, Graham DR, Wilson SE, et al. Telavancin versus vancomycin for the treatment of complicated skin and skin-structure infections caused by gram-positive organisms. Clin Infect Dis. 2008;46:1683–93.PubMedCrossRefGoogle Scholar
  39. 39.
    • Corey GR, Wilcox M, Talbot GH, et al.: Integrated analysis of CANVAS 1 and 2: phase 3, multicenter, randomized, double-blind studies to evaluate the safety and efficacy of ceftaroline versus vancomycin plus aztreonam in complicated skin and skin-structure infection. Clin Infect Dis. 2010;51:641–50. This article reported the combined analysis of data from two parallel studies of ceftaroline compared with vancomycin and aztreonam for treatment of complicated skin and soft tissue infections (CANVAS I & II). PubMedCrossRefGoogle Scholar
  40. 40.
    Centers for Disease Control and Prevention: MRSA and the Workplace. Available at: Accessed 4/21/2011.
  41. 41.
    Begier EM, Frenette K, Barrett NL, et al. A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis. 2004;39:1446–53.PubMedCrossRefGoogle Scholar
  42. 42.
    Rahimian J, Khan R, LaScalea KA. Does nasal colonization or mupirocin treatment affect recurrence of methicillin-resistant Staphylococcus aureus skin and skin structure infections? Infect Control Hosp Epidemiol. 2007;28:1415–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Simor AE, Phillips E, McGeer A, et al. Randomized controlled trial of chlorhexidine gluconate for washing, intranasal mupirocin, and rifampin and doxycycline versus no treatment for the eradication of methicillin-resistant Staphylococcus aureus colonization. Clin Infect Dis. 2007;44:178–85.PubMedCrossRefGoogle Scholar
  44. 44.
    Ellis MW, Griffith ME, Dooley DP, et al. Targeted intranasal mupirocin to prevent colonization and infection by community-associated methicillin-resistant Staphylococcus aureus strains in soldiers: a cluster randomized controlled trial. Antimicrob Agents Chemother. 2007;51:3591–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Miller LG, Diep BA. Clinical practice: colonization, fomites, and virulence: rethinking the pathogenesis of community-associated methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46:752–60.PubMedCrossRefGoogle Scholar
  46. 46.
    Nerandzic MM, Cadnum JL, Pultz MJ, Donskey CJ: Evaluation of an automated ultraviolet radiation device for decontamination of Clostridium difficile and other healthcare-associated pathogens in hospital rooms. BMC Infect Dis. 10:197.Google Scholar
  47. 47.
    Rutala WA, Gergen MF, Weber DJ: Room decontamination with UV radiation. Infect Control Hosp Epidemiol. 31:1025–9.Google Scholar
  48. 48.
    Otter JA, Yezli S, Schouten MA, et al. Hydrogen peroxide vapor decontamination of an intensive care unit to remove environmental reservoirs of multidrug-resistant gram-negative rods during an outbreak. Am J Infect Control. 2010;38:754–6.PubMedCrossRefGoogle Scholar
  49. 49.
    Otter JA, Puchowicz M, Ryan D, et al. Feasibility of routinely using hydrogen peroxide vapor to decontaminate rooms in a busy United States hospital. Infect Control Hosp Epidemiol. 2009;30:574–7.PubMedCrossRefGoogle Scholar
  50. 50.
    Evans HL, Dellit TH, Chan J, et al. Effect of chlorhexidine whole-body bathing on hospital-acquired infections among trauma patients. Arch Surg. 2010;145:240–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Luke F. Chen
    • 1
    Email author
  • Cody Chastain
    • 2
  • Deverick J. Anderson
    • 1
  1. 1.Program for Infection Prevention and Healthcare Epidemiology, Division of Infectious Diseases and International Health, Department of MedicineDuke University Medical CenterDurhamUSA
  2. 2.Department of MedicineDuke University Medical CenterDurhamUSA

Personalised recommendations