Anovaginal colonization with 5 aureus is identified in 10 to 25 percent of obstetrical patients (Top, 2010). Skin and soft tissue infections are the most common presentation of MRSA in pregnant women (Fig. 64-8). Mastitis and breast abscesses have been reported in up to a fourth of cases of MRSA complicating pregnancy (Laibl, 2005; Lee, 2010). Perineal abscesses, wound infections at sites such as abdominal and episiotomy incisions, and chorioamnionitis are also associated with MRSA (Pimentel, 2009; hurman, 2008). Finally, osteomyelitis has been reported (Nguyen, 2015; Tanamai, 2016).
A rise in CA-MRSA infections has been reported in neonatal intensive care units and newborn nurseries. In these settings, infection is frequently associated with maternal and health-care worker skin infections and infected breast milk. Vertical transmission is rare (Jimenez-Truque, 2012; Pinter, 2009).
he Infectious Diseases Society of America has published guidelines for the treatment of MRSA infections (Liu, 2011). Uncomplicated supericial infections are primarily managed by drainage and local wound care. Although historically
FIGURE 64-8 This antepartum patient presented with multiple small microabscesses for which culture identified methicillinresistant Staphylococcus aureus. (Used with permission from
Dr. Stephan Shivvers.) de-emphasized, recent evidence suggests benefit from antibi otic therapy in addition to incision and drainage of smaller abscesses (Daum, 2017; Forcade, 2012). Severe superficial infections, especially those that fail to respond to local care or those in patients with medical comorbidities, are treated with MRSA-appropriate antibiotics. Purulent cellulitis should be treated empirically for CA-MRSA until culture results are available.
Most CA-MRSA strains are sensitive to trimethoprim-sul famethoxazole and clindamycin (\1iller, 2015; T alan, 2016).
for mono therapy. Linezolid, although efective against MRSA, is expensive, and there is little information regarding its use in pregnancy. Doxycycline, minocycline, and tetracycline, although efective for MRSA infections, should not be used in pregnancy. Vancomycin remains the irst-line therapy for inpatient serious MRSA infections.
he control and prevention of HA-NIRSA and CA-MRSA rely on appropriate hand hygiene and prevention of skin-toskin contact or contact with wound dressings. Decolonization should be considered only in cases in which a patient develops recurrent supericial infections despite optimal hygiene measures or if ongoing transmission occurs among household or close contacts (Liu, 2011). Decolonization measures include nasal treatment with mupirocin, chlorhexidine gluconate baths, and oral rifampin therapy if previous measures have failed. Routine decolonization is not efective in the general obstetrical population. For women with culture-proven CA-MRSA infection during pregnancy, we add single-dose vancomycin to routine beta-Iactam perioperative prophylaxis for cesarean deliveries and higher-order perineal lacerations. Breastfeeding in these women is not prohibited, but optimal hygiene and attention to minor skin breaks is encouraged.