Management of MRSA Infection in a Post-Surgical Diabetic Patient

Scenario:

Patient Name: Mary Jane

Age: 68

Gender: Female

Weight: 75 kg

Occupation: Retired teacher

Living Situation: Living with the spouse in one of the suburban-style houses

Chief Complaint:

Mary Jane was admitted to the hospital with fever and chills, general malaise, and redness together with slight pus-like discharge from an incision made on her abdomen, following surgery; the surgery was done to treat bowel obstruction.

Medical History

Past Medical History:

• Surgery: Surgical patent, appendectomy 10 days ago for a confirmed bowel obstruction. An incision that was done surgically has now developed some form of infection.

• Chronic Conditions: DM type II (diagnosed 10 years ago), Hypertension (diagnosed 15 years ago), Hyperlipidemia.

• Allergies: No known drug allergies.

Current Diagnosis:

• Abdominal incision site infection in the first year after surgery confirmed MRSA through culture and sensitivity tests.

• Diabetes mellitus, Type 2

• Hypertension

Past Diagnosis:

• Bowel obstruction

• Diabetic neuropathy

Family History:

Father: Deceased, cause of death Myocardial infarction, Age: 72 years old, Disease: Hypertension

Mother: Passed away from breast cancer when she was 65 years old

Brother: Alive, Type 2 diabetes

Social History:

No: nonsmoker, not a heavy drinker

Diet: Balancing intake of carbohydrate for individuals with diabetes

Exercise: Somatic inactivity because of diabetic neuropathy affecting the legs

Lab Results:

Wound culture: MRSA positive

White blood cell count (WBC): Normally 16000/µl: The value is elevated as it indicates an infection.

Blood glucose levels: 160 mg/Dl (again, reserved but latent for her diabetic experiences)

Renal function tests (BUN/creatinine): In principle, the values of GFR in normal limits range from 60 Ml/min.

Drug Information: Vancomycin

Classification: Glycopeptide antibiotic (MedlinePlus, 2024).

Mechanism of Action: Interferes with bacterial cell wall synthesis by attaching to the D-Ala-D-Ala terminal of peptide subunits of the bacterial cell wall, which disrupts cross linkage leading to bacterial cell breakage and death. It is active principally against Gram-positives such as MRSA and has no activity against Gram-negative organisms (NCBI, 2024).

Intended Use: The drug vancomycin is administered to treat severe infections proven to be caused by gram-positive bacteria particularly Community-acquired Methicillin-resistant Staphylococcus aureus (CA-MRSA) (MedlinePlus, 2024).

Therapeutic Actions: It decreases bacterial count, minimizes infection, and prevents the development of MRSA in other organs or the bloodstream thereby preventing sepsis (NCBI, 2024).

Adverse Effects

The patient should be made aware of the following potential adverse effects:

Red man syndrome: Flushed, rash, hypotension if administered at a rate more than 0.5mg/kg/min (MedlinePlus, 2024).

Nephrotoxicity: Kidneys; specifically, those patients who already have some kidney problems can also suffer from their organs being damaged (NCBI, 2024).

Ototoxicity: Otitis media or hearing impairment especially during long-term or high-dose therapy (MedlinePlus, 2024).

Thrombophlebitis: Pain, edema, and erythema at the site of interstitial fluid administration (NCBI, 2024).

Hypersensitivity reactions: Headache, hyperthermia, or more extensively – anaphylactic reactions (MedlinePlus, 2024).

Contraindications

Hypersensitivity to vancomycin: This medication should not be taken by the patient if he or she has an allergy to vancomycin (MedlinePlus, 2024).

Severe renal impairment: Dose modification may be required in patients with reduced renal function but Jane’s renal function is normal (NCBI, 2024).

Nursing Diagnoses and Monitoring

Monitor renal function: Because of toxicity, it is recommended that serum creatinine and BUN levels be measured routinely in Jane and the dosage adjusted accordingly (NCBI, 2024).

Monitor for signs of red man syndrome: Before administration, confirm the identity of the preparation and ensure that vancomycin is infused over at least 60 minutes observing for flushing or hypotensive effects. If this happens, reduce the flow rate and give the patient antihistamines where necessary (MedlinePlus, 2024).

Priority Teaching Instructions

Complete the entire course: Stress the importance of adhering to the full course of vancomycin as prescribed by the doctor even if the symptoms subside to prevent the infection from recurring or harboring antibiotic resistance (MedlinePlus, 2024).

Report signs of kidney damage: Jane should be told to contact the healthcare provider urgently if she notices decreased urination, swelling, or easily fatigued as these can be symptoms of nephrotoxicity (NCBI, 2024).

Monitor blood sugar levels: Inform her to make sure she checks her blood glucose levels often because stress, infections, and antibiotics will increase them (MedlinePlus, 2024).

Avoid rapid infusion symptoms: Let Jane understand when a person receiving the infusion should report experiences such as flushing, itching, or dizziness (MedlinePlus, 2024).

Hydration: Promote liberal water intake to ensure the kidney and other bodily organs effectively clear the medicine from the system (NCBI, 2024).

NCLEX-Style Questions:

1. A patient on vancomycin tells the nurse he is experiencing tinnitus. What will a nurse do initially?

2. What is the lab value that needs to be closely monitored in patients using vancomycin?

References

MedlinePlus. (2024). Vancomycin. https://medlineplus.gov/druginfo/meds/a604038.html#:~:text=Do%20not%20take%20more%20or,get%20worse%2C%20call%20your%20doctor

NCBI. (2024). Vancomycin. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK459263/