PVL Staph aureus

Post for academic purposes only. It MUST NOT be used to make a clinical decision. For clinical advice, please discuss with your doctor.

Clinical Guide for Diagnosis and Management

In the UK, PVL genes are carried by < 2% of clinical S. aureus isolates

🔍 Clinical Features

Recognize skin/soft tissue infections and invasive disease presentations

⚠️ Risk Factors

5C model and high-risk populations and settings

🧪 Testing & Diagnosis

Sample collection, processing, and PVL testing protocols

🫁 Pneumonia Management

Necrotising pneumonia recognition and treatment protocols

🩹 SSTI Management

Skin and soft tissue infection treatment guidelines

🦴 Osteomyelitis

Deep-seated infection management and treatment options

🛡️ Infection Control

PPE requirements, isolation, and outbreak management

👨‍⚕️ Staff Management

Healthcare worker screening, decolonisation, and return-to-work

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Clinical Features of PVL-SA

Skin and Soft Tissue Infections

• Suspect when: Recurrent skin and soft tissue infections
• Purulent eye infections
• Variable size lesions with/without necrosis
• Pain disproportionate to appearance
• Multiple cases in close contact settings

Invasive Infections

• Necrotising pneumonia - may follow flu-like symptoms
• Necrotising fasciitis
• Purpura fulminans
• Acute haematogenous osteomyelitis
• Osteoarticular infections in children
• Pyomyositis

Key Clinical Signs: Haemoptysis and elevated inflammatory markers may accompany necrotising pneumonia

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Risk Factors for PVL-SA

Remember the 5C Model:

Contaminated items

Shared towels, equipment

Close contact

Direct person-to-person contact

Crowding

Overcrowded living conditions

(Lack of) Cleanliness

Poor hygiene practices

Cuts

Compromised skin integrity

High-Risk Settings

• Households
• Close contact sports (wrestling, American football, rugby, judo)
• Military training camps
• Gyms
• Prisons

Typical Patient Profile: Young, healthy people, students, athletes, and military personnel with no significant medical history

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Testing for PVL

Sample Collection

• Wound swab or pus for skin/soft tissue infections
• Sputum/BAL for respiratory infections
• Blood culture for systemic infections
• Process samples as per national SMI

Clinical Hint: If isolate is MRSA and ciprofloxacin sensitive, higher chance of being PVL positive

PVL Testing Process

1. Grow Staphylococcus aureus from sample
2. Send isolate to reference laboratory for PVL test
3. Results guide treatment decisions

Outbreak Investigation

Outbreak Type	Screening Medium	Notes
PVL MSSA	Non-selective agar (blood agar)	Standard screening approach
PVL MRSA	Selective medium (Mannitol Salt Agar, chromogenic media)	Do NOT use ciprofloxacin for MRSA selection

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Managing PVL Pneumonia

Initial Management: Start treatment as per NICE CAP guidelines (NOT the old PVL guideline recommendations)

Clinical Suspicion Criteria

• Multilobular infiltrates
• Respiratory rate >30, Pulse rate >140
• Haemoptysis
• Leukopenia ± skin and soft tissue infection
• Young patient
• Recent flu-like illness or close contact
• High inflammatory markers, raised CK (pyomyositis)

Management Protocol

1. Admit to intensive care/critical care
2. Send urine for Pneumococcal & Legionella antigen
3. Test for other causes (flu, pulmonary embolism)
4. Take respiratory culture with appropriate PPE
5. Take 2 sets of blood cultures, wound cultures

Empiric Antibiotic Treatment

Standard: Linezolid 600mg bd + Clindamycin 1.2g QDS

Severe disease/TSS: Add IVIG 2g/kg + Rifampicin 600mg bd

If Not Improving

• Check source control and alternative infection sources
• Check for other resistant pathogens
• Consider 2nd dose of IVIG

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Managing Skin and Soft Tissue Infections

Important: Most PVL Staph aureus in the UK are sensitive to flucloxacillin. Always perform sensitivity tests as per EUCAST, including D test for erythromycin-clindamycin.

Minor SSTI

Furunculosis, folliculitis, small abscesses/boils without cellulitis

• Usually no systemic antibiotics needed
• Exceptions: immunocompromised, infants, clinical deterioration
• Incision and drainage optimal for abscesses

Moderate SSTI

Cellulitis and larger abscesses (especially >5cm)

Organism	Treatment Options
MSSA	• Flucloxacillin 500mg qds • Clindamycin 450mg qds
PVL-MRSA (outpatient)	• Rifampicin 300mg bd + Doxycycline 100mg bd • Rifampicin 300mg bd + Fusidic acid 500mg tds • Rifampicin 300mg bd + Trimethoprim 200mg bd • Clindamycin 450mg qds

Severe Infection

• IV vancomycin, teicoplanin, daptomycin, or linezolid
• Tigecycline for broader polymicrobial cover (avoid if sepsis signs)

Severe with Toxic Shock/Necrotising Features

Triple therapy:
• Linezolid 600mg bd
• Clindamycin 1.2-1.8g qds
• Rifampicin 600mg bd
• Surgical debridement
• Treat for 10-14 days

Rifampicin Benefits: Excellent tissue penetration, reaches intracellular staphylococci, synergistic with other antibiotics including linezolid

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Managing Osteomyelitis and Deep-Seated Infections

Investigation

• Blood culture - two sets appropriately filled
• Inflammatory markers (WCC, CRP, ESR) and renal/liver function baseline
• Imaging: MRI/radio-isotope scan
• Assess for DVT

Treatment Options

Category	Treatment
Preferred	• Teicoplanin 400-800mg IV q24h (after loading dose) • Vancomycin 1g IV q12h PLUS one of: • Gentamicin 5-7mg/kg IV once daily • Rifampicin 300mg PO twice daily • Sodium fusidate 500mg PO thrice daily
2nd Choice	• Linezolid 600mg IV/PO q12h • Daptomycin 6-8mg/kg IV once daily (off-label) • Tigecycline 100mg loading, then 50mg IV q12h

If MSSA confirmed: Use sensitivity-guided agents that inhibit toxin production and have good bone penetration (e.g., Clindamycin + rifampicin or linezolid)

If MRSA positive or unknown: Treat as MRSA regardless

Important Considerations

• Hospital assessment likely required with orthopaedic advice
• May require prolonged treatment and repeated surgery
• Monitor drug levels:
  • Teicoplanin trough: 10-20 mg/L
  • Vancomycin trough: 10-15 mg/L
• Linezolid maximum 4 weeks (peripheral neuropathy risk)

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Infection Control

Standard Precautions

• Contact precautions (as per MRSA protocol, even for PVL-MSSA)
• Single room isolation
• Personal protective equipment (plastic apron and gloves)
• Meticulous hand hygiene
• Environmental cleaning

Necrotising Pneumonia PPE:
Healthcare workers must wear face and eye protection (surgical mask with integral eye protection) during intubation and respiratory care

Staff Exposure Protocol

If staff exposed during aerosol-generating procedure without appropriate PPE:

• Screen 3-7 days after exposure
• Advise to report symptoms to physician
• Managed by occupational health

Work Restrictions

Cannot work in: Nursery, hospital, residential/care homes, food industry until all lesions healed

Other professions: May continue work with infected areas covered by clean, dry dressings

Screening and Decolonisation

Primary Case Screening

• Anterior nares and throat swabs
• Any suspicious lesions, including damaged skin
• Additional sites: perineum, axilla

Decontamination Protocol

Body wash: Chlorhexidine 4% or Triclosan 2% once daily for 5 days

Nasal: Mupirocin (Bactroban) three times daily for 5 days

Contact Management

• Close contacts with history of past infection: decolonise without prior screening
• Household contacts of necrotising pneumonia: 5-day topical decolonisation immediately
• Consider oseltamivir prophylaxis if index case had influenza

Notification Requirements

• Hospital cases: Notify infection control
• Suspected outbreak: Inform public health
• Staff involvement: Notify occupational health

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Managing Healthcare Staff with PVL-SA

All staff management done via occupational health

Active Infection

• HCWs should not work with infected skin or purulent eye lesions
• All cuts and grazes must be covered
• Report all lesions promptly to Occupational Health Service

Return to Work Criteria

HCW with proven PVL-SA infection should not work until:

1. Acute infection has resolved
2. 48 hours of five-day decolonisation regimen completed

Contact/Family Management

• Make enquiries in close contact with staff member
• Families can be treated simultaneously if required

Follow-up Screening

• As per MRSA guidelines: three screens, one week apart
• Re-colonisation may occur from community contact
• Staff must stop working if further skin lesions develop

Decolonisation Failure

If staff remains carrier despite two courses of treatment:

• May continue work if not implicated in hospital transmission
• Must cease working immediately if infected skin lesion develops

Community Activity Restrictions

Avoid until lesions healed:
• Gyms, saunas, swimming pools
• Massage, manicure facilities
• Other communal/recreational settings where lesions cannot be adequately covered