Thumb cellulitis attributable to group G streptococcus.

is considered endemic in hospitals and long-term care facilities, an ongoing debate exists about whether all identified cases of MRSA, particularly in asymptomatic individuals, should be treated. There is little disagreement, however, regarding the use of MRSA to treat symptomatic infections. Intermittent as well as continuous bladder irrigation utilizing various pharmacological agents has been used in various clinical settings. In a survey of418 hospitals in japan, 58 kinds of irrigants were prepared.f Though antifungal bladder irrigation has long been used successfully for the treatment of fungal cystitis, antibiotic irrigants have been much less popular, and the outcome of therapy has been lessconsistent. There are no reports on vancomycin bladder irrigation. Several restrictions may limit the usefulness of vancomycin bladder irrigation for MRSA infections. In cases of pylonephritis or infections ascending the ureters, bladder irrigation is clearly an inappropriate delivery system. Even in uncomplicated cystitis, exposure of the bladder mucosa to the irrigant is not uniform. CBI is principally likely to affect organisms near the bladder trigone, with exposure to other areas being less predictable.:' A suggested solution is infusion of 200 to 300 mL of irrigant followed by cross clamping of the catheter for 60 to 90 minutes." Another factor influencing the outcome of therapy is the degree of infection. A study of six antibiotic solutions used in a bladder washout procedure revealed that when the bacterial density was 10 CFU/mL of urine, all six solutions were equally effective in eliminating the infection, but when the bacterial concentration was 10 to 10 CFU/mL, only one irrigant proved successful. It is likely that the bacterial concentration as a determinant of the outcome of antibiotic bladder irrigation holds true for vancomycin as well. Finally, concomitant polymicrobial infections have been noted frequently in patients with MRSA in their urine, and vancomycin may not cover all the pathogens. While bladder absorption of vancomycin was negligible in this case, reports of significant serum levels and even systemic toxicity with other antibiotics exist.s.6 As a result, until vancomycin bladder irrigation is better studied, monitoring serum levels is advisable, particularly in cases of renal failure. Absorption may be enhanced by increased pressure within the bladder and mucosal inflammation (caused by the UTI or the vancomycin), both of which act as driving forces for antibiotic absorption. Whether this method of treating MRSA cystitis will prove to be effective remains to be seen. The best control policy, however, is still primary prevention of spread by observing basic infection control techniques.