What to do When a Patient With MRSA Comes to Our Office: What We Do and Why

By Sandra Lora Cremers, MD, FACS

Every so often a patient arrives at the office who is known to carry MRSA, and the front desk quietly wonders what to do. Should the patient have called ahead? Should they be wearing a gown and gloves? The short answer is reassuring. The patient does not carry the burden of infection control. We do. Here is what MRSA is, how we should treat it, and exactly how our office keeps everyone safe when a patient with MRSA comes in for a visit.

What MRSA Actually Is:

MRSA stands for methicillin resistant Staphylococcus aureus. Staphylococcus aureus is a common bacterium that lives harmlessly on the skin and inside the nose of many healthy people. In some strains it has developed resistance to the antibiotics we once relied on, which is what the methicillin resistant label means. It can cause skin and soft tissue infections, and in eye care it can cause conjunctivitis, eyelid infections, tear duct infections, and, rarely, corneal infections. In the eye, MRSA conjunctivitis is the most common ocular MRSA infection, and it is generally not sight threatening.[1]

Why an Outpatient Office Is Different From a Hospital:

In a hospital, contact precautions begin at the door of the room. In an outpatient office the situation is different, because patients move through shared waiting areas, touch common surfaces, and interact with staff before anyone knows precautions are needed. The framework we follow comes from the 2022 SHEA, IDSA, and APIC update and from the CDC isolation precautions, adapted for the ambulatory setting.[2][3] The guiding principle is simple. The responsibility for infection control rests with the office and its staff, not with the patient. Patients are not expected to arrive wearing gowns and gloves.

What We Should Do When a Patient With MRSA Arrives

We should room the patient quickly. The CDC advises placing a patient who needs contact precautions into an exam room as soon as possible to limit time in shared spaces, and when we know in advance that a patient with an active skin infection or draining wound is coming, we may schedule them at the end of the day or in a designated room.[3]

Our staff, not the patient, wears the protective equipment. Team members put on gloves and a gown before direct contact with the patient or the immediate environment, then remove them and perform hand hygiene before leaving the room.[2][3]

Hand hygiene is the single most important measure we take. Alcohol based hand rubs are effective against MRSA, and we enforce hand hygiene before and after every patient contact. We should also offer hand sanitizer to the patient on arrival, which is a simple and high value step.[2][4]

We should ask that wounds be covered. A patient with an active MRSA skin infection should have all wounds and draining lesions covered with clean, dry bandages before and during the visit. This is the most practical thing a patient can do on their side, and it is the same advice the CDC gives for community MRSA prevention.[5][6]

We should manage our equipment carefully. Whenever possible we should dedicate noncritical items such as stethoscopes, blood pressure cuffs, slit lamps, and chin rests to that patient, or we clean and disinfect shared equipment between patients with an EPA registered hospital disinfectant. In our world this matters especially for ophthalmic equipment such as IPL handpieces, tonometers, and trial frames.[2]

We should clean the room thoroughly afterward. After the visit we disinfect every high touch surface, including door handles, chair arms, countertops, light switches, and any equipment that was touched, using an EPA registered disinfectant with the correct contact time. Standard quaternary ammonium and sodium hypochlorite based products are effective against MRSA.[2][3][4]

We should watch the waiting room. If a patient must wait in a shared area, we make sure they have cleaned their hands, that wounds are covered, and that they are seated away from immunocompromised patients when possible, and we should wipe down the chair once they are roomed.[4]

A More Practical, Risk Tailored Approach

Full gown and glove use for every single interaction is not always practical in a busy office, and the field is evolving toward a smarter model. A 2025 study found that 63 percent of healthcare personnel support a risk tailored approach, meaning gloves and gowns are used selectively for higher risk activities such as direct patient contact and wound care rather than universally for every interaction. Physicians and advanced practice providers showed the strongest support at 77 percent.[7]

How We Treat MRSA Conjunctivitis

MRSA conjunctivitis is usually not sight threatening, and treatment depends on severity. Fortified vancomycin eye drops, typically 25 mg/mL, remain the standard recommendation, and referral to ophthalmology is advised for suspected cases.[8] Vancomycin 1 percent ophthalmic ointment applied four times daily has shown a clinical response rate of about 67 percent and an eradication rate of about 68 percent in refractory cases.[9]

Vancomycin is not always necessary. A 10 year review found that many ocular MRSA infections can be treated effectively without it, reserving vancomycin for refractory or vision threatening disease. Antibiotics with high MRSA susceptibility include chloramphenicol, where resistance is rare and which is an excellent first choice where it is available, along with trimethoprim sulfamethoxazole and gentamicin. Fluoroquinolones such as ciprofloxacin and moxifloxacin have resistance rates of roughly 30 to 60 percent in MRSA and are not reliable as empiric choices.[10][11][12] Newer lipoglycopeptides, including oritavancin, dalbavancin, and telavancin, show stronger activity in the laboratory against ocular MRSA than vancomycin with a comparable safety profile on corneal cells, though they remain investigational for topical eye use.[13]

How We Treat MRSA Skin Infection

For skin and soft tissue infection we follow the 2014 IDSA guidelines, which stratify treatment by severity.[14]

For mild and localized infection, such as a small abscess smaller than 5 cm or impetigo, incision and drainage of an isolated abscess may be enough on its own, and topical mupirocin 2 percent can be used for superficial infection and as an added measure.[15][16]

For moderate infection, such as multiple or larger lesions or purulent cellulitis, we use oral antibiotics for 7 to 10 days. First line options include trimethoprim sulfamethoxazole, which covers roughly 90 to 100 percent of community associated MRSA, doxycycline or minocycline, which we avoid in children under 8 years of age and in pregnancy, clindamycin, where we check local resistance and use a D test to rule out inducible resistance, and linezolid, which is effective but costly and usually reserved for when other agents will not work.[16][17][18]

For severe or complicated infection, with systemic signs, progressive lesions, or an immunocompromised patient, intravenous vancomycin remains the standard of care.[19][20] Alternatives include intravenous linezolid, daptomycin, ceftaroline, and the newer agent ceftobiprole, which was approved in 2024. Long acting lipoglycopeptides such as dalbavancin and oritavancin can be given as a single or two dose intravenous course and allow earlier discharge or outpatient treatment, and tedizolid and omadacycline are additional approved options.[21][22][23]

In atopic dermatitis specifically, a 2024 meta analysis found that the antibiotics with the best susceptibility against Staphylococcus aureus, above 85 percent, include trimethoprim sulfamethoxazole, vancomycin, mupirocin, linezolid, doxycycline, daptomycin, and minocycline, while erythromycin, fusidic acid, and clindamycin performed less well.[24]

Decolonization for Recurrent MRSA

For patients who keep getting MRSA infections, decolonization can help. The CLEAR trial, published in 2019, showed that decolonization after discharge with twice monthly chlorhexidine bathing and nasal mupirocin significantly reduced MRSA infections and rehospitalizations, with a number needed to treat of about 25 to 30.[25] For recurrent community associated MRSA skin infections, a regimen of nasal mupirocin, an antiseptic body wash, and a short course of an oral antibiotic active against MRSA reduced recurrence dramatically, from 0.84 to 0.03 infections per month in one study.[26] The IDSA supports considering decolonization with intranasal mupirocin, together with chlorhexidine or dilute bleach baths, for patients with recurrent skin and soft tissue infections despite good wound care and hygiene.[14][27]

The Bottom Line

When a patient with MRSA comes to our office, we room them promptly, our staff wears gloves and a gown for direct contact and removes them with hand hygiene before leaving, the patient keeps wounds covered, we offer hand sanitizer on arrival, we dedicate or disinfect equipment between patients, and we disinfect every high touch surface afterward. For active infection we may schedule at the end of the day, and for patients who keep getting infections we discuss decolonization. Most important of all, the patient does not need to arrive in a gown and gloves. The responsibility for keeping everyone safe rests with our office workflow and with the steady, consistent habits of our staff.

References

1. Harford DA, Greenan E, Knowles SJ, Fitzgerald S, Murphy CC. The Burden of Methicillin-Resistant Staphylococcus aureus in the Delivery of Eye Care. Eye (London, England). 2022;36(7):1368-1372. doi:10.1038/s41433-021-01643-6.

2. Popovich KJ, Aureden K, Ham DC, et al. SHEA/IDSA/APIC Practice Recommendation: Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute-Care Hospitals: 2022 Update. Infection Control and Hospital Epidemiology. 2023;44(7):1039-1067. doi:10.1017/ice.2023.102.

3. Siegel JD, Rhinehart E, Jackson M, Chiarello L. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings. American Journal of Infection Control. 2007;35(10 Suppl 2):S65-164. doi:10.1016/j.ajic.2007.10.007.

4. Boyce JM. Hand and Environmental Hygiene: Respective Roles for MRSA, Multi-Resistant Gram Negatives, Clostridioides difficile, and Candida spp. Antimicrobial Resistance and Infection Control. 2024;13(1):110. doi:10.1186/s13756-024-01461-x.

5. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and Resurgence of Meticillin-Resistant Staphylococcus aureus as a Public-Health Threat. Lancet (London, England). 2006;368(9538):874-885. doi:10.1016/S0140-6736(06)68853-3.

6. Putukian M, Leclere LE, Herring SA, et al. The Adolescent Athlete and the Team Physician: A Consensus Statement, 2025 Update. Medicine and Science in Sports and Exercise. 2026;58(2):371-402. doi:10.1249/MSS.0000000000003863.

7. O'Hara LM, Calfee DP, Snyder GM, et al. A Discrete Choice Experiment to Evaluate Healthcare Personnel Preferences Regarding Risk-Tailored Policies for Contact Precautions for Patients With Methicillin-Resistant Staphylococcus aureus. Infection Control and Hospital Epidemiology. 2025;46(7):710-715. doi:10.1017/ice.2025.65.

8. Azari AA, Barney NP. Conjunctivitis. JAMA. 2013;310(16):1721-1729. doi:10.1001/jama.2013.280318.

9. Sotozono C, Fukuda M, Ohishi M, et al. Vancomycin Ophthalmic Ointment 1% for Methicillin-Resistant Staphylococcus aureus or Methicillin-Resistant Staphylococcus epidermidis Infections: A Case Series. BMJ Open. 2013;3(1):e001206. doi:10.1136/bmjopen-2012-001206.

10. Wong ES, Chow CW, Luk WK, Fung KS, Li KK. A 10-Year Review of Ocular Methicillin-Resistant Staphylococcus aureus Infections: Epidemiology, Clinical Features, and Treatment. Cornea. 2017;36(1):92-97. doi:10.1097/ICO.0000000000001048.

11. Bineshfar N, Clauss KD, Lee WW, Miller D. Microbiology and Management of Staphylococcus aureus Lacrimal System Infections: A 10-Year Retrospective Study. PLoS One. 2024;19(11):e0314366. doi:10.1371/journal.pone.0314366.

12. Chang VS, Dhaliwal DK, Raju L, Kowalski RP. Antibiotic Resistance in the Treatment of Staphylococcus aureus Keratitis: A 20-Year Review. Cornea. 2015;34(6):698-703. doi:10.1097/ICO.0000000000000431.

13. Andre C, Islam MM, Paschalis E, Bispo PJM. Comparative in Vitro Activity of New Lipoglycopeptides and Vancomycin Against Ocular Staphylococci and Their Toxicity on the Human Corneal Epithelium. Cornea. 2023;42(5):615-623. doi:10.1097/ICO.0000000000003197.

14. Stevens DL, Bisno AL, Chambers HF, et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 2014;59(2):147-159. doi:10.1093/cid/ciu296.

15. Singer AJ, Talan DA. Management of Skin Abscesses in the Era of Methicillin-Resistant Staphylococcus aureus. The New England Journal of Medicine. 2014;370(11):1039-1047. doi:10.1056/NEJMra1212788.

16. Daum RS. Skin and Soft-Tissue Infections Caused by Methicillin-Resistant Staphylococcus aureus. The New England Journal of Medicine. 2007;357(4):380-390. doi:10.1056/NEJMcp070747.

17. John JF. The Treatment of Resistant Staphylococcal Infections. F1000Research. 2020;9:F1000 Faculty Rev-150. doi:10.12688/f1000research.17718.1.

18. DeLeo FR, Otto M, Kreiswirth BN, Chambers HF. Community-Associated Meticillin-Resistant Staphylococcus aureus. Lancet (London, England). 2010;375(9725):1557-1568. doi:10.1016/S0140-6736(09)61999-1.

19. VanEperen AS, Segreti J. Empirical Therapy in Methicillin-Resistant Staphylococcus aureus Infections: An Up-to-Date Approach. Journal of Infection and Chemotherapy. 2016;22(6):351-359. doi:10.1016/j.jiac.2016.02.012.

20. Rodvold KA, McConeghy KW. Methicillin-Resistant Staphylococcus aureus Therapy: Past, Present, and Future. Clinical Infectious Diseases. 2014;58 Suppl 1:S20-27. doi:10.1093/cid/cit614.

21. Tiseo G, Falcone M. The Future Approach for the Management of Acute Bacterial Skin and Skin Structure Infections. Current Opinion in Infectious Diseases. 2025;38(2):128-135. doi:10.1097/QCO.0000000000001092.

22. Hindy JR, Haddad SF, Kanj SS. New Drugs for Methicillin-Resistant Staphylococcus aureus Skin and Soft Tissue Infections. Current Opinion in Infectious Diseases. 2022;35(2):112-119. doi:10.1097/QCO.0000000000000800.

23. FDA Orange Book. U.S. Food and Drug Administration.

24. Elizalde-Jimenez IG, Ruiz-Hernandez FG, Carmona-Cruz SA, et al. Global Antimicrobial Susceptibility Patterns of Staphylococcus aureus in Atopic Dermatitis: A Systematic Review and Meta-Analysis. JAMA Dermatology. 2024;160(11):1171-1181. doi:10.1001/jamadermatol.2024.3360.

25. Huang SS, Singh R, McKinnell JA, et al. Decolonization to Reduce Postdischarge Infection Risk among MRSA Carriers. The New England Journal of Medicine. 2019;380(7):638-650. doi:10.1056/NEJMoa1716771.

26. Miller LG, Tan J, Eells SJ, Benitez E, Radner AB. Prospective Investigation of Nasal Mupirocin, Hexachlorophene Body Wash, and Systemic Antibiotics for Prevention of Recurrent Community-Associated Methicillin-Resistant Staphylococcus aureus Infections. Antimicrobial Agents and Chemotherapy. 2012;56(2):1084-1086. doi:10.1128/AAC.01608-10.

27. Simor AE. Staphylococcal Decolonisation: An Effective Strategy for Prevention of Infection? The Lancet Infectious Diseases. 2011;11(12):952-962. doi:10.1016/S1473-3099(11)70281-X.