Consider methicillin-resistant Staphylococcus aureus (MRSA) in patients with community-acquiredStaphylococcus aureus infections
Consider methicillin-resistant Staphylococcus aureus (MRSA) in patients with community-acquiredStaphylococcus aureus infections: Excerpt from Avoiding Common Pediatric Errors
Author:
Sarika Joshi, MD
What to Do - Interpret the Data
MRSA has increased in prevalence throughout the world. In addition to being resistant to methicillin, these organisms are also resistant to all β-lactam
antibiotics, including cephalosporins. Although they are often thought of
as a nosocomial pathogen, MRSA has been increasing in incidence in the
community, as well. It is imperative for physicians to recognize MRSA as
an important pathogen, and to understand the different characteristics of
nosocomial versus community-acquired microbes.
In the United States, there is a high occurrence of MRSA among hospitalized patients. According to the Surveillance and Control of Pathogens
of Epidemiologic Importance database, the frequency of MRSA responsible for nosocomial bacteremia increased more than 30% from 1995 to 2001.
Significant risk factors for nosocomial MRSA include prolonged hospitalization, prior antibiotic therapy, and proximity to a patient with MRSA. In
addition, the incidence of MRSA is pronounced in patients requiring intensive care, with burns, and with surgical wound infections. In children,
other documented risk factors for acquisition of nosocomial MRSA are the
presence of a central venous catheter or tracheostomy and the undergoing
of frequent surgical procedures. The Hospital Infection Control Practices
Advisory Committee, the Centers for Disease Control and Prevention, and
the Society for Healthcare Epidemiology of America have established guidelines to help prevent the spread of nosocomial MRSA. As the most common
route of transmission for nosocomial MRSA is on the hands of health care
personnel, these recommendations include good hand hygiene and contact
precautions.
The prevalence of community-acquired MRSA varies substantially by
geographicregion.Certainareashaveincidencesashighas35%to83%,with
the highest occurrence in children younger than 2 years of age. Community-
acquired MRSA is genetically distinct from nosocomial MRSA. Although
nosocomial MRSA often causes respiratory and urinary tract infections,
community-acquiredMRSAisassociatedwithskinandsofttissueinfections.
Risk factors for community-acquired MRSA include skin trauma, shaving,
and physical contact with or sharing equipment with a person who has
MRSA. Transmission often occurs within families or within a group of
children in day care. Practical recommendations for reducing the spread
of community-acquired MRSA are keeping nails short, using antimicrobial
soaps, and changing sleep wear and towels daily.
The first step in the treatment of MRSA is identification and removal
of potential foci of infection, such as indwelling catheters and abscesses. For
nosocomial MRSA, intravenous vancomycin is the drug of choice. In children, the dose of vancomycin is 40 to 60 mg/kg/day divided in three to four
doses. Other agents that have been used to treat nosocomial MRSA include
clindamycin, although resistance may be readily induced; and linezolid. For
community-acquired MRSA, trimethoprim-sulfamethoxazole (for skin and
soft tissue infections) and clindamycin are recommended. In children, the
dose of oral trimethoprim-sulfamethoxazole is 8 to 10 mg/kg/day divided
in two doses for minor infections and 20 mg/kg/day divided in three to
four doses for severe infections. The dose of oral clindamycin in children
is 10 to 30 mg/kg/day divided in three to four doses. Other agents that
have been used to treat community-acquired MRSA include linezolid and
minocycline (for children younger than 8 years of age). Because antibiotic
susceptibility of community-acquired MRSA can vary substantially by region, physiciansneed to be aware oflocal resistance patterns.Susceptibilities
of wound cultures should be followed after initiation of empiric antibiotic
therapy.
MRSA infections can be acquired in the hospital or in the community. Nosocomial and community-acquired organisms have differing
antibiotic resistance patterns and are associated with distinct infections.
Vancomycin is the treatment of choice for nosocomial MRSA, whereas
trimethoprim-sulfamethoxazole and clindamycin are recommended for
community-acquired MRSA.
Suggested Readings
Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S. aureus infections among
patients in the emergency department. N Engl J Med. 2006;355:666–674.
Naimi TS, LeDell KH, Como-Sabetti K, et al. Comparison of community-and health care-
associated methicillin-resistant Staphylococcus aureus infection. JAMA. 2003;290:2976–
2984.
Sattler CA, Mason EO Jr, Kaplan SL. Prospective comparison of risk factors and demographic
and clinical characteristics ofcommunity-acquired,methicillin-resistant versus methicillin
susceptibleStaphylococcusaureusinfectioninchildren.PediatrInfectDisJ.2002;21:910–917.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Staphylococcal infection
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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» Next page: Follow patients with Staphylococcal aureus bacteremia closely for development of a new murmur (Avoiding Common Pediatric Errors)
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