Pediatric MRSA: Multiple settings present 'breeding grounds' for disease

October 1, 2008

Schools, sports programs, and day care centers provide ideal "breeding grounds" for methicillin-resistant Staphylococcus aureus infections. Any suspicious lesion should be cultured early. Comprehensive education is needed to minimize risk of transmission and to quell hysteria.

Key Points

"More than 80 percent of CA-MRSA infections involve the skin and soft tissue, and as primary care physicians of the skin, dermatologists are often responsible for recognition, treatment and care coordination," says Dr. Hartley, associate clinical professor of pediatrics and dermatology, George Washington University School of Medicine, Washington, D.C.

Schools, sports programs and day care centers provide ideal "breeding grounds" for MRSA infections, Dr. Hartley tells Dermatology Times.

Diagnosis and therapy

Most children who develop MRSA infections are otherwise healthy and present with a spontaneous abscess, which is often mistaken for a spider bite. Severe pain is a helpful clue that MRSA infection may be the cause.

Suspicious lesions should be cultured promptly.

Incision and drainage (I&D) remains the mainstay of therapy. A cruciate incision should be made to encourage continued drainage, and the wound should not be packed.

Antibiotics may not be necessary if the lesion can be effectively drained, and antibiotic therapy without I&D is not recommended unless the lesion cannot be drained.

Although it is off-label, trimethoprim-sulfamethoxazole is usually the treatment of choice for MRSA skin infections in children and adults. However, an alternative should be selected if there is a strong suspicion that the infection may be caused by streptococcus.

Clindamycin is another reasonable alternative for MRSA, but since inducible clindamycin resistance may occur, the microbiology laboratory should be asked to perform a clindamycin disk induction test (D-test) on isolates that are erythromycin-resistant.

Tetracycline treatment with doxycyline or minocyline is an option for children more than eight years of age.

"Linezolid (Zyvox, Pfizer) is extremely effective, but also extremely expensive, and while sometimes used in children, it is not FDA (Food and Drug Administration) approved in this age group.

"Rifampin may be helpful, but should not be used as monotherapy because of the possibility of resistance," Dr. Hartley says.

Topical treatments

Dr. Hartley suggests avoiding topical mupirocin ointment in all MRSA patients, as the CDC does not recommend its routine use, and MRSA resistance to mupirocin has been increasing.

Dr. Hartley says that as a general rule, mupirocin ointment should be used in short "pulses" - i.e., about a week at a time - to minimize the risk of emergence of resistant strains.

Alternative topical treatments include the newly available retapamulin 1 percent ointment (Altabax, GSK) and the older products, bacitracin, silver sulfadiazine, and triple antibiotic.

Dilute bleach baths are a useful, inexpensive and readily available strategy for body decolonization. While there is no standard protocol, the addition of ¼ to 1 cup of household bleach in a standard tub of water for a 10-minute soak is commonly used.

Patients who have been treated for MRSA infection should be closely monitored for response and complications, Dr. Hartley says.

Disclosure: Dr. Hartley has no financial interests relevant to the material he discussed.

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