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      News & Perspective Drugs & Diseases CME & Education Video Decision Point
      Drugs & Diseases > Pediatrics: General Medicine

      Staphylococcus Aureus Infection Treatment & Management

      Updated: Apr 19, 2024
      • Author: Elizabeth P Baorto, MD, MPH; Chief Editor: Russell W Steele, MD  more...
      • Print
      Treatment

      Medical Care

      Because community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) causes more than one half of all staphylococcal infections in most communities, empiric therapy with penicillins or cephalosporins may be inadequate. [7] Some experts recommend combination therapy with a penicillinase-resistant penicillin or cephalosporin (in case the organism is methicillin-sensitive S aureus [MSSA]) [8] and clindamycin or a quinolone. Others suggest use of clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), rifampin, doxycycline, or a quinolone. Finally, because of concerns about induction of resistance, some recommend using TMP-SMX and rifampin in combination, rather than singly. As data accumulate, clindamycin may become the preferred outpatient antibiotic therapy (compared with TMP-SMX) in regions with a relatively low incidence of clindamycin resistance. [9]  Treatment guidelines have been published. [10]

      A randomized, double-blind study by Thwaites et al that included 758 patients with S aureus bacteremia assigned adjunctive rifampicin or a placebo, reported no overall benefit in adjunctive rifampicin over standard antibiotic therapy. [130]

      Appropriately monitor renal function, CBC count, and serum hepatic transaminase levels while patients with Staphylococcus aureus infection are undergoing therapy.

      Impetigo, folliculitis, furuncle, carbuncle

      Impetigo and other minor skin infections (ie, superficial or localized infections) may be treated with a topical agent such as mupirocin or retapamulin. However, most CA-MRSA strains are or readily become resistant to mupirocin. More extensive or serious skin disease and bullous impetigo are treated with oral antistaphylococcal agents, as noted above. [11, 131, 132, 133, 134]

      Scalded skin syndrome (Ritter disease)

      As with any S aureus toxin–mediated disease, treatment should aim to eradicate the focus of infection and end toxin production. Administer large doses of intravenous antistaphylococcal agents, such as oxacillin (150 mg/kg/d), or a first-generation cephalosporin, such as cefazolin (100 mg/kg/d). In vitro, clindamycin has been shown to inhibit the synthesis of TSST-1 and is extremely effective in combination with one of the agents mentioned above. Children with denuded skin should be touched as little as possible. Topical antimicrobial agents have little use, because skin damage is self-limited once systemic antibiotics are administered.

      Osteomyelitis

      Empirically, initiating a semisynthetic penicillin (eg, oxacillin [150 mg/kg/d]) and clindamycin (30-40 mg/kg/d) is a good choice for most cases of community-acquired osteomyelitis. In patients with allergy to penicillin, a first-generation cephalosporin and clindamycin (30-40 mg/kg/d) are an excellent alternative. Use vancomycin or linezolid when the other drugs mentioned are absolutely not tolerated or when resistance or the clinical course dictates. The duration of therapy is a controversial topic in the literature, but the consensus among multiple authors is that the minimum effective treatment time is 4-6 weeks. A switch to oral therapy is acceptable if the child is able to take oral antibiotics, is afebrile, and if he or she has demonstrated a good clinical response to parenteral antibiotics. [13]

      Septic arthritis

      As in osteomyelitis, initiate an appropriate antistaphylococcal drug (eg, oxacillin, which is penicillinase resistant; clindamycin; cefazolin) parenterally. These antibiotics readily reach joint fluid, and the concentration in the joint fluid is 30% of the serum value. Therapy usually continues for at least 4 weeks. Duration of parenteral therapy is often debated. Some authors have demonstrated efficacy with 1 week of parenteral therapy followed with 3 weeks of oral therapy. Consider a switch to oral therapy based on the considerations mentioned above. Joint fluid that reaccumulates should be removed, and a sample should be cultured to assess the efficacy of therapy and to make the patient more comfortable.

      Endocarditis

      Duration of therapy for endocarditis, which is a life-threatening infection, is at least 4 weeks. [135]

      The combination of a beta-lactam and an aminoglycoside (usually gentamicin) is advocated, because it increases bacterial killing in vitro and in animal models of endocarditis. In patients with MRSA, combinations of vancomycin with aminoglycosides should be used. In all cases the aminoglycoside is only added for the first 3 days.

      Rifampin, because of its lipid solubility, is another potent agent when used in combination with nafcillin and gentamicin or vancomycin and gentamicin, especially in patients with prosthetic valve endocarditis. Rifampin should never be used alone because resistance can develop.

      The response to therapy is usually slow, and patients may continue to have bacteremia, fever, and leukocytosis for at least a week after therapy is initiated.

      Some authors recommend obtaining blood cultures after the end of therapy.

      Treatment with antibiotics is specific to the etiologic agent and its characteristics. For more information, see Endocarditis, Bacterial.

      Next:

      Surgical Care

      Skin and soft tissue infections

      Drainage of any collections of pus is of paramount importance. [12] For small abscesses in afebrile toddlers and children, drainage alone may suffice, since treatment with efficacious and nonefficacious systemic antibacterial therapy was equivalent if adequate drainage had occurred. [136] Placement of a subcutaneous drain, rather than formal incision and drainage, has proven successful. [137]

      Osteomyelitis

      Surgery is usually indicated to drain purulent material from the subperiosteal space or if infected foreign material is present.

      Septic arthritis

      In an infant, septic arthritis of the hip and shoulder is a surgical emergency; these joints should be drained as soon as possible to prevent bony destruction. In addition, if a large amount of fibrin, tissue debris, or loculation is present, preventing adequate drainage with needle aspiration, the joint should be surgically drained.

      Endocarditis

      If endocarditis occurs in the presence of an intracardiac foreign body, it may require removal.

      Toxic shock syndrome (TSS)

      All potential foci of infection should be explored and surgically drained.

      Thrombophlebitis

      Remove the infected intravenous line in patients who are immunocompromised or severely ill or when infection is impossible to eradicate medically.

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      Next:

      Prevention

      In a 5-year multicenter study, the introduction of practices to eliminate Staphylococcus aureus significantly reduced the rate of complex S aureus infection at surgical sites, from 0.36% to 0.20%. The study included 38,049 patients who underwent 42,534 operations (cardiac surgery or hip or knee arthroplasty); 28,218 operations were performed before the intervention was implemented and 14,316 were performed during the intervention period. [138, 139]

      For the intervention, patients were screened for S aureus in the month before surgery. Those with positive screens were asked to apply intranasal mupirocin and to bathe with chlorhexidine for 5 days before surgery. Patients with methicillin-sensitive S aureus received perioperative prophylactic cefazolin, and those with MRSA received cefazolin and vancomycin. Patients who were negative for S aureus bathed with chlorhexidine the night before and the morning of surgery, and received cefazolin. [138, 139]

      A population-based study by Smit et al reported that current statin users had a 27% lower risk of community-acquired Staphylococcus aureus bacteremia and that long-term use was particularly associated with lower risk. [140, 141]

      A large study in adult inpatients has demonstrated that universal surveillance, appropriate use of contact precautions and hand hygiene, and institutional culture change can decrease infections with MRSA. [142]  Another approach likely to be cost-saving and to decrease infection in the intensive care unit is targeted screening and nasal decolonization, [143]  although the benefits of nasal decolonization outside this setting remain undefined. [144, 145, 146]

      Results of a 2-phase interventional study presented at the 23rd European Congress of Clinical Microbiology and Infectious Diseases in April 2013 suggest that in patients at risk for MRSA, PCR screening followed by isolation reduces the frequency of hospital-acquired infections and is cost-effective. [147]

      During phase 1 of the study, 1209 newly admitted patients were screened with a microbiology assay. MRSA-positive patients were placed in contact isolation after the assay result was received (mean, 62.8 ± 15.7 hours). During phase 2, 1200 patients were screened with rapid real-time PCR followed by microbiology assays. Patients were placed in contact isolation if their preliminary PCR test result was positive. All high-risk patients with a preliminary positive PCR result were placed in contact isolation from admission onward.

      The numbers of admitted MRSA cases in phase 1 and 2 were about the same (2.1 vs 1.96 per 100 patients). The nosocomial MRSA infection and colonization rates were reduced in phase 2 compared to phase 1 (nosocomial infection rates, 0.10 vs 0.20 per 1000 patient days, P < .05; colonization rates, 0.35 vs. 0.66; P < .01) and remained so or decreased further in 4 consecutive subsequent 6-month periods. Treatment costs were lower in phase 2, despite increased costs for preventive measures, but might vary with differing reimbursement systems.

      Prevention of transmission of MRSA among hospitalized children is a significant priority. [148]  Increasingly, universal decolonization of ICU patients has been recommended. [149, 150]

      Daily washing of ICU patients with chlorhexidine-impregnated cloths reduced positive cultures of MRSA by 37% and reduced bloodstream infection by any pathogen by 44%, according to a study of 74,256 patients in 74 adult ICUs. [149, 151]

      In the study, hospitals were randomized to 18 months of either screening for MRSA followed by isolation of positive patients, targeted decolonization of MRSA-positive patients and isolation, or universal decolonization of all ICU patients without screening. Decolonization was achieved via daily cleansing with chlorhexidine-impregnated cloths and 5 days of twice-daily intranasal mupirocin treatments. At baseline, there was no significant difference in the rate of MRSA infections between the 3 groups. [149, 151]

      However, patients who underwent universal decolonization showed a significantly larger decline between baseline and intervention periods than those in either of the targeted interventions. Universal decolonization led to a 37% drop in the rate of MRSA infections, while targeted decolonization led to a 25% decline and no significant change was seen in the screening and isolation group. There was no significant difference in outcomes between the targeted decolonization and the screening and isolation groups, while the difference between the universal decolonization and the screening and isolation groups was significant (P = .003). Universal decolonization also significantly reduced ICU-attributed bloodstream infections from any pathogen. [149, 151]

      Compared with passive screening, active screening in hospitalized patients for MRSA was shown to result in a higher incidence of discontinuation of MRSA contact precautions. Patients were randomized to observation with either local standard of care (passive screening; n=202) or screening with culture and commercial polymerase chain reaction (PCR) testing (active screening, n=405). In the active screening group, sensitivity, specificity, and positive and negative predictive values of the first PCR were compared to cultures.

      The researchers showed that contact precautions were discontinued significantly more often in the active screening group (rate ratio [RR], 4.1; 95% confidence interval [CI], 2.3%-7.1%), including in an intent-to-screen analysis (RR, 2.6; 95% CI, 1.5%-4.7%). Compared with 3 cultures, the first PCR detected MRSA with a sensitivity of 93.9% (95% CI, 85.4%-97.6%), a specificity of 92.0% (95% CI, 85.9%-95.6%), a positive predictive value of 86.1% (95% CI, 75.9%-93.1%), and a negative predictive value of 96.6% (95% CI, 91.6%-99.1%). [152]

      Various vaccine candidates are being evaluated. [153, 154, 155, 156, 157, 158, 159]

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