community acquired mrsa in children

1. Community Acquired MRSA in Children Evidenced Based Project

2. PICO Question Would early education, by nurses on MRSA prevention and transmission reduce the number of patients under 18 years of age from contracting Community Acquired MRSA?

3. Define MRSA MRSA stands for methicillin-resistant Staphylococcus aureus. It is a strain of Staph aureus distinguished from most other bacteria by its resistance to beta-lactam, which include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin.

4. Community-Associated MRSA:CDC Population-Based Surveillance Definition MRSA culture in outpatient setting or 1st 48 hours of hospitalization AND patient lacks risk factors for healthcare-associated MRSA: Hospitalization Surgery Long-term care Dialysis Indwelling devices History of MRSA

5. History Staphylococcus aureus was discovered in the 19th century Was shown to be susceptible to Penicillin in the mid 20th century Resistance to methicillin strains surface soon after introduction of methicillin in the 1960s. Around the late 1990s with the appearance of CA-MRSA entering the heath care setting.

8. MRSA Strain Characteristics Were Initially Distinct

9. CA-MRSA Infections are Mainly Skin Infections

11. Clinical Considerations - Evaluation MRSA should also be considered in differential diagnosis of severe disease compatible with S. aureus infection: Osteomyelitis Empyema Necrotizing pneumonia Septic arthritis Endocarditis Sepsis syndrome Necrotizing fasciitis Purpura fulminans

12. Patterns of Carriage Those who always carry a strain Those who carry the organism intermittently with changing strains a minority of people who never carry S. aureus Found in axillae, inguinal, perineal areas and anterior nares. Persistent carriage is more common in children than in adults S. aureus is present everywhere and can commonly be an organism that is composed of (or is carried by) human normal flora found in the axillae, the inguinal and perineal areas, and the anterior nares. S. aureus is present everywhere and can commonly be an organism that is composed of (or is carried by) human normal flora found in the axillae, the inguinal and perineal areas, and the anterior nares.

13. Factors that Facilitate Transmission

14. Hot Zones Dorms

15. Role of Pets Greatest risk of Staph aureus / MRSA exposure in most humans is other humans When household pet animals carry MRSA, likely acquired from a human Transmission of MRSA from an infected or colonized pet to a human is possible, but likely accounts for a very small proportion of human infections Reasonable to consider pet as a source if transmission continues in a household despite optimizing other control strategies Little evidence that antimicrobial-based eradication therapy is effective in pets; however, colonization tends to be short-term*

16. Review of Literature The Children’s Hospital Memphis, TN (2004) 289 MRSA positive children with median age of 2.4 years 151 were defined as community acquired MRSA. Results were based on risk factors Hospitalization Dialysis Surgical Procedures Long term care facilities Group home Catheters Significance showed the prevalence of CA-MRSA in the acute care setting

17. Review of Literature Infectious Disease Society of America Emerging Infections Network (2007) Surveyed 197 pediatric infectious disease consultants from 39 states Results Pediatric consultants reported higher frequency of MRSA skin and soft tissue infections. There was no consensus on current treat regimen

18. Review of Literature Vanderbilt University Medical Center, TN (2005) Nasal swabs were collected 249 healthy children average age was 1-4 years 182 children (36.4%) were colonized for S. aureus and 46 of those isolates (9.2%) were positive for MRSA Significance This study demonstrates the increase in prevalence of CA-MRSA in children

19. Review of Literature Children’s Hospital, Houston, TX (2006) Review of records of 889 children ages 0-10 years. Patients fell into 3 categories Community-acquired Hospital acquired Community onset Tested isolated strains and antibiotic susceptibility Significance Clindamycin resistance increased >4-fold for CO-MRSA Emphasize the importance of separating community acquired from community onset health care-associated S. aureus infections so the most appropriate empirical antibiotic regimen can be determined. Community onset – not hospital acquired but freq exposure to health care facility.Community onset – not hospital acquired but freq exposure to health care facility.

20. Review of Literature Memorial Herman Children’s Hospital, Houston, TX (2005) 239 patients =18 years of age with laboratory confirmation of S. aureus. Compared community acquired methicillin resistant Staphylococcus aureus to community-associated methicillin-susceptible Staphylococcus aureus. Results Increasing prevalence of CA-MRSA in a higher frequency and intensity with more complications in comparison to CA-MSSA. Significance Need for more studies on the molecular genetic analysis of the various strains of CA-MRSA to determine the magnitude of its complications CA-MSSA- CA-MSSA-

21. Review of Literature Driscoll Children’s Hospital, Corpus Christi, TX (2005) 1002 children with confirmed cases of S. aureus, mean age were 7.9 years and 51.3% were boys 928 were classified as community-acquired Significance 94% - no identified risk factors 90.8% was prescribed clindamycin 19% CA-MRSA isolates demonstrates inducible clindamycin resistance More rapid diagnosis needed to initiate appropriate empirical treatment

22. Strategies to Prevent CA-MRSA Infection in the Clinical Setting Establish an institutional culture of safety Strictly adhere to prevention and control guidelines Conduct surveillance Educate Use personal protective equipment Clean and disinfect surfaces Clean and maintain equipment Manage visitors as appropriate Establish an institutional culture of safety, where health care–associated infections are considered unacceptable. Strictly adhere to prevention and control guidelines, including standard precautions, basic hygiene, maintaining fi elds and isolation practices. Strict adherence to hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in health care settings. Conduct surveillance for health care–associated infections to identify which patients need to be placed in isolation or when transmission-based precautions must be instituted. Knowing the local pathogens that are prevalent at an institution (they may be different from unit to unit within the institution) helps staff make informed choices about empiric antimicrobial therapy and about unit-based infection prevention and control strategies, such as cohorting patients and staff. Educate health care workers, patients, visitors and families to ensure that policies and procedures for infection control and prevention are understood and practiced. Patients, families, and visitors should be viewed as partners in preventing transmission. Use personal protective equipment, such as gowns, gloves, eye shields and masks, when appropriate. Clean and disinfect surfaces, especially high-touch, non-critical surfaces in patient care areas, such as bedrails, bedside tables, commodes, doorknobs, sinks, and all surfaces and equipment in close proximity to the patient. Clean and maintain equipment according to manufacturer’s directions, including dedicated noncritical medical equipment, such as stethoscopes, blood pressure cuffs, electronic thermometers, etc. Manage visitors as appropriate. In hospital settings, visitors who are children should visit only their own siblings. Screening of visiting siblings and other children before they are allowed into clinical areas is necessary to prevent the introduction of childhood illnesses and common respiratory infections. Use of barrier precautions by visitors has not been specifi - cally studied. Family members or visitors who are providing care or having very close patient contact should not also have contact with other patients to decrease the potential risk of transmission.Establish an institutional culture of safety, where health care–associated infections are considered unacceptable. Strictly adhere to prevention and control guidelines, including standard precautions, basic hygiene, maintaining fi elds and isolation practices. Strict adherence to hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in health care settings. Conduct surveillance for health care–associated infections to identify which patients need to be placed in isolation or when transmission-based precautions must be instituted. Knowing the local pathogens that are prevalent at an institution (they may be different from unit to unit within the institution) helps staff make informed choices about empiric antimicrobial therapy and about unit-based infection prevention and control strategies, such as cohorting patients and staff. Educate health care workers, patients, visitors and families to ensure that policies and procedures for infection control and prevention are understood and practiced. Patients, families, and visitors should be viewed as partners in preventing transmission. Use personal protective equipment, such as gowns, gloves, eye shields and masks, when appropriate. Clean and disinfect surfaces, especially high-touch, non-critical surfaces in patient care areas, such as bedrails, bedside tables, commodes, doorknobs, sinks, and all surfaces and equipment in close proximity to the patient. Clean and maintain equipment according to manufacturer’s directions, including dedicated noncritical medical equipment, such as stethoscopes, blood pressure cuffs, electronic thermometers, etc. Manage visitors as appropriate. In hospital settings, visitors who are children should visit only their own siblings. Screening of visiting siblings and other children before they are allowed into clinical areas is necessary to prevent the introduction of childhood illnesses and common respiratory infections. Use of barrier precautions by visitors has not been specifi - cally studied. Family members or visitors who are providing care or having very close patient contact should not also have contact with other patients to decrease the potential risk of transmission.

23. Screening and Decolonization In general, colonization cultures of infected or exposed persons in community settings are not recommended. (May have a role in public health investigations). Decolonization regimens: May have a role in preventing recurrent infections (more data needed to establish efficacy and optimal regimens for use in community settings). After treating active infections and reinforcing hygiene and appropriate wound care, consider consultation with an infectious disease specialist regarding use of decolonization when there are recurrent infections in an individual patient or members of a household.

24. Clinical Considerations - Management Alternative agents (More data needed to establish effectiveness!): Clindamycin – Potential for inducible resistance, Relatively higher risk of C. difficile associated disease? TMP/SMX – Group A strep isolates commonly resistant Tetracyclines – Not recommended for <8yo Rifampin – Not as a single agent Linezolid – Expensive, Potential for resistance with inappropriate use

25. Clinical Considerations - Management Not optimal for MRSA (High prevalence of resistance or potential for rapid development of resistance): Macrolides Fluoroquinolones

26. Basic RecommendationsFor Acute Care Settings Make prevention and control of outbreaks of multi-drug resistant organisms an organizational patient safety priority Implement a multidisciplinary process to monitor and improve health care personnel adherence to recommended practices Provide continuing feedback on facility and patient-care unit trends in MDRO incidence and adherence measure Educate and train personnel on prevention and control

27. Basic RecommendationsFor Acute Care Settings Observe standard precautions for all patients Observe contact precautions for patients known to be infected or colonized (masks are not routinely recommended) Monitor trends over time to determine whether additional interventions are needed Use antimicrobial agents judiciously

28. Intensified Interventionsfor Acute Care Settings Collect cultures from patients in populations at risk at the time of admission to high-risk areas and at periodic intervals as needed to assess transmission Observe contact precautions until surveillance cultures are known to be negative Have administration detect and correct any system failures Conduct education and training of personnel and measure adherence to guidelines

29. Intensified Interventionsfor Acute Care Settings Cont’d Monitor trends Cohort staff to the care of patients with multidrug resistant organisms only Utilize enhanced environmental measures Use antimicrobial agents judiciously Consult with experts on case-by-case basis regarding use of ecolonization therapy for patients or staff If transmission continues despite full implementation of above, stop new admissions to the unit

30. Management of Skin Infections in the Era of CA-MRSA I&D should be routine for purulent skin lesions Obtain material for culture No data to suggest molecular typing or toxin-testing should guide management Empiric antimicrobial therapy may be needed Alternative agents have +’s and –’s: More data needed to identify optimal strategies Use local data for treatment Patient education is critical! Maintain adequate follow-up

31. Management of Severe / Invasive Infections Vancomycin remains a 1st-line therapy for severe infections possibly caused by MRSA Other IV agents may be appropriate Consult an infectious disease specialist. Final therapy decisions should be based on results of culture and susceptibility testing Severe community-acquired pneumonia: Vancomycin or linezolid if MRSA is a consideration*

32. Education What does a skin infection look like? Symptoms of a skin infection can include swelling, redness, tenderness and pus. Skin infections sometimes look like “spider bites”, pimples or boils. How serious are skin infections? Skin infections that only involve the skin are usually mild and easily treated. Although it is rare, sometimes the bacteria can cause severe illnesses such as bloodstream infections which may be fatal. Therefore, it is very important to see your healthcare provider if you have a skin infection that is not improving.

33. Education How is Staphylococcus aureus spread? Any drainage from a skin wound should be considered infectious. Staph is primarily spread through contact with the bacteria, either by direct person-to-person contact or indirectly through shared equipment, personal items or contaminated surfaces. Examples of shared objects include towels, soap, razors, clothing and athletic equipment. Frequent hand washing is the best way to prevent the spread of MRSA.

34. Best Prevention Strategies Keep your hands clean by washing thoroughly with soap and warm water for 20 seconds or using an alcohol-based hand sanitizer. Keep cuts and scrapes clean and covered with a bandage until healed to prevent catching an infection. Avoid contact with other people’s wounds or dirty bandages. Avoid using someone else’s personal items such as towels or razors that may be contaminated. Shower or bathe regularly, especially after contact sports practices or events.

35. Conclusions New strains of MRSA have emerged in the community, with implications for management of skin infections and other staphylococcal infections. Incision and drainage remains a primary therapy for purulent skin infections. Oral treatment options are available for patients with skin infections that require ancillary antibiotic therapy. Patient education on proper wound care is a critical component of case management for patients with skin infections. Strategies focusing on increased awareness, early detection and appropriate management, enhanced hygiene, and maintenance of a clean environment have been successful in controlling clusters / outbreaks of infection.

36. More Research Needed Children under age 2 Children with chronic diseases and disorders MRSA Prevention Strategies MRSA Clinical Management and Treatment (i.e. Clindamycin) Standardized Terminology (i.e. community acquired/community associated) Consistent Protocols used throughout U.S. Hospitals

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38. QUESTIONS?