Pediatrics for Parents - Children in hospitals
MRSA Update
Skin and soft tissue infections due to resistant forms of the Staph. bacteria have increased dramatically in recent years. For those of us who take care of kids in hospitals, these conditions have reached near-epidemic proportions.
Articles have appeared in the lay press about the subject, as more and more of the population experiences infections. This, and the fact that we are experiencing an increase in frequency and severity of these infections, prompted me to write, once again, about this subject.
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The main culprit is the bacteria Staphylococcus aureus. This bacteria has been around for ages, but the resistant strains are increasing rapidly. Antibiotics like Augmentin or oxacillin, typically utilized by doctors to treat skin infections, are powerless against this particular resistant organism. Because it is also resistant to Methicillin, an IV antibiotic classically used to treat Staph. infections, the bacteria is referred to as “Methicillin resistant Staph. aureus,” hence the initials MRSA. One child we cared for clearly pointed up the challenges of treating this particular infection.
Brian is a 17-year-old young man with a disabling congenital condition that has left him essentially wheelchair bound and nonverbal. He has a comfort-seeking habit of sucking on the middle finger of his left hand. Because he has done this for many years, he developed a large callous on the flexor surface (palm side) of his finger. A small portion of the calloused skin became worn down, allowing for the introduction of the bacteria into his skin. It should be noted that this bacterium is found in the nose and pharynx of many people, without necessarily causing disease. It is only when it is introduced into the blood stream or the underlying soft tissue that an infection ensues.
When MRSA takes hold, as it did in Brian’s case, the infectious process begins with resulting swelling, redness, warmth and tenderness. Brian’s mother noticed this, and after a couple of days of treatment with warm soaks and Neosporin, the redness and swelling appeared to be getting worse. She brought Brian to his pediatrician, who started him on Augmentin.
During the first 24 hours, Brian’s mother thought she noticed a small degree of improvement, but then the following day, the infection appeared much worse. She brought him back to the pediatrician, who immediately called us for admission to the hospital for IV antibiotics. At this point, Brian had developed a fever, refused to eat and was acting more irritable than was his usual amiable nature. His symptoms signified that the infection had progressed beyond its local effect and was beginning to have effects on his entire body. By the time we saw Brian, his finger was huge and resembled an overstuffed sausage, especially when compared to his other fingers. It was bright red and the tip had begun to take on a purple hue, worrying us that the circulation of his finger may have been compromised.
We started IV antibiotics immediately and choose Vancomycin since this is one of the few antibiotics to which MRSA is still sensitive. We also consulted a surgeon since there is very often abscess formation with this infection, which can benefit from surgical drainage.
A CAT scan was performed and the surgeon determined, based on the findings of the scan along with his physical exam, that there was no need for surgery at the present time. To be safe, we discussed the case with an orthopedist, who felt that since no joints, tendons nor bone seemed to be involved, a nonsurgical course was best.
Remarkably, within 48 hours, Brian’s finger improved dramatically. There had been a slight amount of drainage from the area near the callous when he was first admitted. That fluid was cultured in the lab, and indeed grew MRSA. Luckily, it proved to be sensitive to Vancomycin. After four days of IV antibiotics, Brian was switched to an oral antibiotic shown by the culture to be effective against MRSA, and once his appetite and tolerance of oral medicine improved, he was sent home. His finger was completely back to normal.
From this experience, and the many others like it we have seen in the hospital, we have learned:
1. MRSA is extremely common and increasing in frequency and should be considered earlier rather than later.
2. MRSA is resistant to most antibiotics, particularly oral antibiotics. Clindamycin and Bactrim or Septra appear to be the best oral alternatives.
3. While all MRSA infections do not require surgery, many do. Therefore, careful consideration should be given to surgical involvement if abscess formation appears likely.
4. MRSA infections DO respond well to the proper antibiotics; the trick is getting on the right ones early.
5. If your child has a troubling skin infection that does not seem to be improving, even with antibiotics, ask your doctor about MRSA–it is more common than even he or she may realize!
John E. Monaco, M.D., is board certified in both Pediatrics and Pediatric Critical Care. He lives and works in Tampa, Florida. He welcomes your comments, suggestions, and thoughts on his observations.
COPYRIGHT 2006 Pediatrics for Parents, Inc.
COPYRIGHT 2008 Gale, Cengage Learning
