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Are you undertreating children with community-acquired MRSA?
Numbers are dramatically increasing in emergency departments
An infant with pneumonia, a girl with an infected tattoo, and a child with an insect bite. Would you suspect community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in all these patients? In fact, these are all recent examples of actual MRSA cases seen at Brandon (FL) Regional Hospital’s ED.
Nationwide, ED nurses are reporting a disturbing increase in CA-MRSA cases, especially in children. "I have never seen so many MRSA cases in pediatrics as I have the past year," says Teresa Colletti, RN, CNM, an ED nurse at Brandon Regional. In the first six months of 2004, the number of MRSA cases seen in the ED was double that of the entire previous year, she notes.
Due to an increase in MRSA cases presenting to the ED at Children’s National Medical Center in Washington, DC, an electronic identification process is being developed using the ED’s patient tracking system. "The goal is to help identify MRSA patients when they present at the point of entry to the ED," says Lisa M. Ring, RN, MSN, CPNP, advanced practice specialist for the Emergency Medicine & Trauma Center at Children’s National Medical Center.
According to the Atlanta-based Centers for Disease Control and Prevention (CDC), cases of CA-MRSA are linked to recent antibiotic use, sharing contaminated items, having recurrent skin diseases, and living in crowded settings. The true extent of the problem is not known yet, according to Marti Smith, RN, CCRN, an ED nurse at Memorial Medical Center in Modesto, CA. "What is really frightening is the emergence of this bug and its changing susceptibilities," she says. "I believe that it’s only a matter of time before it becomes more resistant and harder to treat."
To avoid adverse outcomes, ED nurses will need to take quick action and recognize signs and symptoms, says Smith. "If MRSA goes undetected, I would be most worried about undertreatment and insufficient surface disinfection after the patient has been discharged," she adds.
Undertreatment can potentially lead to repeat, and possibly disfiguring, incision and drainage procedures, treatment failure and recurrence of symptoms, and abscess formation in other sites, says Smith. However in rare cases, CA-MRSA can cause severe illness or death, even when treated quickly, such as the cases of four children who died from CA-MRSA.1
To dramatically improve care of pediatric patients with MRSA, take the following steps:
At triage, Smith noticed a disturbing increase in cases of relatively simple abscesses that had gotten worse despite outpatient therapy. "Additionally, I noticed abscesses becoming far more frequent in the less at-risk groups," she says.
Abscesses usually are most common among drug users, homeless patients, and individuals employed in construction or agriculture, explains Smith. "I began seeing young, healthy adults with a spider bite return over and over for worsening abscess and recurrent abscess, at times in distant areas to the previous abscess." Eventually, it was determined that these adults were suffering from CA-MRSA.
Before cases increased significantly, several cases were not identified as CA-MRSA and therefore were treated ineffectively with cephalexin hydrochloride, which MRSA is not susceptible to, or were overtreated with the potentially toxic antibiotic vancomycin, Smith says.
"Though vancomycin would treat CA-MRSA, it is nephrotoxic and the dosing is very individualized, which requires frequent dosage adjustments," says Smith. It also is administered intravenously, which increases cost, inconvenience, and further infection risk to the patient, she adds.
"We care for MRSA as we would any infection, but when the cultures come back positive, we call the family and inform them as well as change the antibiotic," says Colletti. "We also stress the need for the child to follow up with their pediatrician."
The easiest way to distinguish between hospital-acquired MRSA and CA-MRSA is by testing for the susceptibilities, says Smith. "Before CA-MRSA became so well known, most labs only did susceptibilities to vancomycin and a few other antibiotics," she explains. "Thus, there was no quick way to distinguish between hospital-acquired and community-acquired MRSA."
To address this, the ED has expanded sensitivity testing on cultures for MRSA to include sulfamethoxazole-trimethoprim, clindamycin, ciprofloxacin, and tetracycline, she says. "This helps clinicians differentiate the strains and appropriately treat the patients," says Smith.
Unlike standard hospital-acquired MRSA, CA-MRSA is not resistant to sulfamethoxazole-trimethoprim or tetracycline, and it is almost exclusively causing abscesses and cellulitis, says Smith. It can be cultured out of the noses of asymptomatic persons such as nurses and family members, she says. "Like standard MRSA, it can be treated in asymptomatic individuals with topical mupirocin four times daily to the nares," says Smith.
While there have been a few isolated reports of CA-MRSA fatalities, these seem to be in typically immunocompromised patients such as infants and the elderly, says Smith. "We are not seeing CA-MRSA urine, CA-MRSA sputum, or CA-MRSA sepsis like you do see in the hospital-acquired bug," she adds.
Insufficient surface disinfection exposes patients, visitors, and staff to contamination, which can cause transmission of infection via contact with nonintact skin or mucous membranes of other individuals, warns Smith.
Smith recommends following current CDC recommendations, which call for patients to follow careful contact precautions. This means no sharing of towels or linens, disinfection of all shared athletic equipment before and after use, showering with an antibacterial soap daily and after athletic or at-risk activities including construction or agricultural activity, and disinfecting household surfaces that come in contact with non-intact skin and/or mucous membranes.
"I also routinely teach hand hygiene practices with soap and water and alcohol-based hand rubs," says Smith. "I advise patients and family members to wash linens in hot water, to keep wounds covered, and to keep drainage from contaminating the environment."
If the patient is unable to comply with simple precautions because of their age or impairment, place the patient in a private waiting area and post contact precautions outside the door until a room is ready, recommends Smith. "Take the same precautions as you would with a rash or a person who can’t cover their mouth when coughing," she says.
After the patient leaves the ED, the housekeeping staff are instructed to clean for contact precautions, says Smith.
"At triage, I like to get a feel for how this all got started," says Smith. For example, one 50-year-old executive came in with a knee abscess and reported re-tiling the bathroom floor, she says. "Without knowing about the recent home tiling, I would more likely suspect a postoperative wound infection, gout, or possible rejection of a cadaveric anterior cruciate ligament transplant. At triage, all of these would present similarly at a quick glance."
Ask patients how they have treated their abscess before coming to the ED, and ask about previous history of abscesses, and if they are experiencing any systemic symptoms such as fever, chills, nausea, vomiting, and cough, advises Smith. "Systemic symptoms would point me away from CA-MRSA, because it rarely causes sepsis or pneumonia," she says.
1. Centers for Disease Control and Prevention. Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus — Minnesota and North Dakota, 1997-1999. JAMA 1999; 282:1,123-1,125.
Sources and Resources
For more information about caring for patients with community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in the ED, contact:
The Center for Disease Control and Prevention’s National Campaign for Appropriate Antibiotic Use has recommendations to reduce inappropriate antibiotic use and reduce the spread of resistance to antibiotics. For more information, go to www.cdc.gov/drugresistance/community.