Pediatric Nursing - Community-associated MRSA in the pediatric primary care setting
Case Study
Michael, age 4 years, was seen in November for two swollen, red-appearing lesions on his abdomen. The initial diagnosis was cellulites secondary to insect bites. He was prescribed Cephalexin (Keflex[R]) 250 mg TID for 10 days with warm compresses to the lesions BID. Three weeks later he returned to the primary care office and the lesions had not fully resolved and now there were two more additional smaller lesions on the abdomen. He was put on Cefdinir (Omnicel[R]) for 10 days.
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In early January he was again seen with what was then diagnosed as recurrent staphylococcal skin lesions on his arms and was prescribed Keflex 250 mg TID with application of Mupirocin (Bactroban[R]) to the nares to try to limit bacterial spread. No cultures of the lesions were taken. His parents were encouraged to use antibacterial soap at home. In early February Michael was checked again and the skin lesions were improving but not totally cleared. At this visit the parents both reported that they also had similar skin lesions that were being treated with antibiotics by their physician. When asked about medication compliance, the parents reported that it was very difficult to “get Michael to take his medications,” which led the physician provider to believe the previous treatment failures may have been due to poor compliance with antibiotics. Another round of Keflex 250 mg TID for 10 days was ordered for Michael with encouragement to “make sure he takes the medicine.”
In early March the father called the pediatric office to report his recurrent lesions had been cultured and determined to be methicillin-resistant staph aureus (MRSA), and he was started on Trimethoprin/Sulamthoxazole (Bactrim[R]). Michael was ordered Clindamycin 150 mg TID for 10 days. The parents attempted to give Michael the oral medication but he refused and the recurrent skin lesion persisted. The parent’s lesions also returned, probably due to reinfection by contact with Michael’s persistent skin lesions.
In early April, after the first cultures of Michael’s lesions also found MRSA, a peripheral intravenous catheter was inserted into his arm and he was administered Clindamycin 200 mg IV TID for 8 days at home with the assistance of a visiting nurse. He tolerated home intravenous therapy well. After simultaneous treatment of all three family members with culture proven non-resistant antibiotics, Michael’s lesions finally resolved and he has been free of skin infections since then.
Throughout history, infectious diseases have been significant causes of death around the world. The plague, caused by the Yersinia pestis bacteria, killed more than one fourth of the entire population of 14th-century Europe. During the past century, Staphylococcus aureus (S. aureus) was the leading bacterial cause of death during the pandemic influenza of 1918 among individuals who developed secondary bacterial pneumonia (Chambers, 2004; Stevens, 2003). With the use of antimicrobials and preventative measures, i.e. vaccinations, the implementation of Occupational Safety and Health Administration (OSHA) regulations and the Centers for Disease Control and Prevention (CDC) infection control guidelines, infectious diseases have been effectively treated and, in some cases, eliminated.
Yet today, infectious diseases caused by microorganisms account for a significant percentage of all deaths worldwide. A major pathogenic microorganism is S. aureus. It has become an antimicrobial-resistant and virulent bacterium, with hundreds of identifiable isolates worldwide. The World Health Organization (WHO) and the CDC recently identified antimicrobial resistance as a major public health threat (Centers for Disease Control and Prevention [CDC], 2001). They recognize the need for swift action because many significant bacterial infections, especially those caused by S. aureus, are becoming increasingly resistant to antibiotics.
The early overuse and misuse of penicillin created a serious resistance problem during the mid 20th-century, and the use of a penicillin-like compound called methicillin, did little to stop this virulent bacterium from causing serious infectious diseases. Although the most common infections caused by S. aureus are skin and soft tissue infections (SSTIs). S. aureus can lead to serious and sometimes fatal infections such as necrotizing fasciitis, osteomyelitis, endocarditis, and sepsis (CDC, 2001).
Until the early 1990s, the most resistant strains of S. aureus not susceptible to methicillin therapy were confined to individuals in close contact with hospitals and with established risk factors, i.e. having an indwelling medical device, being immunocompromised and having had a hospitalization within the past year (Lowy, 1998; Parsonnet & Deresiewicz, 2001). These strains are known as methicillin-resistant Staphylococcus aureus (MRSA), and more specifically as healthcare-associated or acquired MRSA (HAMRSA) (Gosbell, 2004).
Health care professionals, however, began to identify MRSA in the community setting. Otherwise healthy children and adults without risk factors for HA-MRSA became infected with a different strain of this virulent bacterium (CDC, 2000, 2005b; Fridkin et el., 2005). The origin of these isolates is unclear. It is speculated that these new strains did not arise from HA-MRSA strains but mutated from community-based methicillin-susceptible Staphylococcus aureus strains (Siberry, 2005).
