IDC New York

IDC New York

December 04, 2017
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Proper treatment of S. aureus necessary with changing epidemiology

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Clarence B. Creech
C. Buddy Creech

NEW YORK — While skin and soft tissue infections such as MRSA are decreasing around 3% annually, rates of methicillin-susceptible Staphylococcus aureus, clindamycin and Bactrim resistance are rising, according to a presentation at the Infectious Diseases in Children Symposium.

“Staph does this every 10 to 15 years. It likes to hit the scene and fall back a little bit,” C. Buddy Creech, MD, MPH, associate professor of pediatrics, division of pediatric infectious diseases, and director of the Vanderbilt Vaccine Research Program, said in his presentation. “It then comes back a little different [the next time it appears]. In the 1970s, it was toxic shock syndrome. In the late 1980s, it was health care-associated MRSA. In the early 2000s, it was community-acquired MRSA.”

Creech asserted that uncertainty surrounds the future presentation of S. aureus, although the rate of MRSA and skin and soft tissue infections (SSTIs) has grown significantly in the past few years. He mentioned that between 2001 and 2007, the number of abscesses needing drainage rose from 100 to almost 2,000 in his ED.

“This became much more common than doing spinal taps on kids with Haemophilis or Pneumococcus,” he said. “This became the new procedure that every resident knew how to do.”

According to Creech, S. aureus has the ability to ‘stick’ to proteins that are highly immunogenic. The bacterium then reaches a point where it turns off the surface express proteins and may release a variety of toxins, including enterotoxins, alpha-toxin, hemolysins and cytolytic toxins. Typically, these infections can be treated with a combination of incision and drainage as well as through antibiotics, but some antibiotics have become inferior in the prevention of recolonization.

A study conducted at Vanderbilt that included children aged under 18 years who had received a drainage procedure found that Bactrim was responsible for nearly doubling the risk for treatment failure and increased risk for recurrence by 25%. In additional studies referenced by Creech, clindamycin demonstrated superiority to Bactrim in children with SSTIs. However, it is important to understand how antimicrobial resistance affects your community prior to prescribing antibiotics, Creech said.

“Clindamycin resistance is highly variable,” Creech said. “I would really urge you as you think about this topic in your practice to get an antibiogram.”

Additionally, Creech noted that cleanliness will only do so much to prevent recolonization. Proper precautions should be taken to prevent colonization of the family, including the use of mupirocin 2% two times daily for 5 days, chlorhexidine 4% washes once daily for 5 days, and paying careful attention to bed linens, pajamas, towels, washcloths and high-touch areas such as counters and sinks.

“About 20% will always have staph [in their nose], about 20% will never have staph and the rest of us are prone to constantly getting it and getting rid of it,” Creech said. “That last group is the one giving it to other people.”

“Staph will live on a surface for about 6 to 8 weeks if untouched,” he continued. “Cleanliness in the environment is huge, but if we can get a hold of the anterior nares [where the infection commonly colonizes], the hand colonization goes away.” –by Katherine Bortz

Reference:

Creech CB. S. aureus skin and soft tissue infections. Presented at: IDC NY. November 18-19; New York.

Disclosure: Creech reports working as a consultant for Pfizer, GlaxoSmithKline  and Horizon .He also reports institutional funding for S. aureus vaccine development received through Pfizer and GlaxoSmithKline, as well as funding for an SSTI retrospective study by GlaxoSmithKline.