Management and Prevention of Staphylococcus aureus Infections in Children

Abstract

Staphylococcus aureus is a common skin commensal with the potential to cause severe infections resulting in significant morbidity and mortality. Up to 30% of individuals are colonized with S aureus, though infection typically does not occur without skin barrier disruption. Infection management includes promptly addressing the source of infection, including sites of metastatic infection, and initiation of effective antibiotics, which should be selected based on local antibiotic susceptibility patterns. Given that S aureus colonization is a risk factor for infection, preventive strategies are aimed at optimizing hygiene measures and decolonization regimens for outpatients and critically ill children with prolonged hospitalizations.

Keywords: Bacteremia; Colonization; Decolonization; Meningitis; Osteomyelitis; Pneumonia; Skin infection; Staphylococcus aureus.

Figure 1.

A. MRI of the left thigh and femur with intravenous contrast. Shown is the coronal view demonstrating a T2 hyperintense signal in the left distal femoral metaphysis (arrow) which extends 19 cm proximal to the distal femoral physis consistent with acute MRSA hematogenous osteomyelitis. B. Shown is the sagittal view demonstrating a T2 hyperintense, rim-enhancing subperiosteal abscess measuring 2.8 × 4.5 × 13.0 cm (arrow) and hyperintensity in the vastus intermedius, medialis, lateralis, and semitendinosus muscles, and diffuse subcutaneous edema throughout the left thigh.

Figure 2.

A. Chest CT with contrast. Shown is a patient with extensive MRSA multifocal necrotizing pneumonia throughout both lungs with a lung abscess in the left upper lobe measuring 4.0 × 2.6 × 3.9 cm and additional cavitary lesions in the right middle lobe. There is also moderate global cardiomegaly with a possible vegetation measuring 12 mm along the lateral leaflet of the mitral valve, and moderate pericardial effusion with pericardial enhancement. B. Chest radiograph with scattered bilateral infiltrates from a patient with MSSA bacteremia. C, D. Chest CT angiography with contrast showing bilateral opacities with areas of early cavitation, multiple septic pulmonary emboli including non-occlusive thrombi within the pulmonary arteries.

Figure 3.

A. MRI brainstem and spine with contrast. Shown is the sagittal view of an extensive MRSA spinal epidural abscess with T2 hyperintense fluid collection and peripheral enhancement extending from the level of C3 to the distal sacrum/coccyx, measuring up to 8 mm in thickness in the mid thoracic spine in maximum diameter (arrow). B. Shown is a T2 hyperintense paraspinal abscess extending from the level of C6-T2 along the left side (arrow).

Figure 4.

Staphylococcus aureus skin and soft tissue infections. Shown is a toddler with a left posterior thigh abscess with central head and surrounding area of cellulitis.

Figure 5.

Recommended approach to the management of patients presenting with skin abscesses based on current evidence). Management of the acute infection includes incision and drainage, culture of the purulent material for organism identification and susceptibility testing, and systemic antibiotic therapy. Decolonization should be recommended for patients who experience recurrent skin abscesses or in settings of ongoing transmission (e.g., SSTI in multiple household members) despite optimizing hygiene measures. Specifically, the recommended decolonization regimen is a 5-day protocol consisting of intranasal application of mupirocin (approximately a pea-sized amount to each nostril, applied with a sterile cotton-tipped applicator) twice daily, and daily antimicrobial body washes with either chlorhexidine or dilute bleach water baths. Chlorhexidine should be applied with a clean washcloth to the neck and below (contact with the face and ears should be avoided as ocular and ototoxicity may occur) and should be rinsed off after 1–3 minutes. Dilute bleach baths should consist of ¼ cup of bleach per ¼ filled bathtub for a standard sized bathtub or 1 teaspoon of bleach per gallon of bathwater for a non-standard bathtub; individuals should soak in the dilute bleach water for 15 minutes.