Version May 2024
INTRODUCTION — The prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) infections in children will be discussed here. The epidemiology, clinical spectrum, and treatment of MRSA in children are discussed separately.
●(See "Skin and soft tissue infections in children >28 days: Evaluation and management".)
●(See "Skin and soft tissue infections in neonates: Evaluation and management".)
●(See "Staphylococcus aureus in children: Overview of treatment of invasive infections".)
ANTIMICROBIAL STEWARDSHIP — Optimal use of antimicrobial agents (ie, choice of drug, dose, route, and duration) may help to reduce the prevalence of resistant S. aureus, including MRSA, and may reduce the risk of MRSA colonization [1-3]. Optimal use may also be enhanced by referring children with penicillin allergy to an allergist for skin testing (if it has not already been performed) to reduce exposure to broad-spectrum antibiotics and the risk of developing MRSA infection [1,4]. In a meta-analysis of 18 observational studies, penicillin skin testing was negative in approximately 95 percent of inpatients with a history of penicillin allergy [5]. (See "Choice of antibiotics in penicillin-allergic hospitalized patients", section on 'Impact of penicillin allergy on care'.)
Additional aspects of antimicrobial stewardship in health care and outpatient settings is discussed separately. (See "Antimicrobial stewardship in hospital settings" and "Antimicrobial stewardship in outpatient settings".)
PREVENTION IN THE COMMUNITY
Education to reduce transmission — MRSA transmission requires contact with a colonized individual or a contaminated surface. Community-onset infections frequently recur in individuals and commonly spread within families and among children in daycare centers [6-8]. Colonization of household dogs and cats has been described [9]. (See "Zoonoses: Dogs", section on 'Methicillin-resistant Staphylococcus aureus' and "Zoonoses: Cats", section on 'Methicillin-resistant Staphylococcus aureus'.)
Education of patients and family members about hygiene and cleaning of surfaces and other items that are frequently touched with bare skin (eg, door knobs, bath tubs, counters, television remote controls) is a key component of prevention of MRSA in the community.
Schools and athletic teams also should be educated about hygiene and appropriate cleaning of surfaces and other items that are frequently touched with bare skin (eg, athletic equipment including wrestling, judo, and gymnastic mats).
These common sense measures are not well-studied but have been effective as part of a multifaceted strategy for control of community outbreaks [9-11]. What constitutes an "outbreak" of MRSA in the community is poorly defined in the literature. A reasonable definition is a cluster of at least three cases of MRSA in a specific population (eg, a sports team) over the course of one month.
Measures for all individuals include [12-15]:
●Regularly washing hands with soap and water or an alcohol-based hand gel, particularly after contact with household dogs and cats
●Maintaining good general hygiene with regular bathing, particularly after activities with skin-to-skin contact; keeping fingernails cut short and clean
●Using an appropriate over-the-counter detergent or disinfectant that specifies S. aureus on the product label to clean equipment and environmental surfaces that multiple people touch with bare skin
Specific counseling for patients or caregivers of patients with MRSA skin and soft tissue infections (SSTIs) includes [12-16]:
●Keeping draining wounds covered with clean, dry bandages; if the wound cannot be kept covered, avoiding participation in activities with skin-to-skin contact with other people (eg, athletic activities) until the wound is healed
●Washing hands with soap and water or an alcohol-based hand gel immediately after touching infected skin or items that directly touch a draining wound
●Avoiding reusing or sharing items that have directly contacted a draining wound (eg, common tubs, towels, clothing, bedding, bar soap, razors, athletic equipment)
●Washing bed linens at least weekly and towels and washcloths after each use
●Washing and thoroughly drying clothing that has come in contact with wound drainage after each use
Although the warmest temperature of water recommended on the item's label should be used for laundering, it is not necessary to use hot water or bleach [17].
School or child care attendance — Children with MRSA infection may attend school or child care provided that draining or open wounds or abrasions can be kept covered with a clean, dry dressing [15,18]. Those who are colonized with MRSA should not routinely be excluded from school or child care.
Special populations
Children with recurrent MRSA infection — We suggest intranasal and topical decolonization for children with recurrent MRSA infection despite routine hygiene measures. Other experts may have different indications for decolonization or suggest different regimens. After topical decolonization with bleach baths or chlorhexidine baths or showers, moisturizer should be generously applied; bleach and chlorhexidine both cause drying of the skin. Chlorhexidine may cause local irritation and repeated exposure may be associated with decreased susceptibility [19,20]. (See 'Decolonization regimens' below.)
We use different regimens depending on the clinical scenario:
●First or second recurrence – For children with one or two recurrences of MRSA infection, we suggest intranasal and topical decolonization for the child. We use the following regimen (table 1) (see 'Decolonization regimens' below):
•Mupirocin ointment to the nares two to three times per day for one week
•Chlorhexidine baths or showers once daily for 5 to 14 days
●Multiple recurrences of MRSA despite routine hygiene measures – For children with recurrent MRSA infection despite routine hygiene measures, we suggest intranasal and topical decolonization for the child. We use the following regimen (see 'Decolonization regimens' below):
•Mupirocin ointment to the nares two to three times per day for one week each month for three months
•Dilute bleach baths twice per week for three months
•Chlorhexidine baths or showers once daily on the days of the week that bleach baths are not given for three months
●Recurrent MRSA infection in child and MRSA infection ≥1 other household member – For children with recurrent MRSA infection despite routine hygiene measures who have ≥1 other household member with MRSA infections, we suggest intranasal and topical decolonization for all household members with S. aureus infections in the previous year in addition to intranasal and topical decolonization for the child [21]. We use the regimen described above for the child and the following regimen for household members (see 'Decolonization regimens' below):
•Mupirocin ointment to the nares two to three times per day for one week
•Dilute bleach baths twice per week for one week
•Chlorhexidine baths or showers once daily on the days of the week that bleach baths are not given for one week
Contacts with symptomatic infection should be treated before decolonization. It is not necessary to perform screening cultures in contacts if at least one of the previous infections was confirmed to be MRSA.
Approximately 20 percent of patients treated for MRSA SSTI remain colonized after treatment [22]. Decolonization of the patient and close contacts may reduce the risk of subsequent MRSA infection in the patient and their contacts.
Evidence to support decolonization of the index patient to prevent recurrent MRSA infection is limited and suggests only short-term benefit [23]. In an open-label trial in 300 patients (adults and children) with community-onset SSTI and S. aureus colonization, one-month eradication rates were greater following a five-day regimen of decolonization with mupirocin alone (56 percent) or in combination with chlorhexidine (55 percent) or bleach baths (63 percent) than education alone (38 percent) [16]. However, at four months, the only regimen more effective than education alone was mupirocin plus bleach baths (71 versus 48 percent). Recurrent SSTI was common, occurring in 20 percent of participants at one month and 36 percent of participants at four months, suggesting that factors other than endogenous colonization play a role in MRSA infection. In another open-label randomized trial in 987 children with probable community-associated S. aureus SSTI or invasive infection, the rates of medically attended recurrence over 12 months were similar in those assigned to hygienic measures alone and hygienic measures combined with bleach baths twice per week for three months (21 and 17 percent, respectively) [24].
Although close contacts may serve as a reservoir for MRSA transmission [8,25,26], evidence to support decolonization to prevent household transmission is limited [27,28]. In an open-label randomized trial in 183 children with community-onset S. aureus skin abscess and colonization, decolonization of all household members was not found to be more effective than isolated decolonization of the index patient in eradicating S. aureus colonization [27]. However, over the 12-month follow-up, there was a reduction in self-reported SSTI in the index patient (52 versus 72 percent) and a nonsignificant trend toward fewer reported SSTIs in household contacts (16 versus 22 percent). The five-day decolonization regimen consisted of twice-daily intranasal mupirocin and once-daily chlorhexidine body washes. However, a follow-up randomized trial that compared the same five-day decolonization strategy for the child and members of the household with MRSA infection in the previous year with decolonization for all members of the household found similar frequencies of recurrence in the three months after enrollment (approximately 10 percent) [21]. Additional study is necessary to determine optimal duration of decolonization and/or the effectiveness of environmental decontamination.
Children with atopic dermatitis — Topical decolonization for children with atopic dermatitis is discussed separately. (See "Treatment of atopic dermatitis (eczema)".)
DECOLONIZATION REGIMENS — Studies evaluating the efficacy of decolonization regimens are limited [16,27,29,30] and the optimal regimen for decolonization in specific patient populations is uncertain [31]. Decolonization regimens for neonates in the intensive care unit are discussed below. (See 'Neonatal intensive care unit' below.)
Decolonization regimens suggested by the Infectious Diseases Society of America or that have some evidence of efficacy in clinical trials in infants, children, and adolescents are provided in the bullets below. Intranasal and topical decolonization regimens may be used alone or in combination; topical decolonization regimens may also be used in combination (on different days).
●Intranasal decolonization for infants, children, and adolescents – Regimens for intranasal decolonization include:
•Mupirocin ointment applied to the anterior nares twice daily for 5 to 10 days [13], or
•Mupirocin ointment applied to the anterior nares twice daily for 5 days twice per month for six months [30]
A potential complication of mupirocin therapy is the development of mupirocin resistance, particularly with repeated or long-term use [32-34].
●Topical decolonization for infants, children, and adolescents – Topical decolonization regimens for infants, children, and adolescents include:
•Chlorhexidine (applied with the hands or a clean washcloth and rinsed off) once daily for 5 to 14 days [16], or
•Dilute bleach baths (1 teaspoon of bleach per gallon of water, one-fourth of a cup of bleach per one-fourth of a standard bathtub of water, or one-fourth of a cup of bleach per 13 gallons of water) for 15 minutes twice weekly for approximately three months [13,16,24], or
•Chlorhexidine (applied with the hands or a clean washcloth and rinsed off) once daily for 5 days, twice per month for six months [30], or
•Dilute bleach baths (1 teaspoon of bleach per gallon of water, one-fourth of a cup of bleach per one-fourth of a standard bathtub of water, or one-fourth of a cup of bleach per 13 gallons of water) for 15 minutes twice weekly. On the days that bleach baths are not given, chlorhexidine baths or showers (applied with the hands or a clean washcloth and rinsed off) once daily five times per week for approximately three months.
After bleach baths or chlorhexidine baths or showers, patients should generously moisturize the skin; bleach and chlorhexidine both cause drying of the skin. Chlorhexidine may cause local irritation, and repeated exposure may be associated with decreased susceptibility [19,20].
●Preoperative decolonization – May be warranted for children who will be undergoing cardiac surgery or children who are scheduled for an implantable device (eg, cerebrospinal fluid shunt, spinal instrumentation, baclofen pump) [35]:
•Mupirocin ointment to the anterior nares twice per day for the five days before surgery, and
•Chlorhexidine bath (as described above) or chlorhexidine antiseptic wipes for the five days before surgery
The final chlorhexidine bath or wipe should be performed on the morning of surgery or after 5 PM on the night before surgery; if performed the night before surgery, a full linen change should be performed immediately after the bath.
BASELINE STRATEGIES FOR HEALTH CARE SETTINGS — Prevention of MRSA in health care settings requires a multifaceted approach [31,36]. Baseline strategies are appropriate for most institutions or units.
Infection control
Standard precautions — Standard precautions are recommended in the care of all patients in the health care setting. Standard precautions include hand hygiene before and after contact with every patient and wearing gloves if exposure to blood or body fluids is anticipated. Additional details of standard precautions are discussed separately. (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Standard precautions'.)
In observational studies, increased adherence to hand hygiene has been associated with reductions in rates of MRSA transmission and prevalence of health care-associated infection [37,38].
Contact precautions — In addition to standard precautions, contact precautions are recommended for patients infected or known to be colonized with MRSA and patients with draining wounds or abscesses if the wound cannot be covered or the drainage cannot be contained by the dressing [39-41].
Contact precautions for patients infected or colonized with MRSA include:
●Placing the patient in a private room, or placing two or more patients with MRSA in the same room.
●Wearing clean, nonsterile gloves when entering the patient's room; removing the gloves and performing hand hygiene upon leaving the patient's room.
●Wearing a gown when entering the room if substantial contact with the patient or environmental surfaces in the room is anticipated or if the patient has wound drainage not contained by a dressing.
●Removing the gown and gloves and performing hand hygiene before leaving the patient's room.
●Limiting transport of the patient from the room to essential purposes only.
●When possible, dedicating the use of noncritical equipment (eg, stethoscope) to a single patient or cohort of patients. If use for another patient is unavoidable, the item should be adequately cleaned and disinfected before use.
Additional aspects of contact precautions are discussed separately. (See "Infection prevention: Precautions for preventing transmission of infection", section on 'Contact precautions'.)
Duration of contact precautions
●Patients with MRSA infection – For patients with MRSA infection who are receiving antimicrobial therapy with activity against MRSA, contact precautions should be continued throughout admission [42].
●Patients with MRSA colonization – The duration of contact precautions for patients with MRSA colonization who are not receiving antimicrobial therapy with activity against MRSA varies from institution to institution [31]. The decision to discontinue contact precautions for patients with MRSA colonization must balance the benefit of decreased transmission with potential harms, including cost and unintended consequences (eg, fewer interactions between the patient and health care providers) [43-46].
We agree with the Society for Healthcare Epidemiology of America that the decision to discontinue contact precautions for patients outside the neonatal intensive care unit should be guided by screening cultures [42], although the optimal number of negative cultures or interval between cultures has not been established. Surveillance cultures are discussed below. (See 'Screening asymptomatic patients' below.)
Many institutions require one to three negative surveillance cultures obtained at least 24 hours apart [42,47]. In a multicenter study, 94 percent of patients colonized with MRSA were culture negative after three consecutive cultures collected at weekly intervals [48]. Longer duration of contact precautions may be warranted for patients with chronic wounds or from long-term care facilities [49].
At the author's institution, all of the following criteria must be met for discontinuation of contact precautions:
•No antimicrobial therapy (topical or systemic) with activity against MRSA for ≥7 days before collection of samples for screening cultures or polymerase chain reaction (PCR).
•Negative MRSA culture from the original site of infection, if accessible (eg, wounds, urine if the patient has a urinary catheter, tracheal aspirate if the patient has a tracheostomy or endotracheal tube in place) except if the original site was the bloodstream or cerebrospinal fluid and the patient is clinically cured.
•Negative MRSA PCR surveillance swab (ie, a single swab is used to swab both anterior nares, both axillae, and both inguinal areas [in that order], with each site swabbed for three seconds).
If MRSA PCR is not available, MRSA surveillance cultures may be obtained in a similar manner.
Chlorhexidine bathing for PICU patients — Chlorhexidine bathing of children in the pediatric intensive care unit (PICU) is routine in many institutions. At the author's institution, daily chlorhexidine bathing is routinely employed for PICU patients with central lines.
Chlorhexidine is a broad-spectrum antiseptic agent. Daily bathing with chlorhexidine is safe and may be effective in decreasing hospital-acquired infections (eg, bloodstream infections, ventilator-associated pneumonia) and colonization with drug-resistant organisms, including MRSA [50-54]. In per-protocol analysis of a multicenter, cluster-randomized, crossover trial in PICUs, daily chlorhexidine bathing modestly decreased the incidence of bacteremia (3.28 versus 4.93 per 1000 days, adjusted incidence rate ratio 0.64, 95% CI 0.42-0.98) compared with standard bathing practices [54]. In a meta-analysis of eight randomized trials (including the PICU trial), chlorhexidine bathing reduced the rate of hospital-acquired infections from 9.5 to 7.8 infections per 1000 patient days (rate difference 1.70, 95% CI 0.12-3.29) [55]. The quality of evidence was limited by inconsistency and lack of blinding in most of the included studies.
Identifying MRSA in symptomatic patients — MRSA may be transmitted from infected patients to health care workers or other patients [31,56-58]. Identifying MRSA in symptomatic patients is achieved through laboratory-based detection (eg, clinical cultures). In patients with suspected MRSA infection, microbiologic specimens for culture and other MRSA testing should be obtained from wounds and other relevant sites (eg, blood, joint fluid) as discussed in individual topic reviews. (See "Skin and soft tissue infections in children >28 days: Evaluation and management", section on 'Laboratory evaluation' and "Bacterial arthritis: Clinical features and diagnosis in infants and children", section on 'Laboratory evaluation' and "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Microbiology'.)
Once identified, children with documented MRSA infection should be placed on contact precautions to prevent transmission to health care workers or other patients. Laboratory-based alert systems may facilitate rapid implementation of contact precautions [31]. (See 'Contact precautions' above.)
Patients with documented MRSA infection may remain colonized for months after completion of treatment [22,49]. Tracking such patients permits prompt implementation of contact precautions if they are readmitted [31].
Other baseline measures — Discussions of other baseline measures that may be undertaken at the institutional level (eg, environmental cleaning, monitoring adherence to infection control precautions, prevalence surveys of particular patient populations) are beyond the scope of this review. They are discussed in greater detail in guidelines from the Society for Healthcare Epidemiology of America [31].
SECOND-TIER STRATEGIES FOR HEALTH CARE SETTINGS
Individualized implementation — Decisions regarding implementation of second-tier strategies, which second-tier strategies or combination of strategies to use, and in what order should be individualized in consultation with experts in infection control and hospital epidemiology. The approach described here is consistent with that provided by the Society for Healthcare Epidemiology of America [31].
Second-tier strategies may be warranted in institutions, units, or populations with unacceptably high rates of MRSA despite implementation of baseline strategies (eg, in a health care outbreak) and in high-risk neonates in the neonatal intensive care unit (NICU) (eg, preterm low birth weight, indwelling devices, preoperative) [31,59]. What is considered "unacceptably high" depends upon an institution's background rate of MRSA and whether it is increasing or decreasing in response to baseline strategies. An outbreak is defined as a higher than expected number of MRSA cases for a given area (eg, hospital unit) or population over a specific period of time [60].
Although observational studies provide evidence supporting the effectiveness of various combinations of strategies [50,61,62], there remains much uncertainty about the magnitude of effect and the optimal process for implementation of individual or combined strategies (eg, duration of contact precautions for colonized patients, which anatomic sites to sample to detect colonization, which patients should undergo decolonization, which regimen should be used for decolonization, need for follow-up cultures after decolonization).
Screening asymptomatic patients — Asymptomatic patients who are colonized with MRSA are an important reservoir for MRSA transmission and infection [63]. Decisions about screening asymptomatic patients (ie, active surveillance) for MRSA in a particular institution or unit are individualized according to the rate of health care-associated MRSA infection [31]. Active surveillance facilitates prompt institution of contact precautions and may permit targeted decolonization, but high-quality evidence of benefits (eg, decreased incidence of MRSA, decreased MRSA infection) and harms (resource utilization) is lacking [64].
Although consensus regarding which patients to screen is lacking, active surveillance may be beneficial in the setting of a health care outbreak or in patients at increased risk of MRSA colonization, including patients who:
●Are in the intensive care unit (ICU) or NICU [50,61,65-67]; active surveillance in the NICU is discussed below (see 'Neonatal intensive care unit' below)
●Have skin or soft tissue infection
●Have a history of MRSA colonization [68]
●Are immunocompromised
●Were hospitalized in the previous 12 months [69,70]
●Have received antibiotic therapy in the previous three months [70]
●Are residents of long-term care facilities [64]
When active surveillance is undertaken, MRSA can be detected with culture or polymerase chain reaction (PCR) [31,67,71]. Outside of the NICU setting, bioluminescence assays are another method for active surveillance [31,71]. Surveillance results are available sooner with PCR assays than cultures, but PCR assays are more expensive. Specimens are usually obtained from the anterior nares, which is the most frequently positive site, although sensitivity may be as low as 48 percent [72]. Sampling of additional sites (eg, inguinal area, perineum, perianal area, throat, umbilicus [in neonates]) increases the yield [67,73-76].
Identifying asymptomatic patients colonized with MRSA may help to prevent MRSA transmission and infection in the health care setting because colonized patients may transmit MRSA and because a substantial proportion of patients colonized with MRSA develop MRSA infection [31,58,77,78]. In a retrospective study, 8.5 percent of 153 children who were colonized with MRSA at the time of admission to a pediatric intensive care unit (PICU) subsequently developed MRSA infection, often after discharge; among the 15 children who were newly colonized with MRSA during their ICU stay, 7 developed MRSA infection [78].
Active surveillance has been associated with decreased incidence of MRSA in several observational studies (predominantly in adult patients) [79-82]. However, active surveillance was generally a component of a multifaceted approach, and the individual contribution of active surveillance is uncertain [36].
Decolonization
Targeted decolonization — Targeted decolonization of patients colonized with MRSA may decrease the risk of infection in the colonized patient and transmission to noncolonized patients [59,61,62,83].
Targeted decolonization may be warranted as part of a multifaceted approach in the setting of a health care outbreak and in hospitals or units with an unacceptably high incidence of MRSA. It is also reasonable in the preoperative care of children who will be undergoing cardiac surgery or children who are scheduled for an implantable device (eg, cerebrospinal fluid shunt, spinal instrumentation, baclofen pump) [35]. However, there remain many unanswered questions (eg, optimal regimen, duration) and consensus is lacking. (See 'Decolonization regimens' above.)
Targeted decolonization in of NICU patients is discussed below. (See 'Neonatal intensive care unit' below.)
Universal decolonization — Universal decolonization refers to decolonization of all patients in a particular setting (eg, ICU). It can be implemented immediately upon admission because it does not require surveillance testing [59].
Universal decolonization may be warranted for patients hospitalized in the ICU if there is an unacceptably high rate of MRSA or during an outbreak. Studies in adult ICU patients support universal rather than targeted decolonization for prevention of MRSA infection [50-52]. A multicenter, cluster-randomized, crossover trial supports universal chlorhexidine bathing for prevention of bacteremia (not limited to MRSA bacteremia) [54]. (See 'Chlorhexidine bathing for PICU patients' above.)
Universal decolonization of NICU patients is discussed below. (See 'Neonatal intensive care unit' below.)
Special settings or populations
Neonatal intensive care unit — MRSA colonization and infection is associated with substantial morbidity in neonates [84-87]. In addition to baseline prevention strategies, active surveillance and targeted or universal decolonization may be warranted in a unit with an unacceptably high incidence of MRSA or to control an outbreak [67,88]. Decisions regarding these strategies are individualized in consultation with experts in infection control and hospital epidemiology. Evidence that these strategies are effective is limited. The potential benefits of decolonization must be balanced against the unknown effects on the neonates' microbiota and potential for infections with other microorganisms [59].
●Contact precautions – Contact precautions are recommended for patients known to be colonized with MRSA [39-41]. The duration of contact precautions for MRSA-colonized infants in the NICU varies from institution to institution. Given the high rates of persistent or recurrent colonization, particularly in infants with ventilatory devices (eg, endotracheal tubes, nasal prongs) that may be reservoirs of infection [89-91], we continue contact precautions for the duration of hospitalization. This approach is consistent with guidance from the Society for Healthcare Epidemiology of America [88]. An alternative approach uses serial surveillance testing to document clearance of colonization before discontinuation and continued clearance after discontinuation. This approach is described above. (See 'Duration of contact precautions' above.)
●Active surveillance – Active surveillance for MRSA informs decisions about other infection control measures (eg, contact isolation, decolonization) [88]. In nonoutbreak settings, active surveillance of NICU patients without decolonization does not appear to affect the incidence of MRSA. In observational studies, active surveillance combined with isolation and patient cohorting was not associated with consistent decline in the incidence of MRSA [92,93].
●Active surveillance and targeted decolonization
•Active surveillance and targeted decolonization of neonates – Active surveillance and targeted decolonization successfully eradicates S. aureus carriage in the short-term, but recolonization is common [94-97]. In a multicenter trial, 155 NICU infants <24 months of age who were colonized with S. aureus were randomly assigned to five days of treatment with topical mupirocin every eight hours (intranasal, periumbilical, and perianal) or no treatment [94]. Mupirocin resulted in primary decolonization on day 8 (94 versus 5 percent), but more than 50 percent of treated infants were recolonized by day 22 and 70 percent by day 85.
Targeted decolonization also may reduce the risk of subsequent MRSA infection in colonized neonates [62,89,94-96,98-100]. In an experimental study, decolonization (mupirocin ointment applied to the nares and umbilicus twice daily for five days) of colonized neonates was associated with decreased rate of clinical MRSA infection (3 versus 16 percent) [95]. In the multicenter trial described in the previous paragraph, fewer decolonized neonates developed clinically significant S. aureus infections, but the result was not statistically significant [94].
•Active surveillance and targeted decolonization of parents – Active surveillance and targeted decolonization of parents or caregivers of NICU infants may be helpful in preventing transmission. Parents are a primary reservoir for S. aureus infections in infants [101-103].
In a randomized trial in two NICUs with a comprehensive S. aureus surveillance and decolonization program, S. aureus-colonized parents of 208 NICU infants with no history of positive S. aureus cultures were assigned to a five-day decolonization regimen (intranasal mupirocin and chlorhexidine bathing) or placebo (intranasal petrolatum and bathing with nonmedicated soap) [101]. Among the 190 infants available for follow-up at 90 days, 74 neonates (39 percent) were colonized with S. aureus; 57 percent of colonized neonates had the same strain as their parents. The proportion of concordant S. aureus acquisition was similar for MRSA (8 percent of isolates) and methicillin-susceptible S. aureus (92 percent of isolates). Fewer infants whose parents were assigned to decolonization acquired S. aureus colonization with a concordant strain (14.6 versus 28.7 percent; risk difference -14.1 percent, 95% CI -30.8 to -3.9) or with any strain of S. aureus (31.4 versus 45.5 percent). The study sample was too small to detect differences in rates of S. aureus infection.
Additional studies are necessary to confirm these findings to determine if they are generalizable to other settings (eg, NICUs without preexisting surveillance and decolonization programs) before routine adoption of this strategy.
●Universal decolonization – Universal decolonization of NICU patients may be warranted if other strategies have failed. Evidence of efficacy and safety are limited [59,67,104]. In quasi-experimental studies, universal decolonization of NICU infants with mupirocin was associated with outbreak control and decreased prevalence of MRSA [105-107].
●Decolonization regimen – The optimal decolonization regimen for preterm infants is uncertain [67,88]. Most studies have used mupirocin ointment rather than chlorhexidine for topical decolonization. Topical chlorhexidine may cause skin irritation and burns and may be systemically absorbed in neonates [108-111]. Topical decolonization regimens for neonates include:
•Mupirocin ointment applied to the intranasal, periumbilical, and perianal regions twice per day for five days [94,95]
•Mupirocin ointment applied to the intranasal and periumbilical regions, eroded skin, and wounds twice daily throughout hospitalization [106]
•Mupirocin ointment applied to the intranasal region three times daily for three days, and then three times per week [105]
Topical mupirocin in preterm infants is generally well tolerated. In an open-label randomized trial, rash was more common in mupirocin recipients than in controls (22 versus 5 percent) [94]. Development of mupirocin resistance is a concern [112].
Health care outbreak — Management of a health care outbreak of MRSA requires a multifaceted approach. Individual components (which may be bundled in various combinations) include [61,113-116]:
●Strict adherence to infection control measures (standard and contact precautions) and environmental cleaning (see 'Baseline strategies for health care settings' above)
During a NICU outbreak, soaps containing chlorhexidine or alcohol-based hand rubs are preferred to plain soap and water for hand hygiene [117-119].
●Cohorting patients and nurses
●Active surveillance and decolonization of patients (see 'Screening asymptomatic patients' above and 'Decolonization' above)
●Active surveillance and nasal decolonization of health care workers on the involved unit(s) may be warranted if transmission continues despite appropriate identification and isolation of MRSA cases, particularly if a single strain is responsible
●Universal decolonization [105,120,121] (see 'Universal decolonization' above)
●Molecular analysis to identify sources of MRSA [122,123]
VACCINATION — Efforts to develop a S. aureus vaccine are ongoing [124-126]. Some candidate vaccines demonstrate promise, but none is licensed.
PREVENTION OF VISA AND VRSA — Vancomycin-intermediate S. aureus (VISA) is defined as a vancomycin minimum inhibitory concentration (MIC) 4 through 8 mcg/mL [127,128]. Vancomycin-resistant S. aureus (VRSA) is defined as a vancomycin MIC ≥16 mcg/mL [127,128]. VISA and VRSA isolates have been rarely reported in children [129].
We follow the Centers for Disease Control and Prevention's (CDC) recommendations for prevention of VISA and VRSA infections, including [130]:
●Isolate the patient in a private room
●Minimize the number of personnel caring for the patient (eg, assign dedicated caregivers)
●Implement appropriate infection control precautions (standard and contact precautions); dedicate nondisposable items that cannot be cleaned and disinfected between patients (eg, adhesive tape, cloth-covered blood pressure cuffs) for use only on the patient
●Inform appropriate health care personnel that the patient has VISA/VRSA to ensure they understand the need for contact precautions
●Flag the patient's electronic medical record/chart to indicate infection/colonization with VISA/VRSA
●Consult with the local and/or state health department and CDC before transferring or discharging the patient
●Ensure that the patient's VISA/VRSA status and required infection control precautions are communicated at transfer
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Management of Staphylococcus aureus infection".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Beyond the Basics topic (see "Patient education: Methicillin-resistant Staphylococcus aureus (MRSA) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Prevention in the community
•Education – Education of patients and family members about hygiene and cleaning of surfaces and other items that are frequently touched with bare skin (eg, door knobs, bath tubs, counters, television remote controls, athletic equipment) is a key component of prevention of methicillin-resistant Staphylococcus aureus (MRSA) in the community. (See 'Education to reduce transmission' above.)
•Isolation from school or child care is not routinely necessary – Children with MRSA infection may attend school or child care provided that draining or open wounds or abrasions can be kept covered with a clean, dry dressing. Those who are colonized with MRSA should not routinely be excluded from school or child care. (See 'School or child care attendance' above.)
•Indications for decolonization – For children with recurrent MRSA infection despite routine hygiene measures, we suggest intranasal and topical decontamination (table 1) (Grade 2C).
For children with multiple recurrences of MRSA despite routine hygiene measures who have ≥1 other household member with MRSA infections, we suggest intranasal and topical decolonization for all household members with S. aureus infections in the previous year in addition to intranasal and topical decolonization of the child (Grade 2C).
Decolonization is well tolerated and may reduce the risk of subsequent MRSA infection in the patient and their contacts. (See 'Children with recurrent MRSA infection' above and 'Decolonization regimens' above.)
●Prevention in health care settings
•Baseline strategies – Prevention and control of MRSA in health care settings requires a multifaceted approach. Baseline strategies include standard precautions, contact precautions for patients infected or known to be colonized with MRSA, and identification of MRSA in symptomatic patients. (See 'Baseline strategies for health care settings' above.)
•Second tier strategies – Implementation of second-tier strategies is individualized in consultation with experts in infection control and hospital epidemiology. Second-tier strategies may be warranted in institutions, units, or populations with unacceptably high rates of MRSA despite implementation of baseline strategies. (See 'Individualized implementation' above.)
Second-tier strategies include screening asymptomatic patients and targeted or universal decolonization. These strategies often are used in combination with baseline strategies or other second-tier strategies. Multifaceted approaches have been successful in reducing the incidence of MRSA and controlling outbreaks, but the optimal approach is uncertain. (See 'Screening asymptomatic patients' above and 'Decolonization' above.)
•Prevention in the NICU – In the neonatal intensive care unit (NICU), active surveillance and targeted decolonization successfully eradicates S. aureus in the short term, and may reduce the risk of subsequent MRSA infection, but recolonization is common. Universal decolonization may be warranted if other strategies fail, but evidence of efficacy and safety are limited. The potential benefits of decolonization must be balanced against the unknown effects on the neonates' microbiota and potential for infections with other microorganisms. (See 'Neonatal intensive care unit' above.)
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