IDSA: No Consensus Found for Treating MRSA Infections in Kids

SAN DIEGO, Oct. 8 -- Pediatric infectious disease specialists have no consensus about the optimal approach to treatment of methicillin-resistant Staphylococcus aureus infections in children, a nationwide survey indicated.

No universal agreement exists for the choice of first-line therapy or the duration of therapy, Buddy Creech, M.D., of Vanderbilt University in Nashville, said at the Infectious Diseases Society of America meeting here.

A little more than half of the survey respondents favored clindamycin as first-line therapy, followed by trimethoprim/sulfamethoxazole. About a third of the physicians said they treat for 10 days, but two thirds cited durations ranging from fewer than seven days to more than 14.

"This is a huge problem," said Dr. Creech. "Three fourths of the abscesses treated in our emergency department involve MRSA. It's been that way for at least half a decade."

General guidelines exist for management of skin and soft tissue infections and for prevention, but "there is nothing that is data driven or that clearly states what is a preferred method, what is a preferred agent, what is a preferred duration of therapy," he added.

To see how pediatric infectious disease specialists are managing skin and soft tissue infections involving MRSA, Dr. Creech and colleagues surveyed 197 pediatric consultants included in the IDSA Emerging Infections Network.
The request for information drew responses from 114 (58%) physicians in 39 states.

The survey elicited answers to four key questions:

• What is the first-line antibiotic?
• How long does treatment continue?
• When is MRSA decolonization initiated?
• What is the usual decolonization protocol?

More than three fourths (77.3%) of respondents said the frequency of MRSA infections had increased within the past year, and 60.9% said the number of severe infections also had increased.

Clindamycin was favored by 56% of respondents as initial antibiotic therapy for MRSA, followed by TMP/SMX (38%).

"Even though we wanted to know what drug they typically started treatment with, there is no evidence to say that one drug is better than another," Dr. Creech commented.

Slight more than 30% of respondents said they typically treat MRSA abscesses for 10 days, followed by 10 to 14 days (20%), seven to 10 days and more than 14 (10% to 15% each) and fewer than seven days (about 8%).

Decolonization strategies exhibited even greater variability. No more than 15% to 18% of respondents favored a particular timing for initiation of decolonization, including about 12% who had no routine and about 18% who fell into the category of "other." Initiation after a first episode, a second episode, a severe episode, after familial spread, or some combination was cited by the respondents.

Among respondents who have decolonization protocols, the most common strategies included mupirocin alone (22.7%), mupirocin plus chlorhexidine (22.7%), mupirocin plus bleach (8.2%) and bathing with a topical disinfectant (4.5%).

Forty-nine percent of responders provide decolonization for the entire family regardless of colonization status, 47% do not routinely offer decolonization for family members, and 4% culture and treat only if positive.

"The extreme variability we observed in treatment and decolonization practices emphasizes the need for randomized, controlled clinical trials to provide guidance for management of these difficult infections," said Dr. Creech.