Pediatricians' perspectives on the impact of MRSA in primary care: a qualitative study

Management of afebrile neonates with skin and soft tissue infections in the pediatric emergency department

OBJECTIVE

To describe the management of afebrile neonatal skin and soft tissue infections (SSTIs) in the pediatric emergency department (PED).

METHODS

This is a retrospective cohort study of all patients aged 0 to 28 days seen in the PED for SSTIs from 2004 to 2010. The SSTIs were identified from the International Classification of Diseases, Ninth Revision codes of pustulosis, cellulitis, and abscess. Records were reviewed to determine the absence of fever; anatomical location; cultures of blood, urine, and cerebrospinal fluid; antibiotic usage; and return visits. Data were analyzed to compare admitted versus discharged patients with SSTI subtypes.

RESULTS

Of the 136 neonates identified, 104 met inclusion criteria. Afebrile SSTIs included 8 pustulosis, 45 cellulitis, and 51 abscesses. Blood cultures were obtained in 13% of pustulosis, 96% of cellulitis, and 69% of abscesses. No serious bacterial infection was noted. Three blood cultures grew contaminants. Parenteral antibiotics for neonates with pustulosis, cellulitis, and abscesses were given in 13%, 87%, and 59%, respectively. Admission rates for neonates with pustulosis, cellulitis, and abscesses were 13%, 84%, and 55%, respectively. Cases of cellulitis were more likely to have blood cultures drawn (odds ratio [OR], 13.7; 95% confidence interval [CI], 3.03-62.3), receive intravenous antibiotics (OR, 5.87; 95% CI, 2.16-15.0), and be admitted to the hospital (OR, 5.62; 95% CI, 2.16-14.6) as compared with the other SSTI subtypes.

CONCLUSIONS

None of the neonates who had cultures drawn had serious bacterial infection. The SSTI subtype correlated with the extent of evaluation and dispositions. The findings of this study will help with management strategies for afebrile neonates with SSTIs in the PED.

Community associated methicillin resistant Staphylococcus aureus among New York City men who have sex with men: qualitative research findings and implications for public health practice

Academic literature has recorded increased microbial resistance in the United States and recent news media has adversely portrayed men who have sex with men (MSM) at increased risk for community associated methicillin resistant Staphylococcus aureus (CA-MRSA) transmission. CA-MRSA is a specific type of bacteria resistant to certain antibiotics, which limits treatment options for those needing clinical care. Infection can manifest as painful abscesses and can cause severe illness. With increased CA-MRSA infections overall, and attention given to MSM populations regarding CA-MRSA, as well as the fact that limited data on sociocultural factors that may facilitate transmission, we undertook a qualitative study to explore contextual influences that may fuel infection among MSM in New York City so that public health professionals can better recognize, and respond appropriately to, potential future outbreaks. In-depth interviews were used to qualitatively investigate perceptions and beliefs regarding transmission, as well as community understandings of treatment options. Participants included thirteen MSM who reported a previous CA-MRSA infection and nine community practitioners. A thematic content analysis of these interviews was conducted and data suggests that behaviors and exposures associated with transmission of CA-MRSA are common in certain MSM networks. Specifically, sociocultural influences and methamphetamine use activities were found to contribute to CA-MRSA transmission. We underscore the role of public health and health services practitioners in providing appropriate CA-MRSA awareness and education to MSM populations.

Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development

RATIONALE, AIMS AND OBJECTIVES

The quality of patient care and safety is dependent on addressing both errors of commission (e.g. overuse of medications) and errors of omission (e.g. patients receiving too little care). Despite guidelines recommending the use of certain proven pharmacotherapeutic interventions, a large gap exists between the patients that have an indication for, and those that actually receive such interventions. To address how the rate of implementation of proven interventions can be improved is dependent on a comprehensive knowledge of the factors contributing to their underuse. The aim of the review is to create an evidence-based framework of reasons why eligible patients do not receive proven pharmacotherapeutic interventions.

METHODS

A systemic review of the published reasons for non-use based on the Cochrane methodology.

RESULTS

The systematic review identified 67 articles meeting the inclusion criteria. The reasons for non-use were extracted from the studies and a framework was created from the results.

CONCLUSIONS

The factors associated with lack of implementation of proven pharmacotherapeutic interventions are complex and heterogeneous but can be understood from the perspectives of clinicians, patients and health care delivery systems. Efforts to increase the utilization of proven interventions should focus on disease/intervention-specific programmes that take into account the identified modifiable clinician, patient and system factors.

Adherence to CLSI recommendations for testing of Staphylococcus aureus isolates in Louisiana hospitals: report of a clinical failure and results of a questionnaire study

We report a case of failure of clindamycin therapy due to inducible clindamycin resistance. We surveyed and found that only 52% of reporting hospitals in the state of Louisiana were performing the D test for inducible clindamycin resistance according to guidelines recommended by the Clinical and Laboratory Standards Institute (formerly the National Committee for Clinical Laboratory Standards).

Knowledge, awareness, and attitudes regarding methicillin-resistant Staphylococcus aureus among caregivers of hospitalized children

OBJECTIVES

To explore knowledge, awareness, and attitudes among caregivers of hospitalized children with regard to methicillin-resistant Staphylococcus aureus (MRSA).

STUDY DESIGN

We developed and administered a bedside questionnaire to caregivers of hospitalized children in contact isolation for MRSA colonization or infection.

RESULTS

Of 104 caregivers approached, 100 (96%) consented to participate. The caregivers' children included 28 (28%) newly recognized as colonized or infected with MRSA during the hospitalization and 72 (72%) previously identified as colonized or infected with MRSA. Eighteen (18%) caregivers had no knowledge of MRSA. Twenty-nine (29%) were unaware that their child had MRSA, including caregivers of 9 newly identified patients with MRSA and 20 patients with previously identified MRSA. Of the 71 caregivers aware of their child's MRSA status, 89% had concerns; 77% worried about risks of future MRSA infection, 51% worried about spreading MRSA, and 16% described a feeling of stigma. Worries were more common among caregivers of children with newly identified MRSA (P < .05).

CONCLUSION

Caregivers of children hospitalized with MRSA are frequently unaware that their child has MRSA. Among those aware of their child's MRSA status, many have concerns and worries. Caregivers of children with newly identified MRSA more often are worried and may need additional education and reassurance.

Antibiotic selection for purulent skin and soft-tissue infections in ambulatory care: a decision-analytic approach

OBJECTIVE

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused a nationwide epidemic of skin and soft-tissue infections in ambulatory pediatrics. Antibiotic treatment recommendations suggest incorporating local epidemiology for the prevalence of CA-MRSA. We sought to identify the antibiotic strategy with the highest probability of activity and to identify threshold values for epidemiologic variables including bacterial prevalence and antibiotic resistance.

METHODS

We used decision analysis to evaluate 3 empiric antibiotic strategies: clindamycin, trimethoprim/sulfamethoxazole (T/S), and cephalexin. We calculated the probability of activity against the bacteria causing the infection (CA-MRSA, methicillin-sensitive S. aureus and group A Streptococcus [GAS]) by incorporating estimates of prevalence and antibiotic resistance to determine the optimal strategy. Sensitivity analysis was used to identify thresholds for prevalence and antibiotic resistance where 2 strategies were equal.

RESULTS

Clindamycin (0.95) and T/S (0.89) had substantially higher probability of activity than cephalexin (0.28) using baseline estimates for bacterial prevalence and antibiotic resistance. Cephalexin was the optimal antibiotic only when CA-MRSA prevalence was <10%. The probability of activity for clindamycin and T/S was highly sensitive to changes in the values for bacterial prevalence (both CA-MRSA and GAS) and CA-MRSA resistance to clindamycin.

CONCLUSIONS

Empiric treatment of skin and soft-tissue infections with either clindamycin or T/S maximizes the probability that the antibiotic will be active when CA-MRSA prevalence is >10%. Deciding between T/S and clindamycin requires consideration of antibiotic resistance and prevalence of GAS. This model can be customized to local communities and illustrates the importance of ongoing epidemiologic surveillance in primary care settings.