MRSA in Paediatric Cystic Fibrosis patients, Eradication and Treatment

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METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS [MRSA] IN CYSTIC FIBROSIS  

ERADICATION AND TREATMENT

Background

“MRSA infection will lead to a reduction in options for antibiotic treatment and a likelihood of deterioration in lung function, therefore MRSA infection should be avoided“ 

CF Trust MRSA 2008

 

“At first isolate, or in a person who has been free of MRSA following previous treatment, aim to eradicate the organism.“ 

CF Trust Antibiotic Treatment for CF 2009

 

“There are a small number of studies of the use of treatment regimens to eradicate MRSA lower respiratory tract infection in people with cystic fibrosis. The rate of clearance of infection without treatment is unknown. The eradication regimens in these studies have included combinations of oral, intravenous and nebulised antibiotics. The optimum regimen remains unclear...

If one treatment regimen fails to eradicate MRSA infection, two further attempts with the same or different regimens may still be successful and should be considered.“

CF Trust MRSA 2008

General Recommendations

CF Trust MRSA 2008

 

  1. Every Specialist CF Centre and CF Clinic should have a microbiological surveillance and infection prevention and control policy that considers cross-infection risk for MRSA.
  2. The methods used and extent to which Specialist CF Centres and CF Clinics segregate patients should be determined by local policy.
  3. Good hygiene should be practised in all outpatient clinics and inpatient facilities to minimise the risk of transmission of MRSA between patients.
  4. Specialist CF Centres and CF Clinics should monitor the rate of new acquisition of MRSA. 
  5. A policy of segregation that covers both inpatient admissions and outpatient clinics is advised.
  1. Stop Flucloxacillin/Erythromycin administration on first culture of MRSA
  1. Skin and nasal swabs - To be obtained from patient at baseline and around every inpatient admission. Anterior nares and Perineum are the minimum number of swabs required.  Other sites are included if applicable, such as skin lesions/ wounds, catheter sites, e.g. Central Venous Catheters, Hickman Lines, catheter urine,  umbilicus (neonates only). If patient refuses perineal screening they should be offered throat screening.  
  1. Seek Infection Prevention and Control advice re- extended screening if there is persistent or rapidly recurrent MRSA colonisation of the patient.
  1. Source isolation as per local hospital policies at Out-patient and Inpatient attendances
  1. Sputum / Cough swab cultures obtained to monitor colonization
  1. MRSA would be considered eradicated if cultures remain clear for 12 months or more.
1. Eradication

The CF Team and RHC Microbiology /Infection Prevention and Control Teams have reviewed the available information regarding current MRSA eradication regimens. The following regimens have been selected as being most suitable for use at RHC Glasgow CF Unit

“The aims of decolonisation are to reduce the risk of self-infection with the patient’s MRSA and to prevent transmission of MRSA to other patients.” 

CF Trust MRSA 2008

MRSA COLONISED PATIENTS NOT ON ROUTINE ANTIBIOTICS and NOT EXPERIENCING A RESPIRATORY  EXACERBATION

Regime A: MRSA COLONISATION OF RESPIRATORY TRACT +/- SKIN /NOSE

COLONISATION

Regimen

Duration  6 WEEKS

 

ORAL RIFAMPICIN 

1 month – 1 year

5-10mg/kg twice a day

 

1 – 18 years

10mg/kg (max 600mg) twice a day

 

Give on an empty stomach (half to one hour before food). May colour urine and bodily fluids orange/red. Inform contact lens users.

Use in combination with another appropriate antibiotic (eg. sodium fusidate) to prevent resistance.

Adverse effects; weight loss, GI upset including antibiotic associated colitis, blood dyscrasias, wheezing, elevated LFTs.

Monitor LFTs and FBC in prolonged courses (>14 days). Patients or their carers should be told how to recognise signs of liver disorders (persistent nausea and vomiting, jaundice, unexplained bruising), and blood dyscrasias (malaise, fever, sore mouth etc) and advised to discontinue treatment and seek immediate medical attention if symptoms develop. Always check interactions. Potent enzyme inducer and may substantially reduce plasma levels of other drugs leading to treatment failure. Interacts with Ivacaftor and OCP.

+ ONE OF   

ORAL FUSIDIC ACID/SODIUM

FUSIDATE

 

Neonate – 1 year

15mg/kg fusidic acid (0.3ml/kg) three times a day

1-5 years

250mg fusidic acid (5ml) three times a day

5-12 years

500mg fusidic acid (10ml) three times a day 

OR

375mg sodium fusidate (1.5 tablets) three times a day

>12 years

750mg fusidic acid (15ml) three times a day

OR 500mg sodium fusidate (2 tablets) three times a day

 

OR

 

ORAL TRIMETHOPRIM

 

6/52 – 11 years

4mg/kg twice a day ( Max. 200mg bd )

 

12-17 years

200mg bd

 

Fusidic acid is incompletely absorbed and therefore doses recommended for suspension are proportionately higher than those for sodium fusidate tablets.

Adverse effects: GI upset, drowsiness, dizziness

Monitoring: Monitor liver function tests

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Monitor FBC fortnightly 

Adverse effects : skin rashes ; GI upset 

Repeat respiratory culture at least 48 hours following each treatment course

 

Assume skin swabs and  nasal swabs +ve 

 

 

 

Treat with 4% Chlorohexidine gluconate  washes,   daily for 5 days (whole body including hair)

+

Treat with topical  Mupirocin 2% or Naseptin ( avoid in nut allergy) depending on sensitivities. Apply to both nostrils, four times a day for 5 days

Repeat cultures on two occasions following each eradication period– first culture at least 48 hours after antibiotic/ decolonisation therapy has been completed ; second culture no less than 72 hours after first .

Regime B: MRSA COLONISATION OF SKIN / NOSE ONLY 

If skin swabs or  nasal swabs +ve  

 

 

 

Treat with 4% Chlorohexidine gluconate  washes,   daily for 5 days (whole body including hair)

+

Treat with topical  Mupirocin 2% or Naseptin ( avoid in nut allergy) depending on sensitivities. Apply to both nostrils, four times a day for

5 days

Repeat cultures on two occasions following each eradication period– first culture at least 48 hours after antibiotic/ decolonisation therapy has been completed ; second culture no less than 72 hours after first .

 

Eradication Regimes A and/or B should be undertaken on a maximum of three occasions 

 

 

2. Treatment

IV ANTIBIOTIC REGIMEN (MRSA COLONISATION –RESPIRATORY EXACERBATION OR REGULAR IVs

Regimen

Notes / Duration

1ST LINE

IV TEICOPLANIN*

1 month – 18 years

10mg/kg (max 400mg) twice a day for 3 doses

then once a day thereafter

 

OR

 

2ND LINE

ORAL LINEZOLID 

1 month – 12 years

10mg/kg (max 600mg) three times a day

>12 years

600mg twice a day

 

 

 

 

 

 

Other appropriate IV anti-Gram negative antibiotic(s)

 

 

*TEICOPLANIN levels to be obtained weekly:

Aim for Trough > 15 mg/L

Monitor renal function and auditory function.

 

 

 

 

 

 

LINEZOLID- FBC weekly . Monitor LFTs.

 

For those on prolonged (4 weeks or more) or repeated courses, ophthalmological assessment is mandatory and should be repeated every TWO months. 

 

Where possible patients should be warned to immediately report any visual changes, regardless of treatment duration.

Repeat respiratory culture at least 48 hours following each treatment course

 

Assume skin swabs and  nasal swabs +ve 

 

 

 

Treat with 4% Chlorohexidine gluconate  washes,   daily for 5 days (whole body including hair)

+

Treat with topical  Mupirocin 2% or Naseptin (avoid in nut allergy) depending on sensitivities. Apply to both nostrils, four times a day for 5 days

Repeat cultures on two occasions following each eradication period– first culture at least 48 hours after antibiotic/ decolonisation therapy has been completed ; second culture no less than 72 hours after first .

References
Editorial Information

Last reviewed: 24 April 2018

Next review: 31 October 2018

Author(s): Jane D Wilkinson

Version: 1

Co-Author(s): FOR RHC CF TEAM DR JANE WILKINSON STEVE BOWHAY FOR RHC ICP TEAM DR ROSIE HAGUE PAMELA JOANNIDIS ANGELA JOHNSON

Approved By: Paediatric Drugs & Therapeutics Committee