Staphylococcus Aureus Infection Follow-up

Updated: Jan 15, 2019
  • Author: Elizabeth P Baorto, MD, MPH; Chief Editor: Russell W Steele, MD  more...
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Follow-up

Further Outpatient Care

Appropriately monitor renal function, CBC count, and serum hepatic transaminase levels while patients with Staphylococcus aureus infection are undergoing therapy.

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Deterrence/Prevention

A large study in adult inpatients has demonstrated that universal surveillance, appropriate use of contact precautions and hand hygiene, and institutional culture change can decrease infections with MRSA. [165] Another approach likely to be cost-saving and to decrease infection in the intensive care unit is targeted screening and nasal decolonization, [166] although the benefits of nasal decolonization outside this setting remain undefined. [167, 168, 169]

Results of a 2-phase interventional study presented at the 23rd European Congress of Clinical Microbiology and Infectious Diseases in April 2013 suggest that in patients at risk for MRSA, PCR screening followed by isolation reduces the frequency of hospital-acquired infections and is cost-effective. [170]

During phase 1 of the study, 1209 newly admitted patients were screened with a microbiology assay. MRSA-positive patients were placed in contact isolation after the assay result was received (mean, 62.8 ± 15.7 hours). During phase 2, 1200 patients were screened with rapid real-time PCR followed by microbiology assays. Patients were placed in contact isolation if their preliminary PCR test result was positive. All high-risk patients with a preliminary positive PCR result were placed in contact isolation from admission onward.

The numbers of admitted MRSA cases in phase 1 and 2 were about the same (2.1 vs 1.96 per 100 patients). The nosocomial MRSA infection and colonization rates were reduced in phase 2 compared to phase 1 (nosocomial infection rates, 0.10 vs 0.20 per 1000 patient days, P< .05; colonization rates, 0.35 vs. 0.66; P< .01) and remained so or decreased further in 4 consecutive subsequent 6-month periods. Treatment costs were lower in phase 2, despite increased costs for preventive measures, but might vary with differing reimbursement systems.

Prevention of transmission of MRSA among hospitalized children is a significant priority. [171] Increasingly, universal decolonization of ICU patients has been recommended. [172, 173]

Daily washing of ICU patients with chlorhexidine-impregnated cloths reduced positive cultures of MRSA by 37% and reduced bloodstream infection by any pathogen by 44%, according to a study of 74,256 patients in 74 adult ICUs. [172, 174]

In the study, hospitals were randomized to 18 months of either screening for MRSA followed by isolation of positive patients, targeted decolonization of MRSA-positive patients and isolation, or universal decolonization of all ICU patients without screening. Decolonization was achieved via daily cleansing with chlorhexidine-impregnated cloths and 5 days of twice-daily intranasal mupirocin treatments. At baseline, there was no significant difference in the rate of MRSA infections between the 3 groups. [172, 174]

However, patients who underwent universal decolonization showed a significantly larger decline between baseline and intervention periods than those in either of the targeted interventions. Universal decolonization led to a 37% drop in the rate of MRSA infections, while targeted decolonization led to a 25% decline and no significant change was seen in the screening and isolation group. There was no significant difference in outcomes between the targeted decolonization and the screening and isolation groups, while the difference between the universal decolonization and the screening and isolation groups was significant (P = .003). Universal decolonization also significantly reduced ICU-attributed bloodstream infections from any pathogen. [172, 174]

Compared with passive screening, active screening in hospitalized patients for MRSA was shown to result in a higher incidence of discontinuation of MRSA contact precautions. Patients were randomized to observation with either local standard of care (passive screening; n=202) or screening with culture and commercial polymerase chain reaction (PCR) testing (active screening, n=405). In the active screening group, sensitivity, specificity, and positive and negative predictive values of the first PCR were compared to cultures.

The researchers showed that contact precautions were discontinued significantly more often in the active screening group (rate ratio [RR], 4.1; 95% confidence interval [CI], 2.3%-7.1%), including in an intent-to-screen analysis (RR, 2.6; 95% CI, 1.5%-4.7%). Compared with 3 cultures, the first PCR detected MRSA with a sensitivity of 93.9% (95% CI, 85.4%-97.6%), a specificity of 92.0% (95% CI, 85.9%-95.6%), a positive predictive value of 86.1% (95% CI, 75.9%-93.1%), and a negative predictive value of 96.6% (95% CI, 91.6%-99.1%). [175]

Various vaccine candidates are being evaluated. [176, 177, 178, 179, 180, 181, 182]

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Complications

S aureus infection may result in pneumonia, bone and joint infection, and infection of the heart valves.

In immunocompromised hosts (eg, patients with cancer who are neutropenic and have a central venous line), 20-30% develop serious complications or fatal sepsis following catheter-related S aureus bacteremia or other S aureus infections. [183]

Community-associated methicillin-resistant S aureus (CA-MRSA) infection is more serious and is associated with thrombogenesis. It is becoming endemic in many pediatric and neonatal intensive care units. [184, 185, 186, 187]

Multiple brain abscesses have been reported in premature infants. [188, 189]

S aureus infection complicating influenza infection is associated with significant morbidity and mortality. [190]

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Prognosis

Morbidity and mortality associated with staphylococcal bacteremia in children seem to be less significant than observed in bacteremic adults. [191, 192]

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Patient Education

Parents of infected children may require additional information/education. [193] For patient education resources, see the Women's Health Center and Skin, Hair, and Nails Center, as well as Toxic Shock Syndrome and Boils.

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