Successful decolonization of meticillin-resistant Staphylococcus aureus in paediatric patients with cystic fibrosis (CF) using a three-step protocol

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Summary

Meticillin-resistant Staphylococcus aureus (MRSA) is recognized as a bacterial pathogen in patients with cystic fibrosis (CF) although its clinical effects can be variable. The aim of this study was to evaluate the efficacy of a three-step decolonization protocol for MRSA (Belfast CF MRSA decolonization protocol). Of the 17 paediatric patients treated during the five years of the study, eight (47%) were successfully decolonized following one five-day course of oral rifampicin and fusidic acid. The success rate increased to 12 (71%) patients after a second five-day oral treatment course in the 11 patients who remained culture positive at the end of the first treatment cycle. In a further four patients, clearance was achieved with a course of intravenous teicoplanin, increasing the decolonization rate to 16 of 17 patients (94%). These results compare favourably with other published studies and show that MRSA decolonization can be successful in a high proportion of paediatric CF patients.

Introduction

One of the main aims of cystic fibrosis (CF) treatment is to eradicate potential pathogens from the respiratory tract. Despite the use of effective antibiotics, Staphylococcus aureus remains an important pathogen in CF and is the most frequently cultured respiratory organism in children. Infections with susceptible isolates can usually be treated successfully, with the result that this organism is no longer the major cause of morbidity and mortality that it had been in the 1950s.

Since the 1960s, meticillin-resistant isolates of S. aureus (MRSA) have become more prevalent, causing substantial morbidity and mortality within hospitals.1 Adult CF units have reported that their patients have acquired MRSA strains prevalent in their hospitals.2, 3 The experience in paediatric units is different, with reports of children acquiring a community strain of MRSA.1 The clinical significance of MRSA remains undetermined, with no evidence of increased morbidity within the CF population. MRSA culture-positive patients do pose additional management problems, however, since most hospital infection control policies require segregation of this group of patients from other non-colonized patient populations.

The 1997 consensus meeting entitled, ‘MRSA in Cystic Fibrosis’, advocated strict infection control measures to prevent the spread of MRSA in the CF population and also provided guidance on which antibiotics are most effective in MRSA treatment and decolonization.3 Several CF units have reported various decolonization protocols but there is no overall agreement upon the best methods for decolonization.4, 5, 6, 7 The aim of the current study was to evaluate the efficacy of a three-step decolonization protocol, which had been introduced in 1999 when the Northern Ireland Regional CF Centre first isolated MRSA from a routine respiratory culture from one of its patients.

Section snippets

Patient population and clinical management background

The Northern Ireland Regional Paediatric CF centre is based in The Royal Belfast Hospital for Sick Children and manages all CF patients under the age of 18 in Northern Ireland, with an approximate patient population of 250 during the period of this study. Neonatal screening for CF has been in operation for the past 21 years and most patients have been diagnosed by the age of six weeks. At the time of diagnosis, all patients commence anti-staphylococcal prophylaxis with oral flucloxacillin,

Results

All bacteriological results were reviewed on each patient with a history of MRSA colonization between Jan 1999 and Jan 2004 and who were given the decolonization protocol (Table II).

From the study population of approximately 250 CF paediatric patients, 17 patients, (12 male and five female) had at least one isolate of MRSA. Table II summarizes each child's age at the time of acquisition of MRSA, CF genetic mutational status, bacteriological status at the time of MRSA acquisition, Schwachman

Discussion

There is limited published literature about MRSA decolonization in CF centres; those studies available have only included relatively small numbers of CF patients. Solis et al. reported a 55% success rate with a protocol using oral and nebulized vancomycin for five days.4 Garske et al. reported successful decolonization of five out of seven patients with MRSA, using rifampicin and sodium fusidate for a six-month course of treatment.5 The rationale for this combination of antibiotics was based on

Acknowledgements

We wish to thank the S. aureus Reference Laboratory (Health Protection Agency), Colindale, London, for phage-typing of the MRSA isolates. We also wish to thank Dr John Moore and Dr Colin Goldsmith, Department of Bacteriology, Belfast City Hospital, for critical appraisal of the manuscript.

References (11)

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