Information for health care professionals - MRSA
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Information for health care professionals

Meticillin Resistant Staphylococcus Aureus - MRSA

MRSA surface colonisation is without serious consequences for most CF patients. MRSA can also infect airway secretions. Children with CF who have MRSA in airway secretions may do less well overall than those who are MRSA-free. The presence of MRSA infection can considerable difficulties when patients are being considered for lung/liver transplantation. Current recommendations are that CF patients should be regularly monitored for MRSA in sputum/cough swabs. Prevention is the best policy and strict handwashing, avoiding patient-patient contact, and general high-levels of hygiene are required, as for any other patient. The CF Trust has produced guidelines on the managament of MRSA. Click here to read the guidance.

MRSA eradication protocol

If MRSA is found on a cough swab or sputum culture, the child should have swabs taken from the nares, axilla, and groin and then undergo an eradication procedure. This is an adaptation of the Belfast protocol (Macfarlane et al 2007). This involves:

  • hygiene advice - change bed linen at start of treatment, use own towel, face cloth and tootbrush and replace all nebulization components
  • topical mupirocin 2% ointment (Bactroban) to anterior nares three times per day for 5 days
  • oral fusidic acid (15-20mg/kg/dose tds - should approximate to: 1-5 yrs: 250 mg tds, 6-12 yrs: 500 mg tds, > 12 yrs: 750 mg tds) and rifampicin (10mg/kg/dose bd - maximum of 450mg bd if <50 kg, 600mg bd of >50 kg) for 14 days
  • 4% chlorhexidine baths and hairwashing daily for 5 days. The child should apply 4% chorhexidine (Hibiscrub) all over, expecially axillae and perineum, and then rinse off in the bath. The hair should also be washed with chorhexidine and then rinsed. Ordinary shampoo can be used afterwards if desired.

After completion of the eradication protocol, respiratory samples and surface swabs are repeated. If MRSA persists then REPEAT the eradication protocol and re-culture. If MRSA still persists then give:

  • intravenous teicoplanin 10mg/kg every 12 hours for 3 doses then 10mg/kg od for 10 days

The CF group in Belfast claim that this protocol will result in eradication in over 90% of children. If eradication fails, the presence of MRSA in cough swab or sputum cultures should be approached in the same way as meticillin-sensitive SA. NB: when using oral agents to treat MRSA, 2 antibiotics should be used in combination to prevent resistance developing. MRSA is particularly adept at developing resistance. When the child is well, 2 week courses of Rifampicin and Fusidic acid should be used. Alternatives include Trimethoprim and Tetracycline or Doxycycline. In a child with with respiratory symptoms and MRSA from sputum or cough swab, who does not respond to oral antibiotics, should be treated with iv teicoplanin or vancomycin.

In children with MRSA who have declining lung function despite intravenous antibiotics, tds nebulised vancomycin can considered but only be used for a 2 week course. Prolonged use can result in vancomycin resistance (VRSA). MRSA in the Oxfordshire region is also usually sensitive to aminoglycosides, so nebulised tobramycin is likely to be a simpler option.

MRSA screening

When there are plans to insert either a gastrostomy or a portacath, children should have surface swabs to check their MRSA status. If they are MRSA positive, they should undergo the eradication protocol prior to the procedure. Any child on the lung transplant list should have regular (2 monthly) surface swabs for MRSA. The transplant team should be informed if they are MRSA positive and their advice should be sought regarding eradication protocols.