Community-Associated Methicillin -Resistant Staphylococcus Aureus in Acute Musculoskeletal Infection in Children: A Game Changer

Author(s): Vander Have KL, Karmazyn B, Verma M, Caird MS, Hensinger RN, Farley FA and Lubicky JP

Source: J Pediatr Orthop 29(8):927-931, 2009.

Summary:

A methicillin-resistant staphylococcus aureus was initially a hospital acquired infection.  Recently, MRSA has been discovered in a community setting and it has become a major source of skin, soft-tissue infection and necrotizing fascitis.  Because of the increased incidence of MRSA staphylococcal infections, treatment can no longer be carried out with traditional antibiotics. Genetic alterations have occurred in the community acquired MRSA compared to the hospital acquired MRSA.  This genetic change has made this bacteria specific particularly virulent.

The authors attempt to assess the MRSA infections over a 5 year period at two tertiary children’s hospitals.  They included immunocompetent individuals with a retrospective review of their presentation and data. 

The cohort consisted of 27 children with 18 males and 9 females.  The average was 9 years, but the range from 3 months to almost 18 years.  Clinical presentation involved the upper extremity in 23 of 27 patients.  Twelve patients required admission to an intensive care unit, and 4 of these developed acute multi-system failure requiring extracorporeal membrane oxygenation.  Five patients were managed in the ICU requiring vasopressors for the management of hypotension/septic shock

Routine radiographs were positive for osteomyelitis in only 3 patients.  MRI was performed in 21 patients and was positive in each case.  The white count was elevated in only 14 of 25 patients, with 3 developing a low white count.  Antibiotics used included vancomycin for 16 patients, clindamycin for 9 patients, and a combination regimen for 2 patients.  All patients required surgery.  In 16 of 27 patients, multiple debridements were required.  Eight patients developed deep venous thrombosis requiring systemic anti coagulation. 

Community required MRSA is a severe life threatening and limb threatening disease that occurs in normal healthy children.  The most common manifestation involves the upper extremity and includes septic arthritis, acute hematogenous osteomyelitis, subperiosteal abscess and pyomyositis.  Multi-system organ failure can occur and must be managed effectively to save the life of the infected child.  Early diagnosis is mandatory and the clinician must have a high index of suspicion.  Empiric intravenous antibiotic therapy with vancomycin should be initiated if community required MRSA is suspected.  Unless the diagnosis is recognized early, permanent sequelae and even death can occur.