title: Use of surveillance cultures and enteral vancomycin to control methicillin-resistant Staphylococcus aureus in a paediatric intensive care unit.
abstract: This study assessed the effects of throat and gut surveillance, combined with enteral vancomycin, on gut overgrowth, transmission of methicillin-resistant Staphylococcus aureus (MRSA), infections and mortality in patients admitted to a paediatric intensive care unit (PICU). A 4-year prospective observational study was undertaken with 1241 children who required ventilation for >or=4 days. Patients identified as MRSA carriers following surveillance cultures of throat and rectum received enteral vancomycin. Twenty-nine (2.4%) children carried MRSA, 19 on admission and nine during treatment in the PICU; one patient was not able to be evaluated. Overgrowth was present in 22 (75%) of the carriers. Ten (0.8%) children developed 21 MRSA infections (15 exogenous infections in eight children at a median of 8 days (IQR 3-10.5); five primary endogenous infections at a median of 3 days (IQR 1-25) in three children when they were in overgrowth status; one child developed both types of infection). Enteral vancomycin reduced gut overgrowth significantly, completely preventing secondary endogenous infections. Transmission occurred on nine occasions over a period of 4 years. Four patients died, two (5.9%) with MRSA infection, giving a mortality (11.8%) similar to the study population (9.8%). No emergence of vancomycin-resistant enterococci or S. aureus with intermediate susceptibility to vancomycin was detected. A policy based on throat and gut surveillance, combined with enteral vancomycin, for critically-ill children who were MRSA carriers was found to be effective and safe, and challenges the recommended guidelines of nasal swabbing followed by topical mupirocin.
authors.affiliation: Paediatric Intensive Care Unit, Royal Liverpool Children's Hospital, Alder Hey, Liverpool L12 2AP, UK. kent.thorburn@rlc.nhs.uk
authors.forename: K
authors.initials: K
authors.lastname: Thorburn
authors.forename: N
authors.initials: N
authors.lastname: Taylor
authors.forename: S M
authors.initials: SM
authors.lastname: Saladi
authors.forename: H K F
authors.initials: HK
authors.lastname: van Saene
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002353:Carrier State / Q000382:microbiology; D003470:Culture Media; D004333:Drug Administration Routes; D005260:Female; D006801:Humans; D007223:Infant; D017053:Infection Control / Q000379:methods*; D015278:Intensive Care Units, Pediatric; D008297:Male; D016106:Methicillin Resistance; D010614:Pharynx / Q000382:microbiology; D012007:Rectum / Q000382:microbiology; D013048:Specimen Handling / Q000379:methods; D013203:Staphylococcal Infections / Q000382:microbiology / Q000517:prevention & control*; D013211:Staphylococcus aureus / Q000187:drug effects / Q000302:isolation & purification*; D016896:Treatment Outcome; D014640:Vancomycin / Q000008:administration & dosage*
chemical_list: D000900:Anti-Bacterial Agents; D003470:Culture Media; D014640:Vancomycin