Pedictric_Mrsa

Running head: PEDIATRIC COMMUNITY ACQUIRED MRSA Community Acquired MRSA in Pediatrics Research Critique Paper Master’s Research; Liberty University Abstract The epidemiology of community-acquired methicillin resistant staphylococcus aureus (CA-MRSA) within the pediatric population is increasing, as evidenced by the high prevalence of cases in several U.S. communities. A prospective cross-sectional as well as a retrospective study were performed, both of which supported strong data of an alarming increase of CA-MRSA colonization in healthy children with no predisposing risk factor, compared to three to four year old records of CA-MRSA cases in children. A recent study in several large inner city clinics cultured healthy pediatrics of all ages yielded that 9.2 were colonized with MRSA. It’s a significant increase from a 2001 study (0.8%; P < 0.001). Typically, colonization proceeds infection. Researchers are studying major factors in the emergence of the prevalent incline of CA-MRSA in healthy children with no predisposing risk factors (Creech, 2005; Dietrich, 2004; Frank, 1999; Herold, 1998; & Hussain, 2001). Community Acquired MRSA in Pediatrics Some staphylococcal bacteria are resistant to antibiotics and new, multiple stains of S. aureus have been discovered. Methicillin-Resistant Staphylococcus aureus (MRSA) is a type of staph that is resistant to antibiotics called beta-lactams. Beta-lactam antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. This bacterium is commonly carried on the skin or in the nose of healthy people; the bacteria are present, but not necessarily causing an infection. This is typically the case in adults, not in the pediatric population. Community-acquired methicillin resistant staphylococcus aureus (CA-MRSA), typically, in pediatrics occurred primarily with recognized predisposition risk. An analysis using Pearson's correlation coefficient supports this observation, r (58) = .63, p < .001 (Creech, 2005 & Hussain, 2001). The research in a community study provided strong data of recently increased, observed Community Acquired-MRSA colonization among healthy children, without predisposed risk factors. The study determines the prevalence of MRSA nasal colonization in healthy children, comparing with previous data that was measured in previous years, within the same community. The research utilized previous associated research on the problem for comparison of current observations, which found a significant increase in cases. This difference was tested using an independent groups (t) test, and was shown to be significant, t (18) = 1.23, p = .283. Thus, the data gains to support the notion of increased cases in CA-MRSA in healthy children (Creech, 2005; Dietrich, 2004; Frank, 1999; Herold, 1998; & Hussain, 2001). The research had geographical limitations to the study; it was only conducted at two sites within the same community. This limits any colonization statistics throughout the country and if it’s prominent to certain regions. The research highlights the presence of documents and conducting current laboratory testing to include clinical-oriented treatments arenas with presumed and confirmed increase of CA-MRSA within their community. The hypotheses in each article held consistency with each other and corresponded in the research with available retrospect and current data. The most current research found that the population of healthy children with no predisposed health risk, who were colonized with CA-MRSA in 2001, (0.2-2.2%), had a significant increase from the recent study of nearly 10 percent in 2005. Literature Review The study focused on CA-MRSA in healthy pediatrics with no predisposing risk that had attended primary clinics and recently concluded an alarming increase of CA-MRSA colonizations in healthy children who were asymptomatic. The researchers and authors who conducted the study held either a medical license or field related PhDs. Their target was to ascertain if healthy children with no predisposition risk factors were becoming colonized in the community and becoming an epidemic within the pediatric population. The study focused on estimating the prevalence of CA-MRSA of nasal colonization by culturing healthy children enrolled within an inner city pediatric outpatient clinics. A one way analysis of variance revealed a significant effect of MRSA in children, F (2, 34) = 123.07, p < .001. While 60% of the pediatrics was less than ten years old, the culture map reading was strong with only 35% of the cases over 14 years of age (Creech, 2005, Dietrich, 2004, & Frank, 1999). It did not use cultural or economic factors in the study; however, it did provide data on total subjects per variable groups. This broke down age and race in the study. The study described that CA-MRSA isolates tends to be susceptible antimicrobials, such as clindamycin. The articles, however, did not offer data on medication substitutes in cases where susceptible medication became resistance to the isolates. The research provided a good time frame to compare previous data to current observations. The problem is that from 1998 to 2005 the research showed a significant increase in CA-MRSA, but it did not provide data on effects of older treatment to current (Creech, 2005; Dietrich, 2004; Frank, 1999; Herold, 1998; & Hussain, 2001). It only discussed what used to work and the increase of resistance of the same medications today. The authors did, however, provide some good retrospective data dating as far back as 1987. Most of the research was easy to understand; however, there were a few areas in the study procedure that were confusing and had to be read several times. The tables were well formatted in linear lines complying with APA guidelines. They were easy to follow and the data in the tables matched the text data. The article did a good job explaining how to read the tables and the text did match and point out significant data within the tables. The articles were consistent in explaining their objectives and the type of methods used to gain data. The articles themselves, throughout the reading, seemed repetitious making me feel like I was hitting replay. However, each article was done at different stages and each time frame provided remarkable findings and significant data that motivated which made each study significant. The flowing five literature reviews attempt to demonstrate and support the hypothesis. Study One Hussain, Boyle-Vavra, & Daum’s “Community-Acquired Methicillin Resistant Staphylococcus Aureus Colonization in Healthy Children Attending an Outpatient Pediatric Clinic” (2001). Method Design A prospective cross-sectional study was used (Polit, & Beck, 2006). The data was collected between January to August at a family health center and a primary care outpatient facility at large inner city in the North East. Sample The study set to target 500, unselected healthy children who attended the primary care facility to receive child care. The study focused on children who were 16 years of age or younger (Hussain, 2001). There were no limitations to previous medical history. Gender, race or ethnicity was not a selection factor. An informed written consent was required before given a supervised questionnaire to the caretaker. The questionnaire analyzed the presence of risk factors for MRSA colonization. Procedure A specimen was obtained from the nares and the perineum for culture. This was the best sites for sensitivity. The swab was moistened with sterile water, scraped the areas to be cultured and placed in Amies modified medium (yields a higher percentage of positive cultures than the transport medium). A swab was placed into 5% sheep blood sugar and incubated for 36 to 48 hours at room temperature. Colonies were grown on sheep blood sugar to determine if S. aureus and protein A were detected. Results Of the 500 participants, one hundred and twenty-two (24.4%) were found to be colonized with staphylococcus aureus (s. aureus). This result did not provide data on whether the 122 had any traditional risk factors. It also did not specify how many of the cultures were obtained by nasal or perineum, the two most sensitive sites for sampling. Three of the 122 S. aureus isolates were MRSA (2.5%) (Hussain, 2001). The ages of the colonized participants were nine years, one year, and two weeks. The research specified that these three had no predisposing risk factors for MRSA. The article did contradict itself regarding risk factors. In the supervised questionnaire, a guideline in risk factors was coming in recent contact with healthcare professionals. The two-week old was born in a hospital. The article did not look closely at this data. Borderline methicillin-resistant aureus (BRSA) is valued as being close to the limit of susceptibility. Two of the 122 S. aureus isolates were BRSA, who have a predisposing risk factor for colonization of MRSA. The first one was a one year old with a history of asthma who within six months visited the Emergency Department whose mother was a nurse. The other was a 9-month old who was hospitalized for asthma and had received antibiotics for otitis media four months earlier (Hussain, 2001). The reader had to take a good hard look at the numbers and types of testing methods. Making sense of all of them took reading the testing methods and results a few times in order to understand the results. The tables made it easier to see what the methods were illustrating. For example, the three had zones of 20 mm surrounding the amoxicillin/clavulanate disc with a sharply demarcated margin, suggesting that a hyper production of beta-lactamase mediated borderline resistance were in these isolates. In short, the three were observed having MRSA. Anything above 4ug/ml for isolates was positive but susceptible to ocacillin by Vitek testing (to grow the isolate for confirmation). Table Two provided a good breakdown of the three children that were positive for MRSA colonization. Of the 500 children enrolled, the researchers performed an experiment (the independent variable) with data results showing a probability that healthy children with no predisposition can get colonized with the community acquired MRSA. It also showed an alarming number of 24.4 percent of the tested children had been colonized with S. aureus, which was susceptible to the commonly used antibiotics. Only one of the 122 was resistant to erythromycin. Study Two Creech, B., Kernodle, S., Alsentzer, A., Wilson, C., & Edward’s “Increasing Rates of Nasal Carriage of Methicillin-Resistant Staphylococcus Aureus in Healthy Children” (2005). Method Design The study used a sequential cross-sectional study design, a continuing analysis when the evidence efficacy is sufficiently strong enough to stop the experiment (Polit, & Beck, 2006). The study was done in a six-month period from April to September. The data was collected once at the beginning of that time period. However, restudied prevalence of MRSA nasal colonization in healthy children was used from 2001 and was compared to current results. Sample The sample was from a medium study of collecting nasal swabs from 500 pediatrics going to well-checkups. All children between the age of two weeks and 21 years coming for health maintenance visits were eligible. Written informed consents were required, followed with a brief questionnaire for data pertaining to medical, family, and social history. Details of the questions or a sample of the questionnaire were not provided in the study. Procedure Using a moistened, sterile Culturette, swab into each nare, rotated for five seconds and was to be immediately placed into a culture tube, the samples were to be taken to a lab within eight hours of collection. The study used three samples, one placed in an enriched broth containing MRSA, one diluted 1/100 and 50ul of broth, and the other placed into a mannitol salt sugar plates with and without oxacillin (Creech, 2005). The broth was placed at room temperature. The mannitol sample was flame-loop spread (heat spread). All were incubated for 24 hours. The study was based its results on a previous study, where if yellow or off-white colonies appeared, it indicated fermentation, meaning a presumptive S. aureus was present. It determined that colonies that grew on the oxacillin medium were said to be potential for MRSA. The study used a measurement of 0.8% from a previous study projecting a colonization increase to 3.2%. The methods used for measurements in determining differences in colonization rates with SA and MRSA were methods hard to understand, which was the case here. Examples were (power 80%; @ 0.05, Fisher exact test method) and Pearson x2 test. The analysis was performed with PS version 2.1.30 and Stata 8 for windows (Creech, 2005). These were very confusing to look up and comprehend. Results Of 500 children, 249 (49%) were from one study location and 251 (51%) from another. Both were children’s clinics. Based on the data of the two sites, rates of colonization did not vary. The research did not provide statistics between each location; instead, each was summarized together. This may be due to the non significance of colonization between the two sites. Of 182 children, (36.4%) were found to be colonized with S. Aureus. Exhibited growth was found on 82 selected media and 46 isolates (9.2%) were found positive for the mecA gene, which is considered as being MRSA (Creech, 2005). The research found no significance between any predisposing risk factor of MRSA colonization compared to an associated risk of having a family member who worked in a hospital. This was based on an analysis formula of (odds ratio, 2.0; 95% confidence interval, .00-4.1) (Creech, 2005). The research data was provided in Table 1. Only one table was provided, but it did cover enough supportive information. Of the 46 isolates (having MRSA) 98 percent were susceptible to gentamicin, riflampin, and trimethropine-sulfamethoxazole. Twenty five (54%) were resistant to erythromycin. In all the articles, there were no data provided as to why there was more resistance to erythromycin that any other axocillin antibiotics. Analysis in the study revealed that there were different bands among isolates, but remained similar with susceptibilities. They used the PCR to analyze MRSA strains detected. It encoded the Panton-Valentine Luekocidin in 10 of 46 (22%) of the colonized pediatrics (Dietrich, 2004). Other than identifying certain strains, the study didn’t refer to mutations from the previous study and from PDR literature. Study Three Frank, A., Marcinak, J., Manget, P., & Schreckenberger’s “Community-Acquired and Clindamycin-Susceptible Methicillin-Resistant Staphylococcus Aureus in Children” (1999). Methods Design The design used was a retrospective study (Polit, & Beck, 2006). It observed and gained data from a review of medical records, laboratory experiments, formal methods, and numerical methods used in data from the medical records. This study is using information from old charts within the past three years and separated findings in numeral categories of age, sex, and race. Sample The sample came from laboratory logs of all MRSA cases in pediatrics hospitalized or seen in an outpatient clinic that was documented with having MRSA. Medical records were pulled after gaining a computerized printout of each MRSA isolate with antibiotic susceptibility pattern in a three year span. From available records (84%), the researchers extracted demographic data such as age, sex, and race. There were no restrictions on underlying conditions (Frank, 1999). The research was very poor in providing the total number of qualified charts being used in the research. It yielded further information until you got to the results. Procedure For research purposes of analysis, patients who were seen as outpatients were classified as CA isolates, community acquired (CA) or NA for hospitalized children. The test used for susceptibility was the Vitek system, which other researchers included in their studies. The reliability seems to be based a lot on this system. Analysis was completed from data between various groups; the article did not specify criteria or information on the groups selected. Results The results were very conflicting. The beginning of the results states 103 children with 51 isolates and while in the main body it states 79 MRSA isolates. Unlike the first two articles, this study broke down age, race, and gender into percent data. The research stated that Community acquired MRSA isolates based on chart reviews had a showed clindamycin susceptible in the range of 71 to 93% per year. This was a significant increase from 36% before 1994 (Frank, 1999). Erythromycin or trimethoprim-sulfamethoxazole were considered appropriate therapy for the purposes of this analysis when the infection was superficial, but the research ended its data on nasal results based on community acquired cases. The research took a quick turn into other statistics and research findings. I found that the research did well with using numeric results. With the addition of 1 appropriate treatment with trimethoprim-sulfamethoxazole, 9 (nine) children were treated appropriately and only 4 (four) (31%) inappropriately. When the organism was clindamycin-susceptible, 24 (45%) of the 53 children found in charts whose systemic therapy was instituted were not treated appropriately (P = 0.37 vs. clindamycin-resistant MRSA, Fisher exact test) (Frank, 1999). The article stated an observed correlation (p48 hours after admission, CA if both criteria’s were met of isolates within 48 hours after admission or as an outpatient and no HVA criteria were identified. Procedure Categorical variables (date obtained, age, and lab procedures) used were compared using two-sided Fischer’s test or Pearson’s x2, the proportion of MRSA was increased by year, and then was tested with a simple lease-square linear regression. P < .05 was considered significant. It states that isolates were identified as S. aureus by the microbiology lab with standard methods, using the Vitek system (Dietrich, 2004). Had I not read other research articles, I would not know what those procedures are, as this study doesn’t define the procedure. They were able to recover 48 isolates out of 57. The problem is they had to stereotype the samples of where they came from in the community--for example, lifestyle, exposures, race, etc. This faults accuracy if doing categories of high risk exposures. Variables were compared by using 2-sided Fischer’s extract test or Pearson’s x2. This method was not explained, leaving the reader lost and having to go outside the research for further research on testing procedures. Results Within a five-year chart review, S aureus was isolated in 1861 cultures of 1063 children. Two hundred isolates were MRSA from 57 children (33 males, 5 weeks to 18.8 years old). All had MRSA isolated from at least one sterile site. All had clinical infections. Because nasal culture screenings for MRSA were not routinely performed after admission in pediatric patients at the institutions where the children were tested, it set a limitation as no information was available about all baseline colonization rates. Medical records of the 57 patients were reviewed and 23 patients (40%) met CA-MRSA criteria. Regressing MRSA percent on year revealed a significant positive relationship, with MRSA increasing by 1.67% per year (P=.008; R2 = 0.91). The change we observed was due to increases in both HCA-MRSA and CA-MRSA infections (Dietrich, 2004). There was no hospital outbreaks of MRSA identified in pediatric patients in any of the study years. Susceptibilities of CA-MRSA and HCA-MRSA isolates, respectively, were 48% and 29% for erythromycin, 67% and 90% for tetracycline, 74% and 53% for clindamycin, 87% and 38% for ciprofloxacin, 100% and 94% for gentamicin, 100% and 91% for trimethorprim-sulfamethoxazole, and 100% and 100% for vancomycin. When looking at individual agents, only ciprofloxacin susceptibility was significantly different between the 2 groups, with greater susceptibility among CA-MRSA isolates (P