Skin Infections

Dear Lisa,

My daughter has been having these out breaks on and off. She has had an abscess removed from her chin last winter. She had what appeared as pimples on her back, that went away on its own. But what started to worry me, is when she broke out on her vagina. It started out like a diaper rash and slowly progressed into, what appeared to be boils, very painful. We brought her to the Doctor, and they had diagnosed her with a Staph infection. Prescribed her Antibiotics and they went away. Just last week, I noticed pimples forming on her left side of her stomach, in a cluster, she stated that they had been itching her. My first response was "Chicken Pox", but to my dismay, she was once again diagnosed with Staph infection. What is causing this recurring Staph infection? Why hasn't it affected me or my husband? Is there something we can do to prevent further outbreaks?

“Vivimart721”

Dear “Vivimart721”,

Superficial skin infections occur when a germ or microorganisms enters the body through a break in the skin integrity. This disruption to the skin may be due to a bug bite, a scratch, trauma to the area or an underlying skin disease such as eczema. (1) Once the skin barrier is open, microorganisms can readily enter, replicate and cause an infection. Warm weather has also been associated with an increase incidence of skin infections. (1)

Bacterial skin infections are one of the most common reasons why clinicians prescribe antibiotics for children. In most cases, childhood skin infections resolve on their own or in some cases require a short course of topical or systemic antibiotics. (1) Occasionally, recurrent skin infections do occur. When a child has recurrent skin infections, antibiotic resistance and autoinoculation need to be considered.

Autoinoculation occurs when a child harbors an organism in their nasal passages or from their rectum and then transfers the germ to their skin via their hands.(2,3) Whenever there is a break in skin integrity such as in the case of a rash or small cut, the germs which are considered normal flora in these other parts of the body cause an infection of the skin. This is common in childhood because children frequently touch their nose and then touch or scratch their skin.

In order to determine if autoinoculation is occurring, your child’s doctor can take a culture of your daughter's nasal passages and rectum in order to determine the types of organisms that she is harboring. If the microorganism found in the nasal passages or rectum is the same organism responsible for her skin infection, then autoinoculation is suspected.

In some cases other family members or even dogs can become infected or colonized and serve as a reservoir for the bacteria that is responsible for causing a child’s recurrent skin infections. (4) So it is possible for a parent who is harboring a microorganism in their nasal passages to transfer the microorganism to their child. Therefore a parent does not necessarily need to have a wound or rash in order to spread an infection in their child. In cases of recurrent skin infections in children, it may be necessary for the family members to be tested to see if they are colonized and potential reservoirs for infection.

Impetigo is one of the most common skin infection. It is very contagious and is usually caused by Staphylococcus aureus or Group A beta hemolytic Streptococcus. Other strains of beta hemolytic Streptococci such as type B, C and G can also be responsible for the infection. (1)

Impetigo lesions appear as red papules that may develop vesicles or fluid filled sacs that can easily be broken. Once the vesicle breaks a clear fluid emerges and develops into a honey colored crust surrounded by a rim which is red in color. When impetigo is caused by a Staph infection it appears as a discrete superficial blister that easily breaks and forms into a glistening flat oozing plaque. (5) These lesions occur in clusters and can typically be found on the face, arms and legs. It is also possible for Impetigo to develop anywhere on the body.

Furuncles develop when an infection of a hair follicle evolves into nodules and eventually abscesses. These lesions are quite painful and tend to occur on the face, neck, underneath the arms, on the buttocks and thighs. Staphylococcus aureus is usually the microorganism responsible for furuncles and abscesses. Diabetes mellitus as well as other underlying diseases put a child at risk for developing Furuncles and Abscesses. Furuncles and Abscesses are also commonly found in healthy children that have no underlying medical problems.

The treatment for Furuncles and Abscesses include antibiotic therapy and warm compresses. Applying warm compresses is a very important part of the treatment because they help drain the wound. An incision and drainage needs to be performed by a physician in some cases, especially if the abscess is large.

If a child’s skin infection, abscess or wound does not respond to antibiotic therapy, the microorganism Methicillin Resistant Staph Aureus (MRSA) is most likely the cause. There has been a recent emergence of Methicillin Resistant Staph Aureus (MRSA) in the community. Traditionally, MRSA has been a hospital acquired illness found in chronically ill patients with prolonged hospitalizations, in nursing home patients and in patient with repeated exposure to antibiotics. (1) This however has not been the case over the last few years.

Children with no know risk factors such as previous hospitalization, contact with those in hospitals or long term treatment facilities have been acquiring the disease. Recent research has found that MRSA is now infecting young children, previously healthy individuals, athletes, children in daycare, Native Americans, and military recruits. (6,7)

Most Staphylococcal skin abscesses are now caused by MRSA. (6) Outbreaks of MRSA infection have become common across North America. In the San Francisco Bay area, the incidence of MRSA infections more than quadrupled between 1998 and 2002. (6) More than half of cultured skin and soft-tissue infections seen in Oakland, California emergency departments are now caused by MRSA. (6)

MRSA is not only a concern in the United States, but has become a problem all over the world. In the past few decades MRSA rates have increased worldwide. (2, 7) MRSA is the most commonly identified antibiotic –resistant pathogen in many parts of the world, including Europe, the Americas, North Africa, the Middle East and East Asia. (2)

The problem with a MRSA skin infection is that it is difficult to treat because the organism is resistant to many antibiotics. The organism can be carried in a child’s nasal passages and cause the skin infection to reoccur. (3) In addition, MRSA often colonizes family members and close contacts of the infected patient which can lead to reinfection. (6) The greatest concern about MRSA infections is the risk of disseminated disease. A small percentage of patients with MRSA skin infections can develop disseminated disease or disease which spreads throughout the body that can be life threatening. (8)

Since your child is having recurring skin infections, it may be a reasonable to discuss the possibility of autoinoculation and the presence of a resistant organism such as MRSA with your Doctor. You and your husband may also need to be checked to see if you are harboring MRSA in your nasal passages. If you have a family pet, it would be a good idea to also have it checked by your Veterinarian.

If your child is diagnosed with a MRSA skin infection or colonization of MRSA, your doctor can prescribe systemic antibiotics to treat the problem. If the organism is found in your child’s nasal passages a medication called intra-nasal Bactroban may be prescribed in order to decolonize the area. In addition, environmental measures should be taken in order to prevent the spread of infection to other people.

Since MRSA skin infections as well as other types of skin infections are contagious it is important to follow certain measures to prevent spread of disease. Draining wounds should be covered with clean, dry bandages at all times and items contaminated with drainage from a wound should not be re-used. Contaminated bandages and towels should be discarded appropriately. Towels, bedding bar soap, razors and athletic equipment that may have become contaminated should not be shared. (6)

Handwashing with warm soapy water is recommended especially after handling bandages or touching the affected area. Clothes that have come into contact with a wound should be washed after each use and dried completely. (6) Children should have their nails kept trim and any underlying skin condition such as eczema should be controlled. Activities that involve skin to skin activity (such as contact sports) should be avoided until a skin wound or infection is healed. (6)

Since items and surfaces that come into contact with microorganisms can transmit the germ it is necessary to clean equipment and all other surfaces that come into contact with bare skin. Detergents and disinfectants that specify Staphylococcus aureus on the product label are recommended. (6)

Specific recommendations for outbreak control are available at the following Web site:

http://lapublichealth.org/acd/MRSA.htm

For more information about MRSA log on to:

http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html


References:
(1)Pong A. Managing Bacterial Skin Infections and MRSA: An action Plan. Pediatric Skin Care. 2004. Spring:8-11.
(2) MRSA now global health threat. Infectious Diseases in Children. 2006.Sept:46.
(3)Rosenthal M. Treatment of skin and soft tissue infections changing in an age of MRSA. Infectious Diseases in Children. 2006. April.52.
(4)Rosenthal Marie. Zoonosis reversal: Animals contracting MRSA from humans? Infectious Diseases in Children. 2006. August:33.
(5)Dermclinic. Bullous Impetigo. Consultant for Pediatricians. 2006. April:214.
(6 )Elston D. More MRSA infections are headed your way. The Clinical Advisor. 2006. July:67-69.
(7)Stephenson M. Community-acquired MRSA a “new normal”. Infectious Diseases in Children. 2006. Sept:68.
(8)Rosenthal M. Steps to Manage CA-MRSA skin and soft tissue infections. Infectious Diseases in Children. 2006. August:40-42.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

Pediatric Advice-Updated Health Information