Download Nationwide Trends in Pediatric Staphylococcus aureus Head and

ORIGINAL ARTICLE
Nationwide Trends in Pediatric Staphylococcus aureus
Head and Neck Infections
Iman Naseri, MD; Robert C. Jerris, PhD; Steven E. Sobol, MD, MSc
Objectives: To evaluate the epidemiologic manifesta-
tions of pediatric Staphylococcus aureus head and neck
infections nationwide and to identify possible trends in
the antibiotic drug susceptibility of S aureus during a
6-year period.
Design: Retrospective review of microbiologic data from
a peer-reviewed national database.
Setting: More than 300 hospitals nationwide.
Patients: All pediatric patients with head and neck in-
fections involving S aureus.
Main Outcome Measures: Anatomic sites were divided into oropharynx/neck, sinonasal, and otologic infection categories. Demographic and antimicrobial drug
susceptibility patterns were reviewed.
Results: A total of 21 009 pediatric head and neck S au-
reus infections that occurred between January 2001 and
December 31, 2006 were gathered from the database. Predominance was observed in the oropharyngeal/neck cat-
T
egory (60.3%). For all sites, the mean patient age was 6.7
years (range, 0-18 years), with a 51.7% male predominance. There was a high occurrence in the North East
Central region of the United States. Overall, methicillinresistant S aureus was seen in 21.6% of all patient isolates
(n = 4534), with rates of 11.8%, 12.5%, 18.1%, 27.2%,
25.5%, and 28.1% for 2001 through 2006, respectively.
This represents a 16.3% increase in methicillin-resistant
S aureus during these 6 years for all pediatric head and
neck S aureus infections.
Conclusions: There is an alarming nationwide increase in the prevalence of pediatric methicillinresistant S aureus head and neck infections. Disparities
in the treatment of various head and neck infections nationwide may contribute to the regional differences in
the prevalence of such infections. Judicious use of antibiotic agents and increased effectiveness in diagnosis and
treatment are warranted to reduce further antimicrobial
drug resistance in pediatric head and neck infections.
Arch Otolaryngol Head Neck Surg. 2009;135(1):14-16
HE FIRST OUTBREAKS OF
methicillin-resistant
Staphylococcus aureus
(MRSA) were reported in
the 1960s.1 Today, MRSA
accounts for 50% to 70% of all S aureus
isolates, with a $4.2 billion annual financial impact in the United States.2-6 Before
CME available online at
www.jamaarchivescme.com
and questions on page 7
Author Affiliations:
Departments of
Otolaryngology–Head and Neck
Surgery (Dr Naseri) and
Pediatric Otolaryngology
(Dr Sobol), Emory University
School of Medicine, Atlanta,
Georgia; and Children’s
Healthcare of Atlanta, Egleston
Hospital (Dr Jerris).
the 1980s, MRSA infections were primarily acquired through nosocomial transmission. During the past decade, MRSA
outbreaks have been found in prisons, in
nursing homes, and in chronically ill patients.7-10 Such “community-acquired”
MRSA (CA-MRSA) infections have become increasingly prevalent in patients
without established risk factors, and they
remain a major public health concern.
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 135 (NO. 1), JAN 2009
14
Staphylococcus aureus is a pathogen
commonly seen in many infections involving the head and neck. In recent years,
there have been increasing reports of CAMRSA infections in children.11-15 Studies
of otolaryngologic infections involving CAMRSA emerged in the 1990s.14 Most of
these studies regarding such infections in
the pediatric population have lacked sufficient numbers, and regional discrepancy has not been established. In light of
the clinical and epidemiologic concerns regarding the increasing reports of MRSA nationally, we believed that an evaluation of
national trends in prevalence and microbiologic susceptibility was warranted.
METHODS
After receiving approval from the Emory University institutional review board, we obtained a retrospective microbiologic data query
targeting all pediatric S aureus head and neck
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RESULTS
A total of 21 009 patients aged 0 to 18 years were obtained from The Surveillance Network query. The mean
patient age was 6.7 years, with a male predominance
(10 861[51.7%]). The sex of 296 patients was not reported. Most of the results were obtained from an outpatient setting (15 229[72.5%]) vs an inpatient setting
(5780 [27.5%]). There was significant variance in the
number of results in the different regions: East North Central, 4202 [20.0%]; East South Central, 1878 [8.9%]); MidAtlantic, 2429 [11.6%]; South Atlantic, 2602 [12.4%];
Mountain, 1555 [7.4%]; New England, 562 [2.7%]; Pacific, 3051 [14.5%]; West North Central, 2626 [12.5%];
and West South Central, 2104 [10.0%]. The oropharynx/
neck group included most of the patients, with a total of
12 673 (60.3%). This was followed by the sinonasal group,
totaling 7896 (37.5%), and then by the otologic group
(n=440; 2.0%).
A total of 4534 samples (21.6%) were MRSA, based
on oxacillin sodium resistance. The breakdown for the
6 study years is shown in the Figure . Methicillinsusceptible isolates totaled 16 333. An additional 26 isolates were intermediately susceptible, and 116 isolates had
no results for susceptibility testing and were excluded from
the calculations. Among the 3 head and neck groups, the
highest proportion of MRSA was found in the otologic
group (34%), followed by the sinonasal (28.3%) and oropharynx/neck (14.2%) groups. Clindamycin hydrochloride hydrate resistance was seen in 3714 (18%) of all S aureus samples. However, in considering MRSA samples only,
there were 2118 (47%) with resistance to clindamycin.
COMMENT
The growing concern about the recent worldwide MRSA
epidemic has fueled the curiosity of the scientific community to gain insight into the clinical and epidemiologic manifestations of this microbe. Presently, physi-
4500
Total S aureus
MRSA
MSSA
4000
3500
3000
Patients, No.
infections from January 1, 2001 to December 31, 2006. The data
were acquired from The Surveillance Network (Eurofins Medinet, Chantilly, Virginia), a peer-reviewed national electronic
microbiology database that collects strain-specific antimicrobial drug resistance test results daily from clinical laboratories
representing more than 300 hospitals across the United States.
The query search included demographic information, such as
age, sex, region and state, report date, source, and inpatient vs
outpatient status at the time of culture. In addition, susceptibility results were obtained for various antimicrobial agents.
The US regional representation was divided into 9 areas: East
North Central, East South Central, Mid-Atlantic, South Atlantic, Mountain, New England, Pacific, West North Central, and
West South Central.
The results included specimens obtained from various head
and neck infections from 9 locations: middle ear, external auditory canal, cervical lymph node, mandible, nasopharynx, nasal cavity, oral cavity, sinus cavity, and oropharynx. For analysis, data from each head and neck subsite were allocated into 1
of the following 3 categories: oropharynx/neck, sinonasal, and
otologic. Comparisons were made using the Marascuillo statistical analysis procedure with 95% confidence intervals; P⬍.05
was considered statistically significant.
2500
3988
3157
2842
2506
2902
2893
2530
4131
3078
3998
2874
2585
2000
1500
1000
1086
500
0
1053
1124
572
336
363
2001
2002
2003
2004
2005
2006
Year
Figure. Annual incidence of head and neck methicillin-susceptible
Staphylococcus aureus (MSSA) and methicillin-resistant S aureus (MRSA)
for January 1, 2001 to December 31, 2006.
cians assume MRSA to be the cause of almost every skin
infection, leading to an overall change in the empirical
treatment of such infections. In doing so, selection of
resistant organisms emerges in CA-MRSA and hospitalacquired MRSA. The data presented in this study corroborate with other regional data, specifically demonstrating an increasing trend of MRSA prevalence in all
regions of the United States between January 1, 2001 and
December 31, 2006.
Previous studies16,17 have established that most skin
and soft tissue infections in many US communities are
due to CA-MRSA. In the pediatric population, there have
been several institutional observations of a significant rise
in CA-MRSA in head and neck infections.13,15,18,19 Almost 60% of all MRSA pediatric head and neck infections in this study were from outpatient sources, suggestive of CA-MRSA. This points to the possibility that
CA-MRSA is more common than MRSA from a nosocomial source (hospital-acquired MRSA). In 2001, approximately 12% of all isolated S aureus in this study was methicillin resistant (336 of 2842). During the ensuing 5 years,
this number steadily rose to more than 28% (1124 of
3998), a 16.3% increase. The largest increase, approximately 9%, was seen between 2003 and 2004.
Among the 3 head and neck infection groups, the highest rate of MRSA was seen in the otologic group, which
also demonstrated the highest prevalence of antimicrobial drug resistance. The most resistant antimicrobial drug
pattern is typically seen in hospital-acquired MRSA and
seldom in CA-MRSA. Similarly, 93% of CA-MRSA has
been shown to be susceptible to clindamycin.20 In this
study, more than 46% of all MRSA isolates were resistant to clindamycin. This finding suggests increasing antimicrobial drug resistance in CA-MRSA.
Grouping of the samples into hospital-acquired MRSA
vs CA-MRSA was based on treatment location data given
as inpatient (also rehabilitation and intensive care unit)
and outpatient (also clinic and emergency department).
The lack of detail pertaining to microbiologic characterization of isolates, in addition to the related clinical circumstances surrounding the culture acquisition, may represent a bias in some samples in each of these groups.
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The differences in the numbers in each geographic region occurred because of the unequal hospital participation in The Surveillance Network. This presented a bias
in the ability to accurately determine each regional incidence or prevalence of such infections. Nevertheless,
proportional comparisons within the regions were possible, showing a significant increase in MRSA prevalence in each region between January 1, 2001 and December 31, 2006. Characterization of specific strain
patterns using pulsed-field gel electrophoresis would provide additional insight into the clonal distribution of these
infections.
In conclusion, the results of this study depict an alarming increase in MRSA in the United States. There is an
increasing trend of clindamycin resistance among MRSA
isolates. Expeditious culture of suspected head and neck
infections leading to more appropriate antimicrobial drug
selection is highly recommended to avoid further resistant patterns. Further studies linking the microbiologic
and clinical behaviors of MRSA are warranted to gain additional insight into the dynamic existence of this
organism.
Submitted for Publication: February 6, 2008; final revision received March 13, 2008; accepted April 7, 2008.
Correspondence: Steven E. Sobol, MD, MSc, Department of Pediatric Otolaryngology, Emory University
School of Medicine, 2015 Uppergate Dr NE, Room 218,
Atlanta, GA 30322 (Steven.Sobol@emoryhealthcare
.org).
Author Contributions: All authors had full access to all
of the data in the study and take responsibility for the
integrity of the data and the accuracy of the data analysis. Study concept and design: Naseri, Jerris, and Sobol. Acquisition of data: Naseri. Analysis and interpretation of data:
Naseri, Jerris, and Sobol. Drafting of the manuscript: Naseri, Jerris, and Sobol. Critical revision of the manuscript
for important intellectual content: Naseri and Jerris. Obtained funding: Sobol. Administrative, technical, and material support: Jerris and Sobol. Study supervision: Naseri, Jerris, and Sobol.
Financial Disclosure: None reported.
Funding/Support: An unrestricted educational research grant from Alcon Laboratories Inc supported all
phases of this large, multi-institutional study, including
funding for research supplies, data acquisition, and data
analysis and interpretation.
Previous Presentation: This study was presented at the
2008 American Society of Pediatric Otolaryngology Scientific Program; May 2, 2008; Orlando, Florida.
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