The social determinants of health play a pivotal role in the development of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). There is a paucity of specific clinical practice guidelines for NPs to manage CA-MRSA in remote Indigenous settings.1 NPs require evidence-based guidelines to effectively manage CA-MRSA and prevent complications, thereby minimizing morbidity and mortality among Indigenous children.
Children living in remote environments face more challenges than their urban counterparts.1 Remote populations often experience inadequate access to health services, which is a major barrier to receiving optimal healthcare. In Canada, Indigenous people residing in First Nations communities receive health services funded by the federal and provincial governments. These health services are provided within nursing stations or health centers. Limited physical and human resources complicate the management of many health conditions. Most health facilities in First Nations communities are staffed by nurses working under an expanded scope of practice with some advanced education.2
Optimal management of CA-MRSA in Indigenous communities requires consideration of the epidemiologic, microbiologic, social, and environmental factors that contribute to these infections, as well as evidence-based practice guidelines.1,3 The purpose of this article is to provide a synthesis of the current evidence and identify best practices for the assessment and management of CA-MRSA among Indigenous children in remote settings.
The first cases of MRSA presented in 1961, shortly after methicillin was discovered in 1959.4 Hospital-acquired MRSA (HA-MRSA) was the predominant strain until the 1990s.5 In 1993, CA-MRSA was reported among Australian Aboriginals.5 An Australian study reported high prevalence rates of CA-MRSA among Indigenous people and among those under age 40.6 In this study, the researchers examined incidences of CA-MRSA from 2008 to 2014 and identified an odds ratio of 2.6 for Indigenous people when compared with the non-Indigenous population.6 This disproportionate burden of illness must be considered alongside other causes of disparity among Indigenous populations.
The first pediatric cases of CA-MRSA were documented in the 1990s.7 Engelman and colleagues investigated invasive Staphylococcus aureus infections among children in northern Australia.8 In this study, the retrospective data highlighted a high burden of disease among Indigenous children with an incidence rate of 46.6 per 100,000. This rate was 10 times greater than that among non-Indigenous children. This finding illustrated the significant disparity of CA-MRSA infection between Indigenous and non-Indigenous children. Indigenous children are particularly at risk for acquiring CA-MRSA.1,3,8,9
Children with skin and soft tissue infections (SSTIs) can develop life-threatening complications, such as osteomyelitis, necrotizing fasciitis, bacteremia, endocarditis, sepsis, and necrotizing pneumonia, which need to be recognized immediately and treated in a healthcare facility with appropriate human and physical resources.10-15 Increased morbidity and mortality may be associated with a toxin or a concomitant invasive bacterial infection.10 Children with the above complications, or, in other words, invasive CA-MRSA require timely transport to tertiary centers, where they can receive specialized care.14
In Canada, one of the first reported pediatric deaths related to CA-MRSA pneumonia occurred in Ontario in 2006.11 In 2007, Larcombe and colleagues reported that cases of MRSA were rapidly increasing among children in First Nations communities in northern Manitoba, Canada.12 Another child death attributed to MRSA occurred in a First Nations community in northern Manitoba in 2011.13 This case involved an autopsy and subsequent inquest, outlining multiple recommendations to prevent future deaths from CA-MRSA.14
An inquest is a court hearing to examine the facts surrounding a death that is requested by the Chief Medical Examiner.16 Following an inquest, a judge may recommend strategies to prevent similar deaths.16 As a result of this child's death, the first author was motivated to prevent future devastating outcomes of CA-MRSA in remote communities. The Drianna Ross Inquest Report, written by Judge Slough, indicated that MRSA was often normalized in First Nations communities.14 Following this inquest, educational webinars and recommendations were provided to healthcare professionals to improve the management of CA-MRSA in Manitoba.15 (See Summary of Judge Slough's recommendations.)
S. aureus is a part of normal skin flora that can become a life-threatening human pathogen.17 CA-MRSA has distinct genetic, epidemiologic, and phenotypic characteristics when compared with HA-MRSA.18 The CA-MRSA bacteria are resistant to all beta-lactam antibiotics, including penicillins, cephalosporins, and monobactams, whereas the HA-MRSA bacteria are resistant to different antibiotics.17,19 In addition, CA-MRSA infections are most likely to affect young, otherwise healthy people whereas HA-MRSA infections tend to occur in older individuals in the presence of other comorbidities.18,20 CA-MRSA is the predominant cause of all SSTIs among outpatients in the US.21
CA-MRSA occurs in the absence of any known risk factors for HA-MRSA, including: more than 48 hours of hospitalization, residence in a long-term-care facility, renal dialysis, recent surgery, and presence of indwelling catheter or percutaneous device at the time of culture analysis.18,22
Risk factors for CA-MRSA in remote Indigenous communities
Researchers clearly identified the social determinants of health as risk factors for CA-MRSA SSTIs among Indigenous populations.1,3,12,18,23-25 CA-MRSA infection was associated with poor hygiene, overcrowded homes, frequent skin-to-skin contact, and the sharing of contaminated personal items.26 CA-MRSA is a common cause of SSTIs among people who live in overcrowded housing and lack access to clean water, both of which are common features of remote Indigenous communities in Canada.27 In summary, the “5 Cs” implicated in the transmission of CA-MRSA include: Crowding, frequent skin Contact, Compromised skin integrity, sharing of Contaminated personal care items, and lack of general Cleanliness.17,28
Socioeconomic status has been identified as a key factor contributing to the development of CA-MRSA in remote Australian Aboriginal communities.29,30 Tong and colleagues identified that these community members experienced poverty, overcrowding, substandard housing conditions, sharing of personal items (clothing, towels, utensils), and limited resources such as clean water, laundry facilities as well as proper sewage systems.29 In a subsequent study, Tong's group identified that the rates of CA-MRSA episodes among Indigenous Australian populations were 29.2 times higher when compared with non-Indigenous Australians.30 Although all populations in the lowest income brackets had increased infections, there remained a disparity between Indigenous and non-Indigenous populations across all income categories.30 Although it is unclear why Indigenous groups experience higher rates of CA-MRSA, a study in Canada identified suboptimal healthcare among First Nations patients with SSTIs in Canada.1 Thus, consideration of these complex social determinants of health as well as use of an evidence-based algorithm may be extremely helpful to NPs when assessing and managing CA-MRSA in remote Indigenous communities.
Typical presentation of CA-MRSA
Because it is challenging to distinguish between the clinical presentations of SSTIs caused by CA-MRSA versus SSTIs related to other pathogens, it is important for NPs to consider the local prevalence rate of CA-MRSA.17,21,22 The clinical presentation of CA-MRSA SSTIs depends on the severity.17 Mild SSTIs typically involve furuncles (boils), carbuncles (cluster of boils under the skin), and small abscesses. Mild CA-MRSA SSTIs are often misidentified as a suspected spider bite by patients.31
Moderate SSTIs involve deeper tissues and may include purulent or nonpurulent cellulitis and erysipelas.31 Erysipelas is a superficial form of cellulitis. Nonpurulent cellulitis is often described as warm, painful, erythematous areas with or without swelling in various regions of the body that do not drain purulent discharge. Purulent SSTIs present with fluctuance, a yellow or white center, a central point or head, and purulent exudate. These SSTIs may present in various areas and are frequently characterized by redness, warmth, pain/tenderness, and swelling. Moderate SSTIs may or may not present with systemic features including an ill appearance, low-grade fever, mild hypotension, and mild tachycardia.
Severe or invasive MRSA infections present with more pronounced systemic signs including high fever, marked hypotension, and tachycardia.31 Invasive infections can occur spontaneously or as complications of SSTIs or after viral respiratory tract infections (such as influenza).32,33 Therefore, a comprehensive history and physical exam in infants and children is required.
History and physical exam
When children present with SSTIs, a thorough history of the chief complaint and present illness is required along with a review of systems.18,22 Age plays a significant role in the presentation of illness and clinical decision-making.17 For example, the presentation of an SSTI in a neonate may be significantly different and more worrisome than that in a school-age child. It is also essential to assess the social history such as housing conditions, access to clean water, overcrowding, and sharing of personal items, remaining cognizant of the determinants of health.25,26,28,34
After obtaining a thorough history, a complete physical exam should be performed to determine the severity of the disease. The NP should differentiate between furuncles, carbuncles, and abscesses to develop appropriate treatment plans.
Important aspects of the clinical exam include: general appearance, vital signs including weight, a thorough respiratory and cardiovascular assessment, and extent of involvement of the SSTI and features such as purulent versus nonpurulent. It is important to assess systemic signs of infection (fever, hypotension, tachycardia, level of consciousness).
Children exhibiting systemic signs of infection will require a prompt and more thorough physical assessment. Suboptimal assessments may result in ineffective treatment of CA-MRSA infections contributing to the possibility of septic joints, necrotizing fasciitis, endocarditis, necrotizing pneumonia, or bacteremia.8,10,11,35 MRSA pneumonia as a complication of influenza has been linked with increased morbidity and mortality among pediatric patients.10
Best practices for managing SSTIs caused by CA-MRSA among Indigenous children
Although clinical guidelines for adult and pediatric clients with SSTIs were developed, the pediatric clinical guidelines were insufficient as they only included basic information about MRSA infections.17,21,22,31,36,37 These guidelines did not provide detailed information for the effective management of CA-MRSA, specifically related to incision and drainage (I&D) procedures and antimicrobial therapy. Researchers identified the need for improved clinical decisions specific to this population and setting.1,29 Although I&D was identified as one aspect of the management of SSTIs, only 8.76% of cases of SSTIs among First Nations patients in one retrospective chart review received such treatment.1 However, oral antibiotics were commonly prescribed reflecting high antibiotic use among First Nations compared with the rest of the Canadian population.1 Further, diagnostic testing (such as swab for culture and sensitivity) was rarely documented in this patient population.1
With permission, the authors adapted the 2014 Northern Saskatchewan management pathway for SSTIs in rural and remote settings and a literature review.1-37 This algorithm outlines important steps in the assessment and management related to mild, moderate, and severe SSTIs. (See Management of CA-MRSA in Indigenous children in remote settings.)
Localized SSTIs, such as furuncles and carbuncles, can often be managed with warm compresses, topical antibiotics, dressings (if draining), meticulous personal hygiene, and behavioral changes (avoidance of personal item sharing). Abscesses less than 5 cm can be treated with I&D only, along with a swab for culture and sensitivity.17 Antibiotics may be warranted if the abscess fails to respond to I&D and warm compresses or if the patient shows signs of clinical deterioration.17,33,34,38
The selection of an antibiotic is determined by local susceptibility patterns and other patient characteristics.22,31,33,34,38 Antibiotic therapy is often recommended for abscesses associated with severe or extensive disease, rapidly progressing cellulitis, systemic illness, comorbidities, extremes in age, abscesses in areas that are difficult to drain (face, hands, and genital areas), and lack of response to I&D.34 These invasive clinical scenarios require emergency care and consultation with pediatric infectious disease specialists to assist in management of care prior to transport to a hospital.11 Transfer to a tertiary care hospital is recommended for any patient with an abscess that measures greater than 5 cm, even in the absence of any signs of systemic illness. Practitioners may refer to the Anti-Infective Guidelines for Community-Acquired Infections that includes a section on the management of CA-MRSA skin infections as well as the recommended antibiotic therapies for adults and children.38
Antibiotic therapy stewardship is necessary to prevent further antibiotic resistance in populations living in remote settings.1,9,12,23 Inappropriate antibiotic use has been implicated in the increasing rates of MRSA in remote communities.1,12,23
NPs should collaborate with public health officials or public health representatives in the local community or region. By documenting cases of CA-MRSA, NPs and public health nurses may work together to prevent recurrent infections.
The NP's role in preventing CA-MRSA
Evidence-based guidelines for the management of SSTIs may be helpful for primary care providers and healthcare organizations.1 In remote settings, NPs are instrumental in advocating for improved living conditions and adequate housing as well as appropriate access to clean water, healthcare, and quality foods. Housing is a widely accepted determinant of health. Unfortunately, housing issues in Indigenous communities are often related to limited funding for building new homes. Overcrowding remains an issue in First Nations communities, where household capacity far exceeds the Canadian standards.39 First Nations people living in remote environments continue to struggle with access to clean water for basic needs, including personal hygiene. Many Indigenous communities are still living under boil water advisories. In addition, access to adequate primary healthcare continues to be a major barrier in Indigenous communities. Food insecurity, related to reliance on outsourced foods and the high costs of fresh produce, also contributes to poor health in many of these communities. Future research is warranted to determine uptake of Judge Slough's recommendations.
An algorithm was presented to assist NPs with assessing and managing CA-MRSA infections in Indigenous children living in remote settings. It is important for NPs to collaborate with public health agencies to document the incidence and prevalence rates of CA-MRSA when providing care to pediatric populations. The recommendations outlined by Judge Slough provide actionable items to address the spread of MRSA in Indigenous communities and seek to prevent future child deaths.11-15 Community management of MRSA must identify patients at risk, particularly when a child presents with an SSTI or undiagnosed systemic illness.1,11-15
The normalization of CA-MRSA in First Nations communities is unacceptable and must be disrupted.11-15 It would be highly beneficial for NPs to collaborate with community leaders to address social factors that contribute to high rates of CA-MRSA. NPs are also in an ideal position to educate community members on the significance of MRSA and the impact of antibiotic overuse. NPs can empower communities to be informed about the complex issues that impact their health and help prevent the spread of CA-MRSA.
Summary of Judge Slough's recommendations14,15
- Ensure adequate equipment for proper monitoring of cases across facilities.
- Facilitate communication via video conferencing with more specialized hospitals.
- Assign cases to nurses based on experience.
- Identify appropriate antibiotics to treat CA-MRSA.
- Promote healthy work environments and schedule appropriate breaks for all healthcare professionals to facilitate optimal care.
- Collaborate with educational institutions in developing and delivering programs for nurses working in remote communities.
- Improve training and utilization of NPs.
- Provide adequate support staff to healthcare professionals.
- Standardize equipment to foster connectivity with other healthcare facilities.
- Establish a process to determine the best point of care test in nursing stations.
- Provide secure seats in all Medevac flights to ensure child's safety.
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