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Child Health
Recurrent Skin Sepsis

Assessment

  1. Establish Carriage Decolonisation Definitions

    • Recurrence
      • Recurrence is defined by the clinical context i.e., several episodes may be required to lead to action if minor clinical problem, however two episodes may be acted on if there is significant consequence or co-morbidity. The issue is recurrent seeding of the skin with Staphylococcus aureus secondary to carriage, most commonly in the nose but also in other sites (throat, axilla, groin etc).
    • Underlying carriage is the issue
      • Deprived households more at risk (generally due to overcrowding) and consequently eradication of carriage must be affordable.
      • Certain ages are more susceptible due to their close skin to skin societal contact.
    • Risk factors
      • Close contact due overcrowding or susceptible age. (Who lives in your house? -Genogram may assist).
      • Compromised skin integrity (provides portal of entry)-eczema, insect bites, abrasions, devices e.g., PEG.
      • Nutritional factors notably iron deficiency. Consider dietary history and growth chart.
      • Co-morbidities e.g., diabetes and more uncommonly renal or immune deficiency disease. (self and others).
    • Differential diagnosis
      • Hidradenitis suppurativa see dermnet for in depth information.
      • Inflammatory skin diseases notably eczema and psoriasis.
      • Chronic granulomatous disease
      • Persistent/resistant/recurrent candida (thrush)
      • Herpes zoster (Shingles)
    • Other definitions
      • Clinical Treatment Failure is defined as new lesion(s) after full treatment completed.
      • Partial Treatment Failure- history or diary indicates some improvement consider repeating last treatment regimen again before preceding to next step.
  2. Investigation Summary

    • Regarding swabs
      • 1st pass swabs: Nasal swab index case or if >1 family member affected nasal swab entire household.
      • 2nd pass swabs: Reswab nose, throat and groin of index case and nasal swabs of whole household even if no-one else affected.
      • 3rd pass swabs: Swab nose, throat, and groin of all treatment failures in household.
      • If nasal swabs negative and clinical scenario convincing: consider other sites eg throat, flexures.
      • Treat the clinical scenario not the swabs.
    • Consider and investigate as necessary for:
      • Co-morbidities e.g., diabetes and more uncommonly renal or immune deficiency disease.
      • Nutritional factors notably iron deficiency in children.

Management

  1. 1st Pass Management Topical Decolonisation

    • Always treat active skin infection first with standard systemic antibiotics (guided by sensitivity results where available) emphasizing exact compliance e.g., Flucloxacillin, erythromycin or clindamycin must be QID to achieve sufficient time with drug serum concentration above minimum (MIC).
    • Always aim for optimum treatment and maintenance of skin integrity through effective management of eczema, psoriasis, scabies, athletes foot etc.
    • Encourage washing (preferably hot) of linen and towels at beginning of each treatment step.
      • Establish Staphylococcus aureus carriage:
        • Nasal swab index case or if >1 family member affected swab the whole household
        • Provide patient information sheet
      • Treat with 7 days of:
        1. Mupirocin to both nares three times a day - see patient information sheet (NB Fucidin second line due to increased background resistance) and
        2. Daily antiseptic bath or shower with one of:
          • Janola (Sodium hypochlorite / household bleach) bath only avoid facial immersion.
            (1 capful/15mls Janola per 10 litres (1 bucket) bathwater, NB 2 buckets =1 baby bath)
          • Dettol (Chloroxylenol) (not subsidised expensive) Bath only.
          • See below Information section for detailed antiseptic bathing options.
      • General advice (Summarised in Patient Information):
        • Attention to hand washing for all family members and before and after dressing infected skin.
        • Regular bathing but try not to share bathwater - e.g., put the person with infection in on their own last - showering maybe preferable.    
        • Launder sheets, towels and clothing using disinfectant or hot water or hot iron at beginning of treatment and weekly.
        • Limit sharing of beds, sheets and towels.
        • Keep finger and toenails short and scrub with antiseptic washes during treatment, as Staph can be carried there.
        • Encourage elimination of mosquito and other insect triggers.
        • Clean and cover cuts and scratches.
        • Consider script of Betadine or hydrogen peroxide (Crystacide) to treat minor abrasions. Colloidal silver also appropriate but not subsidised.
  2. If clinical treatment failure, 2nd Pass Management Cyclical Topical Treatment

    • Partial Treatment Failure- history or diary indicates some improvement consider repeating last treatment regimen again before preceding to next step.
    • If Clinical Treatment Failure(defined as new lesion(s) after full treatment completed) has occurred proceed to:
    • Cyclical Topical Treatment:
      • Re-swab this time the nose, throat and groin of index case and take nasal swabs from the whole household even if no-one else affected.
      • Cyclical pulse topical treatment (mupirocin, one week on, 3 off for 3 months) see information for patients and issue patient diary for index case.
      • Cyclical daily antiseptic baths/showers - one week on, 3 off for 3 months.
      • Simultaneous topical nasal decolonisation treatment rest of household with positive nasal swabs for 1 week only.
    • Note: Clinicians are welcome to contact (via Hospitals switchboard or Pathlab BOP) infectious disease specialist or microbiologist/pathologist at any stage of this guideline for further advice.
  3. If clinical treatment failure, 3rd Pass Management Cyclical Systemic Treatment

    • If Partial Treatment Failure -history or diary indicates some improvement, consider repeating last treatment regimen again before preceding to next step.
    • If Clinical Treatment Failure(defined as new lesion(s) after full treatment completed) has occurred proceed to:
      • Simultaneous Cyclical antiseptic daily baths or showers (one week on, 3 weeks off for 3 months) and
      • Cyclical systemic antibiotics, according to sensitivities from previous swabs (one week on, 3 weeks off for 3 months) see information for patients and use diary for index case.
        1. Co-trimoxazole alone first choice (Children 240mg/5mls give 0.5mls/kg/dose bid to maximum of 960mg bid, adult dose is 960mg bid) or
        2. If allergy or resistance: Rifampicin (10mg/kg/twelve hourly to maximum of 300mg bid which is the adult dose) plus a second Staph-active antibiotic to prevent resistance e.g., Doxycycline 100mg bid (over 12 years) or Flucloxacillin (PO 50 mg/kg/day in four divided doses up to a max. 500 mg QID on an empty stomach. Adult dose is 500mg QID).
    • A simple guide for flucloxacillin dosage is:
      • <2 years Flucloxacillin 125mg/5ml 2.5ml qid
      • 2-5 years Flucloxacillin 125mg/5ml 5ml qid
      • >5 years Flucloxacillin 250 mg/5ml 5ml qid (using 50 mg/kg/day as a cross check).
    • Note: both Rifampicin and Flucloxacillin suspension are unpalatable.
    • Beware drug interactions with rifampicin (especially oral contraceptive pill) and propensity for rifampicin to change colour of urine and secretions etc.
    • If carried or infecting organism isolated is MRSA, or case has multiple antibiotic allergies, consider early discussion with Infectious Diseases Physician or Clinical Microbiologist- phone via Tauranga Hospital switchboard 
    • NB: Clinicians are welcome to contact (via Hospitals switchboard or Pathlab BOP) infectious disease specialist or microbiologist/pathologist at any stage of this guideline for further advice.
  4. If clinical treatment failure, 4th Pass Management Simultaneous Cyclical Topical & Systemic Treatment

    • If further Clinical Treatment Failure (defined as new lesion(s) after full treatment completed) has occurred proceed to:
      • Simultaneous Cyclical Systemic and Nasal Antibiotic treatment index case(s) and  
      • Simultaneous Cyclical Nasal Antibiotic treatment entire household.
    • Note: Clinicians are welcome to contact (via Hospitals switchboard or Pathlab BOP) infectious disease specialist or microbiologist/pathologist at any stage of this guideline for further advice.
  5. Persistent Treatment Failure

      • Adherence to treatment particularly consider financial issues including ability to pay for scripts or buy antiseptics.
      • Undiagnosed or untreated household contacts.
      • Non-household but close contacts - especially boyfriends/girlfriends, very occasionally pets have been shown to be important in carriage and transmission of  aureus.
      • Other underlying issues around infection or transmission - particularly scabies.
      • Wrong diagnosis -things to consider if the swabs are negative.
      • Hydradenitis suppurativa - particularly if lesions mostly in axillae or groin.
      • Co-morbidities e.g., diabetes and more uncommonly renal or immune deficiency disease.
      • Nutritional factors notably iron deficiency. Consider dietary history and growth chart in children.
      • Discuss with Infectious disease physician, Micro/pathologist or Paediatrician or
      • REFER including documentation of treatment regimen followed to date.

Information

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.