2005 Spring Issue

Contents:

• Chair's Column
• Methicillin-Resistant Staphylococcus aureus
• Use of NSAIDS in Children and Adolescents
• Calendar

Chair's Column

Dear Friend and Colleagues,

Happy springtime! We hope that you are well and enjoying the warm weather. At KU Pediatrics, spring continues to bring growth and change to our department.

To begin, we would like to welcome two new colleagues to our department. Dr. Jo-Ann Harris joined our department last fall in the division of infectious diseases. A KU alumna, Dr. Harris returns from a 20 year stint at The Boston University School of Medicine to join long-time faculty member Dr. Cheng Cho. Her research interests include respiratory diseases in adolescents, nosocomial infections, antibiotic trials, and urinary tract infections in children with neurogenic bladders.

Robert Fletcher, PA-C, joins our department in the division of pediatric endocrinology. A former assistant professor at the Rosalind Franklin School of Heath Services in Chicago, Bob is an experienced clinician and teacher. We are delighted to welcome him to our department.

Additionally, our new PICU continues to thrive, having stayed near capacity throughout the winter. Our physicians and staff have done an outstanding job, and we deeply appreciate your continued referrals.

For those of you in Johnson County, we would like to remind you that we continue to welcome referrals to our Overland Park satellite clinic. We continue to offer general pediatric care there, enhanced by specialty appointments in behavioral medicine, endocrinology, asthma, allergy, rheumatology, and gastroenterology.

Finally, I would like to remind you to mark your calendars for the annual pediatric symposium, which is scheduled for May 5-6, 2005. Electronic medical records, coding, environmental health and sports medicine are only a few of the topics to be covered.

As always, I welcome your comments and suggestions. Please email me at cjohnson5@kumc.edu with your thoughts.

Chet D. Johnson, MD

Professor and Chair, Pediatrics

Community Acquired Methicillin-Resistant Staphylococcus aureus

Jo-Ann S. Harris MD

Clinical Professor of Pediatrics and Director, Division of Infectious Diseases

What is community acquired methicillin-resistant S. aureus (CA-MRSA)?

Methicillin-resistant S. aureus has been recognized since the 1960s. Initially this pathogen was predominantly found in hospitalized patients, but community acquired MRSA infections were also recognized. In the 1990s, CA-MRSA was increasingly reported in patients without healthcare related risk factors. CA-MRSA has become an increasingly common infection, accounting for 35-50% of staphylococcal isolates in some geographic areas. Because the mechanism of resistance to beta-lactam antibiotics is altered in CA-MRSA, the antibiotic susceptibility patterns differ from healthcare-associated MRSA.

Who gets CA-MRSA?

CA-MRSA is spread by direct physical contact and indirect contact by touching fomites (towels, sheets, wound dressings, clothes, sports equipment). CA-MRSA has been associated with sharing contaminated items, recurrent skin diseases, and living in crowded settings. There have been clusters of infections in injection drug users, incarcerated persons, players of contact sports, and men who have sex with men. CA-MRSA is commonly spread within families and among children in day care centers.

What is the clinical presentation of CA-MRSA in children?

The most common manifestations of CA-MRSA are skin and soft tissue infections including cellulitis, abscesses, and furuncles. The next most common presentation is pneumonia. The severity of CA-MRSA in children appears similar to infections caused by methicillin-sensitive S. aureus. Although severe infection is rare, there have been four reports of children who have died from CA-MRSA.

When should the clinician suspect CA-MRSA in a child?

Suspect CA-MRSA when the child has no risk factors for healthcare-related MRSA and has any of the following: contact with a prisoner or prison, recurring skin infections, or plays contact sports or is in contact with a sports facility. The clinician should know the amount of CA-MRSA that has been identified in his or her community. In a highly endemic area, there should be a high index of suspicion that a skin or soft tissue infection in a child is CA-MRSA.

How is CA-MRSA diagnosed?

A culture of the infected wound must be obtained in order to identify the pathogen and determine the antibiotic susceptibilities. Previously, pediatricians could treat skin infections empirically with common and inexpensive agents such as dicloxacillin or cephalexin and know that the organism was susceptible. This is no longer true.

What antibiotics are available for the treatment of CA-MRSA?

Oral agents potentially useful for CA-MRSA include clindamycin, trimethoprim/sulfamethoxazole, fluoroquinlones, and some tetracyclines, depending on the sensitivities of the isolate. Rifampin can be used with another agent, but if used alone, rifampin will develop resistance rapidly. If the infection is severe, parenteral vancomycin is recommended. For strains of MRSA resistant to standard therapy, there are newer agents available such as daptomycin, quinupristin-dalfopristin and linezolid. Their use has been restricted to limit emergence of resistance. Linezolid is the only agent approved for children, and is the only agent with an oral preparation.

What advice should be given to the patient/family to prevent transmission of CA-MRSA?

1. Keep infections covered with clean, dry bandages, and carefully follow wound care instructions.
2. Caretakers should wash hands frequently with soap and warm water, especially if they change bandages or touch the wound.
3. Avoid sharing personal items (towels, razors, clothing etc.) that may have had contact with the wound. Wash linens and clothes that become soiled with hot water and laundry detergent, and use a hot dryer.
4. Notify any healthcare providers they visit that they (or their family members) have MRSA.

Useful References:

www.cdc.gov

1. MRSA infections among competitive sports participants.
   MMWR August 22, 2003 / 52(33); 793-795
2. Red Book: 2003 Report of the Committee on Infectious Diseases. 26th ed. Elk Grove Village, Il. American Academy of Pediatrics: 2003.
3. Johnson LB and Saravolatz LD. Community-acquired MRSA: Current epidemiologic and management issues. Infect Med 2005;22:16-20

Other references upon request.

Jo-Ann S. Harris MD

Clinical Professor of Pediatrics and Director, Division of Infectious Disease

Use of NSAIDS in Children and Adolescents

Carol Lindsley, MD

Recent Events:

In November 2004, Merck voluntarily removed refcoxib (Vioxx®) from the world market due to adverse cardiovascular and cerebrovascular events. Since then, multiple reports of other NSAIDs possibly causing these same adverse effects have been released to the press. Many patients and physicians are disconcerted by the conflicting preliminary data regarding potential risks from taking celecoxib (Celebrex®), valdecoxib (Bextra®), and most recently naproxen (Aleve®).

The newest data reported by Pfizer suggest the possibility of increased risk of serious cardiovascular events for patients taking Celebrex® at doses of 400 mg to 800 mg daily. Information reported in November 2004 suggested that Bextra® posed similar risks for cardiovascular events as that of Vioxx®. In another trial, Aleve®, a drug previously believed to have some preventive cardiovascular effects, also showed indications of elevating cardiovascular risk. In each case, the FDA is analyzing the data and has offered limited warnings. It is important to note that none of these trials included any participants under age 18.

Pediatric Experience:

Although COX-2 inhibitors (Celebrex, Vioxx and Bextra) are prescribed infrequently in children, they are often a mainstay of therapy in the care of patients with chronic musculoskeletal disease. In spite of intense scrutiny, there is no evidence to date that these drugs have adverse cardiovascular effects in patients under 18 years of age.

Treatment Guidelines:

For patients with arthritis and the physicians who treat them, it remains critical to consider factors that affect the risk/benefit ratio when determining whether to continue or discontinue any pharmaceutical product, including those NSAIDs that are currently under scrutiny. What follows is a brief overview of several commonly used NSAIDs, including information on treatment guidelines and possible side effects.

Naproxen:
Naproxen/Naproxen Sodium is available by prescription: Anaprox, Naprosyn, Naprelan; Non-prescription: Aleve

Patients should not exceed the recommended doses for naproxen (15 – 20 mg/kg/d) and should not take naproxen for longer than ten days unless a physician directs otherwise. Naproxen was first sold as a prescription drug in 1976. FDA approved its use as an over-the-counter drug in 1994. Overall this drug has been well tolerated and the most common adverse events in children are dyspepsia, pseudoporphyria and allergic reactions.

Valdecoxib / Bextra
Valdecoxib is available by prescription only.

The new boxed warning states that patients taking Bextra have reported serious, potentially fatal skin reactions, including Steven-Johnson Syndrome and toxic epidermal necrolysis. These skin reactions are most likely to occur in the first 2 weeks of treatment, but can occur at any time during therapy. In a few cases, these reactions have resulted in death. The labeling advises that Bextra should be discontinued at the first appearance of a skin rash, muscosal lesions, or any other sign of allergic reactions. The warning also states that Bextra contains sulfa, and patients with a history of allergic reactions to sulfa may be at a greater risk of skin reactions.

Other information includes increased cardiovascular risk in patients treated with Bextra compared to placebo. Observed cardiovascular events included thromboembolic events such as myocardial infarction, cerebrovascular accident, deep vein thrombosis, and pulmonary embolism. Again, none of the cardiovascular events have been reported in children, but it should only be prescribed in the lowest dose - 10 mg / day, and only in adolescents that have significant pain or ongoing inflammation.

Celecoxib / Celebrex
Celecoxib is available by prescription only.

There is good pediatric experience with this drug since its release in 1989. It, along with Bextra, is used primarily in children with childhood rheumatic disease who can not tolerate older NSAIDs. The dosage is 100 - 200 mg / day in adolescents. Most common adverse events are allergic reactions and dyspepsia.

Blood pressure monitoring is required with all chronic NSAID usage. All of these drugs also inhibit renal prostaglandins and should be discontinued on any patient with vomiting, dehydration or volume depletion for any reason.

Carol Lindsley, MD

Division Chief, Pediatric Rheumatology

MARK YOUR CALENDARS

Pediatric Symposium is scheduled for May 6, 2005 in the School of Nursing Auditorium.

Pediatric Grand Rounds are held on Fridays at 8:00 am. Registration begins at 7:30 am. The weekly programs and location are listed on the KU Pediatrics website:
http://www2.kumc.edu/kids

These programs are designated for 1 credit hour each in Category 1 of the Physicians Recognition Award of the AMA. These programs are also accredited for nurses to receive 1.2 contact hours provided by the University of Kansas Medical School of Nursing, Continuing Nursing Education. The attendance certificates will be paid by the Department of Pediatrics. If you would like more information, please call (913) 588-6339.