Recurrent Staphylococcus aureus skin and soft tissue infection

This guideline supports General Practitioners in the initial assessment, management and referral of children with recurrent Staphylococcus aureus skin and soft tissue infections, or invasive Staphylococcus aureus infections. It aims to ensure timely care, including counselling and investigations, to streamline referrals and reduce outpatient clinic wait times.

Introduction

Recurrent Staphylococcus aureus (S. aureus) skin and soft tissue infections (SSTIs) include abscesses and cellulitis. These infections cause significant morbidity (e.g., pain, scarring), repeated antibiotic use, and are a leading cause of paediatric hospital admission.

Methicillin-resistant Staphylococcus aureus (MRSA) is a specific type of S. aureus bacteria that has developed resistance to several commonly prescribed antibiotics. MRSA prevalence is particularly high in parts of WA, with the highest notification rates seen in remote regions like the Kimberley⁽¹⁾

S. aureus is highly transmissible via person-to-person direct contact, or from the patient's own reservoirs. Recurrence is common because the bacteria colonise the nares and skin of the patient and household contacts, often perpetuated by environmental contamination (fomites).

These guidelines aim to ensure that a complete, household-based 5-day decolonisation regimen is thoroughly attempted to break the recurrence cycle before considering specialist referral. Decolonisation may not be completely effective and does often need to be repeated.

Pre-referral investigations

Microbiology:

• Recent microbiology culture and susceptibility report from a skin/soft tissue infection.
• If the patient is currently well, consider performing a S. aureus carriage screen (dry or charcoal swab of nares, axilla; or umbilical swab in neonates) to confirm colonisation.

Clinical Assessment:

• Identify and document any pre-existing or concurrent skin conditions (e.g., eczema, psoriasis, scabies) as these are common factors in decolonisation failure.
• Rule out other persistent reservoirs (e.g., indwelling catheters, chronic wounds, possible throat carriage).

History:

• Other affected household members with infections and / or known colonisations
• Other comorbidities, prior antibiotics
• Details of previous infections / hospitalisations
• Presence of reservoirs

Pre-referral management

Decolonisation should be attempted for the patient and all household members at the same time before referral.

CRITICAL STEP:

Decolonisation should only commence AFTER any open skin lesions have healed.

1. Topical Decolonisation (5-day course)

Note: Decolonisation procedures can dry the skin and potentially exacerbate underlying skin conditions such as eczema. Moisturisers are recommended following use of any body wash or bleach baths.

2. General and environmental measures

• Household Contacts: all family members and close contacts living in the same household must undergo the full 5-day decolonisation course simultaneously.
• Hygiene: do not share towels.
• Cleaning: thoroughly vacuum floors/soft furnishings and wipe frequently touched surfaces in the home on Day 2 and Day 5 of treatment.
• Laundry: wash clothes, pyjamas, bed linen, and towels using a hot wash cycle and dry in the sun (if possible) on Day 2 and Day 5.
• Dental/Shaving: replace toothbrushes and razors at the start of treatment. Removable orthodontic/dental devices should be soaked overnight in a suitable cleaning product.
• Skin Management: optimise the treatment of any underlying skin conditions (e.g., eczema) as per existing guidelines and consider avoidance of triggers such as insect bites. Consider referral to a dermatologist if these are not controlled.

When to refer

Referral to Infectious Diseases is generally warranted if:

1. Decolonisation failure: the patient experiences a relapse or recurrent S. aureus infection after patient and household contacts successfully complete a full 5-day decolonisation course (chlorhexidine or bleach baths). Decolonisation procedures with chlorhexidine, mupirocin ointments and bleach baths for the patient and family members can be safely repeated if infections reoccur.
2. Complicating factors: there is a strong suspicion of persistent reservoirs that require specialist input (e.g., chronic wounds, indwelling devices, confirmed throat carriage).
3. Age: the patient is less than 3 months old requiring decolonisation.
4. Non-standard therapy required: the patient has a documented allergy or adverse reaction to both Chlorhexidine and Triclosan, requiring discussion regarding alternative agents (e.g., Octenisan).

Families and children awaiting a specialist infectious diseases appointment are likely to face significant wait times to access our service, which risks further delaying effective management and treatment for their S. aureus infections.

Please continue conversations with families after referral, provide ongoing support and treatment in your practice where appropriate (including repeating decolonisation efforts), and inform us of any significant clinical changes or if the family's treatment plan progresses prior to a clinic appointment becoming available.

How to refer

• Routine Non-Urgent Referrals (GP or Consultant): Submit via the Central Referral Service.
• Urgent Referrals (less than 7 days): Call PCH Switch on (08) 6456 2222 to discuss the referral with the Infectious Diseases registrar on call.
• Nurse Practitioner/Non-Medical Referrers/Private Hospitals: Submit to CRA

Essential information to include in your referral

For the most efficient review, the referral must clearly state:

• Confirmed diagnosis: date and site of the S. aureus-positive culture(s) and sensitivity results.
• Infection history: details and dates of all recurrent skin/soft tissue infections.
• Decolonisation details:
  • Specific Decolonisation Regimen Used (e.g., Mupirocin + Chlorhexidine 2% wash).
  • Dates when decolonisation attempted
• Compliance: confirmation that all household members completed the course and followed environmental measures.
• Underlying conditions: severity, location, and current management of any dermatological conditions (e.g., Eczema).
• Reservoir check: Any clinical evidence of persistent S. aureus reservoirs (e.g., perianal infection, chronic sinusitis).

Useful resources

1. Staphylococcus aureus Decolonisation (Health Fact Sheet)
2. Bleach baths for children with eczema (Health Fact Sheet)
3. WA Health: Decolonisation treatment for MRSA – information for healthcare providers

References

1. Bloomfield LE, Coombs G, Armstrong P. Community-associated methicillin-resistant Staphylococcus aureus in the Kimberley region of Western Australia, epidemiology and burden on hospitals. Epidemiol Infect. 2024 Nov 27;152:e147. doi: 10.1017/S0950268824001201. PMID: 39601098; PMCID: PMC11626457.

This document can be made available in alternative formats on request for people with disability.