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mrsa and cystic fibrosis

Hi my daughter is 12 years old and has cf , in the last year she seems to be contracting and growing mrsa on her cough swabs.
The first time this happened was about a year ago and she was treated with a two week course on the antibiotic-RIFAMPICIN and a body wash and nasel spray which she used for 5 days.
10 months later she grew mrsa again on a cough swab and was prescribed a 2 week course of DOXYCYCLIN AND FUCIDIC ACID, no body wash and no nasel spray- this was something that i questioned at the time, knowing how and where mrsa lives.
We also as a family had our selfs checked for mrsa and the tests came back negative.
Then again three weeks ago her cough swab tested positive for mrsa and she has been prescribed the DOXYCYCLIN AND FUCIDIC ACID, with no body wash and nasel spray.
I have decided to ask for a second opinion now, on the type of anitbiotic being prescribed and the fact that there is no body wash and nasel spray.
When she had the first prescription RIFAMPICIN plus body wash she seemed to get rid of the mrsa.
I realise that the mrsa bug this time has been decribed as being resistant to RIFAMPICIN. but seeing as the mrsa has returned so quicky I am doubtful about her having DOXYCYCLINE and FUCIDIC ACID minus a body wash again and it being effective. She also had to have a blood test at the begining and the end of the DOXYCYCLIN AND FUCIDIC ACID to monitor her liver function.
The results of this test were, that her liver function on those antibiotics was fine.
However it has been made apparent that they are a heavy course of antibiotics which i would personally like to avoid giving her if it is not looking like it's is getting rid of the mrsa.
Can you suggest any other effective antibiotics and do you think she should be having a body wash and nasel spray?.
I feel that really the whole family should be having a body wash whilst she is on the antibiots to prevent a cycle of colonisation, which is what i think we may have happening.
I am also keen for the family to do cough swabs to see if we are carrying it in our lungs after reading the article below which i found on this site.
If a CF patient is culturing MRSA, how high is the risk of transmitting MRSA to a partner(without cf) through kissing and sexual activity?
Dear Questioner

Staphylococcus aureus is a type of bacteria that is commonly found living on the body surfaces of many people- it can colonize the nose, throat, armpits and other body areas without causing disease. In recent years, S.aureus has been identified which is resistant to many types of antibiotics which would commonly be used to treat infections, and this is called Meticillin resistant S. aureus (MRSA). MRSA is found only rarely among people in outside hospitals- however, it can spread rapidly within healthcare settings or in cases where people live and have close contact with each other. In most cases, acquiring MRSA probably won’t result in disease in that individual. However, if the person has a wound, or other skin breaks, or has an underlying medical condition that might make them more likely to pick up infections, it could cause a serious infection.

It is possible for people who have MRSA (CF or non-CF) to pass it to household contacts or to people with whom they have close contact- even pets!- and recent studies have suggested that MRSA can be spread from the respiratory tract by coughing, sneezing and kissing. Partners of people with MRSA are at increased risk of transmission, probably because of increased bodily contact1. However, unless those contacts have a medical condition, its not likely that they would develop an infection but there is a chance that they become colonized with MRSA. This colonization may well be short-lived, but might be long enough to pass it back to the person with CF- this is particularly a problem if the person with CF is undergoing decolonization (i.e. a course of antibiotics designed to get rid of the MRSA).

In order to avoid a cycle of colonization being established, it would be important to consider some important, but simple, infection control measures2. Regular showering using a medicated wash, containing chlorhexidine and handwashing, particularly after coughing or sneezing, by all household contacts may reduce the risk of colonization- alcohol based hand rubs may be particularly useful in this case. In addition, regular changing of bed linen and bed clothes may cut down the risk of MRSA spread.

Also can you tell me what effect the mrsa in my daughters lungs has on her health and particularly on her lung health?
.It seems there are no real answers, and it is all a bit of a stab in the dark.
Obviously I would like to irradicate the mrsa, but i would like to go about it effectively avoiding intravenous antibiotics.
As we have been able to avoid these so far and her health is good.
Many thanks.
Kind regards and i look forward to your reply.

Dear questioner,
MRSA (methicillin resistant Staphylococcus aureus) is a strain of Staphylococcus aureus that is characterized by resistance to a number of antibiotics, the “normal” Staphylococcus aureus is sensitive to, so eradication therapy becomes more difficult. As you already found out yourself, there are a lot of question about MRSA on the English site of ECORN-CF, find even more in the Central English Archive of ECORN-CF (I gave you some links at the end of the answer). As there is so much information available in the system, yet, I try to focuss briefly on your specific questions.
Stapylococcus aureus in general (the one still sensitive to methicillin) can be asymptomatic in CF patients (we talk about colonization), however can also result in increased cough, decreased lung function (we talk about infection). Several investigations could show that it has a pathogenetic role for CF patients as there was a correlation between early colonization and increased inflammation of the airways. A colonization with S. aureus is thought to be a predecessor of later infection with P. aeruginosa. Therefore, even if there is no uniform consensus about it, if S. aureus is found in CF airways, an eradication therapy is in general initiated. The methicillin resistant strain of S. aureus (MRSA) is in general not more virulent than the “sensitive” S. aureus, however data suggests that it is a marker of more severe disease in CF and the treatment can be problematic. So here, the strategy of an eradication trial is at least as important as for S. aureus, as chronic colonization has the same negative impact on lung disease via increased airway inflammation.
If a patient, like your daughter, has a positive cough swab for MRSA, it is important to test, if MRSA is also present elsewhere, e.g. by also doing a nasal swab or skin swabs. It would be also important to know, if MRSA can also be found in the sputum of your daughter, an indication for colonization also of the lower airways. If the nasal swab is also positive, an eradication trial can be made with an oral antibiotic plus local antibiotic . The oral antibiotic has to be chosen according to sensitivity testing of the germ to different antibiotics (so we can not tell you the exact drug here, some possibilities found in literature are for example rifampicin + fusidic acid, rifampicin + clindamycin or linezolid). The nasal eradication can e.g. be done with mupirocin nasal ointment. Probably your daughter did not get a nasal decontamination and body wash because the nasal swab and other skin swabs were negative; however it has to be admitted, that swabs can be falsely negative so to be on the safe side, a nasal and skin decontamination can nevertheless be considered. Please discuss this with your team.
In general, you already listed in the former question you found on this topic, all the necessary hygiene measures that helps to have a successful eradication. If eradication with oral antibiotics is not successful, an i.v. therapy should be tried (here often vancomycin and fosfomycin are used, however, sensitivity testing is crucial. There are different eradication protocols for the finding of MRSA in the literature, some have success rates of 94% and some include a step by step procedure (please see links at the end of the answer to get more detailed information). However, it is not seldom, that after successful eradication the germ might occur again, either as reinfection from another source or it was not totally eradicated before; therefore it is important to do frequent microbiological controls.

For the family members, they should be tested with cough/throat swabs, nasal swabs and skin swabs if MRSA is present and in case of a positive or unclear result, nasal decontamination and probably also body washings and the mentioned hygiene measures are necessary.
Very much of interest for you could be these former question in ECORN-CF:

Yours sincerely,
Dr. Daniela d’Alquen (Coordinator of the Central English Archive of ECORN-CF)