Community-Acquired Methicillin-Resistant Staphylococcus Aureus and Intrafamily Spread of Pustular Disease

To The Editors: Recent publications suggest that community-acquired methicillin-resistant Staphylococcus aureus (MRSA) is becoming increasingly more common among adults and children. 1–3 We report an outbreak of pustular disease caused by MRSA among three children in a single family. AA was a 13-year-old boy who developed a pustular rash on both lower legs, left forearm and scrotum. Empiric treatment with cephalexin failed after 10 days. Culture of a pustule yielded S. aureus susceptible to clindamycin, trimethoprim-sulfamethoxazole, tetracycline and ciprofloxacin and resistant to amoxicillin, amoxicillin/clavulanate, cephalothin, erythromycin and oxacillin. Ten days of clindamycin therapy improved the lesions. Two months later the lesions reappeared. At the same time his two sisters, ages 9 and 16 years, developed similar lesions on their extremities. Cultures of the pustules yielded MRSA. Each child was successfully treated with 10 to 20 days of oral trimethoprim-sulfamethoxazole therapy. In addition mupirocin ointment was applied to their nares twice a day for 5 days to eradicate potential nasal colonization. Although no specific cause for the household outbreak was identified, the bathtub was suspect. The tub was extensively cleaned with chlorax, and no further episodes of disease occurred. This report emphasizes the increasing prevalence of community-acquired MRSA disease. It also demonstrates the value of antibiotic susceptibility testing and the effectiveness of an oral agent such as trimethoprim-sulfamethoxazole in infections due to MRSA. Howard Faden, M.D. Shawn Ferguson, M.D.