Household Versus Individual Approaches to Eradication of Community-Associated Staphylococcus aureus in Children: A Randomized Trial

The incidence of staphylococcal skin and soft tissue infection (SSTI) has risen dramatically over the past decade [1, 2]. This epidemic has been driven largely by a community-associated Staphylococcus aureus clone designated USA300, which includes methicillin-resistant and methicillin-sensitive strains [3, 4]. Recurrent S. aureus SSTIs are especially problematic; recurrence rates >20% over 3 months have been reported [5–7]. Community-associated S. aureus infections cluster within households [8–10]. We previously demonstrated that children were at a 7-fold greater risk for developing SSTI if a household member had a recent SSTI [11]. Although community-associated methicillin-resistant Staphylococcus aureus (MRSA) transmission dynamics are not well established, it is believed that household contacts may serve as reservoirs for S. aureus transmission. Thus, patients treated for S. aureus infection may reacquire the organism from colonized household contacts, potentially placing them at risk for recurrence. Staphylococcus aureus nasal colonization is a risk factor for SSTI development [11–13]. Decolonization measures used to prevent healthcare-associated MRSA infections (eg, mupirocin ointment and chlorhexidine antiseptic) [14–18] are often prescribed for patients in community settings in an effort to prevent recurrent SSTI [19]. However, it is unclear whether decolonization should be performed by all household members or only by affected individuals. The primary objective of this study was to compare S. aureus eradication from index cases when decolonization measures were performed by the index case alone compared with measures performed by all household members. Secondary objectives included comparing incidence of SSTI in index cases and household contacts between treatment groups and evaluating adherence to decolonization measures. We hypothesized that decolonization of all household members would be twice as effective in eradicating index case S. aureus carriage compared with decolonization of the index case alone.