should tell all adolescents and caregivers (most commonly a parent or both parents) at the beginning of the
interview about confidentiality, including limitations
to confidentiality. State-by-state confidentiality laws
can be found at the Guttmacher Institute’s website at
For example, the health care provider may say to the
teen: “To best help you, I need to ask some personal
questions. Your answers will be kept confidential and
will not be passed along to your parents or any other
providers outside of this clinic or hospital without your
This introduction should end with a clear description
of when the law requires disclosure such as suicidal or
homicidal ideation or physical or sexual abuse.
Pediatricians then should share that if they learn the
patient is doing something seriously damaging to his/
her health, it may be necessary to get help from another
health care provider or even the parent/caregiver. How-
ever, this would only happen if the teen agrees. If the
adolescent disagrees, there will need to be an additional
discussion on next steps.
Health care providers may be confronted with difficult situations in which their belief system is “tested,”
e.g., a youth is seeking options due to an unwanted
pregnancy. In such situations, it is suggested that the
health care provider consult with a colleague or refer
the youth for developmentally appropriate care.
The final recommendation — take a deep breath
and use the screens. There is a positive “screen time”
to use with your teen patients that will help you help
them (and their families) have healthier, safer and
Dr. Breuner is chair of the AAP Committee on Adolescence.
• Bright Futures: Guidelines for Health Supervision of
Infants, Children, and Adolescents, 4th Edition, http://
• Preparticipation Physical Evaluation, 4th Edition, http://
• Preparticipation physical evaluation forms, http://bit.
• CRAFFT screening interview, http://bit.ly/2oEvptd
• Healthy People 2020 resources on adolescent health,
• Society for Adolescent Health and Medicine, https://
• Office of Adolescent Health, https://www.hhs.gov/ash/
• Screening guidelines for sexually transmitted diseases
from the Centers for Disease Control and Prevention,
by Ishminder Kaur, M.D., FAAP, and
Emily Souder, M.D., FAAP
The Centers for Disease Control and Prevention estimates that about 30% of the general population is colonized with Staphylococcus aureus in their nasal mucosa.
The majority are colonized with methicillin-sensitive S.
aureus (MSSA), with up to 10% harboring methicillin-resistant S. aureus (MRSA). S. aureus also colonizes
the oropharynx, rectum and skin folds.
Risk factors for S. aureus colonization include health
care exposure (previous hospitalization, long-term
acute care facility or nursing home residents), certain
comorbid conditions (HIV infection, chronic dialysis,
eczema) and groups in close contact (prisoners, military
recruits and athletes).
S. aureus colonization is associated with subsequent
invasive and non-invasive infections. Two-thirds of
individuals with MRSA skin and soft tissue infections
(SSTI) may experience recurrences (Creech CB, et al.
Infect Dis Clin North Am. 2015;29:429-464), often
caused by identical strain types (Al-Zubeidi D, et al. J
Pediatric Infect Dis Soc. 2014;3:261-264).
Decolonization strategies have been used to reduce
the burden of or eradicate pathogen carriage, with the
goal of decreasing the risk of transmission and subsequent infections.
MRSA vs. MSSA: Decolonize both?
The burden of MRSA infections among children
increased for several decades, with emergence of the
epidemic USA300 strains of community-associated
MRSA. Recent years have seen an overall rise in methi-cillin susceptibility among S. aureus isolates, with identification of similar USA300 strains among these isolates
(Sutter DE, et al. Pediatrics. 2016;137:e20153099).
Studies also suggest that among patients hospitalized with invasive S. aureus infection, overall morbidity
and mortality between MRSA and MSSA are similar
(Wang JL, et al. Clin Infect Dis. 2008;46:799-806).
These trends suggest that attempts to decolonize both
MSSA and MRSA may be prudent for some patients.
Duration of colonization
The reported median duration of MRSA colonization varies from 21 days to nine months and even years
(Calderwood MS, et al. Clin Infect Dis. 2015;60:1497-
1499). Most data represent colonization detected by
surveillance cultures at hospital readmission. The
shorter duration was described in the setting of MRSA
SSTI, where 92% of patients received appropriate systemic antibiotics (Cluzet VC, et al. Clin Infect Dis.
Longer duration of MRSA colonization has been
associated with older age, repetitive health care facility
exposures and ongoing contact with colonized household members. Further, studies of colonization are
problematic due to variations in body sites sampled,
with many based on nares-only surveillance.
S. aureus decolonization strategies
Decolonization regimens often combine topical nasal antibiotics (mupirocin, retapamulin) and antiseptic body washes (chlorhexidine gluconate (CHG) or
bleach baths), with or without environmental decontamination. Systemic antibiotics, including rifampin,
generally are not recommended.
S. aureus is frequently transmitted among household
members, and evidence supports decolonization of all
household members of individuals with recurrent S.
aureus SSTIs. However, in a recent multicenter study,
total household decolonization did not decrease time
to MRSA eradication among index cases (Cluzet VC, et
al. Infect Control Hosp Epidemiol. 2016;37:1226-1233).
While this study could not assess the impact on recurrent SSTIs, other studies have shown that household
decolonization decreases incidence of recurrent infections (Fritz S, et al. Clin Infect Dis. 2012;54:743-751).
Decolonization agents in the community setting
usually are prescribed as short regimens (i.e., five to
seven days). Longer regimens have not been shown to
decrease the rate of medically attended recurrent SSTI
(Kaplan SL, et al. Clin Infect Dis. 2014;58:679-682).
However, concerns regarding duration of protection
of short regimens lead some experts to recommend
periodic decolonization in patients with multiple re-
currences (Creech CB, et al. Infect Dis Clin North Am.
Hospitals often use decolonization regimens to prevent health care-associated infections (HAIs), targeted
to colonized patients or implemented to all high-risk
patients. Several studies in pediatric and neonatal intensive care units (NICUs) have shown that various
decolonization strategies reduce the burden of S. aureus
colonization and the risk of HAIs.
The success of decolonization varies across studies,
ranging from 25%-95% depending on the regimen,
population and adherence. Recolonization following
decolonization is frequent, with rates as high as 60%
among hemodialysis patients (Price A, et al. J Hosp
Infect. 2015;90: 22-27).
Topical antimicrobial use is not without the risk of
resistance. Rates of in-vitro and genotypic mupirocin
and CHG resistance vary widely across reports and
need further exploration.
The unpredictable success of decolonization with
varying regimens and the conflicting data on its success
have made it difficult to develop general guidelines.
The decision to decolonize in the community setting
should be patient-specific, based on that individual’s
burden of disease or recurrence risk.
Patients and families should understand the variable
success of decolonization methods, lack of a superior
regimen, the importance of simultaneous decolonization if considering total household regimens and adherence to the chosen regimen.
Dr. Kaur is AAP Section
on Infectious Diseases
(SOID) Executive Committee training fellow liaison. Dr. Souder is SOID
training fellow liaison.
Developing guidelines for S. aureus decolonization a difficult task
Dr. Kaur Dr. Souder
Screening continued from page 12