Staphylococcus aureus risk in infants and neonatologist considerations with Aaron Milstone, MD

Aaron Milstone, MD, MHS, pediatric infectious disease specialist at Johns Hopkins Children’s Center and professor of pediatrics at Johns Hopkins University School of Medicine, emphasized the importance of pediatrician guidance and parent engagement in the prevention of Staphylococcus aureus infections in the neonatal intensive care unit (NICU).

In a recent interview, Milstone explained that while Staphylococcus aureus is a common cause of minor skin or eye infections in children, the infection can become life-threatening in vulnerable populations—particularly preterm infants during their first few weeks of life.

“For most primary care providers, this is not going to be a common topic,” Milstone said. “Staphylococcus aureus is incredibly common in children... but it rarely, in children outside of the hospital, is life-threatening. Babies in the first few months of life are really a unique population that is especially high at risk.”

Milstone co-authored a recent study published in JAMA Pediatrics, which found that late-onset invasive Staphylococcus aureus infections occurred at a rate of 37.6 per 10,000 infants across 315 NICUs between 2016 and 2021.1 Infants born with very low birth weight (VLBW)—under 1500 grams—made up just 12.7% of the population but accounted for 76.7% of infections and 90.4% of attributable deaths. The mortality rate among infected infants was more than five times higher than those without infection.¹

For pediatricians, Milstone pointed to opportunities to provide proactive guidance to families with infants in the NICU.

“Pediatricians spend a lot of time providing anticipatory guidance for families,” he said. “They may already have a relationship with the family from an older sibling... so they’re in a unique position to help.”

Related: Renewed focus into Staphylococcus aureus risk in infants, with Aaron Milstone, MD²

One example is hygiene reinforcement for families with babies in the NICU. “We’ve previously shown in a trial that parents are a reservoir for spreading staph to babies, just like moms can spread Group B strep,” Milstone said. “So there are things pediatricians can recommend—like making sure they’re washing their hands, not visiting when sick, or wearing a mask to protect the baby.”

Milstone also noted that colonization screening and targeted decolonization protocols may offer future benefit for prevention. “There’s a growing body of literature showing that if kids are colonized with staph... there is an opportunity to treat or try to make that carriage go away,” he said. “The benefit of decolonizing a child as a prevention strategy may outweigh the potential risk.”

“When we talk about a 5% increase [in mortality], we’re talking about similar babies. When we compared similar children, the risk of mortality was about 1% in children that didn't have an infection, and more than 5% in those that did. So it wasn't just a 5% absolute increase, but it went from about 1% to 5%," he explained. "That is a huge mortality difference in similar babies that do or don't have infections, so the impact of this is great."

References:

1. Fitch J. Aaron Milstone, MD, highlights persistent risk of Staphylococcus aureus in premature infants. Contemporary Pediatrics. June 5, 2025. Accessed June 12, 2025. https://www.contemporarypediatrics.com/view/aaron-milstone-md-highlights-persistent-risk-of-staph-aureus-in-premature-infants

2. Fitch J. Renewed focus into Staphylococcus aureus risk in infants, with Aaron Milstone, MD. Contemporary Pediatrics. June 6, 2025. Accessed June 12, 2025. https://www.contemporarypediatrics.com/view/renewed-focus-into-staphylococcus-aureus-risk-in-infants-with-aaron-milstone-md