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Kawamura H, Imuta N, Ooka T, Shigemi A, Nakamura M, Mougi K, Obama Y, Fukuyama R, Arimura S, Murata N, Tominaga H, Sasaki H, Nagano S, Taniguchi N, Nishi J. Impact of control measures including decolonization and hand hygiene for orthopaedic surgical site infection caused by MRSA at a Japanese tertiary-care hospital. J Hosp Infect 2024; 146:151-159. [PMID: 37516280 DOI: 10.1016/j.jhin.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/16/2023] [Accepted: 07/01/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Meticillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen in orthopaedic surgical site infections (SSIs). However, few studies have investigated the transmission process of orthopaedic MRSA SSI. AIM To investigate the transmission process of orthopaedic MRSA SSI using epidemiological and molecular analyses and to determine a method to prevent MRSA SSI in nosocomial orthopaedic surgery. METHODS Active MRSA surveillance, preoperative decolonization and contact precautions for MRSA-positive cases was performed at our institution. Changes in epidemic strains were evaluated and the possibility of transmission from patients in an orthopaedic ward of a Japanese tertiary-care hospital was assessed by genotyping stored MRSA strains. In addition, data on the prevalence of MRSA SSI, MRSA colonization, and use of an alcohol antiseptic agent (mL/patient-days) during 2005-2022 were retrospectively assessed. FINDINGS SCCmec type II strain in the SSI group decreased over time, associated with fewer outbreaks. Even during a period of high infection rates, no cases of transmission-induced SSI from nasal MRSA carriers were identified. The infection rate correlated negatively with the use of an alcohol antiseptic agent (r = -0.82; P < 0.0001). Two cases among five nasal carriers developed MRSA SSI caused by strains different from those related to nasal colonization. CONCLUSION The infection control measures for transmission from the hospital reservoirs including strict adherence to hand hygiene and decolonization of carriers is likely to be important for the prevention of orthopaedic MRSA SSI. However, the need for contact precautions for decolonized nasal carriers might be low.
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Affiliation(s)
- H Kawamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | - N Imuta
- Department of Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - T Ooka
- Department of Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - A Shigemi
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - M Nakamura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - K Mougi
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - Y Obama
- Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - R Fukuyama
- Clinical Laboratory, Kagoshima University Hospital, Kagoshima, Japan
| | - S Arimura
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - N Murata
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan
| | - H Tominaga
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - H Sasaki
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - S Nagano
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - N Taniguchi
- Department of Orthopaedic Surgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - J Nishi
- Department of Infection Control and Prevention, Kagoshima University Hospital, Kagoshima, Japan; Department of Microbiology, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Mitsumoto-Kaseida F, Morinaga Y, Sasaki D, Ota K, Kaku N, Sakamoto K, Kosai K, Hasegawa H, Hayashi J, Yanagihara K. The clinical characteristics and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) among very elderly people in Japan. Geriatr Gerontol Int 2023; 23:744-749. [PMID: 37694453 DOI: 10.1111/ggi.14664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 08/02/2023] [Accepted: 08/28/2023] [Indexed: 09/12/2023]
Abstract
AIM Methicillin-resistant Staphylococcus aureus (MRSA) is a major nosocomial infection-causing pathogen. The clonal shift from staphylococcal cassette chromosome mec (SCCmec) type II MRSA to SCCmec type IV MRSA has occurred rapidly in acute-care hospitals. However, the epidemiology and clinical impacts of MRSA in geriatric hospitals are poorly documented. We performed a molecular epidemiological analysis of the clinical isolates and retrospectively investigated the clinical characteristics of SCCmec type IV MRSA in elderly individuals. METHODS MRSA isolates were grouped according to the SCCmec type and virulence genes (tst, sea, seb, sec, and lukS/F-PV), and multi-locus sequence typing (MLST) was performed. RESULTS Of the 145 MRSA isolates obtained from patients with a median age of 85 years, 100 (69.0%) were obtained from sputum samples, 22 (15.2%) from skin and soft tissues, and seven (4.8%) from blood samples. The most prevalent clone was SCCmec type IV/clonal complex (CC)1/sea+ (59.3%), followed by SCCmec type I/sequence type (ST) 8 (17.3%). Of the 17 (11.7%) strains to which an anti-MRSA drug was administered by a physician, only three were SCCmec type IV/CC1/sea+ (17.6%) and five were SCCmec type I/ST8 (29.4%). SCCmec type IV/CC1/sea+ MRSA was more frequently isolated in long-term care wards than were SCCmec type I/ST8 strains (odds ratio: 2.85, 95% confidence interval: 1.08-7.54) and was less frequently treated as the cause of MRSA infections (odds ratio: 0.15, 95% confidence interval: 0.03-0.73). CONCLUSIONS SCCmec type IV/CC1/sea+ MRSA was the predominant clone and could be easily transmissible and be capable of colonization. Geriatr Gerontol Int 2023; 23: 744-749.
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Affiliation(s)
- Fujiko Mitsumoto-Kaseida
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Kyushu General Medicine Center, Haradoi Hospital, Fukuoka, Japan
| | - Yoshitomo Morinaga
- Department of Microbiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Daisuke Sasaki
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kenji Ota
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norihito Kaku
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kei Sakamoto
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kosuke Kosai
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroo Hasegawa
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Jun Hayashi
- Kyushu General Medicine Center, Haradoi Hospital, Fukuoka, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Shoji T, Muto R, Sakai R, Matsumura H, Uchida T, Kitta F, Inoue O, Kawata K, Akazawa M. Estimated medical costs of methicillin-resistant Staphylococcus aureus infection classified by polymerase chain reaction-based open reading frame typing in Japan. AIMS Microbiol 2022; 8:528-543. [PMID: 36694583 PMCID: PMC9834076 DOI: 10.3934/microbiol.2022034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/25/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022] Open
Abstract
This retrospective, observational cohort study investigated the economic impact of genotype by classifying methicillin-resistant Staphylococcus aureus (MRSA) by using the polymerase chain reaction-based open reading frame typing (POT) method. Using administrative claims and bacteriological data for April 2016 to March 2021 from the University of Yamanashi Hospital, we ascertained the POT1 numbers and classified MRSA as either "hospital-derived" or "community-derived". We defined MRSA-associated medical practices and estimated the associated medical costs. After applying inverse probability of treatment weighting (IPTW)-based adjustment for patient characteristics between the two groups, we estimated the differences in medical costs during the "total therapy period" (defined as the interval from specimen submission to Day 42 after the susceptibility report) and the "definitive therapy period" (defined as the interval from susceptibility reporting to Day 42). Among the 135 MRSA-infected patients, 54 and 81 were classified as having hospital-derived and community-derived MRSA infections, respectively. Significant differences in patient characteristics were observed with regard to age (p = 0.0478), sex (p = 0.0422), surgery (p = 0.0349), chemotherapy (p = 0.0457) and immunosuppressive drug use (p = 0.0222). The median duration of the definitive therapy was 29 and 27 days, and the mortality rate during this period was 11% and 5% for the hospital-derived and community-derived types, respectively. After IPTW-based adjustment, the medical costs for the total therapy period were 324,480 and 296,462 Japanese yen (JPY) per patient for the hospital-derived and community-derived types, respectively, whereas the medical costs for the definitive therapy period were 279,635 and 256,542 JPY per patient for the hospital-derived and community-derived types, respectively. No statistically significant difference was detected (p = 0.5813 and p = 0.6355, respectively). In this study, MRSA healthcare costs were compared according to the POT scores, and no statistically significant differences were observed between hospital-derived and community-derived MRSA infections.
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Affiliation(s)
- Tomokazu Shoji
- Department of Pharmacy, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan,Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 2–522–1, Noshio, Kiyose, Tokyo 204–8588, Japan,Division of Infection Control and Prevention, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan,* Correspondence: ; Tel: +81552731111; Fax: +81552736672
| | - Ryusei Muto
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 2–522–1, Noshio, Kiyose, Tokyo 204–8588, Japan
| | - Ryoko Sakai
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 2–522–1, Noshio, Kiyose, Tokyo 204–8588, Japan
| | - Hiroki Matsumura
- Department of Pharmacy, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan,Division of Infection Control and Prevention, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan
| | - Takashi Uchida
- Division of Infection Control and Prevention, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan,Department of Clinical Laboratory, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan
| | - Fumihiko Kitta
- Department of Pharmacy, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan
| | - Osamu Inoue
- Division of Infection Control and Prevention, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan
| | - Keishi Kawata
- Department of Pharmacy, University of Yamanashi Hospital, 1110, Shimokato, Chuo, Yamanashi 409–3898, Japan
| | - Manabu Akazawa
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 2–522–1, Noshio, Kiyose, Tokyo 204–8588, Japan
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Clinical characteristics and molecular analysis of USA300 and ST 764 methicillin-resistant Staphylococcus aureus isolates from outpatients in Japan by PCR-Based open reading frame typing. J Infect Chemother 2020; 27:466-472. [PMID: 33139181 DOI: 10.1016/j.jiac.2020.10.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 10/12/2020] [Accepted: 10/17/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION USA300 is the most common community-acquired methicillin-resistant Staphylococcus aureus (MRSA) strain. Sequence type (ST) 764 MRSA is a new local variant of the ST 5 lineage. The objective of this study was to determine the clinical characteristics of USA300 and ST 764 infections among outpatients in Japan. METHODS We obtained MRSA isolates from 132 outpatients who visited our hospital from January 2016 to December 2017 and compared USA300 infection group to ST 764 infection group. Molecular analysis, including that of various toxins and other virulence factors, of the MRSA isolates were performed. In particular, we investigated the relationships among PCR-based open reading frame typing (POT) scores, MRSA clones, and virulence factors. RESULTS Twenty-seven USA300 isolates (20.5%) and 16 ST 764 isolates (12.1%) were identified. Although USA300 and ST 764 had lower rates of risk factors, their infection rates were higher. USA300-infected patients had higher rates of deep skin and soft tissue infections compared with the non-USA300 CA-MRSA-infected patients. Notably, the USA300 and ST 764 isolates had unique POT scores. CONCLUSIONS Our results indicated that USA300 MRSA was spreading in an area 120 km west of Tokyo, Japan. We observed multiple cases of ST 764 MRSA infection, raising concerns about the antimicrobial resistance of ST 764, as it limits the choices of antibiotics to treat infection. The POT score can predict the presence of toxins and virulence factors, as well as the clone identity of MRSA with high accuracy.
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The increased frequency of methicillin-resistant Staphylococcus aureus with low MIC of beta-lactam antibiotics isolated from hospitalized patients. J Infect Chemother 2020; 26:604-610. [PMID: 32094050 DOI: 10.1016/j.jiac.2020.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/27/2019] [Accepted: 01/30/2020] [Indexed: 12/27/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) causes severe infectious diseases and can be life-threatening in healthcare-settings. MRSA is classified into health-care associated (HA)-MRSA strains and community acquired (CA)-MRSA strains based on genotype and phenotype. CA-MRSA has been reported to show the lower minimal inhibitory concentration (MIC) of some antibiotics as compared to HA-MRSA. Recently, the prevalence of CA-MRSA has been increased in worldwide. CA-MRSA is isolated not only from the healthy individuals in a community but also from the patients in healthcare settings. However, the changing trend in frequency of HA-MRSA and CA-MRSA in the hospital setting is not clear. Therefore, we analyzed the trend of MIC to speculate the frequency of HA-MRSA and CA-MRSA in the facility. Moreover, gene mutations were evaluated on resistant gene loci with next generation sequencer. The frequency of strains with low MIC of beta-lactam antibiotics was gradually increased in isolated MRSA strains from the hospitalized patients. Whole genome analysis revealed the frequency of gene mutation was also decreased in some resistant loci, such as blaZ and blaR1. These findings highlight the changing trend of MRSA strains isolated from hospitalized patients.
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Ogawa Y, Kasahara K, Asada T, Yoshihara S, Hirai N, Furukawa R, Nishimura T, Ohmori K, Nakano R, Yano H, Mikasa K. Scrotal ulcer due to community-acquired methicillin-resistant Staphylococcus aureus USA300 clone in an HIV-positive man who has sex with men in Japan: a case report. Int J STD AIDS 2019; 30:1229-1231. [PMID: 31558138 DOI: 10.1177/0956462419870986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A genital ulcer can be associated with sexually transmitted infections, such as syphilis and herpes, and sexually transmitted organisms, such as Chlamydia trachomatis. We report a case of scrotal ulcer caused by Staphylococcus aureus clone USA300 in a 56-year-old man living with human immunodeficiency virus in Osaka, Japan. It is important to enhance the awareness and surveillance regarding the potential of spread of this organism in the community of men who have sex with men in this district.
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Affiliation(s)
- Yoshihiko Ogawa
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Kei Kasahara
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Tomoko Asada
- Department of Microbiology and Infectious Diseases, Nara Medical University, Nara, Japan
| | - Shingo Yoshihara
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Nobuyasu Hirai
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Ryutaro Furukawa
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Tomoko Nishimura
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Keitaro Ohmori
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
| | - Ryuichi Nakano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Nara, Japan
| | - Hisakazu Yano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Nara, Japan
| | - Keiichi Mikasa
- Center for Infectious Diseases, Nara Medical University, Nara, Japan
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Kitagawa H, Ohge H, Hisatsune J, Kajihara T, Katayama K, Takahashi S, Sueda T, Sugai M. Prosthetic Valve Endocarditis Caused by ST8 SCCmecIVl Type Community-associated Methicillin-resistant Staphylococcus aureus. Intern Med 2019; 58:743-747. [PMID: 30333402 PMCID: PMC6443554 DOI: 10.2169/internalmedicine.1415-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The emergence of a Japan-intrinsic community associated methicillin-resistant Staphylococcus aureus strain (CA-MRSA/J) has been reported. A 70-year-old man with recurrent colon cancer and a history of mitral valve replacement was admitted to the hospital in a state of shock. He was diagnosed with prosthetic valve endocarditis (PVE) caused by MRSA and underwent cardiac surgery. The MRSA isolates belonged to multilocus sequence type 8 and carried staphylococcal cassette chromosome mec IVl and the genes of toxic shock syndrome toxin-1, enterotoxin C, and enterotoxin L. These characteristics indicated a CA-MRSA/J clone. This is the first reported case of PVE caused by CA-MRSA/J.
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Affiliation(s)
- Hiroki Kitagawa
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Japan
| | - Hiroki Ohge
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Japan
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Junzo Hisatsune
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Japan
- Department of Bacteriology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Toshiki Kajihara
- Department of Infectious Diseases, Hiroshima University Hospital, Japan
| | - Keijiro Katayama
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Shinya Takahashi
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Taijiro Sueda
- Department of Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
| | - Motoyuki Sugai
- Project Research Center for Nosocomial Infectious Diseases, Hiroshima University, Japan
- Department of Bacteriology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan
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Hirose M, Aung MS, Fukuda A, Murata Y, Saitoh M, Kobayashi N. Prevalence and Genetic Characteristics of Methicillin-Resistant Staphylococcus aureus and Coagulase-Negative Staphylococci Isolated from Oral Cavity of Healthy Children in Japan. Microb Drug Resist 2019; 25:400-407. [PMID: 30694723 DOI: 10.1089/mdr.2018.0333] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Prevalence and genetic characteristics of methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci in oral cavity of healthy children were studied in Hokkaido, northern main island of Japan. From saliva of 526 children, a total of 248 staphylococcal isolates comprising S. aureus (n = 143), S. epidermidis (n = 84), S. warneri (n = 13), S. haemolyticus (n = 5), S. hominis (n = 2), and S. intermedius (n = 1) were recovered. Presence of mecA was confirmed in 6.3% of S. aureus, 50% of S. epidermidis, and 7.7% in S. warneri. SCCmec was mostly classified into type IV, and ACME (arginine catabolic mobile element)-arcA was detected in S. epidermidis (23.8%) and S. intermedius. Nine MRSA isolates belonged to staphylocoagulase gene (coa) type Ia, IIa, IIIa, VIIb/sequence type 1 (ST1), ST5, ST8, ST89, ST120, and were negative for PVL (Panton-Valentine leukocidin) genes. These isolates included two clones of emerging community-acquired MRSA (CA-MRSA) that had been described recently in Japan: ST5/SCCmec IVc, which resembles the "Pediatric clone," and ST8/SCCmec IVl belonging to coa-IIIa/agr-I with sasL gene, designated "CA-MRSA/J" clone. Various enterotoxin genes were found in all the MRSA and some methicillin-susceptible S. aureus (MSSA) isolates examined, while tst-1 was detected in four MRSA isolates. Notably, a variant of elastin-binding protein gene (ebpS-v) was identified in ST120 MRSA and ST45 MSSA isolates, and exfoliative toxin D gene (etd) was detected in an MSSA isolate. The present study revealed the presence of MRSA, including the novel CA-MRSA clones, and high prevalence of methicillin-resistant S. epidermidis in oral cavity of healthy children in Japan.
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Affiliation(s)
- Mina Hirose
- 1 Division of Pediatric Dentistry, Department of Oral Growth and Development, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan
| | - Meiji Soe Aung
- 2 Department of Hygiene, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Atsushi Fukuda
- 1 Division of Pediatric Dentistry, Department of Oral Growth and Development, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan
| | - Yukie Murata
- 1 Division of Pediatric Dentistry, Department of Oral Growth and Development, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan
| | - Masato Saitoh
- 1 Division of Pediatric Dentistry, Department of Oral Growth and Development, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan
| | - Nobumichi Kobayashi
- 2 Department of Hygiene, Sapporo Medical University School of Medicine, Sapporo, Japan
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Sohail M, Latif Z. Molecular analysis, biofilm formation, and susceptibility of methicillin-resistant Staphylococcus aureus strains causing community- and health care-associated infections in central venous catheters. Rev Soc Bras Med Trop 2018; 51:603-609. [PMID: 30304265 DOI: 10.1590/0037-8682-0373-2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 07/18/2018] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The behavior of methicillin-resistant Staphylococcus aureus (MRSA) isolated from central venous catheter-related infection was evaluated to determine its biofilm potential, antimicrobial resistance, and adhesion genes. METHODS A total of 1,156 central venous catheters (CVC) were evaluated to screen for pathogens. Antimicrobial sensitivity, biofilm formation potential, and molecular analysis of MRSA were examined following standard guidelines. RESULTS Of the 1,156 samples, 882 (76%) were colonized by bacteria or candida. Among the infected patients, 69% were male and 36% were female with median age of 32 years. Staphylococcus aureus infected 39% (344/882) of CVCs in patients. Of the 59% (208/344) of patients with MRSA, 57% had community acquired MRSA and 43% had hospital acquired MRSA. Linezolid and vancomycin killed 100% of MRSA; resistance levels to fusidic acid, doxycycline, clindamycin, azithromycin, amikacin, trimethoprim-sulfamethoxazole, gentamycin, tobramycin, and ofloxacin were 21%, 42%, 66%, 68%, 72%, 85%, 95%, 97%, and 98% respectively. Strong biofilm was produced by 23% of samples, moderate by 27%, and weak by 50% of MRSA. The presence of adhesion genes, sdrC and sdrD (90%), eno (87%), fnbA (80%), clfA and sdrE (67%), fnbB, sdrD (61%), and cna (51%), in most MRSA samples suggested that the adhesion genes are associated with biofilm synthesis. CONCLUSIONS The superbug MRSA is a major cause of CVC-related infection. Antibiotic resistance to major classes of antibiotics and biofilm formation potential enhanced superbug MRSA virulence, leading to complicated infection. MRSA causes infection in hospitals, communities, and livestock.
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Affiliation(s)
- Muhammad Sohail
- Department of Microbiology and Molecular Genetics, Quaid-e-Azam Campus, University of the Punjab, Lahore, Pakistan
| | - Zakia Latif
- Department of Microbiology and Molecular Genetics, Quaid-e-Azam Campus, University of the Punjab, Lahore, Pakistan
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Kato H, Ide K, Fukase F, Shimura Y, Yasuda S, Goto H, Fukuyama A, Nakajima H. Polymerase chain reaction-based open reading frame typing (POT) method analysis for a methicillin-resistant Staphylococcus aureus (MRSA) outbreak through breast-feeding in the neonatal intensive care unit. IDCases 2018; 12:1-3. [PMID: 29942739 PMCID: PMC6010953 DOI: 10.1016/j.idcr.2018.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 02/16/2018] [Accepted: 02/16/2018] [Indexed: 11/04/2022] Open
Abstract
Introduction The route of methicillin-resistant Staphylococcus aureus (MRSA) transmission in the neonatal intensive care unit (NICU) is not clearly explained. We investigate an MRSA outbreak involving five babies in the NICU. The molecular investigation using polymerase chain reaction-based open reading frame typing (POT) method was performed. Presentation of outbreak A MRSA outbreak occurred in a six-bed NICU affecting 5 babies. Within 13 days of the emergence of index case, all five babies including triplets and other two babies were found to colonize MRSA by the active surveillance culture. Environmental surveillance cultures revealed that the preserved breast milk provided by the triplets' mother was the only item in the NICU that was positive for MRSA. The mother had a bite wound on the nipples, and the breast milk was not pasteurized. The POT method revealed that MRSA strains detected from the triplets, the breast milk, and the other baby who was fed the triplets' mother's milk were genetically identical (POT index: 106-247-33). The all strains of MRSA carried Staphylococcal cassette chromosome mec (SCCmec) IV and had good susceptibility for the non-ß-lactam antimicrobial agents, suggesting the strains were community-acquired MRSA. Conclusions The mother’s milk contaminated with community-origin MRSA is serving as the reservoir of MRSA and one of the sources of MRSA outbreaks in the NICU. It is important to closely monitor the condition of the mothers of the children in the NICU. Pasteurization of breast milk should be considered when the skin on the nipple is broken.
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Affiliation(s)
- Hideaki Kato
- Infection Control Team, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan.,Infection Prevention and Control Department, Yokohama City University Hospital, 3-9, Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan.,Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
| | - Kazuo Ide
- Infection Control Team, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan
| | - Fumie Fukase
- Infection Control Team, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan
| | - Yukihiro Shimura
- Infection Control Team, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan
| | - Shuhei Yasuda
- Infection Control Team, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan
| | - Hideto Goto
- Infection Control Team, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan
| | - Ayako Fukuyama
- Department of Pediatrics, National Hospital Organization Yokohama Medical Center, 3-60-2, Harajuku, Totsuka-ku, Yokohama, 245-8575, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, 3-9, Fukuura, Kanazawa-ku, Yokohama, 236-0004, Japan
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11
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Nakaminami H, Takadama S, Ito A, Hasegawa M, Jono C, Noguchi M, Shoshi M, Wajima T, Fujii T, Maruyama H, Sakamoto H, Ito Y, Okamoto S, Masaki Y, Tsuchiya K, Nishinarita S, Noguchi N. Characterization of SCC mec type IV methicillin-resistant Staphylococcus aureus clones increased in Japanese hospitals. J Med Microbiol 2018; 67:769-774. [PMID: 29676727 DOI: 10.1099/jmm.0.000735] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Recently, the prevalence of staphylococcal cassette chromosome mec (SCCmec) type IV isolates, which are the major community-acquired methicillin-resistant Staphylococcus aureus (MRSA), have increased in Japanese hospitals. The aim of this study was to elucidate the detailed molecular epidemiological features of the SCCmec type IV clones in Japanese hospitals. When 2589 MRSA isolated from four hospitals in Tokyo, Japan between 2010 and 2014 were analysed, the proportion of SCCmec type IV overtook that of type II, which was the major type of hospital-acquired MRSA in 2014. Multilocus sequence typing showed that CC1 was the most predominant clone in the SCCmec type IV isolates. The clinical departments that the patients belonged to, pulsed-field gel electrophoresis analysis and antimicrobial susceptibility profiles suggested that the origin of the CC1-SCCmec type IV (CC1-IV) clone was a community setting. Our data show that the CC1-IV clone is becoming a predominant MRSA clone in Japanese hospitals.
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Affiliation(s)
- Hidemasa Nakaminami
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Shunsuke Takadama
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Ayumu Ito
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Mariko Hasegawa
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Chika Jono
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Miyuki Noguchi
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Manami Shoshi
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Takeaki Wajima
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
| | - Takeshi Fujii
- Department of Infectious Diseases, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998, Japan
| | - Hiroshi Maruyama
- Department of Surgery, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo 206-8512, Japan
| | - Haruo Sakamoto
- Department of Oral Surgery, Tokai University Hachioji Hospital, 1838 Ishikawa, Hachioji, Tokyo 192-0032, Japan
| | - Yutaka Ito
- Department of Digestive Surgery, National Hospital Organization Disaster Medical Center, 3256 Midori, Tachikawa, Tokyo 190-0014, Japan
| | - Satsuki Okamoto
- Department of Pediatrics, Fussa Hospital, 1-6-1 Kamidaira, Fussa, Tokyo 197-8511, Japan
| | - Yukiyoshi Masaki
- Department of Surgery, Ome Municipal General Hospital, 4-16-5 Higashiome, Ome, Tokyo 198-0042, Japan
| | - Kayoko Tsuchiya
- Department of Respiratory Medicine, Tachikawa Sogo Hospital, 1-16-15 Nishiki, Tachikawa, Tokyo 190-8578, Japan
| | - Susumu Nishinarita
- Department of Internal Medicine, Akiru Municipal Medical Center, 78-1 Hikita, Akiruno, Tokyo 197-0834, Japan
| | - Norihisa Noguchi
- Department of Microbiology, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, 1432-1 Horinouchi, Hachioji, Tokyo 192-0392, Japan
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12
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Maeda N, Hagiya H, Takiuchi T, Kusakabe S, Maeda T, Kimura K, Iwai S, Kawasaki K, Hori Y, Morii E, Kanakura Y, Kimura T, Tomono K. Persistent methicillin-resistant Staphylococcus aureus bacteremia owing to placental abscess. J Infect Chemother 2018; 24:975-979. [PMID: 29804839 DOI: 10.1016/j.jiac.2018.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/05/2018] [Accepted: 05/01/2018] [Indexed: 10/16/2022]
Abstract
Staphylococcus aureus as a pathogen in human gestational membranes, a rather rare phenomenon, has recently been the focus of several researches. S. aureus forms biofilms on these membranes and potentially causes chorioamnionitis in pregnant women. We report a case of persistent methicillin-resistant S. aureus (MRSA) bacteremia owing to placental infection, causing chorioamnionitis and preterm birth. A 29-year-old Japanese woman at the 27th gestational week was diagnosed with acute promyelocytic leukemia and underwent all-trans retinoic acid therapy. Soon after hospitalization, the patient presented with persistent MRSA bacteremia of unknown origin. Despite various antimicrobial therapies, she experienced 12 MRSA bacteremia episodes over 6 weeks. However, after child birth, MRSA bacteremia disappeared without any complications. A pathologic examination of her placenta revealed placenta abscess, resulting in a diagnosis of MRSA-associated chorioamnionitis. Molecular analysis proved that a single MRSA strain (SCCmec Type IVa), which tested negative for Panton-Valentine leukocidin and toxic shock syndrome toxin-1, caused the obstinate infection. We should be aware that persistent MRSA bacteremia in pregnant women can originate from placental abscess.
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Affiliation(s)
- Naomi Maeda
- Division of Infection Control and Prevention, Osaka University Hospital, Japan
| | - Hideharu Hagiya
- Division of Infection Control and Prevention, Osaka University Hospital, Japan.
| | - Tsuyoshi Takiuchi
- Department of Obstetrics and Gynecology, Osaka University Hospital, Japan
| | | | - Tetsuo Maeda
- Department of Hematology, Osaka University Hospital, Japan
| | - Keigo Kimura
- Laboratory for Clinical Investigation, Osaka University Hospital, Japan
| | - Sayuri Iwai
- Department of Obstetrics and Gynecology, Osaka University Hospital, Japan
| | | | - Yumiko Hori
- Department of Pathology, Osaka University Hospital, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Hospital, Japan
| | | | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Hospital, Japan
| | - Kazunori Tomono
- Division of Infection Control and Prevention, Osaka University Hospital, Japan
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13
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A Colonization Outbreak of Penicillin-Susceptible mecA-Positive Staphylococcus aureus in a Neonatal Ward of Children’s Hospital. Infect Control Hosp Epidemiol 2018; 39:239-241. [DOI: 10.1017/ice.2017.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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14
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Cho SY, Chung DR. Infection Prevention Strategy in Hospitals in the Era of Community-Associated Methicillin-Resistant Staphylococcus aureus in the Asia-Pacific Region: A Review. Clin Infect Dis 2018; 64:S82-S90. [PMID: 28475795 DOI: 10.1093/cid/cix133] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as an important cause of healthcare-associated infection. CA-MRSA clones have replaced classic hospital MRSA clones in many countries and have shown higher potential in transmission and virulence than hospital MRSA clones. In particular, the emergence of CA-MRSA in the Asia-Pacific region is concerning owing to insufficient infection control measures in the region. The old strategies for infection prevention and control of MRSA comprised adherence to standard precaution and policy of active screening of MRSA carriers and decolonization, and it has been controversial which strategy is better in terms of outcome and cost-effectiveness. Epidemiological changes in MRSA has made the development of infection prevention strategy more complicated. Based on the literature review and the questionnaire survey, we considered infection prevention strategies for healthcare settings in the Asia-Pacific region in the era of CA-MRSA.
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Affiliation(s)
- Sun Young Cho
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, and.,Center for Infection Prevention and Control, Samsung Medical Center, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, and.,Center for Infection Prevention and Control, Samsung Medical Center, Seoul, Republic of Korea
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15
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Kale P, Dhawan B. The changing face of community-acquired methicillin-resistant Staphylococcus aureus. Indian J Med Microbiol 2017; 34:275-85. [PMID: 27514947 DOI: 10.4103/0255-0857.188313] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of infection, both in hospitalised patients with significant healthcare exposure and in patients without healthcare risk factors. Community-acquired methicillin-resistant S. aureus (CA-MRSA) are known for their rapid community transmission and propensity to cause aggressive skin and soft tissue infections and community-acquired pneumonia. The distinction between the healthcare-associated (HA)-MRSA and CA-MRSA is gradually fading owing to the acquisition of multiple virulence factors and genetic elements. The movement of CA-MRSA strains into the nosocomial setting limits the utility of using clinical risk factors alone to designate community or HA status. Identification of unique genetic characteristics and genotyping are valuable tools for MRSA epidemiological studies. Although the optimum pharmacotherapy for CA-MRSA infections has not been determined, many CA-MRSA strains remain broadly susceptible to several non-β-lactam antibacterial agents. This review aimed at illuminating the characteristic features of CA-MRSA, virulence factors, changing clinical settings and molecular epidemiology, insurgence into the hospital settings and therapy with drug resistance.
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Affiliation(s)
- P Kale
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - B Dhawan
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
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16
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Mitsumoto-Kaseida F, Murata M, Toyoda K, Morokuma Y, Kiyosuke M, Kang D, Furusyo N. Clinical and pathogenic features of SCCmec type II and IV methicillin-resistant Staphylococcus aureus in Japan. J Infect Chemother 2017; 23:90-95. [DOI: 10.1016/j.jiac.2016.11.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/23/2016] [Accepted: 11/01/2016] [Indexed: 10/20/2022]
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17
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Lamanna O, Bongiorno D, Bertoncello L, Grandesso S, Mazzucato S, Pozzan GB, Cutrone M, Chirico M, Baesso F, Brugnaro P, Cafiso V, Stefani S, Campanile F. Rapid containment of nosocomial transmission of a rare community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) clone, responsible for the Staphylococcal Scalded Skin Syndrome (SSSS). Ital J Pediatr 2017; 43:5. [PMID: 28061866 PMCID: PMC5217574 DOI: 10.1186/s13052-016-0323-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/21/2016] [Indexed: 12/04/2022] Open
Abstract
Background The aims of this study were to identify the source and the transmission pathway for a Staphylococcal Scalded Skin Syndrome (SSSS) outbreak in a maternity setting in Italy over 2 months, during 2014; to implement appropriate control measures in order to prevent the epidemic spread within the maternity ward; and to identify the Methicillin-Resistant Staphylococcus aureus (MRSA) epidemic clone. Methods Epidemiological and microbiological investigations, based on phenotyping and genotyping methods, were performed. All neonates involved in the outbreak underwent clinical and microbiological investigations to detect the cause of illness. Parents and healthcare workers were screened for Staphylococcus aureus to identify asymptomatic carriers. Results The SSSS outbreak was due to the cross-transmission of a rare clone of ST5-CA-MRSA-SCCmecV-spa type t311, exfoliative toxin A-producer, isolated from three neonates, one mother (from her nose and from dermatological lesions due to pre-existing hand eczema) and from a nurse (colonized in her nose by this microorganism). The epidemiological and microbiological investigation confirmed these as two potential carriers. Conclusions A rapid containment of these infections was obtained only after implementation of robust swabbing of mothers and healthcare workers. The use of molecular methodologies for typing was able to identify all carriers and to trace the transmission.
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Affiliation(s)
| | - Dafne Bongiorno
- MMARLab - Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | | | | | | | | | | | | | | | | | - Viviana Cafiso
- MMARLab - Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Stefania Stefani
- MMARLab - Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Via Santa Sofia 97, 95123, Catania, Italy
| | - Floriana Campanile
- MMARLab - Department of Biomedical and Biotechnological Sciences (BIOMETEC), University of Catania, Via Santa Sofia 97, 95123, Catania, Italy.
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18
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Huh K, Chung DR. Changing epidemiology of community-associated methicillin-resistant Staphylococcus aureus in the Asia-Pacific region. Expert Rev Anti Infect Ther 2016; 14:1007-1022. [PMID: 27645549 DOI: 10.1080/14787210.2016.1236684] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become an important threat to public health in the Asia-Pacific region, which is characterized by a large population and relatively insufficient resources. Better understanding on the current status of CA-MRSA in the region is of paramount importance. Areas covered: This article reviews the published literatures on the prevalence, molecular epidemiology, colonization, and hospital spread of CA-MRSA. Expert commentary: The burden of CA-MRSA has been increasing in the past two decades. The molecular epidemiology of CA-MRSA in the Asia-Pacific region shows a marked diversity in each country. Still, some strains - multilocus sequence type (MLST) ST59, ST30, ST72, ST8, and ST772 - are unique clones that have successfully established themselves as predominant, often spreading into nosocomial settings. More coordinated and comprehensive surveillance to understand the true epidemiology of CA-MRSA in the Asia-Pacific region is urgently needed.
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Affiliation(s)
- Kyungmin Huh
- a Division of Infectious Diseases, Department of Internal Medicine , Armed Forces Capital Hospital , Seongnam , Korea
| | - Doo Ryeon Chung
- b Division of Infectious Diseases, Department of Internal Medicine, Samsung Medical Center , Sungkyunkwan University School of Medicine , Seoul , Korea
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