Community-acquired methicillin-resistant Staphylococcus aureus colonization in healthy children attending an outpatient pediatric clinic

Antibiotic resistance pattern of Staphylococcus aureus with reference to MRSA isolates from pediatric patients

Aim:

The extent of methicillin-resistant Staphylococcus aureus (MRSA) infection in Nepalese children is largely unknown.

Materials & methods:

Six hundred and seventy-two clinical samples collected from 232 patients between June and November 2016 were processed in a microbiology laboratory.

Results:

Out of 300 culture-positive samples, 52 (17.3%) were S. aureus isolates. Among those 52, 39 (75.0%) were found to be MRSA. The infection rate of S. aureus was shown to be higher in inpatients (55.7%) compared with outpatients (44.3%) at p = 0.637, 95% CI. Thirteen types of antibiotics were used in the antibiotic susceptibility test. MRSA isolates showed 100 and 0% resistance to penicillin and vancomycin, respectively. The D-test showed inducible clindamycin-resistant phenotype in 15.4% of MRSA isolates.

Conclusion:

This demonstrates the utmost need for routine testing for MRSA in Nepalese hospitals.

The problem of antibiotic resistance is rising worldwide. Methicillin antibiotic-resistant Staphylococcus aureus (i.e., MRSA) infection is one of the bacterial infections that contribute to increased health and economic burdens. An accurate understanding of the MRSA infection status in Nepalese children is not available to date. Thus, the current research was performed in a pediatric hospital. We also discovered that MRSA is not tested routinely and thus we recommend it should be monitored regularly, as with other bacterial infections.

Screening of nasal carriage of methicillin-resistant Staphylococcus aureus during admission of patients to Frantz Fanon Hospital, Blida, Algeria

A study was performed of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) strains isolated from nasal preoperative samples. Of 663 samples assessed, staphylococcus was detected in 143 (21.57%). The disc diffusion method (cefoxitin 30 μg), a screening test (oxacillin 6 μg/mL) and a search for Protein Binding Additional Penicillin 2 (PLP2a) allowed the detection and confirmation of resistance to methicillin for 36 strains, a rate of 5.43% of the total population studied. Eight MRSA carriers received care in the trauma service, 14 in cardiology, five in ear, nose and throat, four in neurosurgery and paediatrics, and one in SCI. Thirty-six methicillin-resistant of the nasal portage strains are in their great majority, 27 of 36, rather limited multi-R character (two to three families namely resistance: tetracyclines, fluoroquinolones, aminoglycosides, macrolides). One of the MRSA strains was found to have intermediate sensitivity to vancomycin.

Assessing the potential for raw meat to influence human colonization with Staphylococcus aureus

The role of household meat handling and consumption in the transfer of Staphylococcus aureus (S. aureus) from livestock to consumers is not well understood. Examining the similarity of S. aureus colonizing humans and S. aureus in meat from the stores in which those individuals shop can provide insight into the role of meat in human S. aureus colonization. S. aureus isolates were collected from individuals in rural and urban communities in Iowa (n = 3347) and contemporaneously from meat products in stores where participants report purchasing meat (n = 913). The staphylococcal protein A (spa) gene was sequenced for all isolates to determine a spa type. Morisita indices and Permutational Multivariate Analysis of Variance Using Distance Matrices (PERMANOVA) were used to determine the relationship between spa type composition among human samples and meat samples. spa type composition was significantly different between households and meat sampled from their associated grocery stores. spa types found in meat were not significantly different regardless of the store or county in which they were sampled. spa types in people also exhibit high similarity regardless of residential location in urban or rural counties. Such findings suggest meat is not an important source of S. aureus colonization in shoppers.

Risk of Skin and Soft Tissue Infections among Children Found to be Staphylococcus aureus MRSA USA300 Carriers

Introduction

The purpose of this study was to examine community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) carriage and infections and determine risk factors associated specifically with MRSA USA300.

Methods

We conducted a case control study in a pediatric emergency department. Nasal and axillary swabs were collected, and participants were interviewed for risk factors. The primary outcome was the proportion of S. aureus carriers among those presenting with and without a skin and soft tissue infection (SSTI). We further categorized S. aureus carriers into MRSA USA300 carriers or non-MRSA USA300 carriers.

Results

We found the MRSA USA300 carriage rate was higher in children less than two years of age, those with an SSTI, children with recent antibiotic use, and those with a family history of SSTI. MRSA USA300 carriers were also more likely to have lower income compared to non-MRSA USA300 carriers and no S. aureus carriers. Rates of Panton-Valentine leukocidin (PVL) genes were higher in MRSA carriage isolates with an SSTI, compared to MRSA carriage isolates of patients without an SSTI. There was an association between MRSA USA300 carriage and presence of PVL in those diagnosed with an abscess.

Conclusion

Children younger than two years were at highest risk for MRSA USA300 carriage. Lower income, recent antibiotic use, and previous or family history of SSTI were risk factors for MRSA USA300 carriage. There is a high association between MRSA USA300 nasal/axillary carriage and presence of PVL in those with abscesses.

Management of Outbreaks of Methicillin-ResistantStaphylococcus aureusInfection in the Neonatal Intensive Care Unit: A Consensus Statement

Objective.

In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistantStaphylococcus aureus(MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation.

Design.

Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices.

Setting.

Level III NICUs at Chicago-area hospitals.

Participants.

Neonates and healthcare workers associated with the level III NICUs.

Methods.

From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS.

Results.

Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs.

Conclusion.

The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.

Nasal Carriage and Resistance Pattern of Multidrug Resistant Staphylococcus aureus Among Healthy Children in Kashan, Iran

Background:

Nasal carriage of Staphylococcus aureus is a substantial source of human infections. Detection and treatment of nasal carriage in children with methicillin-resistant and multidrug resistant S. aureus (MRSA and MDRSA, respectively) may be an important modality in prevention of infections.

Objectives:

This study determined the prevalence, antibiotic resistance patterns and risk factors for nasal carriage of MDRSA among healthy children.

Patients and Methods:

This cross-sectional study was carried out on 350 one-month to 14-year-old healthy children in Kashan city, Iran. From all health-care centers, four were chosen by simple random sampling. Nasal samples were cultured in blood agar medium for S. aureus and antibiotic susceptibility profile was determined by disc diffusion and E-test. Risk factors for nasal carriage of MDRSA were also determined.

Results:

A total of 92 (26.3%) S. aureus isolates were obtained, of which 33 (35.9%) were MRSA and 27 (29.3%) were MDRSA. Of MRSA strains, 19 (70.4%) were MDRSA. S. aureus isolates showed 52.2% resistance to cephalothin, 33.7% to co-trimoxazole, 26.1% to clindamycin, 26.1% to ciprofloxacin, 4.3% to vancomycin, and 35.9% to oxacillin. The risk factors for nasal carriage of MDRSA were antibiotic usage during the last three months (P = 0.006), family size of more than four members (P = 0.044), and parental smoking (P = 0.045).

Conclusions:

MDRSA was not uncommon among healthy children in Kashan and prevention of its spread in the population is judicious.

Molecular epidemiology of nasal isolates of methicillin-resistant Staphylococcus aureus from Jordan

Asymptomatic carriage of methicillin-resistant Staphylococcus aureus (MRSA) can predispose the host to a wide range of infections. To inform public health strategies, this study sought to determine the prevalence and the phenotypic and genotypic characteristics of MRSA from nasal swabs of health care workers (HCWs) and other healthy individuals in Jordan. Overall, 716 nasal swabs were collected from 297 HCWs, 141 adults and 278 children in the community. MRSA was recovered from 56 (7.8%) nasal swabs, which represented carriage rates of 10.1%, 4.3% and 7.2% among HCWs, adults and children, respectively. The MRSA isolates were resistant to oxacillin (100%), erythromycin (42.8%), tetracycline (37.5%), clindamycin (5.3%), fucidin (5.3%), and ciprofloxacin (3.5%). A total of 17 different spa types belonging to eight different clonal complexes (CCs) were identified. All isolates were mecA positive, and mecC-MRSA was not detected. Analysis of the staphylococcal cassette chromosome mec (SCCmec) elements revealed that the majority (54; 96.4%) of the samples harbored the smaller type IV and V elements (the most common were SCCmec IVa or IVc, and there were two each of the IVg and V elements), and two were nontypable. The genes for Panton-Valentine leukocidin (luk-PV) were detected in 5.4% of the study isolates. A tst-positive, CC22-MRSA-SCCmecIVa clone (spa type t223) was identified as the dominant MRSA lineage among the nasal carriage isolates from both HCWs and other individuals (adults and children) in the community. These findings provide important information for public health personnel for the formulation of effective infection prevention and control strategies. Studies to further our understanding of the distribution, pathogenicity, transmissibility and fitness of this lineage would be prudent.

Atopic dermatitis

Atopic dermatitis (AD) is a common chronic inflammatory skin condition characterized by intense pruritus and a waxing and waning course. AD often presents in infancy and childhood and can persist throughout adulthood. The exact cause of AD is unknown, but it likely reflects an interplay between genetic and environmental factors. AD affects up to 20% of children in the United States, and prevalence may be increasing. Treatment can be effective in alleviating symptoms but serves only to manage the disease, not cure it. Appropriate therapy can also prevent significant complications, such as infection, sleep disturbance, behavioral problems, and growth impairment.

MRSA nasal colonization in children: prevalence meta-analysis, review of risk factors and molecular genetics

BACKGROUND

We report a meta-analysis of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization prevalence in children and a review of the risk factors as well as molecular genetic characterization.

METHODS

All relevant studies reporting prevalence data on MRSA nasal colonization in children published between January 2000 and August 2010 were retrieved from the MEDLINE database and analyzed.

RESULTS

After screening 544 studies, 50 studies were included. We obtained an estimate of MRSA prevalence of 2.7% (95% confidence interval [CI]: 2.2-3.1); of 5.2% (95% CI: 3.1-7.3) in children with underlying conditions and of 2.3% (95% CI: 1.8-2.7) in healthy children; 5.4% (95% CI: 3.1-7.7) in children recruited in hospitals and 3% (95% CI: 2.4-3.6) in children recruited in the community. Staphylococcal cassette chromosome mec type IV is the most diffused cassette globally.

CONCLUSION

The hospital remains the environment where the microorganism circulates most. Children with underlying conditions could act as vectors of microorganisms between the hospital and the community. MRSA prevention strategies should be tailored to each specific institution, taking into account the nosocomial prevalence of MRSA nasal colonization and infections, and the prevalence of nasal colonization in the community that refers to the specific health care center.

A serologic correlate of protective immunity against community-onset Staphylococcus aureus infection

BACKGROUND

Staphylococcus aureus is among the leading causes of human infection. Widespread drug resistance, emergence of highly virulent strains, and the ability of S. aureus to colonize >30% of the human population contribute to this organism's pathogenic success. Human serologic responses to S. aureus and their relationship to protective immunity remain incompletely defined, challenging the strategic development of efficacious vaccines.

METHODS

We measured humoral responses to 2 staphylococcal exotoxins, α-hemolysin (Hla) and Panton-Valentine leukocidin (PVL; LukF-PV/LukS-PV subunits), both premier targets of current vaccine and immunotherapy development. We correlated acute and convalescent serum antibody levels with incidence of recurrent infection over 12 months follow-up in 235 children with S. aureus colonization, primary or recurrent skin and soft tissue infection, or invasive disease.

RESULTS

Cutaneous infection elicited transient increases in anti-Hla and anti-PVL antibodies; however, subsequent infection risk was similar between primary and recurrent cutaneous infection cohorts. Patients with invasive infections had the lowest preexisting titers against Hla and LukF but displayed the highest convalescent titers. Across cohorts, convalescent anti-Hla titers correlated with protection against subsequent S. aureus infection.

CONCLUSIONS

Cutaneous S. aureus infection does not reliably provoke durable, protective immune responses. This study provides the first link between protection from disease recurrence and the humoral response to Hla, a virulence factor already implicated in disease pathogenesis. These observations can be utilized to refine ongoing vaccine and immunotherapy efforts and inform the design of clinical trials.

Changing epidemiology of methicillin-resistant Staphylococcus aureus colonization in paediatric intensive-care units

Community-associated methicillin-resistant S. aureus (CA-MRSA) accounts for a growing proportion of hospital-onset infections, and colonization is a risk factor. This study aimed to determine changes in the prevalence of CA-MRSA colonization in paediatric intensive-care units (ICUs). A total of 495 paediatric patients colonized with MRSA from neonatal, medical, surgical, and cardiac ICUs between 2001 and 2009 were identified. Isolates were characterized by spa type, staphylococcal cassette chromosome (SCC) mec type and the presence of the genes encoding Panton–Valentine leukocidin (PVL). The proportion of patients colonized with MRSA remained stable (average 3·2%). The proportion of isolates with spa type 1, SCCmec type IV and PVL increased over time to maximums in 2009 of 36·1% (P < 0·001), 54·2% (P = 0·03) and 28·9% (P = 0·003), respectively. Antibiotic susceptibility patterns showed increasing proportions susceptible to clindamycin, gentamicin, tetracycline and trimethoprim-sulfamethoxazole (P values <0·001). In conclusion, the proportion of MRSA-colonized children in ICUs with CA-MRSA increased significantly over time.

Genetic structure of community acquired methicillin-resistant Staphylococcus aureus USA300

Background

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a significant bacterial pathogen that poses considerable clinical and public health challenges. The majority of the CA-MRSA disease burden consists of skin and soft tissue infections (SSTI) not associated with significant morbidity; however, CA-MRSA also causes severe, invasive infections resulting in significant morbidity and mortality. The broad range of disease severity may be influenced by bacterial genetic variation.

Results

We sequenced the complete genomes of 36 CA-MRSA clinical isolates from the predominant North American community acquired clonal type USA300 (18 SSTI and 18 severe infection-associated isolates). While all 36 isolates shared remarkable genetic similarity, we found greater overall time-dependent sequence diversity among SSTI isolates. In addition, pathway analysis of non-synonymous variations revealed increased sequence diversity in the putative virulence genes of SSTI isolates.

Conclusions

Here we report the first whole genome survey of diverse clinical isolates of the USA300 lineage and describe the evolution of the pathogen over time within a defined geographic area. The results demonstrate the close relatedness of clinically independent CA-MRSA isolates, which carry implications for understanding CA-MRSA epidemiology and combating its spread.

Population-based study of the increased incidence of skin and soft tissue infections and associated antimicrobial use

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has spread rapidly throughout the world in the last decade. We sought to demonstrate the impact of the emergence of CA-MRSA in Western Canada on physician visits, incision-and-drainage procedures, and antibiotic prescribing for skin and soft tissue infections (SSTI). We used the provincial physician billing system to determine the rate of physician visits (per 1,000 population per year) of SSTI and incision-and-drainage procedures. A database capturing all outpatient prescriptions in the province was anonymously linked to associated physician billing codes to quantify prescriptions associated with SSTI. Antibiotic prescriptions (overall and class specific) were expressed as their defined daily dose (DDD) per 1,000 inhabitants per day. Between 1996 and 2008, the rate of visits for all SSTI increased by 15%, and the majority of visits did not include an incision-and-drainage procedure. The rate of antibiotic prescribing for SSTI increased by 49%. The majority of this increase was attributable to the higher rates of use of clindamycin (627%), trimethoprim-sulfamethoxazole (380%), cephalosporins (160%), and amoxicillin-clavulanate (627%). Health care utilization and antibiotic prescribing rates for SSTI, but not incision-and-drainage procedures, have increased in association with the CA-MRSA epidemic. While much of the increase in antibiotic use reflects an appropriate change to trimethoprim-sulfamethoxazole, there is room for education regarding the limitations of cephalosporins and clindamycin, given current susceptibility profiles.

Emergence of resistance to antibacterial agents: the role of quaternary ammonium compounds--a critical review

Quaternary ammonium compounds (QACs) are widely distributed in hospitals, industry and cosmetics. Little attention has been focused on the potential impact of QACs on the emergence of antibiotic resistance in patients and the environment. To assess this issue, we conducted a literature review on QAC chemical structure, fields of application, mechanism of action, susceptibility testing, prevalence, and co- or cross-resistance to antibiotics. Special attention was paid to the effects of QACs on microflora; in particular, the issue of the potential of QACs for applying selective pressure on multiple-antibiotic-resistant organisms was raised. It was found that there is a lack of standardised procedures for interpreting susceptibility test results. QACs have different impacts on the minimum inhibitory concentrations of antibacterials depending on the antibacterial compound investigated, the resistance genes involved, the measuring methodology and the interpretative criteria. The unmet needs for adequate detection of reduced susceptibility to QACs and antibiotics include (i) a consensus definition for resistance, (ii) epidemiological cut-off values and (iii) clinical resistance breakpoints. This review advocates the design of international guidelines for QAC use.

Increased prevalence of methicillin-resistant Staphylococcus aureus nasal colonization in household contacts of children with community acquired disease

Background

To measure Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization prevalence in household contacts of children with current community associated (CA)-MRSA infections (study group) in comparison with a group of household contacts of children without suspected Staphylococcus aureus infection (a control group).

Methods

This is a cross sectional study. Cultures of the anterior nares were taken. Relatedness of isolated strains was tested using pulse field gel electrophoresis (PFGE).

Results

The prevalence of MRSA colonization in the study group was significantly higher than in the control group (18/77 (23%) vs 3/77 (3.9%); p ≤ 0.001). The prevalence of SA colonization was 28/77 (36%) in the study group and 16/77 (21%) in the control group (p = 0.032). The prevalence of SA nasal colonization among patients was 6/24 (25%); one with methicillin-susceptible S. aureus (MSSA) and 5 with MRSA. In the study (patient) group, 14/24 (58%) families had at least one household member who was colonized with MRSA compared to 2/29 (6.9%) in the control group (p = 0.001). Of 69 total isolates tested by PFGE, 40 (58%) were related to USA300. Panton-Valetine leukocidin (PVL) genes were detected in 30/52 (58%) tested isolates. Among the families with ≥1 contact colonized with MRSA, similar PFGE profiles were found between the index patient and a contact in 10/14 families.

Conclusions

Prevalence of asymptomatic nasal carriage of MRSA is higher among household contacts of patients with CA-MRSA disease than control group. Decolonizing such carriers may help prevent recurrent CA-MRSA infections.

Methicillin-resistant Staphylococcus aureus colonization in schoolteachers in Ontario

A prospective study of methicillin-resistant Staphylococcus aureus (MRSA) colonization was performed involving teachers at a science teachers' conference in Toronto, Ontario. Nasal swabs and questionnaire data were collected from consenting individuals. MRSA colonization was identified in seven of 220 (3.2%) participants. No colonized individuals reported recent contact with the health care system, antimicrobial therapy, residence with health care workers or previous MRSA infections. Methicillin-susceptible S aureus colonization was identified in 72 of 220 (33%) individuals. The prevalence of MRSA colonization was higher than expected for a purportedly low-risk population.

Nasal carriage of methicillin resistant Staphylococcus aureus and their antibiotic susceptibility patterns in children attending day-care centers

Nasal colonization with community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) is being increasingly reported, especially in places where people are in close contact and in reduced hygiene, such as day-care centers. In this study we investigated the frequency of MRSA colonization and their antibiotic susceptibility patterns in 1-6 years old children of day-care centers in Hamadan, West of Iran.Five hundred nasal swabs were collected from children of 27 day-care centers that had no risk factors for colonization by S. aureus. The specimens were cultured for isolation of S. aureus by standard methods. Antimicrobial susceptibility testing was performed according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. For evaluation of the frequency of erythromycin induced clindamycin resistance, disk approximation test (D-test) was applied.Totally, 148 (29.6%) children were colonized by S. aureus. Out of 260 male, 94 (36.2%) and of 240 female, 54 (22.5%) cases were nasal carriers of S. aureus (P value = 0.001). Six (4.1%) of the 148 S. aureus isolated from children were MRSA strains. None of MRSA and methicillin susceptible S. aureus (MSSA) was resistant to vancomycin and clindamycin. Three of the 6 strains of MRSA and 7 (4.9%) of the 142 MSSA strains were resistant to erythromycin, and D-test was positive in all of them.We conclude that the rate of colonization by S. aureus is high in children attending day-care centers but colonization with MRSA is not common in our areas. Clindamycin or trimethoprim-sulfamethoxazol could be used in mild to moderataly severe diseases caused by CA-MRSA. However, if the CA-MRSA isolates are erythromycin resistant, D-test should be carried out for detection of inducible clindamycin resistance.

Prevalence and characterization of methicillin-resistant Staphylococcus aureus among healthy children in a city of Argentina

Community acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is a major global problem. Healthy carriers of S. aureus strains have an important role in the dissemination of this bacterium. The aim of this study was to estimate the prevalence of S. aureus and methicillin-resistant S. aureus (MRSA) carriage among healthy children in a city of Buenos Aires province, Argentina, and to determine the potential risk factors for its acquisition. We also described the molecular features of MRSA strains circulating in this population. S. aureus carriage was investigated in all children attending the last year of kindergarten during the 2008 school- year period. Household contacts of MRSA carriers were also screened. Of 316 healthy children, 98 (31.0%) carried S. aureus, including 14 MRSA carriers (4.4%) and 84 methicillin susceptible S. aureus (MSSA) carriers (26.6%). All MRSA isolates carried the SCCmec type IV cassette. Eight of the fourteen isolates were closely related to the clone responsible for most severe community-acquired MRSA infections caused in our country (CAA: PFGE A, SCCmec IV, spa t311, ST5). Two subtypes (A(1) and A(2)) were distinguished in this group by PFGE. Both had agr type II and presented the same virulence determinants, except for PVL coding genes and sea that were only harbored by subtype A(1). Our results, based on the analysis of MRSA isolates recovered in the screening of healthy children, provide evidence of a community reservoir of the major CA-MRSA clone described in Argentina.

Panton-Valentine leukocidin in the pathogenesis of community-associated methicillin-resistant Staphylococcus aureus infection

Methicillin-resistant Staphylococcus aureus (MRSA) is an important human pathogen that causes serious infectious diseases and was endemic in hospitals by the late 1960s. Beginning with its first report in the late 1990s, the rapid emergence of community-associated MRSA (CA-MRSA) worldwide responsible for a wide spectrum of diseases ranging from minor skin infections to fatal necrotizing pneumonia has been found in previously healthy individuals without established risk factors for MRSA acquisition. Recently, various virulence determinants unique to CA-MRSA have been uncovered, which explain how the pathogen spreads easily and causes severe CA-MRSA infections among humans. However, the role of Panton-Valentine leukocidin (PVL) in the pathogenesis of CA-MRSA infection is currently a matter of much debate because of conflicting data from epidemiologic studies of CA-MRSA infections and various murine disease models. Identifying specialized pathogenic traits of CA-MRSA and the concerted regulation of these factors remains a challenge that will foster development of vaccines and therapies designed to control CA-MRSA infections. This review focuses on the current status of molecular epidemiology associated with CA-MRSA in Taiwan and progresses toward understanding the enhanced virulence properties of CA-MRSA, with an emphasis on the role of Panton-Valentine leukocidin.

Comparative genome sequencing of an isogenic pair of USA800 clinical methicillin-resistant Staphylococcus aureus isolates obtained before and after daptomycin treatment failure

We describe here a clinical daptomycin treatment failure in a patient with recurrent methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in whom daptomycin was administered after a failed empirical treatment course with vancomycin and piperacillin-tazobactam. We had the opportunity to compare the genome sequences of an isogenic pair of daptomycin-susceptible and -resistant MRSA isolates obtained before and after initiation of daptomycin therapy, respectively. The genotype of both isolates was USA800, ST5, SCCmec type IV, agr type II. There was no increase in cell wall thickness in the daptomycin-resistant strain despite having decreased susceptibility to both vancomycin and daptomycin. By comparing the genome sequences by pyrosequencing, we identified a polymorphism (S337L) in the tenth transmembrane segment of the multiple peptide resistance factor, MprF, encoding lysyl phosphatidylglycerol transferase. This enzyme has been shown previously to promote repulsion of daptomycin at the cell surface by addition of positively charged lysine to phosphatidylglycerol. Also, the hlb open reading frame (ORF) encoding the β-toxin was interrupted by a prophage in the daptomycin-susceptible strain; this phage was missing in the daptomycin-resistant isolate and the hlb ORF was restored. Loss of the phage in the resistant isolate also resulted in loss of the virulence factor genes clpP, scn, and sak. This is the first study to use pyrosequencing to compare the genomes of a daptomycin-susceptible/resistant MRSA isolate pair obtained during failed daptomycin therapy in humans.

Changes in the nasal colonization with methicillin-resistant Staphylococcus aureus in children: 2004-2009

BACKGROUND

Staphylococcus aureus is an important cause of infection, particularly in persons colonized with this organism. This study compared the annual prevalence and microbiological characteristics of methicillin-resistant S. aureus (MRSA) nasal colonization in Taiwanese children from 2004 through 2009. Risk factors for MRSA were determined for the overall study period.

METHODS

Children from birth to ≤14 years of age presenting for health maintenance visits or attending 1 of 57 kindergartens were recruited. Nasal swabs were obtained, and a questionnaire was administered. The prevalence and microbiological characteristics of MRSA colonization were also calculated for two 3-year periods: 2004-2006 and 2007-2009.

RESULTS

Cultures of the anterior nares were positive for S. aureus in 824 (25.8%) of the 3,200 children, and MRSA colonization was found in 371 (11.6%) children. The prevalence of S. aureus colonization decreased from 28.1% in 2004-2006 to 23.3% in 2007-2009 (p<0.01), whereas the prevalence of MRSA colonization increased from 8.1% to 15.1% during this period (p<0.0001). Multivariate analysis revealed that the independent risk factors for MRSA carriage were different for male and female children, and also among age groups. Most MRSA isolates belonged to sequence type 59 (ST59) (86.3%); however, a multiresistant MRSA clone with ST338 background emerged in 2007-2009. Ten (62.5%) of the 16 MRSA isolates expressed the genotypic profile ST338/staphylococcal cassette chromosome mec V(T)/Panton-Valentine leukocidin-positive/staphylococcal enterotoxin B-positive, and differed only in their antimicrobial susceptibility patterns.

CONCLUSION

The prevalence of nasal colonization by MRSA increased among healthy Taiwanese children from 2004-2006 to 2007-2009, despite an overall decrease in the prevalence of nasal colonization by S. aureus. A multiresistant MRSA clone characterized as ST338 was identified from these children.

Prevalence and risk factor analysis for methicillin-resistant Staphylococcus aureus nasal colonization in children attending child care centers

Children attending child care centers (CCCs) are at increased risk for infections, including those caused by methicillin-resistant Staphylococcus aureus (MRSA). Nasal colonization often precedes infection, and MRSA colonization has been associated with increased infection risk. Community-associated MRSA (CA-MRSA) has caused increased MRSA infections in the general population, including children. Little is known about the frequency of MRSA nasal colonization in young children, particularly in those attending CCCs where disease transmission is common. We sampled the nares of 1,163 children in 200 classrooms from 24 CCCs in North Carolina and Virginia to assess S. aureus colonization. MRSA strains were molecularly analyzed for staphylococcal cassette chromosome mec (SCCmec) type, Panton-Valentine leukocidin status, and multilocus sequence type. A case-control study was performed to identify risk factors for MRSA colonization. We found that 18.1% children were colonized with S. aureus and 1.3% with MRSA. Molecular analysis of the MRSA strains identified 47% as CA-MRSA and 53% as health care-associated MRSA (HA-MRSA). Although two centers had multiple children colonized with MRSA, genotyping indicated that no transmission had occurred within classrooms. The case-control study did not detect statistically significant risk factors for MRSA colonization. However, MRSA-colonized children were more likely to be nonwhite and to have increased exposure to antibiotics and skin infections in the home. Both CA-MRSA and HA-MRSA strains were found colonizing the nares of children attending CCCs. The low frequency of colonization observed highlights the need for a large multicenter study to determine risk factors for MRSA colonization and subsequent infection in this highly susceptible population.

Efficacy of fosfomycin and its combination with linezolid, vancomycin and imipenem in an experimental peritonitis model caused by a Staphylococcus aureus strain with reduced susceptibility to vancomycin

The objective of this study was to evaluate the in vitro and in vivo efficacies of therapies including fosfomycin against clinical Staphylococcus aureus isolates with reduced susceptibility to vancomycin (hGISA). Time-kill curves were performed over 24 h. Peritonitis in C57BL/6 mice was induced by intraperitoneal inoculation of 10(8) CFU/ml. Four hours later (0 h), therapy was started and the treatment groups were: control (not treated), fosfomycin (100 mg/kg/5 h), vancomycin (60 mg/kg/5 h), imipenem (30 mg/kg/5 h), fosfomycin plus linezolid, fosfomycin plus vancomycin and fosfomycin plus imipenem, receiving subcutaneous therapy over 25 h. Bacterial counts in peritoneal fluid, bacteraemia and mortality rates were determined. In vitro, fosfomycin showed a synergistic effect when combined with the other antimicrobials tested. In the animal model, fosfomycin combinations were effective and significantly reduced the bacteraemia rates achieved in the control, imipenem and vancomycin groups (p < 0.05). The best combination in vivo was fosfomycin plus imipenem. Also, fosfomycin plus linezolid was significantly better than vancomycin alone, reducing the bacterial concentration in the peritoneal fluid. In conclusion, in vitro and in vivo, fosfomycin in combination with linezolid, vancomycin or imipenem exerted a good activity. Fosfomycin plus imipenem was the most active combination, decreasing 3 log CFU/ml, and appears to be a promising combination for clinical practice.

Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic

Staphylococcus aureus is an important cause of skin and soft-tissue infections (SSTIs), endovascular infections, pneumonia, septic arthritis, endocarditis, osteomyelitis, foreign-body infections, and sepsis. Methicillin-resistant S. aureus (MRSA) isolates were once confined largely to hospitals, other health care environments, and patients frequenting these facilities. Since the mid-1990s, however, there has been an explosion in the number of MRSA infections reported in populations lacking risk factors for exposure to the health care system. This increase in the incidence of MRSA infection has been associated with the recognition of new MRSA clones known as community-associated MRSA (CA-MRSA). CA-MRSA strains differ from the older, health care-associated MRSA strains; they infect a different group of patients, they cause different clinical syndromes, they differ in antimicrobial susceptibility patterns, they spread rapidly among healthy people in the community, and they frequently cause infections in health care environments as well. This review details what is known about the epidemiology of CA-MRSA strains and the clinical spectrum of infectious syndromes associated with them that ranges from a commensal state to severe, overwhelming infection. It also addresses the therapy of these infections and strategies for their prevention.

Importance of colonization site in the current epidemic of staphylococcal skin abscesses

OBJECTIVE

The goal was to compare rectal and nasal Staphylococcus aureus colonization rates and S aureus pulsed-field types (PFTs) for children with S aureus skin and soft-tissue abscesses and normal control subjects.

METHODS

Sixty consecutive children with S aureus skin and soft-tissue abscesses that required surgical drainage and 90 control subjects were enrolled. Cultures of the nares and rectum were taken in both groups. S aureus isolates from all sites were characterized through multiple-locus, variable-number, tandem-repeat analysis, pulsed-field gel electrophoresis, staphylococcal cassette chromosome mec typing for methicillin-resistant S aureus isolates, and determination of the presence of Panton-Valentine leukocidin genes.

RESULTS

S aureus was detected significantly more often in the rectum of children with abscesses (47%) compared with those in the control group (1%; P = .0001). Rates of nasal colonization with S aureus were equivalent for children with abscesses (27%) and control subjects (20%; P = .33). S aureus recovered from the rectum was identical to S aureus in the abscess in 88% of cases, compared with 75% of nasal isolates. PFT USA300, staphylococcal cassette chromosome mec type IV, and Panton-Valentine leukocidin genes were significantly increased in the S aureus isolates from children with abscesses compared with those from control subjects.

CONCLUSIONS

Skin and soft-tissue abscesses in the current epidemic of community-associated staphylococcal disease are strongly associated with rectal colonization by PFT USA300. Nasal colonization in children does not seem to be a risk factor.

Epidemiology of methicillin-susceptible Staphylococcus aureus in a university medical center day care facility

BACKGROUND

Few data are available on methicillin-susceptible Staphylococcus aureus (MSSA) colonization in day care. We performed a study in a child care center on a medical university campus to study the epidemiology of MSSA in this population.

METHODS

A cross-sectional study was done on 104 day care attendees and 32 adult employees of the child care center. Swab samples were taken from the nose, oropharynx, axilla, groin, and perirectal area of children, from the nose and oropharynx of employees, and from the environment. Parents and employees completed questionnaires. Swabs were placed in broth, then plated on agar and identified as MSSA by routine methods. Molecular typing was performed.

RESULTS

The prevalence of MSSA was 21.15% in children and 28.13% in employees. MSSA was found in 8.72% of environmental samples. Univariate analysis identified 3 risk factors and 5 protective factors for MSSA colonization. In multivariable analysis, only 2 variables remained significantly related to MSSA colonization, with older age remaining as a risk factor and receipt of beta-lactams approaching significance as being protective. Many of the isolates were indistinguishable by molecular typing.

CONCLUSIONS

The prevalence of MSSA colonization in children and care providers in a university medical center child care center is similar to that of the general population. Children colonized with MSSA tended to be older and to have received fewer courses of antibiotics than children who did not have MSSA. The relatedness of many of the isolates indicates that transmission of MSSA occurred at this child care center.

'Feral' and 'wild'-type methicillin-resistant Staphylococcus aureus in the United Kingdom

Circulation of methicillin-resistant Staphylococcus aureus (MRSA) outside hospitals could alter the impact of hospital-based control strategies. We investigated two groups of cases (each matched to controls with MRSA): 61 'community cases' not in acute hospital in the year before MRSA isolation; and 21 cases with ciprofloxacin-sensitive (CipS) MRSA. Multi-locus sequence typing, spa-typing and Panton-Valentine leukocidin gene testing were performed and demographics obtained. Additional questionnaires were completed by community case GPs. Community cases comprised 6% of Oxfordshire MRSA. Three community cases had received no regular healthcare or antibiotics: one was infected with CipS. Ninety-one percent of community cases had healthcare-associated sequence type (ST)22/36; CipS MRSA cases had heterogeneous STs but many had recent healthcare exposure. A substantial minority of UK MRSA transmission may occur outside hospitals. Hospital strains are becoming 'feral' or persisting in long-term carriers in the community with regular healthcare contacts; those with recent healthcare exposure may nevertheless acquire non-hospital epidemic MRSA strains in the community.

Epidemiology of methicillin-resistant Staphylococcus aureus in a university medical center day care facility

OBJECTIVE

Few data are available on methicillin-resistant Staphylococcus aureus (MRSA) colonization in day care. We performed a study in a medical university child care center to study the epidemiology of MRSA in this population.

DESIGN

Survey.

SETTING

A child care center on the campus of a university medical center.

METHODS

One hundred four children who attended the child care center and 32 employees gave samples that were cultured for MRSA. Seventeen household members of the children and employee found to be colonized with MRSA also gave samples that were cultured. Parents and employees completed questionnaires about demographic characteristics, medical conditions and treatments, and possible exposure risks outside the child care center. In addition, 195 environmental samples were taken from sites at the childcare center. Isolates were analyzed for relatedness by use of molecular typing, and statistical analysis was performed.

RESULTS

The prevalence of MRSA in the children was 6.7%. One employee (3.1%) was colonized with MRSA. Cultures of samples given by 6 of 17 (35.3%) family members of these children and the employee yielded MRSA. MRSA was recovered from 4 of 195 environmental samples. Molecular typing revealed that many of the MRSA isolates were indistinguishable, and 18 of the 21 isolates were community-associated MRSA. Multivariable analysis revealed that receipt of macrolide antibiotics (P = .002; odds ratio, 39.6 [95% confidence interval, 3.4-651.4]) and receipt of asthma medications (P = .024; odds ratio, 26.9 [95% confidence interval, 1.5-500.7]) were related to MRSA colonization.

CONCLUSIONS

There was a low prevalence of MRSA colonization in children and employees in the child care center but a higher prevalence of colonization in their families. Molecular typing showed that transmission of MRSA likely occurred in the child care center. The use of macrolide antibiotics and asthma medications may increase the risk of MRSA colonization in this population.

Staphylococcus aureus nasal colonization among pediatric cystic fibrosis patients and their household contacts

BACKGROUND

Little is known about the prevalence of Staphylococcus aureus nasal colonization and the epidemiology of methicillin-susceptible and methicillin-resistant S. aureus (MRSA) among cystic fibrosis (CF) patients and their household members.

OBJECTIVES

We sought to determine the epidemiology of S. aureus among children and adolescents with CF and their household members.

METHODS

Three CF centers enrolled case subjects with at least 1 MRSA-positive respiratory tract culture from 2001 to 2006 and control subjects with MRSA-negative cultures. S. aureus isolates from the anterior nares of CF subjects and their household members were assessed for staphylococcal chromosomal cassette (SCC) mec type. Strain similarity was determined by pulsed-field gel electrophoresis.

RESULTS

S. aureus nasal colonization occurred in 52.4% (22/42), 27.0% (17/63), and 25.0% (72/288) of case, control, and household participants, respectively. Case subjects and their contacts were more likely to harbor MRSA in their nares and be from a multipatient CF family. Of 31 MRSA strains, 10 (32.3%) were SCCmec type IVa, associated with community-acquisition. Overall, 27.6% of 98 households had > or =2 members colonized with closely related isolates. Household members were equally likely to be colonized with closely related strains of MRSA (20/31, 65%) versus MSSA (38/80, 48%).

CONCLUSIONS

This study demonstrated that household members of CF children harbor both MSSA and MRSA, including CA-MRSA, and that S. aureus is transmitted within CF households. Carriage of S. aureus by household members of CF children may have implications for infection control and treatment strategies. Future studies should monitor the distribution and virulence of SCCmecA types in patients with CF.

A multicenter, cross-sectional study on the prevalence and risk factors for nasal colonization with Staphylococcus aureus in patients admitted to children's hospitals in Switzerland

The rate of nasal carriage of Staphylococcus aureus and associated risk factors were determined in a cross-sectional study involving Swiss children's hospitals. S. aureus was isolated in 562 of 1363 cases. In a stepwise multivariate analysis, the variables age, duration of antibiotic use, and hospitalization of a household member were independently associated with carriage of S. aureus.

Prevalence of and risk factors for colonization by methicillin-resistant Staphylococcus aureus among adults in community settings in Taiwan

In order to determine the prevalence of methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) colonization among adults in community settings in Taiwan and identify its risk factors, we conducted the present study. For a 3-month period, we enrolled all adults who attended mandatory health examinations at three medical centers and signed the informed consent. Nasal swabs were taken for the isolation of S. aureus. For each MRSA isolate, we performed multilocus sequence typing, identification of the staphylococcal cassette chromosome mec, tests for the presence of the Panton-Valentine leukocidin gene, and tests for drug susceptibilities. Risk factors for MRSA colonization were determined. The results indicated that the MRSA colonization rate among adults in the community settings in Taiwan was 3.8% (119/3,098). Most MRSA isolates belonged to sequence type 59 (84.0%). Independent risk factors for MRSA colonization included the presence of household members less than 7 years old (P < 0.0001) and the use of antibiotics within the past year (P = 0.0031). Smoking appeared to be protective against MRSA colonization (P < 0.0001).

Staphylococcus aureus colonization of anterior nares of school going children

OBJECTIVE

To determine the colonization rates of S. aureus in anterior nares of school going children, evaluate the antimicrobial resistance of such isolates against various antibiotics.

METHODS

Nasal swabs taken for S. aureus in 392 healthy school going children aged between 5 and 15 yr belonging to three schools surrounding Kamineni Institute of Medical Sciences, Narketpally, Andhra Pradesh, India. Swabs were inoculated in to Mannitol Salt Agar (MSA) and incubation at 37 degrees C for 24hr, Staphylococcus aureus isolates were identified by standard microbiological methods such as Gram's stain, catalase and coagulase. MICs were determined by Agar dilution technique against Vancomycin, Ciprofloxacin, Sparfloxacin, Sparfloxacin beta Cyclodextrin. Antimicrobial resistance patterns of all the isolates against Oxacillin (1 microg) Penicillin (10 units), Ampicillin (10 microg), Co-trimoxazole (23.75 microg), Erythromycin (15 microg), Tetracycline (30 microg) and Gentamicin (10 microg) were tested using Kirby-Baeur disk diffusion method in accordance with CLSI standards.

RESULTS

Of the 392 samples screened 63(16%) showed the growth of Staphylococcus aureus. 12(19%) isolates were found to be MRSA. Antimicrobial susceptibility testing using Agar dilution method against Vancomycin, ciprofloxacin, Sparfloxacin, and Sparfloxacin beta Cyclodextrin revealed MICs in the range of 0.52 microg/ml, 0.51 microg/ml, 0.5 microg/ml and <0.0312-0.250 microg/ml respectively. Disk diffusion method showed that all the isolates were resistant to Penicillin and Ampicillin. A resistance of 14.3%, 25% and 22.2% was observed against Co-trimoxazole, Erythromycin and Tetracycline respectively. Gentamiicin was the only antibiotic against which most of the isolates were sensitive.

CONCLUSION

Our results suggests that healthy school going children under 16 yr of age are potential carriers of S. aureus and in particular MRSA and multi-drug resistant strains.

Epidemiology and risk factors for Staphylococcus aureus colonization in children in the post-PCV7 era

BACKGROUND

The incidence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) has risen dramatically in the U.S., particularly among children. Although Streptococcus pneumoniae colonization has been inversely associated with S. aureus colonization in unvaccinated children, this and other risk factors for S. aureus carriage have not been assessed following widespread use of the heptavalent pneumococcal conjugate vaccine (PCV7). Our objectives were to (1) determine the prevalence of S. aureus and MRSA colonization in young children in the context of widespread use of PCV7; and (2) examine risk factors for S. aureus colonization in the post-PCV7 era, including the absence of vaccine-type S. pneumoniae colonization.

METHODS

Swabs of the anterior nares (S. aureus) were obtained from children enrolled in an ongoing study of nasopharyngeal pneumococcal colonization of healthy children in 8 Massachusetts communities. Children 3 months to <7 years of age seen for well child or sick visits in primary care offices from 11/03-4/04 and 10/06-4/07 were enrolled. S. aureus was identified and antibiotic susceptibility testing was performed. Epidemiologic risk factors for S. aureus colonization were collected from parent surveys and chart reviews, along with data on pneumococcal colonization. Multivariate mixed model analyses were performed to identify factors associated with S. aureus colonization.

RESULTS

Among 1,968 children, the mean age (SD) was 2.7 (1.8) years, 32% received an antibiotic in the past 2 months, 2% were colonized with PCV7 strains and 24% were colonized with non-PCV7 strains. The prevalence of S. aureus colonization remained stable between 2003-04 and 2006-07 (14.6% vs. 14.1%), while MRSA colonization remained low (0.2% vs. 0.9%, p = 0.09). Although absence of pneumococcal colonization was not significantly associated with S. aureus colonization, age (6-11 mo vs. > or =5 yrs, OR 0.39 [95% CI 0.24-0.64]; 1-1.99 yrs vs. > or =5 yrs, OR 0.35 [0.23-0.54]; 2-2.99 yrs vs. > or =5 yrs, OR 0.45 [0.28-0.73]; 3-3.99 yrs vs. > or =5 yrs, OR 0.53 [0.33-0.86]) and recent antibiotic use were significant predictors in multivariate models.

CONCLUSION

In Massachusetts, S. aureus and MRSA colonization remained stable from 2003-04 to 2006-07 among children <7 years despite widespread use of pneumococcal conjugate vaccine. S. aureus nasal colonization varies by age and is inversely correlated with recent antibiotic use.

Immunological mechanisms underlying the genetic predisposition to severe Staphylococcus aureus infection in the mouse model

Host genetic variations play a significant role in conferring predisposition to infection. In this study, we examined the immune mechanisms underlying the host genetic predisposition to severe Staphylococcus aureus infection in different mouse strains. Whereas C57BL/6 mice were the most resistant in terms of control of bacterial growth and survival, A/J, DBA/2, and BALB/c mice were highly susceptible and succumbed to infection shortly after bacterial inoculation. Other strains (C3H/HeN, CBA, and C57BL/10) exhibited intermediate susceptibility levels. Susceptibility of mice to S. aureus was associated with an inability to limit bacterial growth in the kidneys and development of pathology. Resistance to S. aureus in C57BL/6 mice was dependent on innate immune mechanisms because Rag2-IL2Rgamma(-/-) C57BL/6 mice, which are deficient in B, T, and NK cells, were also resistant to infection. Indeed, neutrophil depletion or inhibition of neutrophil recruitment rendered C57BL/6 mice completely susceptible to S. aureus, indicating that neutrophils are essential for the observed resistance. Although neutrophil function is not inhibited in A/J mice, expression of neutrophil chemoattractants KC and MIP-2 peaked earlier in the kidneys of C57BL/6 mice than in A/J mice, indicating that a delay in neutrophil recruitment to the site of infection may underlie the increased susceptibility of A/J mice to S. aureus.

Methicillin-resistant Staphylococcus aureus colonization in children with atopic dermatitis

Children with atopic dermatitis are more frequently colonized with Staphylococcus aureus than children without atopic dermatitis. However, little epidemiological data exist regarding the prevalence of methicillin-resistant S. aureus among children with atopic dermatitis. Recent studies have revealed an increasing prevalence of community-associated methicillin-resistant S. aureus among patients presenting to hospitals with serious bacterial infections, particularly those with cutaneous and soft tissue infections. As many atopic dermatitis patients are treated empirically with antibiotics for secondary skin infections, an understanding of the epidemiology of bacterial colonization and superinfection is essential for directing proper treatment in the atopic patient population. This study investigates the prevalence of risk factors for community-associated, methicillin-resistant S. aureus colonization among pediatric atopic dermatitis patients encountered at an academic pediatric dermatology clinic. An observational cross-sectional study was conducted at the Children's Hospital of Philadelphia in which 54 patients previously diagnosed with atopic dermatitis were enrolled. A detailed patient questionnaire, a complete cutaneous examination, and an evaluation of eczema severity according to the Eczema Area and Severity Index were completed at the time of enrollment. Bacterial cultures from the skin and nares were obtained to determine the frequency of colonization with either methicillin-sensitive S. aureus or methicillin-resistant S. aureus. Although most atopic dermatitis patients studied were colonized with S. aureus (43/54 [80%]), methicillin-resistant S. aureus was isolated from only seven atopic dermatitis patients (7/43 [16%]). Patients colonized with S. aureus were more likely to be male, to have been previously hospitalized, to have used a topical calcineurin inhibitor in combination with a topical steroid, and less likely to have used topical antibiotics. Bivariable analysis, however, revealed that only previous hospitalization was independently associated with an increased risk of methicillin-resistant S. aureus colonization. We observed that 80% of atopic dermatitis patients were colonized with S. aureus, and that of these patients, 16% of colonized patients were colonized with a methicillin-resistant strain. Methicillin-resistant S. aureus colonization was found to be significantly associated with previous hospitalization. Evidence also indicates that topical calcineurin inhibitors used in conjunction with topical steroids is associated with increased S. aureus colonization, while topical antibiotic use appears to decrease S. aureus colonization.

Molecular characterization of methicillin-resistant Staphylococcus aureus nasal isolates from Turkey

Methicillin-resistant Staphylococcus aureus (MRSA) colonize most frequently in the anterior nares of the nose and cause serious infections all over the world. The aim of this study was to determine the nasal carriage rate of S. aureus and MRSA strains in Turkish elementary school children. We also analyzed molecular characterizations of MRSA strains by using pulse field gel electrophoresis (PFGE), multi locus sequence typing (MLST), staphylococcal chromosomal cassette mec (SCCmec) typing, and detection of the Panton-valentine leucocidin (PVL) gene. The nasal swabs were obtained from 4,050 children during a 4 month period in Ankara. In vitro antimicrobial susceptibility testing to 1 mug oxacillin and 30 mug cefoxitin was determined by a disk diffusion method. We found that the 1,001 of 4,050 (24.7%) children were colonized with S. aureus. Three S. aureus strains were resistant to oxacillin and cefoxitin. The rate of MRSA among all children was 0.07%. The MRSA strains revealed three different PFGE pattern. All MRSA isolates by harbored the SCCmec type IV element, but not the PVL gene. The two MRSA isolate belonged to sequence type (ST) 30, whereas the other one was a unique type. The results of this study demonstrated that S. aureus nasal carriage rate was consistent with previous studies. However, MRSA carriage rate was low. This study also indicated that the ST30-type IV without PVL gene MRSA clone may be expected to spread in Turkish community.

Prevalence of and risk factors for community-acquired methicillin-resistant and methicillin-sensitive staphylococcus aureus colonization in children seen in a practice-based research network

OBJECTIVE

We sought to define the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus nasal colonization in the St Louis pediatric population.

METHODS

Children from birth to 18 years of age presenting for sick and well visits were recruited from pediatric practices affiliated with a practice-based research network. Nasal swabs were obtained, and a questionnaire was administered.

RESULTS

We enrolled 1300 participants from 11 practices. The prevalence of methicillin-resistant S aureus nasal colonization varied according to practice, from 0% to 9% (mean: 2.6%). The estimated population prevalence of methicillin-resistant S aureus nasal colonization for the 2 main counties of the St Louis metropolitan area was 2.4%. Of the 32 methicillin-resistant S aureus isolates, 9 (28%) were health care-associated types and 21 (66%) were community-acquired types. A significantly greater number of children with community-acquired methicillin-resistant S aureus were black and were enrolled in Medicaid, in comparison with children colonized with health care-associated methicillin-resistant S aureus. Children with both types of methicillin-resistant S aureus colonization had increased contact with health care, compared with children without colonization. Methicillin-sensitive S aureus nasal colonization ranged from 9% to 31% among practices (mean: 24%). The estimated population prevalence of methicillin-sensitive S aureus was 24.6%. Risk factors associated with methicillin-sensitive S aureus colonization included pet ownership, fingernail biting, and sports participation.

CONCLUSIONS

Methicillin-resistant S aureus colonization is widespread among children in our community and includes strains associated with health care-associated and community-acquired infections.

Methicillin-resistant Staphylococcus aureus infections among healthy full-term newborns

OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged in the community, causing disease among healthy people lacking traditional risk factors for MRSA infection. This article describes an outbreak of MRSA among healthy full-term newborns.

DESIGN

Cases were identified and corresponding medical information collected. Telephone interviews were conducted with mothers of cases and surveillance cultures from mothers and newborns were performed. MRSA isolates were genotyped.

SETTING

Hospital in Chicago, Illinois, USA.

PARTICIPANTS

Newborns, their mothers and hospital healthcare workers.

INTERVENTION

Nursery infection control practices were enhanced. The MRSA-colonised healthcare workers received intranasal mupirocin.

MAIN OUTCOME

Within 4-23 days of birth, 11 newborns were identified with pustules, vesicles or blisters located on the head, groin, perineum, ears, legs, chin and trunk. All received antimicrobials and recovered without incident.

RESULTS

None of 432 peripartum women, one of 399 newborns, and two of 135 healthcare workers were nasal MRSA carriers. Available isolates from six patients, two healthcare workers, and one from an MRSA-colonised newborn were similar by pulsed-field gel electrophoresis. Other than contact with the hospital, no common exposures of MRSA transmission were identified.

CONCLUSIONS

MRSA strains that initially emerged in the community are now causing disease in healthcare settings. Providers should be aware that MRSA can cause skin infections among healthy newborns. Adherence to standard infection control practices is important to prevent transmission of MRSA in nurseries.

Prevalence of methicillin-resistant Staphylococcus aureus nasal colonization among Taiwanese children in 2005 and 2006

From July 2005 to October 2006, a total of 3,046 children, of ages between 2 months and 5 years, presented for a well-child health care visit to one of three medical centers, which are located in the northern, central, and southern parts of Taiwan, and were surveyed for nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). The overall prevalences of S. aureus and MRSA nasal carriage among the children were 23% and 7.3%, respectively (18% and 4.8% in the central region, 25% and 6.7% in the southern region, and 27% and 9.5% in the northern region). Of the 212 MRSA isolates (96%) available for analysis, a total of 10 pulsed-field gel electrophoresis (PFGE) patterns with two major patterns (C [61%] and D [28%]) were identified. One hundred forty-nine isolates (70%) contained type IV staphylococcal cassette chromosome mec (SCCmec) DNA, and 55 isolates (26%) contained SCCmec V(T). The presence of Panton-Valentine Leukocidin (PVL) genes was detected in 60 isolates (28%). Most MRSA isolates belonged to one of two major clones, characterized as sequence type 59 (ST59)/PFGE C/SCCmec IV/absence of PVL genes (59%) and ST59/PFGE D/SCCmec V(T)/presence of PVL genes (25%). We concluded that between 2005 and 2006, 7.3% of healthy Taiwanese children were colonized by MRSA in nares. MRSA harbored in healthy children indicates an accelerated spread in the community.

Methicillin-resistant Staphylococcus aureus infection or colonization present at hospital admission: multivariable risk factor screening to increase efficiency of surveillance culturing

Identifying methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection present at admission has become important in reducing subsequent nosocomial transmission, but the most efficient surveillance methods remain to be defined. We performed anterior nares surveillance cultures of all patients upon admission to and discharge from the general internal medicine floor in our community hospital over a 7-week period, and patients completed a questionnaire on MRSA risk factors. Of the 401 patients, 41 (10.2%) had MRSA upon admission. Of the 48 risk measures analyzed, 10 were significantly associated with admission MRSA, and 7 of these were independently associated in stepwise logistic regression analysis. Factor analysis identified eight latent variables that contained most of the predictive information in the 48 risk measures. Repeat logistic regression analysis including the latent variables revealed three independent risk measures for admission MRSA: a nursing home stay (relative risk [RR], 6.18; 95% confidence interval [95% CI], 3.56 to 10.72; P < 0.0001), prior MRSA infection (RR, 3.97; 95% CI, 1.94 to 8.12; P = 0.0002), and the third latent variable (factor 3; RR, 3.14; 95% CI, 1.56 to 6.31; P = 0.0013), representing the combined effects of homelessness, jail stay, promiscuity, intravenous drug use, and other drug use. Multivariable models had greater sensitivity at detecting admission MRSA than any single risk measure and allowed detection of 78% to 90% of admission MRSA from admission surveillance cultures on 46% to 58% of admissions. If confirmed in additional studies, multivariable questionnaire screening at admission might identify a subset of admissions for surveillance cultures that would more efficiently identify most admission MRSA.

Practical management: community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA): the latest sports epidemic

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has gained international recognition as a superbug that causes serious infectious outbreaks in high-risk populations such as athletes. Clusters of cases in various athletic teams, particularly contact sports, have been reported since 1993 in the United States and more recently in Canada. CA-MRSA infections are not limited to North America, and all athletes are considered high risk. Skin-to-skin contact appears to be the primary mode of transmission. While typical infections are local skin and soft-tissue abscesses, CA-MRSA infections can spread systemically and lead to significant morbidity and mortality if not promptly identified and treated. The gold standard of treatment for all abscesses is incision and drainage with wound culture for bacterial identification and antibiotic sensitivity testing. A limited number of antibiotics are currently useful in the treatment of CA-MRSA and are reviewed. Geographical variation in patterns of antibiotic resistance further complicates the treatment. Meticulous, consistent use of infection prevention strategies is critical to control outbreaks in the athletic population. Good hygiene, prompt identification of infection, limited exposure to infected persons and contaminated objects, and proper treatment combined with close follow-up of infected athletes will help contain CA-MRSA outbreaks. Future research is needed to explore person-to-person and fomite transmission risks, to define the significance of nasal carriage and skin colonization in relation to CA-MRSA infections, and to further investigate antibiotic resistance patterns. Universal education is needed for all athletes and personnel who provide care in the athletic setting to help control this widespread epidemic.

Community-associated methicillin-resistant Staphylococcus aureus prevalence: how common is it? A methodological comparison of prevalence ascertainment

BACKGROUND

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections are becoming increasingly prevalent. There is geographic variation in their reported prevalence across the United States; however, studies reporting on CA-MRSA prevalence also demonstrate great variability in their case-finding methodology. We conducted a study to see how three different methods to ascertain CA-MRSA prevalence would lead to different estimates.

METHODS

Different methods were used to identify cases of CA-MRSA colonization and/or infection in New York City. Method 1: retrospective review of clinical and surveillance cultures identified through a hospital computer database. Method 2: prospective collection of surveillance cultures in the same hospital's emergency department. Method 3: prospective collection of surveillance cultures in a community setting.

RESULTS

Differing values for CA-MRSA prevalence resulted depending on the method and denominator used. All nares cultures as the denominator led to prevalence estimates of 0.3%-0.6%; all S. aureus as the denominator led to rates of 1.2%-5%; all MRSA as the denominator led to estimates of 5.5%-50%.

CONCLUSIONS

A comparison of three methods revealed that variability in case-finding methodologies can lead to different prevalence estimates. Key factors to consider when comparing CA-MRSA rates include the definition of CA-MRSA, choice of denominator, and method and setting of sample collection.