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Lynch JP, Zhanel GG. Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment. Expert Rev Anti Infect Ther 2023; 21:115-126. [PMID: 36469648 DOI: 10.1080/14787210.2023.2154654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections. AREAS COVERED The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides. EXPERT OPINION Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Professor-Department of Medical Microbiology and Infectious Diseases, Winnipeg, Manitoba, Canada
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Zasowski EJ, Trinh TD, Claeys KC, Dryden M, Shlyapnikov S, Bassetti M, Carnelutti A, Khachatryan N, Kurup A, Pulido Cejudo A, Melo L, Cao B, Rybak MJ. International Validation of a Methicillin-Resistant Staphylococcus aureus Risk Assessment Tool for Skin and Soft Tissue Infections. Infect Dis Ther 2022; 11:2253-2263. [PMID: 36319943 PMCID: PMC9669284 DOI: 10.1007/s40121-022-00712-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/03/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION To promote judicious prescribing of methicillin-resistant Staphylococcus aureus (MRSA)-active therapy for skin and soft tissue infections (SSTI), we previously developed an MRSA risk assessment tool. The objective of this study was to validate this risk assessment tool internationally. METHODS A multicenter, prospective cohort study of adults with purulent SSTI was performed at seven international sites from July 2016 to March 2018. Patient MRSA risk scores were computed as follows: MRSA infection/colonization history (2 points); previous hospitalization, previous antibiotics, chronic kidney disease, intravenous drug use, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), diabetes with obesity (1 point each). Predictive performance of MRSA surveillance percentage, MRSA risk score, and estimated MRSA probability (surveillance percentage adjusted by risk score) were quantified using the area under the receiver operating characteristic curves (aROC) and compared. Performance characteristics of different risk score thresholds across varying baseline MRSA prevalence were examined. RESULTS Two hundred three patients were included. Common SSTI were wounds (28.6%), abscess (25.1%), and cellulitis with abscess (20.7%). Patients with higher risk scores were more likely to have MRSA (P < 0.001). The MRSA risk score aROC (95%CI) [0.748 (0.678-0.819)] was significantly greater than MRSA surveillance percentage [0.646 (0.569-0.722)] (P = 0.016). Estimated MRSA probability aROC [0.781 (0.716-0.845)] was significantly greater than surveillance percentage (P < 0.001) but not the risk score (P = 0.192). The estimated negative predictive value (NPV) of an MRSA score ≥ 1 (i.e., a score of 0) was greater than 90% when MRSA prevalence was 30% or less. CONCLUSION The MRSA risk score and estimated MRSA probability were significantly more predictive of MRSA compared with surveillance percentage. An MRSA risk score of zero had high predictive value and could help avoid unnecessary empiric MRSA coverage in low-acuity patients. Further study, including impact of such risk assessment tools on prescribing patterns and outcomes are required before implementation.
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Affiliation(s)
- E. J. Zasowski
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201 USA ,Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA USA ,Geriatrics, Palliative and Extended Care Service Line, San Francisco Veterans Affairs Health Care System, San Francisco, CA USA ,Department of Clinical Pharmacy, University of California, San Francisco School of Pharmacy, San Francisco, CA USA
| | - T. D. Trinh
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201 USA ,Department of Clinical Pharmacy, University of California, San Francisco School of Pharmacy, San Francisco, CA USA
| | - K. C. Claeys
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201 USA ,Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD USA
| | - M. Dryden
- Royal Hampshire County Hospital, Winchester, UK
| | - S. Shlyapnikov
- I.I. Dzhanelidze Institute of Emergency Medicine, Saint Petersburg, Russia
| | - M. Bassetti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - A. Carnelutti
- Department of Health Sciences, Infectious Diseases Clinic, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - N. Khachatryan
- Department of Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A. Kurup
- Infectious Diseases Care, Mount Elizabeth Hospital, Singapore, Singapore
| | | | - L. Melo
- Hospital Dona Helena, Joinville, Brazil
| | - B. Cao
- Department of Pulmonary and Critical Care Medicine, Centre for Respiratory Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Michael J. Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, 259 Mack Ave, Detroit, MI 48201 USA ,Department of Medicine, Division of Infectious Diseases, School of Medicine, Wayne State University, Detroit, MI USA ,Department of Pharmacy Services, Detroit Medical Center, Detroit, MI USA
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Novel application of published risk factors for methicillin-resistant S. aureus in acute bacterial skin and skin structure infections. Int J Antimicrob Agents 2017; 51:43-46. [PMID: 28668679 DOI: 10.1016/j.ijantimicag.2017.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 04/19/2017] [Accepted: 05/14/2017] [Indexed: 11/24/2022]
Abstract
Methicillin-resistant Staphylococcus aureus acute bacterial skin and skin structure infections (MRSA ABSSSIs) are associated with a significant clinical and economic burden; however, rapid identification of MRSA remains a clinical challenge. This study aimed to use a novel method of predictive modeling to determine those at highest risk of MRSA ABSSSIs. Risk factors for MRSA ABSSSI were derived from a combination of previously published literature and multivariable logistic regression of individual patient data (IPD) using the 'adaptation method.' A risk-scoring tool was derived from weight-proportional integer-adjusted coefficients of the predictive model. Likelihood ratios were used to adjust posterior probability of MRSA. Risk factors were identified from 12 previously published studies and adapted based on IPD (n = 231). Risk factors were: history of diabetes with obesity (adapted odds ratio [aOR] = 1.1), prior antibiotics (90 days) (aOR = 2.6), chronic kidney disease/hemodialysis (aOR = 1.4), intravenous drug use (aOR = 2.8), previous MRSA exposure/infection (12 months) (aOR = 2.8), previous hospitalization (12 months) (aOR = 7.5), and HIV/AIDS (aOR = 4.0). Baseline prevalence of MRSA was 42.7%. Scores ranged from 0 - 8 points. Post-test probability of MRSA: score 0 = 35.0%; score 1 - 2 = 45.0%; score 3 = 63.0%. The newly derived risk-scoring tool is proof-of-concept of the adaptation method. This study is hypothesis generating and such a tool remains to be validated for clinical use.
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Venniyil PV, Ganguly S, Kuruvila S, Devi S. A study of community-associated methicillin-resistant Staphylococcus aureus in patients with pyoderma. Indian Dermatol Online J 2016; 7:159-63. [PMID: 27294048 PMCID: PMC4886585 DOI: 10.4103/2229-5178.182373] [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] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Health care-associated methicillin-resistant Staphylococcus aureus(HA-MRSA) are resistant to multiple antibiotics, therefore infections caused by them are difficult to treat resulting in high morbidity and mortality. While most of the research activities and public health initiatives are focused on HA-MRSA, the newly emerging pathogen, community-associated methicillin-resistant Staphylococcus aureus(CA-MRSA) is gaining in significance in respect to patient morbidity. There is a significant paucity of data regarding CA-MRSA in the developing parts of the world. AIM To study the proportions of HA-MRSA and CA-MRSA infections among patients with culture-proven S. aureus infection and to find out how many of these patients showed presence of MRSA in nasal cultures of healthy contacts. MATERIALS AND METHODS Clinical details of 227 patients were recorded in the study, such as the duration and recurrence of the infection, history of antibiotic intake, and the presence of other medical illnesses. A pus swab was taken from each lesion and sent for culture and sensitivity. If the culture grew S. aureus, they were screened for methicillin resistance. A swab from the anterior nares of the healthy contact of each patient, whenever available, was collected and it was screened for MRSA. RESULTS Furunculosis was most common among the primary pyodermas (53/134; 39. 5%). Out of 239 pus culture samples obtained from 227 patients, 192 (84.58%) grew S. aureus; of these 150 (78.12%) were methicillin-sensitive S. aureus (MSSA), whereas 42 (21.98%) were MRSA. Out of the 42 MRSA isolated, 33 turned out to be CA-MRSA (78%) and 9 (22%) were HA-MRSA. Nasal swabs of healthy contacts of 34 MRSA patients were cultured. Out of them, two grew MRSA in the culture. CONCLUSION The isolation rate of S. aureus was high in our study. Furthermore, our study, although hospital based, clearly indicated the substantial magnitude of the CA-MRSA problem in the local population.
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Affiliation(s)
- Prasanth V Venniyil
- Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Satyaki Ganguly
- Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Sheela Kuruvila
- Department of Dermatology, Venereology and Leprosy, Pondicherry Institute of Medical Sciences, Pondicherry, India
| | - Sheela Devi
- Department of Microbiology, Pondicherry Institute of Medical Sciences, Pondicherry, India
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Ray GT, Suaya JA, Baxter R. Incidence, microbiology, and patient characteristics of skin and soft-tissue infections in a U.S. population: a retrospective population-based study. BMC Infect Dis 2013; 13:252. [PMID: 23721377 PMCID: PMC3679727 DOI: 10.1186/1471-2334-13-252] [Citation(s) in RCA: 183] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 05/23/2013] [Indexed: 12/12/2022] Open
Abstract
Background Skin and soft tissue infections (SSTIs) are commonly occurring infections with wide-ranging clinical manifestations, from mild to life-threatening. There are few population-based studies of SSTIs in the period after the rapid increase in community-acquired methicillin-resistant Staphyloccus aureus (MRSA). Methods We used electronic databases to describe the incidence, microbiology, and patient characteristics of clinically-diagnosed skin and soft tissue infections (SSTIs) among members of a Northern California integrated health plan. We identified demographic risk factors associated with SSTIs and MRSA infection. Results During the three-year study period from 2009 to 2011, 376,262 individuals experienced 471,550 SSTI episodes, of which 23% were cultured. Among cultured episodes, 54% were pathogen-positive. Staphylococcus aureus (S. aureus) was isolated in 81% of pathogen-positive specimens, of which nearly half (46%) were MRSA. The rate of clinically-diagnosed SSTIs in this population was 496 per 10,000 person-years. After adjusting for age group, gender, race/ethnicity and diabetes, Asians and Hispanics were at reduced risk of SSTIs compared to whites, while diabetics were at substantially higher risk compared to non-diabetics. There were strong age group by race/ethnicity interactions, with African Americans aged 18 to <50 years being disproportionately at risk for SSTIs compared to persons in that age group belonging to other race/ethnicity groups. Compared to Whites, S. aureus isolates of African-Americans and Hispanics were more likely to be MRSA (Odds Ratio (OR): 1.79, Confidence Interval (CI): 1.67 to 1.92, and, OR: 1.24, CI: 1.18 to 1.31, respectively), while isolates from Asians were less likely to be MRSA (OR: 0.73, CI: 0.68 to 0.78). Conclusions SSTIs represent a significant burden to the health care system. The majority of culture-positive SSTIs were caused by S. aureus, and almost half of the S. aureus SSTIs were methicillin-resistant. The reasons for African-Americans having a higher likelihood, and Asians a lower likelihood, for their S. aureus isolates to be methicillin-resistant, should be further investigated.
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Ray GT, Suaya JA, Baxter R. Microbiology of skin and soft tissue infections in the age of community-acquired methicillin-resistant Staphylococcus aureus. Diagn Microbiol Infect Dis 2013; 76:24-30. [PMID: 23537783 DOI: 10.1016/j.diagmicrobio.2013.02.020] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Revised: 01/22/2013] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
The objectives of this study were to determine the etiology of skin and soft-tissue infections (SSTIs) in a general population, and to describe patient characteristics, SSTI types, frequency of microbiologic testing, and the role of methicillin-resistant Staphylococcus aureus (MRSA) over time. Using electronic databases, we identified SSTI episodes and microbiologic testing among members of a large US health plan. Between 2006 and 2009, 648699 SSTI episodes were identified, of which 23% had a specimen, of which 15% were blood. A pathogen was identified in 58% of SSTI cultures. S. aureus was the most common pathogen (80% of positive cultures). Half of S. aureus isolates were MRSA. Among cellulitis and abscess episodes with a positive blood culture, 21% were methicillin-sensitive S. aureus, 16% were MRSA, 21% were beta-hemolytic streptococci and 28% were Gram negative bacteria. Between 1998 and 2009, the percentage of SSTIs for which a culture was obtained increased from 11% to 24%. In SSTI episodes with a culture-confirmed pathogen, MRSA increased from 5% in 1998 to 9% in 2001 to 42% in 2005, decreasing to 37% in 2009. These data can inform the choice of antibiotics for treatment of SSTIs.
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Affiliation(s)
- G Thomas Ray
- Division of Research, Kaiser Permanente Medical Care Program, Northern California Region, Oakland, CA, USA.
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Bell MC, Stovall SH, Scurlock AM, Perry TT, Jones SM, Harik NS. Addressing antimicrobial resistance to treat children with atopic dermatitis in a tertiary pediatric allergy clinic. Clin Pediatr (Phila) 2012; 51:1025-9. [PMID: 22514191 DOI: 10.1177/0009922812441669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Secondary skin infection with Staphylococcus aureus is a significant problem in atopic dermatitis (AD) patients. OBJECTIVE This study evaluated antimicrobial resistance patterns of S aureus isolates from skin lesions in AD patients and empiric antimicrobial prescribing patterns. METHODS Resistance patterns from positive skin cultures obtained from AD patients in the Allergy/Immunology clinic from May 1, 2006, to December 31, 2008, were compared with all outpatient wound cultures over the same period. RESULTS Fifty-nine cultures were obtained from 38 AD patients. S aureus was the most common pathogen cultured from AD patients (53/59 cultures). S aureus resistance to clindamycin and methicillin differed significantly between the study group and the outpatient reference population (37.7% vs 9.4% and 45.3% vs 76.4%). Clindamycin was the most commonly prescribed antimicrobial (59%). Overall, 31.4% of organisms showed resistance to the antimicrobial prescribed. CONCLUSIONS Susceptibility profiles of S aureus isolates from AD patients vary significantly from that of the general population.
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Affiliation(s)
- Matthew C Bell
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
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