Shift in Staphylococcus aureus clone linked to an infected tattoo

Histopathologic Spectrum of Findings Associated With Tattoos: Multicenter Study Series of 230 Cases

IMPORTANCE

Reactions to tattoo may simulate common dermatosis or skin neoplasms. Histopathology allows diagnosis and helps determining the level and degree of inflammation associated, consequently orientating treatment.

OBJECTIVE

To describe the histological features found in biopsies of cutaneous reactions to tattoo.

DESIGN

This study was designed as a multicenter case series.

SETTING

All consecutive histopathological samples of tattoos referred from 1992 to 2019 to the Hospital General de Catalunya, Hospital Germans Trias i Pujol, and a private practice, all in Barcelona, Spain, and from the Kempf und Pfaltz Histologische Diagnostik in Zurich, Switzerland were retrieved from the files.

PARTICIPANTS AND EXPOSURE

The inclusion criteria were all cosmetic/permanent makeup, artistic/professional, and traumatic tattoos associated with either inflammatory reactions alone and/or with tumors and/or infections. Exclusion criteria were cases without any associated pathologic finding in the place of the ink, amalgam tattoos, and medical or temporary tattoos.

MAIN OUTCOMES AND MEASURES

In all patients, clinical features (age, sex, location, tattoo color, and presentation) were recorded. Histological features evaluated included ink color, associated tumors or infections, and inflammatory reaction pattern. Inflammation was graded in low to moderate or severe.

RESULTS

From 477 biopsies diagnosed as tattoos, 230 cases from 226 patients met the inclusion criteria. Samples corresponded to 107 male and 120 female subjects and 3 of unknown gender. Median age was 39 years (ranging from 9 to 84 years). Fifty-three samples were referred from centers in Spain and 177 from the center in Switzerland. The series was analyzed in 2 parts: tattoos associated only with inflammatory reactions (117/230) and tattoos associated with tumors or infections (113/230). The most common form of inflammatory pattern associated with tattoo was the fibrosing reaction (79/117, 68%), followed by granulomatous reaction (56/117, 48%), lichenoid reaction (33/117, 28%), epithelial hyperplasia (28/117, 24%), pseudolymphoma (27/117, 23%) and spongiotic reaction (27/117, 23%). Combined features of 2 or more types of inflammatory patterns were seen in 64% cases.

CONCLUSIONS AND RELEVANCE

Our series confirms that cutaneous reactions to tattoos are polymorphous. Inflammation tends to present with combined patterns. Infections are tending to decline, and pathologic findings are not specific to ink color or clinical features.

Methicillin-Resistant Staphylococcus aureus: Molecular Characterization, Evolution, and Epidemiology

Staphylococcus aureus, a major human pathogen, has a collection of virulence factors and the ability to acquire resistance to most antibiotics. This ability is further augmented by constant emergence of new clones, making S. aureus a "superbug." Clinical use of methicillin has led to the appearance of methicillin-resistant S. aureus (MRSA). The past few decades have witnessed the existence of new MRSA clones. Unlike traditional MRSA residing in hospitals, the new clones can invade community settings and infect people without predisposing risk factors. This evolution continues with the buildup of the MRSA reservoir in companion and food animals. This review focuses on imparting a better understanding of MRSA evolution and its molecular characterization and epidemiology. We first describe the origin of MRSA, with emphasis on the diverse nature of staphylococcal cassette chromosome mec (SCCmec). mecA and its new homologues (mecB, mecC, and mecD), SCCmec types (13 SCCmec types have been discovered to date), and their classification criteria are discussed. The review then describes various typing methods applied to study the molecular epidemiology and evolutionary nature of MRSA. Starting with the historical methods and continuing to the advanced whole-genome approaches, typing of collections of MRSA has shed light on the origin, spread, and evolutionary pathways of MRSA clones.

The Risk of Bacterial Infection After Tattooing

BACKGROUND

Tattooing is a globally growing trend. Overall prevalence among adults in industrialized countries is around 10-20%. Given the high and increasing numbers of tattooed people worldwide, medical and public health implications emerging from tattooing trends require greater attention not only by the public, but also by medical professionals and health policy makers.

METHODS

We performed a systematic review of the literature on tattooassociated bacterial infections and bacterial contamination of tattoo inks. Furthermore, we surveyed tattoo inks sampled during an international tattoo convention in Germany to study their microbial status.

RESULTS

Our systematic review identified 67 cases published between 1984 and 2015, mainly documenting serious bacterial infectious complications after intradermal deposition of tattoo inks. Both local skin infections (e.g. abscesses, necrotizing fasciitis) and systemic infections (e.g. endocarditis, septic shock) were reported. Published bacteriological surveys showed that opened as well as unopened tattoo ink bottles frequently contained clinically relevant levels of bacteria indicating that the manufactured tattoo product itself may be a source of infection. In our bacteriological survey, two of 39 colorants were contaminated with aerobic mesophilic bacteria.

CONCLUSION

Inappropriate hygiene measures in tattoo parlors and non-medical wound care are major risk factors for tattoo-related infections. In addition, facultative pathogenic bacterial species can be isolated from tattoo inks in use, which may pose a serious health risk.

Pediatric Staphylococcus aureus Isolate Genotypes and Infections from the Dawn of the Community-Associated Methicillin-Resistant S. aureus Epidemic Era in Chicago, 1994 to 1997

Widespread infections with community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) have occurred in the United States with the dissemination of the USA300 strain beginning in 2000. We examined 105 isolates obtained from children treated at the University of Chicago from 1994 to 1997 (75 methicillin-susceptible S. aureus [MSSA] and 30 MRSA isolates) in order to investigate for possible evidence of USA300 during this period. Infections were defined epidemiologically based on medical record review. The isolates underwent multilocus sequence typing (MLST), as well as assays for the Panton-Valentine leukocidin (PVL) genes, the protein A gene (spa), and arcA and opp3, proxy markers for the arginine catabolic mobile element (ACME), characteristic of USA300 MRSA. MRSA isolates also underwent staphylococcal cassette chromosome mec (SCCmec) typing and pulsed-field gel electrophoresis (PFGE) subtyping. MSSA isolates belonged to 17 sequence type (ST) groups. The 12 epidemiologically defined CA-MRSA infection isolates were either ST1 (n = 4) or ST8 (n = 8). They belonged to 3 different PFGE types: USA100 (n = 1), USA400 (n = 5), and USA500 (n = 6). Among the CA-MRSA infection isolates, 8 (67%) were PVL(+). None of the MRSA or MSSA isolates contained arcA or opp3. Only one MRSA isolate was USA300 by PFGE. This was a health care-associated (HA) MRSA isolate, negative for PVL, that carried SCCmec type II. USA300 with its characteristic features was not identified in the collection from the years 1994 to 1997.

Anti-infective drug development for MRSA

Staphylococcus aureus is an important pathogen linked to serious infections both in the hospital and the community settings. The challenge to treat infections caused by S. aureus has increased because of the emergence of multidrug-resistant strains such as methicillin-resistant S. aureus (MRSA). A limited spectrum of antibiotics is available to treat MRSA infections. This chapter reviews antimicrobial agents currently in use for the treatment of MRSA infections as well as agents that are in various stages of development. This chapter also reviews the alternate approaches that are being explored for the treatment of staphylococcal infections.

Comprehensive analysis of systemically disseminated ST8/non-USA300 type community-acquired methicillin-resistant Staphylococcus aureus infection

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) is genetically heterogeneous and various genotypes are spreading worldwide. We herein report a case of systematically disseminated Japan-intrinsic CA-MRSA infection that was successfully treated. A genetically identical single strain was isolated from a total of 11 different parts of the patient's body, and the pathogen was found to be multilocus sequence type 8, staphylococcal cassette chromosome mec IV, coagulase type III and negative for both Panton-Valentine leukocidin and arginine catabolic mobile element. The epidemiology and pathogenicity of the Japan-intrinsic CA-MRSA strain remain unknown, and further investigation of this life-threatening organism is warranted.

Adverse reactions after tattooing: review of the literature and comparison to results of a survey

The number of tattooed people has substantially increased in the past years. Surveys in different countries reveal this to be up to 24% of the population. The number of reported adverse reactions after tattooing has also increased including infections, granulomatous and allergic reactions and tumors. However, the case reports do not reflect the frequency of adverse reactions. This review compares the medically documented adverse reactions published in 1991-2011 with the findings of a nation-wide survey that recently revealed the features and health problems associated with tattoos. To compare the data with the survey, the sex of patients was reported and the location and color of tattoos were evaluated. The results show clearly that colored tattoo inks are mainly responsible for adverse skin reactions and that tattoos on the extremities are involved most.

Arginine catabolic mobile element encoded speG abrogates the unique hypersensitivity of Staphylococcus aureus to exogenous polyamines

Polyamines, including spermine (Spm) and spermidine (Spd), are aliphatic cations that are reportedly synthesized by all living organisms. They exert pleiotropic effects on cells and are required for efficient nucleic acid and protein synthesis. Here, we report that the human pathogen Staphylococcus aureus lacks identifiable polyamine biosynthetic genes, and consequently produces no Spm/Spd or their precursor compounds putrescine and agmatine. Moreover, while supplementing defined medium with polyamines generally enhances bacterial growth, Spm and Spd exert bactericidal effects on S. aureus at physiological concentrations. Small colony variants specifically lacking menaquinone biosynthesis arose after prolonged Spm exposure and exhibited reduced polyamine sensitivity. However, other respiratory-defective mutants were no less susceptible to Spm implying menaquinone itself rather than general respiration is required for full Spm toxicity. Polyamine hypersensitivity distinguishes S. aureus from other bacteria and is exhibited by all tested strains save those belonging to the USA-300 group of community-associated methicillin-resistant S. aureus (CA-MRSA). We identified one gene within the USA-300-specific arginine catabolic mobile element (ACME) encoding a Spm/Spd N-acetyltransferase that is necessary and sufficient for polyamine resistance. S. aureus encounters significant polyamine levels during infection; however, the acquisition of ACME encoded speG allows USA-300 clones to circumvent polyamine hypersensitivity, a peculiar trait of S. aureus.

Noninvasive in vivo imaging to evaluate immune responses and antimicrobial therapy against Staphylococcus aureus and USA300 MRSA skin infections

Staphylococcus aureus skin infections represent a significant public health threat because of the emergence of antibiotic-resistant strains such as methicillin-resistant S. aureus (MRSA). As greater understanding of protective immune responses and more effective antimicrobial therapies are needed, a S. aureus skin wound infection model was developed in which full-thickness scalpel cuts on the backs of mice were infected with a bioluminescent S. aureus (methicillin sensitive) or USA300 community-acquired MRSA strain and in vivo imaging was used to noninvasively monitor the bacterial burden. In addition, the infection-induced inflammatory response was quantified using in vivo fluorescence imaging of LysEGFP mice. Using this model, we found that both IL-1α and IL-1β contributed to host defense during a wound infection, whereas IL-1β was more critical during an intradermal S. aureus infection. Furthermore, treatment of a USA300 MRSA skin infection with retapamulin ointment resulted in up to 85-fold reduction in bacterial burden and a 53% decrease in infection-induced inflammation. In contrast, mupirocin ointment had minimal clinical activity against this USA300 strain, resulting in only a 2-fold reduction in bacterial burden. Taken together, this S. aureus wound infection model provides a valuable preclinical screening method to investigate cutaneous immune responses and the efficacy of topical antimicrobial therapies.

[Cutaneous infections related to permanent tattooing]

Decorative tattooing is made by introducing exogenous pigments and/or dyes into the dermis to permanently mark the body for decorative or other reasons. Unfortunately, this procedure is not harmless and various complications may occur including the potential inoculation of virulent microorganisms in the dermis. Cutaneous infections usually develop within days to weeks after the procedure and may include: pyogenic infections (staphylococcus, streptococcus, Pseudomonas aeruginosa, etc.), but also atypical bacteria (commensal mycobacteria, tuberculosis, leprosy, etc.), viral infections (molluscum contagiosum, verruca vulgaris, herpes, etc.), and also fungal and parasitic infections. This review focuses on dermatological infections occurring on tattoos and their management.

[Multiresistant bacteria in ophthalmology]

Multidrug-resistant bacteria have emerged as an increasing threat in many areas of medicine. The most prominent multidrug-resistant pathogens are methicillin-resistant S. aureus (MRSA), vancomycin-resistant MRSA (VMRSA), vancomycin-resistant enterococci (VRE), and Enterobacteriaceae with extended-spectrum beta-lactamase (ESBL). In particular, MRSA and VRE cause infections seen in ophthalmology. The lids, lacrimal duct, and ocular surface are frequently involved.

Virulence genes and genotypic associations in nasal carriage, community-associated methicillin-susceptible and methicillin-resistant USA400 Staphylococcus aureus isolates

It is not well understood why strains of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), a major cause of skin and soft tissue infections, became successful so quickly, overtaking the place of methicillin-sensitive S. aureus (MSSA) in many communities. To evaluate the genetic basis of differences in their virulence traits, 293 S. aureus isolates consisting of three cohorts, genotypically defined clinical CA-MRSA (n = 77), clinical MSSA (n = 103), and nasal carriage MSSA (n = 113), collected over a 19-year period in two Midwestern states in the United States, were (i) extensively genotyped and (ii) screened for 40 known virulence genes which included those for enterotoxins, leukocidins, hemolysins, and surface proteins and several newly identified putative toxin genes from the USA400 lineage of CA-MRSA. Genotypically, nasal carriage and clinical MSSA isolates were much more diverse than was the CA-MRSA group, which was found to be of USA400 lineage only. Virulence gene profiles of the three groups showed that CA-MRSA strains harbored significantly higher percentages (≥95%; P value, <0.05) of the sea, sec, sec4, seg2, seh, sek, sel, sel2, ear, ssl1, lpl10, lukSF-PV, lukD, lukE, and clfA genes than did the carriage and the clinical MSSA group (range, 0% to 58%). Genes of the enterotoxin gene cluster, seg, sei, sem, sen, and seo, were present in the clinical and carriage isolates but not in the CA-MRSA group. These results suggest that the presence of additional virulence factors in USA400 CA-MRSA strains compared to the nasal carriage and clinical MSSA strains probably contributed to their enhanced virulence.

Community-associated meticillin-resistant Staphylococcus aureus

Meticillin-resistant Staphylococcus aureus (MRSA) is endemic in hospitals worldwide, and causes substantial morbidity and mortality. Health-care-associated MRSA infections arise in individuals with predisposing risk factors, such as surgery or presence of an indwelling medical device. By contrast, many community-associated MRSA (CA-MRSA) infections arise in otherwise healthy individuals who do not have such risk factors. Additionally, CA-MRSA infections are epidemic in some countries. These features suggest that CA-MRSA strains are more virulent and transmissible than are traditional hospital-associated MRSA strains. The restricted treatment options for CA-MRSA infections compound the effect of enhanced virulence and transmission. Although progress has been made towards understanding emergence of CA-MRSA, virulence, and treatment of infections, our knowledge remains incomplete. Here we review the most up-to-date knowledge and provide a perspective for the future prophylaxis or new treatments for CA-MRSA infections.

Characterization of Staphylococcus aureus nasal carriage from children attending an outpatient clinic in Seoul, Korea

Nasal swabs were collected to isolate S. aureus in 296 children, who visited the pediatrics department with a variety of symptoms. Staphylococcus aureus was isolated from 95 children (32.1%). Of the isolates, 18 were methicillin-resistant S. aureus (MRSA) (18.9%). Antimicrobial susceptibility testing was performed for all S. aureus cultured and the molecular characteristics were investigated. Forty-nine spa types were identified among the S. aureus isolates, and were classified into 13 spa groups (A-L). The most prevalent clone (34 isolates, 35.8%) belonged to the spa group B (spa repeat motif, WG/FKAOMQ), which corresponded to sequence type 30 (ST30) and its variants. Sixteen different spa types, within the spa group B, suggested that this group has evolved over a long period of time. In addition, all S. aureus isolates belonging to the spa group B were methicillin-susceptible, indicating that this group might represent successful adaptation of this clone in the community setting with low antibiotic pressure. The most frequently found clone in the MRSA group was spa group C (spa repeat motif, DMGGM) and SCCmec type IVA, which represented half of the MRSA isolates and corresponded to ST72. ST5-MRSA-II, the most prevalent MRSA clone in Korean hospitals, was found in only two isolates. These findings suggest that strains of S. aureus nasal carriage in Korean children visiting an outpatient pediatric department were different from the strains identified in hospital infections.

Clinical practice: colonization, fomites, and virulence: rethinking the pathogenesis of community-associated methicillin-resistant Staphylococcus aureus infection

Community-associated methicillin-resistant Staphylococcus aureus (MRSA) infection is increasingly common worldwide and causes considerable morbidity and mortality. Of concern, community-associated MRSA infections are often recurrent and are highly transmissible to close contacts. The traditional tenet of pathogenesis is that MRSA colonization precedes infection. This has prompted persons involved in efforts to prevent community-associated MRSA infection to incorporate the use of intranasal topical antibiotics for nasal decolonization. However, data from outbreaks of community-associated MRSA infection suggest that skin-skin and skin-fomite contact represent important and common alternative routes of acquisition of the infecting strain. Furthermore, strain characteristics of the most successful community-associated MRSA strain, USA300, may contribute to a distinct pathogenesis. As we develop strategies to prevent community-associated MRSA infection, we must reconsider the pathogenesis of S. aureus. Reliance on models of health care-associated MRSA transmission for prevention of community-associated MRSA infection may result in the development of flawed strategies that attenuate our ability to prevent this serious and potentially deadly infection.

Epidemiology, clinical manifestations, and treatment options for skin and soft tissue infection caused by community-acquired methicillin-resistant Staphylococcus aureus

PURPOSE

This article reviews the evolving epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) and the appropriate outpatient management of CA-MRSA skin and soft tissue infection. Further, the paper will provide the basis upon which an individualized patient educational plan may be developed.

DATA SOURCES

To complete this review, a search of English language publications was conducted through Medline and CINAHL databases (1966-2006).

CONCLUSIONS

The epidemiology of CA-MRSA is becoming increasingly complex. Research that addresses the impact of this organism in high-risk populations and within families is urgently needed.

IMPLICATIONS FOR PRACTICE

Nurse practitioners must remain informed of the epidemiology of common and emerging drug-resistant organisms in their patient populations.

Community-acquired methicillin-resistant Staphylococcus aureus skin infections: implications for patients and practitioners

Dermatologists and other healthcare providers need to be aware of the epidemiology, clinical features, management, and prevention of community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infection. Currently, infection caused by CAMRSA is considered to represent a worldwide epidemic and infectious skin lesions are a frequent occurrence. Athletes, certain ethnic populations, children, homeless persons, homosexual men, household members of infected people, HIV-infected patients, intravenous drug abusers, military personnel, newborns, pregnant and postpartum women, tattoo recipients, and urban dwellers of lower socioeconomic status in crowded living conditions are individuals at increased risk of developing CAMRSA infection. Although the observed incidence of cutaneous CAMRSA lesions in patients with atopic dermatitis or other conditions that are characterized by a non-intact skin barrier is less than that reported in other groups of people at risk for this skin infection, close surveillance for the emergence of CAMRSA skin infection in children and adults with atopic dermatitis and other patients whose skin barrier is disrupted is justified since colonization by S. aureus in these individuals represents a potential reservoir for CAMRSA. It is also important to note that infection-associated risk factors are absent in many individuals who develop cutaneous CAMRSA infection. CAMRSA skin lesions are pleomorphic. The most common presentations of CAMRSA infection are abscess, cellulitis, or both. These infectious lesions are not uncommonly misinterpreted by the patient as spider bites or insect bites. Other manifestations of cutaneous CAMRSA infection are impetigo, folliculitis, and paronychia. Incision and drainage of abscesses, systemic antibacterial therapy, and adjunctive topical antibacterial treatment are the essential components of management of CAMRSA skin infections. At the initial visit, a bacterial culture of the infectious lesion is recommended to confirm identification of the pathogen and to determine antimicrobial susceptibility. Subsequently, based upon the reported antibacterial sensitivity, alteration (if necessary) of the patient's empiric systemic antimicrobial treatment can be initiated. Direct skin-to-skin transmission of the causative bacteria, damage to the skin's surface, sharing of personal items, and a humid environment are potential mechanisms for the acquisition and transmission of CAMRSA skin infection. The spread of cutaneous CAMRSA infection can potentially be prevented by incorporating personal, environmental, and healthcare measures that strive to eliminate the causes of acquisition and transmission of the bacteria.

Sporadic "transitional" community-associated methicillin-resistant Staphylococcus aureus strains from health care facilities in the United States

We describe phenotypic and genotypic traits of a group of methicillin-resistant Staphylococcus aureus (MRSA) clones that are either remnants of unsuccessful community-associated MRSA (CA-MRSA) clones or represent a transitional state with some yet-to-be-acquired characteristics of CA-MRSA. These rare strains (n = 20) were identified during a 10-year period (1990-1999) from 13 unrelated health care facilities in Wisconsin. The isolates were recovered from patients in nosocomial or long-term chronic care facilities (60%) and outpatient settings (40%). Sixty percent (n = 12) of the isolates were recovered from skin and soft tissue infections, whereas the remaining isolates (n = 8) were from invasive infections. Ninety percent of isolates were susceptible to all antibiotic classes tested or resistant to erythromycin and clindamycin. Pulsed-field gel electrophoresis, multilocus sequence typing, and spa typing clustered these isolates into 8, 8, and 14 clonal groups, respectively. Eight plasmid profiles were represented in these strains. All four agr types were represented, with type IV being predominant (40%). All strains harbored subtypes of type IV staphylococcal cassette chromosome mec but lacked genes for the virulence factor Panton-Valentine leukocidin (PVL). The strains harbored one or more of the following toxin genes: sea, seb, sec, sed, see, seh, sej, sek, sel, seg, sei, sem, sen, and seo. Individual clonal groups maintained the same set of enterotoxin genes even though they were isolated over extended time periods, suggesting significant genomic stability. The potential role of PVL-carrying phages and plasmids in the success of CA-MRSA clones has been discussed.