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Vendrik KEW, Kuijper EJ, Dimmendaal M, Silvis W, Denie-Verhaegh E, de Boer A, Postma B, Schoffelen AF, Ruijs WLM, Koene FMHPA, Petrignani M, Hooiveld M, Witteveen S, Schouls LM, Notermans DW. An unusual outbreak in the Netherlands: community-onset impetigo caused by a meticillin-resistant Staphylococcus aureus with additional resistance to fusidic acid, June 2018 to January 2020. Euro Surveill 2022; 27:2200245. [PMID: 36695440 PMCID: PMC9732922 DOI: 10.2807/1560-7917.es.2022.27.49.2200245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022] Open
Abstract
In this retrospective observational study, we analysed a community outbreak of impetigo with meticillin-resistant Staphylococcus aureus (MRSA), with additional resistance to fusidic acid (first-line treatment). The outbreak occurred between June 2018 and January 2020 in the eastern part of the Netherlands with an epidemiological link to three cases from the north-western part. Forty nine impetigo cases and eight carrier cases were identified, including 47 children. All but one impetigo case had community-onset of symptoms. Pharmacy prescription data for topical mupirocin and fusidic acid and GP questionnaires suggested an underestimated outbreak size. The 57 outbreak isolates were identified by the Dutch MRSA surveillance as MLVA-type MT4627 and sequence type 121, previously reported only once in 2014. Next-generation sequencing revealed they contained a fusidic acid resistance gene, exfoliative toxin genes and an epidermal cell differentiation inhibitor gene. Whole-genome multilocus sequence typing revealed genetic clustering of all 19 sequenced isolates from the outbreak region and isolates from the three north-western cases. The allelic distances between these Dutch isolates and international isolates were high. This outbreak shows the appearance of community-onset MRSA strains with additional drug resistance and virulence factors in a country with a low prevalence of antimicrobial resistance.
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Affiliation(s)
- Karuna E W Vendrik
- Leiden University Medical Center, Leiden, the Netherlands
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
| | - Ed J Kuijper
- Leiden University Medical Center, Leiden, the Netherlands
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
| | - Marieke Dimmendaal
- Municipal health service North and East Gelderland, Warnsveld, The Netherlands
| | - Welmoed Silvis
- Laboratory for Medical Microbiology and Public Health (LabMicTA), Hengelo, The Netherlands
| | | | | | - Bent Postma
- Slingeland Hospital, Doetinchem, The Netherlands
| | - Annelot F Schoffelen
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
| | - Wilhelmina L M Ruijs
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
| | - Fleur M H P A Koene
- Medical Laboratory Services, Willemstad, Curacao
- Public Health Service of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Sandra Witteveen
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
| | - Leo M Schouls
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
| | - Daan W Notermans
- National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu, RIVM), Bilthoven, the Netherlands
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van den Besselaar JH, Spaargaren M, Smalbrugge M, Koene FMHPA, Termeulen L, Hertogh CMPM, Buurman BM. Implementation of a national testing policy in Dutch nursing homes during SARS-CoV-2 outbreaks. J Am Geriatr Soc 2022; 70:940-949. [PMID: 35080774 PMCID: PMC9305839 DOI: 10.1111/jgs.17687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 01/10/2022] [Accepted: 01/16/2022] [Indexed: 11/30/2022]
Abstract
Background To evaluate how a national policy of testing for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) regardless of symptoms was implemented during outbreaks in Dutch nursing homes in the second wave of the pandemic and to explore barriers and facilitators to serial testing. Methods We conducted a mixed‐method study of nursing homes in the Netherlands with a SARS‐CoV‐2 outbreak after 15 September 2020. Direct care staff and management from 355 healthcare organizations were invited to participate in a digital survey. A total of 74 out of 355 (20.9%) healthcare organizations participated and provided information about 117 nursing homes. We conducted 26 in‐depth interviews on the outbreak and the testing strategy used. We also conducted four focus group meetings involving managers, physicians, nurses, and certified health assistants. Recordings were transcribed and data were thematically analyzed. Results One hundred and four nursing homes (89%) tested residents regardless of their symptoms during the outbreak, and 85 nursing homes (73%) tested the staff regardless of their symptoms. However, interviews showed testing was sometimes implemented during later stages of the outbreak and was not always followed up with serial testing. Barriers to serial testing regardless of symptoms were lack of knowledge of local leaders with decisional making authority, lack of a cohort ward or skilled staff, and insufficient collaboration with laboratories or local public health services. Important facilitators to serial testing were staff willingness to undergo testing and the availability of polymerase chain reaction (PCR) tests. Conclusions Serial testing regardless of symptoms was only partially implemented. The response rate of 21% of nursing home organizations gives a risk of selection bias. Barriers to testing need to be addressed. A national implementation policy that promotes collaboration between public health services and nursing homes and educates management and care staff is necessary.
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Affiliation(s)
- Judith H van den Besselaar
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Marije Spaargaren
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Fleur M H P A Koene
- Department of Medical Microbiology, Amsterdam UMC, Meibergdreef 9, Amsterdam, the Netherlands.,Department of Infectious Diseases, Public Health Laboratory, Public Health Service of Amsterdam, Amsterdam, The Netherlands
| | - Loes Termeulen
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, Amsterdam, the Netherlands
| | - Bianca M Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, the Netherlands.,Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan, Amsterdam, the Netherlands.,Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
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van den Besselaar JH, Sikkema RS, Koene FMHPA, van Buul LW, Oude Munnink BB, Frénay I, te Witt R, Koopmans MPG, Hertogh CMPM, Buurman BM. Are presymptomatic SARS-CoV-2 infections in nursing home residents unrecognised symptomatic infections? Sequence and metadata from weekly testing in an extensive nursing home outbreak. Age Ageing 2021; 50:1454-1463. [PMID: 33963830 PMCID: PMC8136016 DOI: 10.1093/ageing/afab081] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Sars-CoV-2 outbreaks resulted in a high case fatality rate in nursing homes (NH) worldwide. It is unknown to which extent presymptomatic residents and staff contribute to the spread of the virus. AIMS To assess the contribution of asymptomatic and presymptomatic residents and staff in SARS-CoV-2 transmission during a large outbreak in a Dutch NH. METHODS Observational study in a 185-bed NH with two consecutive testing strategies: testing of symptomatic cases only, followed by weekly facility-wide testing of staff and residents regardless of symptoms. Nasopharyngeal and oropharyngeal testing with RT-PCR for SARs-CoV-2, including sequencing of positive samples, was conducted with a standardised symptom assessment. RESULTS 185 residents and 244 staff participated. Sequencing identified one cluster. In the symptom-based test strategy period, 3/39 residents were presymptomatic versus 38/74 residents in the period of weekly facility-wide testing (P-value < 0.001). In total, 51/59 (91.1%) of SARS-CoV-2 positive staff was symptomatic, with no difference between both testing strategies (P-value 0.763). Loss of smell and taste, sore throat, headache or myalga was hardly reported in residents compared to staff (P-value <0.001). Median Ct-value of presymptomatic residents was 21.3, which did not differ from symptomatic (20.8) or asymptomatic (20.5) residents (P-value 0.624). CONCLUSIONS Symptoms in residents and staff are insufficiently recognised, reported or attributed to a possible SARS-CoV-2 infection. However, residents without (recognised) symptoms showed the same potential for viral shedding as residents with symptoms. Weekly testing was an effective strategy for early identification of SARS-Cov-2 cases, resulting in fast mitigation of the outbreak.
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Affiliation(s)
- Judith H van den Besselaar
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, 1105 AZ Amsterdam, the Netherlands
| | - Reina S Sikkema
- Department of Viroscience, Erasmus Medical Center, 3015 CN Rotterdam, the Netherlands
| | - Fleur M H P A Koene
- Department of Medical Microbiology, Amsterdam University Medical Center, 1105 AZ Amsterdam, the Netherlands
- Department of Infectious Diseases, Public Health Laboratory, Public Health Service of Amsterdam, 1018WT Amsterdam, The Netherlands
| | - Laura W van Buul
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, 1081 BT Amsterdam, The Netherlands
| | - Bas B Oude Munnink
- Department of Viroscience, Erasmus Medical Center, 3015 CN Rotterdam, the Netherlands
| | - Ine Frénay
- Regional Laboratory for Medical microbiology (RLM) Dordrecht- Gorinchem, 3318 AT Dordrecht, The Netherlands
| | - René te Witt
- Eurofins|NMDL-LCPL, 2280 CA Rijswijk, The Netherlands
| | - Marion P G Koopmans
- Department of Viroscience, Erasmus Medical Center, 3015 CN Rotterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, 1081 BT Amsterdam, The Netherlands
| | - Bianca M Buurman
- Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam Public Health Research Institute, Amsterdam University Medical Center, 1105 AZ Amsterdam, the Netherlands
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