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PubMed2002

Occurrence of methicillin-resistant Staphylococcus aureus infections in German intensive care units.

BACKGROUND: This study aims to describe the occurrence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infections and the relation between endemic and epidemic nosocomial MRSA infections in intensive care units (ICUs) in Germany. METHODS: The ICU component within the German national nosocomial infections surveillance system (KISS) was established in January 1997. The number of participating ICUs increased from 25 in 1997 to 178 (June 2000). In every case of nosocomial infection (NI), the pathogens identified were referred to the surveillance system. To identify clusters and outbreaks and distinguish them from mere single events, the following simple definitions were applied: a "cluster" was two nosocomial MRSA infections within 3 months; an "outbreak" was three or more nosocomial MRSA infections within 3 months; all other MRSA infections were classed as "single events." RESULTS: A total of 10,261 NIs were identified during the observation period in the 139 ICUs which had been participating for at least 6 months. Among the 1,535 nosocomial S. aureus infections, 219 MRSA infections were identified (14.3%). Only 51 (36.7%) of the 139 KISS ICUs identified nosocomial MRSA infections. In 12 ICUs (8.6%) however, more than 50% of all nosocomial S. aureus infections were caused by MRSA. The mean incidence density was 0.31 nosocomial MRSA infections/1,000 patient days (range 0-3.6). Outbreaks were registered in 13 ICUs, clusters in 12 further ICUs and only single events in the remaining 26. 64.0% of all MRSA infections were registered during outbreaks and 12.8% in cluster situations. Thus, only 23.2% of MRSA infections were single events. CONCLUSION: These definitions of clusters and outbreaks can only provide an estimate of the real number of cases. However, through the targeted identification of ICUs with endemic and epidemic MRSA problems and subsequent strict measures to prevent the spread of MRSA within these ICUs, it may be possible to retain, or even reduce, the present level of MRSA infections in Germany.

Cross Infection↗
PubMed2003

Community-acquired methicillin-resistant Staphylococcus aureus infection in Singapore is usually "healthcare associated".

OBJECTIVE: To assess the frequency of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections. SETTING: A teaching hospital in Singapore. METHODS: Prospectively collected surveillance data were reviewed during a 1-year period to determine the extent and origin of community-acquired MRSA infections. RESULTS: Whereas 32% of 383 MRSA infections were detected less than 48 hours after hospital admission and would, by convention, be classified as "community acquired," all but one of these were among patients who had been exposed to outpatient centers including dialysis or chemotherapy clinics, visiting nurses, community hospitals, or all three. CONCLUSIONS: With health care increasingly being delivered in an outpatient setting, community-acquired MRSA infections are often acquired in hospital-related sites and most may be more accurately described as "healthcare acquired." Infection control measures need to move beyond the traditional paradigm of acute care hospitals to effectively control the spread of resistant pathogens.

Community-Acquired Infections↗
PubMed2000

Cytokines and T-cell responses in superantigen-related glomerulonephritis following methicillin-resistant Staphylococcus aureus infection.

BACKGROUND: We have previously reported that 10 patients who developed glomerulonephritis (GN) in association with methicillin-resistant Staphylococcus aureus (MRSA) infection showed a marked increase in DR+CD4+ and DR+CD8+ subsets of T cells and in T cells expressing several T-cell receptor (TCR) V beta+cells, perhaps representing V beta-specific T-cell activation by MRSA-derived superantigens (Kidney Int 1995; 47: 207-216). In this study we examine cytokine levels, T-lymphocyte subsets, natural killer NK cells, memory T cells, and the expression of IL-2 receptors in order to better understand the role of bacterial superantigens and cytokines in the pathogenesis of MRSA-associated GN. METHODS: Twenty-two patients with MRSA infection who later developed GN caused by staphylococcal enterotoxin were evaluated immunologically in comparison with patients whose MRSA infection was not followed by GN (non-GN group) and normal individuals. RESULTS: Among peripheral lymphocytes, the frequency of T cells expressing several TCR V betas, especially V beta 5-family TCR, was higher in the GN group than in both the non-GN group and the normal healthy control group. GN patients also showed increased serum levels of several cytokines, including tumour necrosis factor-alpha (TNF-alpha), interleukin-1 beta (IL-1 beta), IL-2, IL-6, IL-8, and IL-10, which have been implicated in the onset of nephritis. Memory cells, and IL-2 receptors also were elevated in the GN group. CONCLUSION: These results suggest that T cells activated by MRSA-derived staphylococcal enterotoxins and subsequent production of cytokines may play an important role in the pathogenesis of MRSA-associated GN.

Adult↗
PubMed2004

A protracted outbreak of Staphylococcus epidermidis infections among patients undergoing valve replacement.

OBJECTIVE: To investigate a Staphylococcus epidermidis outbreak among patients undergoing cardiac surgery. DESIGN: Retrospective cohort study. SETTING: A 260-bed community referral center. PATIENTS: Case-patients were patients with S. epidermidis mediastinitis, endocarditis, or both after valve implantation at Hospital de La Ribera from January to June 2002. The study population included patients undergoing valve surgery at Hospital de La Ribera from January 2000 to June 2002. RESULTS: From January to June 2002, 8 cases of mediastinitis, endocarditis, or both occurred among 53 patients undergoing cardiac surgery. In the same months of 2000, there had been no cases among 22 patients, and in 2001, only 1 case among 47 patients (P = .095 and P = .034, respectively). In 2002, there were 4 cases of mediastinitis and endocarditis, 3 cases of mediastinitis, and 1 case of endocarditis, all following aortic valve replacement. The epidemic curve suggested a protracted outbreak. Patients with chronic obstructive lung disease were six-fold more likely to be case-patients (95% confidence interval, 1.6-23.8). The mean duration of surgery tended to be longer in non-case-patients (161.4 +/- 57.9 minutes) than in case-patients (123.7 +/- 23.7 minutes) (P = .06). CONCLUSION: The cause of this protracted outbreak was likely multifactorial. Reemphasis of existing policies was associated with resolution of the outbreak.

Adult↗
PubMed1988

Purified capsular polysaccharide-induced immunity to Staphylococcus aureus infection.

In this study, we determined that immunization with capsular polysaccharide from Staphylococcus aureus could protect mice against nonlethal infections induced by encapsulated staphylococci. We immunized mice with either formalin-killed bacteria or purified capsular polysaccharide (PCP) and challenged them with one of three related S. aureus strains that varied in capsule size. Quantitative cultures of blood and kidney from the animals were performed to evaluate protection. Immunization with whole bacteria protected mice against infection with the homologous strain. Mice immunized with PCP were protected when challenged intravenously with either a highly encapsulated S. aureus strain or a microencapsulated mutant but not with an unencapsulated mutant. Protection correlated with capsular antibody levels in the immunized animals. Immunity to staphylococcal infection could be passively transferred to naive animals by using immune serum. These experiments suggest that the S. aureus capsular polysaccharide merits further study as a potential vaccine candidate for preventing staphylococcal infection.

Animals↗
PubMed2005

Surgical treatment of methicillin-resistant Staphylococcus aureus infection following infrainguinal arterial reconstruction.

A 64-year-old man was referred to our hospital with Methicillin-resistant Staphylococcus aureus (MRSA) infection following infrainguinal arterial reconstruction. As repeated MRSA sepsis occurred, we decided to remove the infected graft with distal revascularization via circuitous graft tunneling to avoid serious infections and allow limb salvage. An iliofemoro bypass was performed via an extra-anatomical bypass, from just below the iliac crest into the musculus quadriceps femoris using an 8 mm-ringed polyester gelatin polypropylene tube graft, with complete debridement of a groin infection. Postoperative 3-dimentional CT angiography revealed that the prostheses was patent and the patient had an uneventful postoperative course. We concluded that this extra-anatomical bypass was a safe procedure and an excellent option for patients with an infected vascular prosthetic graft in the groin after previous revascularization, like in our case with no available autogeneous vein grafts.

Angiography↗
PubMed1994

[Clinical efficacy of arbekacin in patients with methicillin-resistant Staphylococcus aureus infections. Research Group of MRSA Forum].

We investigated the clinical efficacy of arbekacin (ABK) in patients with methicillin-resistant Staphylococcus aureus (MRSA) infections, and also studied coagulase types, beta-lactamase producing activity and drug sensitivity of MRSA isolated from various clinical specimens. A total of 23 patients with MRSA infections (13 cases of pneumonia, 1 case of sepsis, 1 case of pneumonia and sepsis and 8 cases of the others) who were hospitalized from April 1992 to September 1993 were enrolled in this study. They were 14 males and 9 females, and the mean age was 66.9 years (range, 18-91 years). All patients had underlying diseases (mainly malignant tumors and cerebrovascular diseases). ABK was given intravenously at doses ranging from 75 to 100 mg twice daily. The clinical efficacy rate was 90%; 8 cases showed excellent responses, 10 cases good, 1 case fair, 1 case poor and 3 cases were unevaluable. The eradication rate of MRSA was 81.8%; 16 cases were judged as eradicated, 3 cases decreased, 2 cases replaced, 1 case unchanged and in 1 case the bacteriological response was unknown. Side effects were not observed, but S-GPT was elevated in 1 case. Coagulase types of MRSA (123 strains) isolated at the institutes involved in the study were type II (56 strains), type IV (12 strains), type VII (13 strains) and other types (2 strains), but coagulase types of 40 strains could not be determined. Eighty-four strains (68.3%) produced beta-lactamases. MICs of ABK were 0.5 microgram/ml against 43 strains and 1 microgram/ml against 37 strains, and all of the MICs were under 4 micrograms/ml. In summary, ABK showed high antimicrobial activity against MRSA and clinical usefulness in the infections investigated.

Adolescent↗
PubMed1996

Staphylococcus aureus infection on cut wounds in the mouse skin: experimental staphylococcal botryomycosis.

Staphylococcus aureus cells were inoculated on the cut wounds in the skin of cyclophosphamide-treated mice. Biopsy specimens were taken from three mice at 1, 3, 6, 12, 24, 36, 48 and 60 h after the inoculation and were examined by light and electron microscopies. One hour after the inoculation Staphylococcus aureus cells were seen around the cut wound and deeper into the subcutaneous tissue. By 6 h after the inoculation, Staphylococcus aureus cells formed clusters of bacterial colonies. By 36 h after the inoculation inflammatory cells, mainly polymorphonuclear leukocytes and macrophages, were seen around the clusters. Electron microscopic examination revealed fibril-like structures around the Staphylococcus aureus cells at 1 h. The Staphylococcus aureus cells were enclosed in membrane-like structures at 3 h. The membrane-like structures and the fibril-like structures were positive for Ruthenium red. By 12 h after the inoculation, the membrane-like structures increased in thickness and in electron density. Inflammatory cells were seen around but outside of the membrane-like structures at 24, 36 and 48 h. At 60 h the tissues around the membrane-like structures were degenerated and almost necrotic. These results suggest that Staphylococcus aureus cells may form biofilm in dermal or subcutaneous tissues in a neutropenic condition.

Animals↗
PubMed1984

Commercially available (ENDO-STAPH) assay for teichoic acid antibodies. Evaluation in patients with serious Staphylococcus aureus infections and in controls.

We have evaluated the clinical usefulness of a commercially available teichoic acid antibody assay (ENDO-STAPH). Teichoic acid antibody titers up to a 1:2 serum dilution were observed in 20% of normal subjects, thus, titers of 1:4 or more were considered positive. Of patients with Staphylococcus aureus infections, 16 of 23 with endocarditis, 12 of 20 with complicated bacteremia, three of 17 with uncomplicated bacteremia, and ten of 20 with nonbacteremic infections had positive titers. Only four of 70 controls had positive titers. Results agreed with those using our standard assay in 130 of 151 specimens. Results were reproducibly positive or negative in 17 of 18 specimens that were retested. Results were also reproducible in ten specimens retested using a different lot of standardized antigen. The ENDO-STAPH assay should broaden the clinical applications of assays for TAA.

Antibodies, Bacterial↗
PubMed2003

Prevention of methicillin-resistant Staphylococcus aureus infections in neonates.

Reports of methicillin-resistant Staphylococcus aureus (MRSA) infection in neonatal intensive care units (NICU) and normal newborn nurseries in Japan were investigated, and various methods of preventing transmission were evaluated. In the late 1980s, MRSA which had spread in adult wards also invaded NICU. Very low birthweight or premature infants had become the targets of MRSA infection and this has now become a serious problem. Recent reports have revealed that 87% of major NICU in Japan have suffered from MRSA infections. However, we have found that preventive measures can greatly reduce the risk of a newborn being infected by a carrier, while also controlling the disease caused by MRSA infection. Recently, MRSA infections in normal newborn nurseries have also become a serious problem in pediatric departments. Methicillin-resistant Staphylococcus aureus which can colonize in the newborn baby just after birth, is passed on to the newborn by carrier medical staff. It was found to be of great importance that infant's mothers hold and nurse their babies immediately after birth, and start breast-feeding while still in the delivery room. Furthermore, the most appropriate and ideal newborn nursery is one where mother and child are roomed together and there is little intervention by the hospital. In neonatal care, it is of utmost importance to treat carriers of MRSA bacteria, and to inhibit the spread of the bacterium in babies by taking standard precautionary measures.

Breast Feeding↗
PubMedDate not supplied

Henoch-Schönlein purpura after postoperative Staphylococcus aureus infection with hepatic IgA nephropathy.

A 66-year-old man with a two-year history of hepatitis C viral liver cirrhosis, was diagnosed as having ascending colon cancer. Right hemicolectomy was performed, and a drain was fed down to the anastomosis. On post-operative day (POD) 9, and methicillin-sensitive Staphylococcus aureus (MSSA) was isolated from both drains. After POD 12, relapsing persistent diarrhea with some blood occurred. On POD 20, the temperature increased to 39 degrees C, with symmetrical purpura and swelling in the femurs, and knee arthralgia developed. HSP was suspected. Clinical follow-up showed slight spontaneous reduction of diarrhea and purpura on POD 26. However, despite the negative drain culture, the high fever was maintained on POD 27. Therefore, intravenous steroid pulse therapy was performed. The purpura subsequently disappeared, except for a slight pigmentation and the temperature returned to normal. A renal biopsy was performed 26 days after the appearance of purpura. Pathological views demonstrated acute focal segmental glomerulonephritis-like nephropathy in addition to cirrhotic nephropathy with a membranoproliferative glomerulonephritis (MPGN)-like pattern and the mesangial proliferative glomerulonephritis type. We describe a case of Henoch-Schönlein purpura (HSP) after postoperative Staphylococcus aureus infection of the intra-abdominal drain with IgA nephropathy associated with hepatitis C virus liver cirrhosis.

Aged↗
PubMed2001

Population-based incidence and characteristics of community-onset Staphylococcus aureus infections with bacteremia in 4 metropolitan Connecticut areas, 1998.

This study retrospectively analyzed the magnitude and epidemiology of community-onset Staphylococcus aureus (COSA) infections and methicillin-resistant S. aureus (MRSA) infections in 4 Connecticut metropolitan areas (population, 1.1 million). The study looked at hospital medical records of persons admitted with S. aureus bacteremia in 1998. COSA was categorized as "health care associated," "with underlying medical condition," or "no underlying medical condition." Overall, 48% of S. aureus bacteremic infections were COSA (incidence, 17 cases/100,000 persons). Incidence increased with age and higher population density. In all, 62% of infections were health care associated; 85% of the remaining cases had underlying medical conditions. MRSA accounted for 16% of health care-associated cases and cases with underlying conditions but no cases with no underlying conditions. COSA bacteremic infections are as common as those due to pneumococci. MRSA is a well-established cause of COSA among persons at high medical risk for S. aureus infection. Additional study to understand community-onset MRSA acquisition is needed.

Adolescent↗
PubMed2004

Prevention and control of methicillin-resistant Staphylococcus aureus infections.

PURPOSE OF REVIEW: This article reviews many recent publications relevant to the prevention and control of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. RECENT FINDINGS: Higher risk-adjusted costs and mortality have been found for MRSA infections than for methicillin-susceptible S. aureus infections confirming their epidemiologic importance. Staphylococcal cassette chromosome mec, the genetic basis for MRSA, does not develop in methicillin-susceptible S. aureus exposed to antimicrobials. Instead virtually all patients acquire MRSA via spread. Nevertheless, antibiotic therapy provides a selective advantage for such spread, especially within healthcare settings where antimicrobial therapy is most frequent. Several studies have suggested better control of MRSA through antibiotic control, but far more studies have reported control using surveillance cultures and contact precautions for preventing spread (rather than just using standard precautions). More rapid detection of MRSA (within 6 h) has been reported using polymerase chain reaction, but studies using this method to reduce spread have not yet been published. A structured survey of research methods used regarding MRSA control noted that many studies had methodologic shortcomings (for example, none was a randomized trial), but nevertheless concluded that active detection and isolation work should be used. A Society for Healthcare Epidemiology of America guideline emphasized the same approach noting that scores of studies on multiple continents had reported success with this approach, with best results in several northern-European countries where all facilities used it routinely. SUMMARY: Improved MRSA control is possible by detecting and isolating colonized patients.

Cross Infection↗
PubMed1994

Combined therapy with arbekacin and fosfomycin for methicillin-resistant Staphylococcus aureus infections.

We examined the clinical efficacy of a combination of arbekacin and fosfomycin in the treatment of various methicillin-resistant Staphylococcus aureus (MRSA) infections. The combination of arbekacin plus fosfomycin displayed 65.4% (17/26) clinical efficacy and 65.4% (17/26) bacteriological efficacy. This combination thus appeared to be an effective regimen for the treatment of MRSA infections. However, its bacteriological efficacy against concomitant Pseudomonas aeruginosa strains was only 16.7% (1/6). In addition, in 4 episodes of superinfection involving P. aeruginosa strains developed during the combination therapy.

Aminoglycosides↗
PubMed2006

High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity.

BACKGROUND: Vancomycin hydrochloride treatment failure for infections caused by susceptible methicillin-resistant Staphylococcus aureus (MRSA) strains with high minimum inhibitory concentration (MIC) has prompted recent guidelines to recommend a higher vancomycin target trough of 15 to 20 microg/mL. METHODS: A prospective cohort study of adult patients infected with MRSA was performed to determine the distribution of vancomycin MIC and treatment outcomes with vancomycin doses targeting an unbound trough of at least 4 times the MIC. The microbiology laboratory computer records were used to identify all patients from whom MRSA was isolated from August 1, 2004, through June 30, 2005. Primary outcome measures were clinical response, mortality, and nephrotoxicity. Patients were placed into subgroups based on target trough attainment and high vs low vancomycin MIC (>/=2 vs <2 microg/mL) for efficacy and high vs low trough (>/=15 vs <15 microg/mL) for nephrotoxicity analyses. RESULTS: Of the 95 patients in the study, 51 (54%) were infected with high-MIC strains and had pneumonia (77%) and/or bacteremia. An initial response rate of 74% was achieved if the target trough was attained irrespective of MIC. However, despite achieving the target trough, the high-MIC group had lower end-of-treatment responses (24/39 [62%] vs 34/40 [85%]; P = .02) and higher infection-related mortality (11/51 [24%] vs 4/44 [10%]; P=.16) compared with the low-MIC group. High MIC (P = .03) and Acute Physiology and Chronic Health Evaluation II score (P = .009) were independent predictors of poor response in multivariate analysis. Nephrotoxicity occurred only in the high-trough group (11/63 [12%]), significantly predicted by concomitant therapy with other nephrotoxic agents. CONCLUSIONS: High prevalence of clinical MRSA strains with elevated vancomycin MIC (2 microg/mL) requires aggressive empirical vancomycin dosing to achieve a trough greater than 15 microg/mL. Combination or alternative therapy should be considered for invasive infections caused by these strains.

Aged↗
PubMed1982

The emergence of methicillin-resistant Staphylococcus aureus infections in United States hospitals. Possible role of the house staff-patient transfer circuit.

Infections with methicillin-resistant strains of Staphylococcus aureus appear to be occurring with increasing frequency in some U.S. hospitals about a decade after a similar increase in Britain and other countries. In the United States, clustered methicillin-resistant S. aureus infections reported in scientific journals and in three hospital surveys have been almost entirely in large, tertiary referral hospitals affiliated with medical schools. Among 63 hospitals regularly reporting infections from 1974 to 1981 in the National Nosocomial Infections Study, the increase in methicillin-resistant S. aureus infections was entirely due to substantial increases in only four hospitals, all of which were large, tertiary referral centers affiliated with medical schools. The predominance of methicillin-resistant S. aureus infections in these large hospitals may be due to the large numbers of patients at high risk of infection and to the interhospital spread of the organism by the transfer of infected patients and house staff from similar hospitals or from nursing homes.

Cross Infection↗
PubMed1989

The effect of local antibiotics in treating chronic osseous Staphylococcus aureus infection.

The purpose of this study was to determine if antibiotic-supplemented bone allografts (ASBA) would enhance healing and reduce infection in chronic osteomyelitis. Intramedullary injection of Staphylococcus aureus was used to create osteomyelitis in the tibia of New Zealand white rabbits. Twenty-one days postinoculation, the animals were randomly assigned to one of the following six treatment groups: 1. debridement of the infected tibia; 2. debridement + bone graft; 3. debridement + bone graft + gelatin powder; 4. debridement + bone graft + gelatin powder supplemented with antibiotics; 5. debridement + gelatin powder supplemented with antibiotics; and 6. no surgical intervention. The debrided material was cultured for identification of microorganisms. All groups received cephalothin sodium, 100 micrograms/kg subcutaneously every 12 hours for 21-days. At time of death the tibia were assessed to determine the degree of healing. Radiographs, bacterial cultures and specimens for histologic study were obtained. Qualitative grading demonstrated a significant difference between groups (P less than .001). Groups (4 and 5) receiving local antibiotic supplementation demonstrated improved healing compared with the remaining groups. However, there was no difference between groups 4 and 5. Bacteriologic culturing indicated the greatest reduction in colony-forming units of S aureus in the postsacrifice graft sites to be in groups 4 and 5. Histologic findings paralleled qualitative assessment of healing of the gross specimens. The results of this study suggest that local antibiotic supplementation of graft preparations may be useful for treatment of chronic osseous infection.

Animals↗