Environmental contamination due to methicillin-resistant Staphylococcus aureus: possible infection control implications

OBJECTIVE: To study the possible role of contaminated environmental surfaces as a reservoir of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals. DESIGN: A prospective culture survey of inanimate objects in the rooms of patients with MRSA. SETTING: A 200-bed university-affiliated teaching hospital. PATIENTS: Thirty-eight consecutive patients colonized or infected with MRSA. Patients represented endemic MRSA cases. RESULTS: Ninety-six (27%) of 350 surfaces sampled in the rooms of affected patients were contaminated with MRSA. When patients had MRSA in a wound or urine, 36% of surfaces were contaminated. In contrast, when MRSA was isolated from other body sites, only 6% of surfaces were contaminated (odds ratio, 8.8; 95% confidence interval, 3.7-25.5; P < .0001). Environmental contamination occurred in the rooms of 73% of infected patients and 69% of colonized patients. Frequently contaminated objects included the floor, bed linens, the patient's gown, overbed tables, and blood pressure cuffs. Sixty-five percent of nurses who had performed morning patient-care activities on patients with MRSA in a wound or urine contaminated their nursing uniforms or gowns with MRSA. Forty-two percent of personnel who had no direct contact with such patients, but had touched contaminated surfaces, contaminated their gloves with MRSA. CONCLUSIONS: We concluded that inanimate surfaces near affected patients commonly become contaminated with MRSA and that the frequency of contamination is affected by the body site at which patients are colonized or infected. That personnel may contaminate their gloves (or possibly their hands) by touching such surfaces suggests that contaminated environmental surfaces may serve as a reservoir of MRSA in hospitals.     

Postoperative enteritis caused by methicillin-resistant Staphylococcus aureus

We examined the clinical features of 14 men (mean age 72 years) with postoperative enteritis caused by methicillin-resistant Staphylococcus aureus (MRSA). The patients had all undergone surgery for the treatment of digestive diseases and had received antibiotic prophylaxis consisting of an extended-spectrum cephem. Diarrhea appeared a mean of 3.3 days postoperatively and lasted for 5 days on average. In severe cases organ insufficiency was involved. Coagulate-positive staphylococci were the predominant organisms isolated from watery diarrhea. In 13 of 14 patients, coagulase type II isolates producing enterotoxins A, C and toxic shock syndrome toxin-1 (TSST-1) with enterotoxin A, C, and 1st genes were isolated. These strains were sensitive to vancomycin and arbekacin; however, they were highly resistant to many other antibiotics. We also investigated the effects of a glucocorticoid hormone and gamma globulin on production of tumor necrosis factor-alpha (TNF-alpha) and interleukin-2 (IL-2) obtained from healthy volunteers. TNF-alpha and IL-2 production was enhanced by TSST-1 and the supernatant of Iscove-modified dulbecco medium, in which coagulase type II isolates producing enterotoxins A, C and TSST-1 with enterotoxin A, C were cultured for 24 h. Both glucocorticoid hormone and gamma globulin suppressed TNF-alpha and IL-2 production, thus suggesting that these drugs may be effective in treating postoperative MRSA enteritis.     

Reemergence of gentamicin-susceptible strains of methicillin-resistant Staphylococcus aureus: roles of an infection control program and changes in aminoglycoside use

We have tested the effect of stromal cells on the proliferation in long- and short-term cultures of primitive (Thy-1+, CD34+, CD33-, CD38- , HLA-DR , adherent in vitro and quiescent in vivo) progenitors in normal human bone marrow. These primitive cells produce granulocyte-macrophage colony-forming cells (CFU-GM) that are measured in secondary clonogenic assays. Addition of stromal cells to normal adherent haemopoietic progenitor cells reduced CFU-GM production by 80% (P =0.0002) after 1 week of incubation. In long-term culture (LTC), in the presence of stroma. the normal adherent cells did not produce significant numbers of CFU-GM until 3-4 weeks later which suggests that stromal cells reduce the probability of quiescent cell activation. This effect could not be attributed to soluble inhibitory factors and was specific to stroma grown with, rather than without, methylprednisolone. It was blocked by heparanase (H'ase) II treatment of stromal cells, by phosphatidylinositol-specific phospholipase C (PI-PLC) treatment of progenitor cells, by antibody blocking of beta1 integrin molecules or by exposure to glucose/N-acetyl-D-glucosamine/alpha-methyl-D-mannoside, but not by exposure to galactose or fructose. Moreover, these interventions enabled the progenitor cells to respond to stimulatory factors in the culture supernatant. We interpret these results as support for a model involving primitive progenitor cell binding to stroma by PI-CAM/HS, beta1 integrin activation via lectin-like interactions and the transduction of signals which reduce the ability of primitive cells to respond to ambient stimulators. This model provides a mechanism for the maintenance of the quiescent state of stem cells by adhesion to stromal cells.     

Impact of control measures on the course of an outbreak of methicillin-resistant Staphylococcus aureus

BACKGROUND: Outbreaks of nosocomial infection by methicillin resistent Staphylococcus aureus (MRSA) are a problem in many hospitals with the control measures to be adopted being controversial. An outbreak of MRSA in a 550-bed university hospital is herein described and the impact of the adopted control measures on the evolution of the epidemic in the general hospitalization area (GHA) was analyzed. PATIENTS AND METHODS: The adopted control measures in the GHA were: microbiologic surveillance, cutaneous isolation measures, treatment of nasal carrier, and the early discharge of the cases. Hand washing was reinforced and a study of carriers was carried out on detection of sporadic cases (not related to the ICU). A molecular study of 70 strains of MRSA was performed with analysis of total plasmids, plasmid restriction pattern and chromosomic DNA analysis by pulsed field gel electrophoresis (PFGE). RESULTS: From December 1990 to December 1993, 273 cases of MRSA were reported. One hundred seventy-two cases originated in the ICU and 101 cases in the GHA (sporadic cases). The incidence of MRSA in 1991-1993 was 13.6, 14.3, and 6.6% in the ICU and 0.17, 0.36, and 0.15% in the GHA, respectively. Molecular study of MRSA isolates (1991 and 1992) demonstrated two plasmid and two chromosomic patterns. The latter had a similarity coefficient > 0.90, probably belonging to the same "clone". CONCLUSIONS: Despite the control measures adopted in the GHA the outbreak of MRSA originated in the ICU thereafter extending to the GHA. The rates of colonization detected, however, remained stable during the 3 years studied. On the other hand, the observation of a single "clone", responsible for the epidemic, suggest that most of the sporadic cases were autoctonous and due to failure in fulfillment of the established norms.     

Rapid detection of epidemic strains of methicillin-resistant Staphylococcus aureus

Fifty methicillin-resistant Staphylococcus aureus (MRSA) initial isolates obtained from patients hospitalized in the orthopedic clinic of the Frankfurt University Hospital and 150 methicillin-sensitive Staphylococcus aureus (MSSA) isolates were investigated in this study to determine whether the Slidex Staph-Kit is capable of differentiating between MRSA and MSSA owing to its unique performance characteristics. The Slidex Staph-Kit is a combined latex hemagglutination test designed to detect clumping factor, protein A, and a specific surface immunogen for S. aureus. Clumping factor-positive strains cause erythrocytes sensitized with fibrinogen to hemagglutinate, thereby resulting in visible red clumps. S. aureus strains deficient in clumping factor agglutinate latex particles sensitized with specific antibodies against surface proteins of S. aureus, thereby resulting in visible white clumps. Our results demonstrate that white clumping has a 99% specificity as well as a 98% positive predictive value for MRSA. Clumping factor-negative MRSA, which have been reported to occur in several countries, are epidemic in the Frankfurt area and account for 80% of all MRSA initial isolates in the orthopedic clinic of the Frankfurt University Hospital. Genotyping of all MRSA isolates by macrorestriction analysis of chromosomal DNA revealed that 83% of clumping factor-negative MRSA are closely related to the "southern-German" epidemic strain. This is the first study demonstrating the Slidex Staph-Kit's capability for identifying epidemic clumping factor-negative S. aureus strains as methicillin resistant even prior to antimicrobial susceptibility testing.     

Intercontinental spread of a multidrug-resistant methicillin-resistant Staphylococcus aureus clone

Two hundred ten methicillin-resistant Staphylococcus aureus (MRSA) isolates recovered between 1990 and 1997 from three Portuguese hospitals located in Lisbon and Oporto were analyzed by molecular fingerprinting techniques. The hybridization of ClaI restriction digests with the mecA- and Tn554-specific DNA probes combined with pulsed-field gel electrophoresis documented the abrupt appearance and extensive intrahospital spread of the Brazilian epidemic MRSA clone in the 1995 samples of each one of the three hospitals analyzed-suggesting the intercontinental transfer of this strain from Brazil to Portugal. The appearance of this clone may challenge the dominance of another highly epidemic imported clone-the Iberian MRSA, currently the most widely spread MRSA clone in Portuguese hospitals.     

A molecular epidemiologic study of methicillin-resistant Staphylococcus aureus infection in patients undergoing middle ear surgery

The incidence of methicillin-resistant Staphylococcus aureus (MRSA) infections after middle ear surgery has recently increased at our hospital. Most of these infections were thought to be hospital-acquired when medical personnel in contact with an MRSA-infected patient may have inadvertently transmitted the pathogen to other patients. To prevent further transmission it is essential that such sources of MRSA infection and transmission routes be selected out and eradicated. Therefore, it is necessary to determine whether the strains of MRSA isolated from infected patients are identical to those obtained from medical personnel in order to prove a reciprocal transmission of organisms between medical personnel and patients. Surveillance bacterial cultures from the anterior nares and hands of medical personnel working in the Department of Otolaryngology, Korea University Guro Hospital, were performed at two different time points: 6 December 1994 and 17 June 1996. Ribotyping with Southern blot technique was used to compare 12 MRSA strains from medical carriers with 60 strains identified from the otorrhea of MRSA-infected patients undergoing middle ear surgery. As results, six different MRSA strains were identified (types I, II, III, IV, V and VI) from ribotyping with EcoR1. One distinct subtype, type I strain, was the most frequently identified strain in both medical carriers and patients. Results also showed that 6 MRSA isolates from 10 medical carriers and 20 from 30 patients contained type I ribotype at first culture. Two medical carriers' isolates and 13 isolates from 30 patients shared the same type I strain at the second surveillance culture. In all, 41 out of 72 MRSA strains (56.9%) shared an identical ribotype pattern. Postoperative MRSA infection rates after treatment of medical carriers and the application of rigorous preventive procedures decreased from 11.9 to 5.7% after first culture and 9.0 to 7.7% following second cultures. These findings confirm that MRSA transmission can occur between medical personnel and patients and that effective preventive measures can reduce the postoperative infection rate.     

Clonal heterogeneity, distribution, and pathogenicity of methicillin-resistant Staphylococcus aureus

Four thousand eighty-eight Staphylococcus aureus isolates obtained from patients hospitalised in a university clinic and four community hospitals over a period of one year were screened for methicillin resistance. A resistance rate of 5% was detected among initial isolates. Distribution of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive Staphylococcus aureus showed an increased prevalence of MRSA in clinically significant specimens such as blood, central venous catheter tips, bronchial secretions, and wound secretions. Typing of 110 MRSA strains (initial isolates) by macrorestriction analysis of chromosomal DNA revealed 26 different genotypes that could be divided into five epidemic and 21 sporadic strains. More than 50% of all isolates belonged to one type that was confirmed to be closely related to the "southern-German" epidemic strain. Production of virulence factors such as enterotoxin A-D and toxic shock syndrome-toxin 1 among MRSA strains (initial isolates) occurred in ten of 26 different MRSA types. A strong correlation between genotype and toxin production was demonstrated.     

Mixed pulmonary infection with Nocardia, Candida, methicillin-resistant Staphylococcus aureus, and group D Streptococcus species

A 67-year-old man on prednisolone and azathioprine for ulcerative colitis, developed severe pneumonia due to Nocardia otitidis caviarum, methicillin-resistant Staphylococcus aureus, a group D Streptococcus and Candida albicans. The patient responded well to aggressive antimicrobial therapy.     

Examination of methicillin-resistant and methicillin-susceptible Staphylococcus aureus mutants with low-level fluoroquinolone resistance

For Staphylococcus aureus, stepwise mutations result in high-level quinolone resistance. Methicillin-resistant and -susceptible quinolone-resistant, first-step mutants generated in vitro were obtained and found to be no different than those recovered from murine abscesses. Approximately 10% of all first-step mutants were resistant to ethidium bromide, and selected strains had mutations that mapped to flqB. NorA-mediated resistance among first-step mutants may be more prevalent than previously reported.     

Contrasting methicillin-resistant Staphylococcus aureus colonization in Veterans Affairs and community nursing homes

OBJECTIVE: Effects of a 6-day snow skiing trip on 14 adolescents with limb deficiencies were explored. The purpose was to determine whether components of mastery and self-esteem could be identified. METHOD: Participant observation data collection methods included videotape, interviews, daily progress notes by ski instructors, and a 1-month posttrip questionnaire. Data were analyzed for evidence of efficiency, effectiveness, and satisfaction to self and others (properties of relative mastery described in occupational adaptation.) Skier reports of positive effects were analyzed for indications of an impact on self-esteem. Three occupational therapists who have extensive experience working with adolescents also reviewed videotapes and written information. RESULTS: The therapists acknowledged the presence of skill mastery as an important component of skiers' positive self-evaluation. They also commented that evidence of preexisting self-esteem and social aspects of the trip were as likely to produce positive effects as mastery of skiing. CONCLUSION: Research method considerations (use of participant observation for hypothesis testing) preclude definitive interpretation of a link between skill mastery and self-esteem. Short-term positive effects of the skiing experience reported by questionnaire were present 1 month after the trip. Long-term effects should be studied.     

Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk

OBJECTIVE: To assess the factors that predict operative mortality after intestinal infarction, and show what effect referral patterns have on mortality. DESIGN: Retrospective study. SETTING: Two university departments of surgery, France. SUBJECTS: 144 patients with intestinal infarctions operated on between January 1980 and August 1995. INTERVENTIONS: Univariate and multivariate analyses. MAIN OUTCOME MEASURES: Operative mortality and the factors associated with it. RESULTS: Operative mortality was 67% (96/144) during the first 45 days postoperatively. The univariate analysis showed that age over 75 years (p=0.0002), female sex (p=0.007), the presence of shock (p < 0.0001), and referral from cardiovascular medical or surgical unit (p=0.01) were significantly associated with mortality. However, the multivariate analysis reduced these to extent of infarction (p=0.0001), the presence of shock (p=0.0002), age over 75 years (p=0.0001), and recent cardiac or vascular operation (p=0.03). CONCLUSIONS: The influence of referral pattern was related to previous cardiac or vascular operation, and the risk among women to the fact that their age was 10 years older than that of men. This study shows how the type of referral may explain the wide variations in reported mortality. To compare published series, care should be taken to avoid any selection bias.     

Vancomycin-gentamicin synergism revisited: effect of gentamicin susceptibility of methicillin-resistant Staphylococcus aureus

Vancomycin monotherapy of deep-seated staphylococcal infection may be associated with poor bacteriological response. We evaluated 24 unique patient isolates of methicillin-resistant Staphylococcus aureus (MRSA) for vancomycin-gentamicin synergism by determining time-kill curves for vancomycin at 10 micrograms/ml and gentamicin at 1 microgram/ml. Nine MRSA strains showed high-level gentamicin resistance (HLGR) (MIC, > 500 micrograms/ml), and 15 did not. Vancomycin-gentamicin demonstrated synergism against none of the HLGR strains. For the non-HLGR strains, gentamicin agar dilution MICs ranged from 0.5 to > 128 micrograms/ml. Vancomycin-gentamicin demonstrated synergism against six of these strains and indifference against nine of them. There was no relationship between the agar dilution MIC of gentamicin and the occurrence of synergism against non-HLGR strains. We conclude that a gentamicin MIC of > 500 micrograms/ml predicts a lack of vancomycin-gentamicin synergism for strains of MRSA. For non-HLGR strains, synergism is not predictable from the gentamicin MIC.     

Spread of methicillin-resistant Staphylococcus aureus. Are our hygienic precautions sufficient?

A patient was transferred from Pakistan to a Danish orthopaedic ward. In Denmark he was tested MRSA-positive. Two months after he was discharged, similar MRSA strains were found in another patient. The two patients had been on the same ward for one week. All hygienic precautions had been taken. Staff and other patients on the ward at the relevant time all tested MRSA-negative.     

Influences of type and duration of antimicrobial prophylaxis on an outbreak of methicillin-resistant Staphylococcus aureus and on the incidence of wound infection

Pneumothorax corresponds to the extravasation of air in the pleural cavity. This produces a partial or complete collapse of the adjacent lung. This is a common thorax disease resulting from a leak between the broncho-pulmonary gas compartment and the usually virtual pleural space. Pneumothorax is called spontaneous when no traumatic or iatrogenic factors are present. Spontaneous pneumothorax can be primary (when no radiographic or clinical injuries can be detected) or secondary to an underlying pulmonary disorder. Evolution of spontaneous pneumothorax is usually benign. However, recurrence is frequent. Preventing recurrences is the basis of all the therapeutic controversies which, after drainage, are based on pleurodesia indications. Vital prognosis may be compromised when pneumothorax is compressive, bilateral, or when it results in respiratory failure in patients with chronic respiratory insufficiency.