Community-associated methicillin-resistant Staphylococcus aureus, Switzerland.Two case-control studies evaluated the prevalence of community-associated methicillin-resistant Staphylococcus aureus methicillin-resistant Staphylococcus aureus Methicillin-aminoglycoside resistant Staphylococcus aureus, MRSA An organism with multiple antibiotic resistances–eg, aminoglycosides, chloramphenicol, clindamycin, erythromycin, rifampin, tetracycline, (CA-MRSA CA-MRSA Community Acquired Methicillin-Resistant Staphylococcus Aureus ) carriage at hospital admission and characteristics of patients with CA-MRSA. Among 14,253 patients, CA-MRSA prevalence was 0.9/1,000 admissions. Although 5 CA-MRSA isolates contained Panton-Valentine leukocidin Panton-Valentine leukocidin a nonhemolytic toxin produced by Staphylococcus aureus which kills segmented neutrophils and macrophages. , only 1 patient had a previous skin infection. No easily modifiable risk factor for CA-MRSA was identified. ********** Recently, new strains of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA), which cause soft tissue infections in healthy people, have been detected worldwide (1). The unique molecular feature of these CA-MRSA strains consists of 2 particular genetic elements, the type IV staphylococcal staphylococcal pertaining to Staphylococcus spp. staphylococcal clumping test used as a means of measuring the quantity of fibrinogen-split products in a sample of blood. cassette chromosome (SCC SCC - strongly connected component ) mec element and a virulence gene encoding a leukocyte-killing toxin called Panton-Valentine leukocidin (PVL PVL Periventricular Leukomalacia PVL Prevail PVL Parameter Value Language PVL Pade Via Lanczos (circuit modeling) PVL Physical Volume Library PVL Pascack Valley Line (New Jersey Transit commuter rail line) ), not found in hospital-acquired MRSA MRSA Methicillin-resistant Staphylococcus aureus. See MARSA. isolates (1). Risk factors for CA-MRSA carriage are incompletely understood. Although antimicrobial drug use is well recognized as risk factor for hospital-acquired MRSA (2), results of previous investigations have been inconsistent regarding the association between previous antimicrobial drug use and acquisition of CA-MRSA (3,4). Recently, 2 studies from North America North America, third largest continent (1990 est. pop. 365,000,000), c.9,400,000 sq mi (24,346,000 sq km), the northern of the two continents of the Western Hemisphere. have suggested that recent antimicrobial drug use plays a role in CA-MRSA colonization (5,6). Few systematic studies have assessed the epidemiology of CA-MRSA in Europe (7). Determining the epidemiology of CA-MRSA could help develop control measures and guide clinicians in identifying patients at high risk for CA-MRSA. Therefore, our prospective investigation sought to 1) determine the prevalence of CA-MRSA on hospital admission, 2) examine characteristics of patients carrying CA-MRSA, 3) test the hypothesis that previous antimicrobial drug exposure is associated with CA-MRSA carriage, and 4) evaluate the genetic diversity of CA-MRSA strains. The Study Details of this prospective, observational study In statistics, the goal of an observational study is to draw inferences about the possible effect of a treatment on subjects, where the assignment of subjects into a treated group versus a control group is outside the control of the investigator. have been presented elsewhere (8). In brief, the study population consisted of 14,253 patients who were screened for MRSA carriage on admission to the Geneva Geneva, canton and city, Switzerland Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva. University Hospitals between January 20, 2003, and August 31,2003. Of these patients, 12,072 (85%) were hospitalized in the adult wards, 102 (1%) in pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children. pe·di·at·ric adj. Of or relating to pediatrics. wards, and 361 (2%) in psychiatric wards; 1,718 (12%) were seen in the emergency room and were discharged within 24 hours. MRSA screening was performed by nasal and inguinal inguinal /in·gui·nal/ (in´gwi-n'l) pertaining to the groin. in·gui·nal adj. 1. Of or located in the groin. 2. swab samples, and cultures of specimens from other sites were performed when clinically indicated. A person fulfilled the CA-MRSA case definition if 1) the person had an MRSA isolate that yielded a SCCmec type different from the prevailing hospital-associated strain in the Geneva region (SCCmec type I [9]) and 2) the person had not been hospitalized within the last 3 years (3). We performed 2 case-control studies. The first control group comprised all patients with MRSA carriage identified on admission who did not fulfill our case-definition of CA-MRSA. If a patient was admitted more than once during the study period, only the first admission was included in this analysis. The second control group consisted of a group of randomly selected MRSA-negative patients. The following potential risk factors for CA-MRSA carriage were documented: age, sex, origin of patient, coexisting conditions, severity of underlying illness, functional status, patient's prior location, presence of skin lesions Skin Lesions Definition A skin lesion is a superficial growth or patch of the skin that does not resemble the area surrounding it. Description Skin lesions can be grouped into two categories: primary and secondary. , and antimicrobial drug use within the past 6 months. MRSA was identified according to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. NCCLS NCCLS National Committee for Clinical Laboratory Standards guidelines (10). Typing of SCCmec elements and detection of PVL genes were carried out as described (9). A novel multiplex polymerase chain reaction polymerase chain reaction (pŏl`ĭmərās') (PCR), laboratory process in which a particular DNA segment from a mixture of DNA chains is rapidly replicated, producing a large, readily analyzed sample of a piece of DNA; the process is (PCR PCR polymerase chain reaction. PCR abbr. polymerase chain reaction Polymerase chain reaction (PCR) ) based assay was used for rapid genotyping of S. aureus The aureus (pl. aurei) was a gold coin of ancient Rome valued at 25 silver denarii. The aureus was regularly issued from the 1st century BC to the beginning of the 4th century AD, when it was replaced by the solidus. isolates (11). This assay is based on variable-number tandem repeat This is a term from genetics, which describes a pattern that helps determine an individual's inherited traits. Tandem repeats and variable number tandem repeats in DNA occur when a pattern of two or more nucleotides is repeated and the repetitions are directly adjacent to typing (12) and has been modified to allow high throughput and automated analysis. In addition, 13 CA-MRSA isolates, 2 hospital-acquired MRSA isolates, and 2 references strains from the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. were genotyped by multilocus sequence typing Multilocus sequence typing (MLST) is a technique in molecular biology for the typing of multiple loci. The procedure characterizes isolates of bacterial species using the DNA sequences of internal fragments of multiple (usually seven) housekeeping genes. (MLST MLST Multi Locus Sequence Typing MLST Medical Logistics Support Team MLST Mini Losi Super Truck (1/18th scale radio control vehicle) ) (13). PCR products were sequenced with an ABI Abi (ā`bī) [short for Abijah], in the Bible, King Hezekiah's mother. (Application Binary Interface) A specification for a specific hardware platform combined with the operating system. Prism 3100 DNA sequencer A DNA sequencer is an instrument used to automate the DNA sequencing process. DNA sequencers have become more important due to large genomics projects and the need to increase productivity. (Applied Biosystems Applied Biosystems, Inc. (formerly NASDAQ: ABIO) is the original name of a pioneer biotechnology company founded in 1981 in Foster City, California, among the Silicon Valley cities of the southern San Francisco Bay Area. , Foster City, CA, USA). Allele allele (əlēl`): see genetics. allele Any one of two or more alternative forms of a gene that may occur alternatively at a given site on a chromosome. numbers were assigned according to the program available from the MLST Web site (http://www.mlst.net). We used the Student t test to compare continuous variables and the chi-square test chi-square test: see statistics. or Fisher exact test to compare proportions. Univariate comparisons were performed to determine characteristics of CA-MRSA patients. Data were analyzed with STATA, version 8.0 (Stata Corp, College Station, TX, USA). During January through August 2003, 428 of 14,253 screened patients were discovered to be MRSA carriers on admission (prevalence 3.0%). Most MRSA isolates belonged to the type I cassette (n = 371, 26/1,000 admissions). MRSA SCCmec type IV was recovered in 46 patients (3.2/1,000 admissions), whereas types II, III and V were only rarely identified (n = 11). Thirty-seven of 46 patients (80%) with SCCmec type IV isolates had previous contact with the healthcare system, in particular with hospitals in neighboring France. Thirteen patients fulfilled our case definition for having CA-MRSA (prevalence 0.9/1,000 admissions). The prevalence of CA-MRSA varied according to the hospital sector: it was highest in pediatric patients (9.8/1,000), followed by adult outpatients staying <24 hours (1.7/1,000) and adult inpatients (0.7/1,000). Important features of the 13 CA-MRSA cases are shown in the Table. Six CA-MRSA patients lived outside Switzerland: Kosovo (n = 2), France (n = 1), Senegal (n = 1), Madagascar (n = 1), and Libya (n = 1). Ten CA-MRSA isolates harbored the SCCmec type IV, 2 the type V, and 1 the type II element (Figure). All CA-MRSA isolates were susceptible to trimethoprim-sulfamethoxazole, clindamycin, and vancomycin vancomycin (văn'kōmī`sĭn), antibiotic resembling penicillin in the way it acts. It is derived from the bacterium Streptomyces orientalis, which was isolated from soil of India and Indonesia. . Two isolates (SCCmec type V) were resistant to gentamicin gentamicin /gen·ta·mi·cin/ (jen?tah-mi´sin) an aminoglycoside antibiotic complex isolated from bacteria of the genus Micromonospora, ; 2 other isolates (SCCmec type IV) showed resistance to fluoroquinolones; and 1 (SCCmec type II) was resistant to macrolides. Although 5 (38%) of 13 CA-MRSA isolates possessed the pvl gene, only 1 patient had a skin infection on admission. The other 4 patients had no history of infection. Genetic analysis combining genotyping and MLST showed substantial diversity among CA-MRSA isolates (Figure). In particular, they were not related to the nosocomial nosocomial /noso·co·mi·al/ (nos?o-ko´me-il) pertaining to or originating in a hospital. nos·o·co·mi·al adj. 1. Of or relating to a hospital. 2. strain endemic in the Geneva hospital setting (strains B5-63 and B5-64). Dendrogram A dendrogram is a tree diagram frequently used to illustrate the arrangement of the clusters produced by a clustering algorithm (see cluster analysis). Dendrograms are often used in computational biology to illustrate the clustering of genes. analysis identified 2 closely related CA-MRSA isolates from patients living in Geneva (strains B2-55 and B3-11) who had never been hospitalized and had no apparent epidemiologic link. The pattern of 1 CA-MRSA isolate (B2-19), from a 38-year-old Geneva woman who used injection drugs, was related to the MW2 strain from North Dakota. MLST of CA-MRSA isolates identified 7 sequence types (ST-1, -5, -8, -45, -80, -88, and -152), belonging to patients from different geographic origins (Figure). Five strains represented 2 distinct ST clones (ST-45 and ST-152) previously described in northern Europe and Israel; 1 isolate was related to the prototype CA-MRSA strain MW2 (ST-1); and 2 isolates corresponded to a clone reported from Asia (ST-88). The largest cluster contained strains previously described from several continents, including French clone ST-8, Mediterranean clone ST-80, and the international, so-called pediatric clone ST-5 (SCCmec type IV). Patients with CA-MRSA differed in several ways from those who carried healthcare-associated MRSA (n = 346) and those who were free of MRSA on admission (n = 1,542, Table). Patients with CA-MRSA were younger and more likely to have a permanent residency outside Switzerland. Compared to non-MRSA controls, no significant differences were noted in previous outpatient antimicrobial drug use and presence of coexisting conditions (Table). By contrast, CA-MRSA patients had fewer coexisting conditions and less prior exposure to antimicrobial drugs than patients with healthcare-associated MRSA. The presence of skin lesions on admission was not predictive of CA-MRSA carriage. Conclusions This study provides information about the epidemiology of CA-MRSA on admission to the largest hospital in Switzerland. It showed 1) a low prevalence of CA-MRSA, 2) a reservoir of asymptomatic persons colonized Colonized This occurs when a microorganism is found on or in a person without causing a disease. Mentioned in: Isolation with PVL-containing CA-MRSA strains, 3) a high degree of CA-MRSA diversity, and 4) no readily modifiable risk factor for CA-MRSA carriage. Several investigators have recently attempted to describe the epidemiology of CA-MRSA more precisely (5,14). These study findings are not consistent since they were conducted in different settings and used various case definitions (3). Typically, most studies used an epidemiologic case definition that excluded patients with recent healthcare system contact in whom MRSA was detected within 48 hours after hospital admission (15). This type of study, however, cannot prove that MRSA acquisition was unrelated to healthcare system contact. Therefore, how to define true community-acquired MRSA remains controversial. Although we added a molecular component to increase the validity of our case definition, we used the more conservative term "community-associated'" MRSA, since we cannot exclude the fact that CA-MRSA case-patients may have previously been in contact with outpatient care or hospitalized family members. Described risk factors associated with CA-MRSA infection include intravenous drug use intravenous drug use Intravenous drug abuse The habitual IV injection of drugs of abuse Epidemiology In the US ± 2.5 million–population ± 235 million have used IVDs Infections Pyogenic–eg, endocarditis, pneumonia, sepsis Common agents , military training, jail exposure, team sport activities, homosexuality, low socioeconomic class, and being member of a "closed population" such as Native Americans and Australian aborigines (5,6). Two recent analyses found an increased risk in patients exposed to antimicrobial drugs (5,6). Our study did not confirm this hypothesis, making it unlikely that antimicrobial drug control measures will substantially decrease transmission of CA-MRSA. Control of CA-MRSA remains a challenge, since transmission is linked to migration and travel (16). Our study showed that the ratio of 4:1 between colonization and infection with CA-MRSA possessing the pvl gene was larger than previously thought. Restricting surveillance to infected carriers will underestimate the prevalence of PVL-producing CA-MRSA. Thus, CA-MRSA surveillance should not rely on clinical specimens alone. Several study limitations merit consideration. First, we may have underestimated CA-MRSA prevalence since our study was not truly population-based. Second, we may have misclassified CA-MRSA cases. Thorough review of medical charts minimized this potential bias. Finally, we were not able to elucidate the route of transmission for those CA-MRSA carriers living in the Geneva community. MLST results suggest that nonendemic hospital strains may already circulate in the Geneva community. In summary, the prevalence of CA-MRSA remains relatively low in our community. Yet migration will likely increase CA-MRSA carriage in the near future. This development will influence clinical practice by changing the choice of empiric antimicrobial drug therapy for severe skin and soft tissue infections.
Table. Characteristics of patients with community-associated,
methicillin-resistant Staphylococcus aureus (CA-MRSA), compared
to those of patients without MRSA and patients with
healthcare-associated MRSA
Patients
Patients with without MRSA
CA-MRSA (n = 1,542)
Characteristic (n = 13) (%) (%)
Mean age (y [+ or -] SD) 45 [+ or -] 25 70 [+ or -] 18
Male sex 6 (46) 682 (44)
Residency outside Switzerland 6 (46) 10 (1)
Healthcare worker 0 (0) 31 (2)
Emergency admission 9 (69) 724 (48)
Severity of disease
Presence of [greater than or 8 (62) 1,082 (70)
equal to] coexisting condition
Rapidly or ultimately fatal 0 277 (18)
disease
Complete dependence for daily 0 114 (7)
activities
Antimicrobial drug exposure
Previous exposure (<6 mo) 1 (8) 318 (21)
Current use at admission 3 (23) 148 (10)
Presence at admission of indwelling 0 73 (5)
urinary catheter
Open skin lesions 2 (15) 100 (6)
Patients with
healthcare-
associated MRSA
Characteristic p value * (n = 346) (%)
Mean age (y [+ or -] SD) <0.001 75 [+ or -] 15
Male sex 1.0 199 (58)
Residency outside Switzerland <0.001 8 (2)
Healthcare worker 1.0 3 (1)
Emergency admission 0.17 166 (48)
Severity of disease
Presence of [greater than or 0.55 289 (84)
equal to] coexisting condition
Rapidly or ultimately fatal 0.11 95 (27)
disease
Complete dependence for daily 0.62 57 (16)
activities
Antimicrobial drug exposure
Previous exposure (<6 mo) 0.49 197 (57)
Current use at admission 0.13 41 (12)
Presence at admission of indwelling 1.0 64 (19)
urinary catheter
Open skin lesions 0.21 65 (19)
p value
Characteristic ([dagger])
Mean age (y [+ or -] SD) <0.001
Male sex 0.57
Residency outside Switzerland <0.001
Healthcare worker 1.0
Emergency admission 0.16
Severity of disease
Presence of [greater than or 0.05
equal to] coexisting condition
Rapidly or ultimately fatal 0.02
disease
Complete dependence for daily 0.24
activities
Antimicrobial drug exposure
Previous exposure (<6 mo) <0.001
Current use at admission 0.21
Presence at admission of indwelling 0.14
urinary catheter
Open skin lesions 1.0
* Community-associated MRSA case-patients versus non-MRSA controls.
([dagger]) Community-associated MRSA case-patients versus controls
with healthcare-associated MRSA strains (SCCmec type I isolates).
Figure. Analysis of genotyping patterns,
multilocus sequence typing (ST) results,
presence of Panton-Valentine leukocidin
(PVL), staphylococcal cassette chromosome
mec (SCCmec) type, and country of
patient origin of 13 community-associated,
methicillin-resistant Staphylococcus aureus
isolates (CA-MRSA). The dendrogram illustrates
the genetic relatedness of the 13 CA-MRSA
in comparison to 1) 2 nosocomial
MRSA isolates representing the prevailing
endemic strain in the Geneva healthcare
setting (strains B5-63, B5-64) and to 2) profiles
obtained for strains MW2 and
HT20030642 from the United States, 2
closely related CA-MRSA isolates used as
controls.
ST PVL SCCmec Patient Origin
[ILLUSTRATION 45 - IV Switzerland
OMITTED] 45 - IV Switzerland
45 - IV Switzerland
1 + IV Switzerland
1 + IV USA
1 + IV USA
8 - IV Switzerland
5 - IV Switzerland
80 + IV Lybia
228 - I Switzerland
228 - I Switzerland
5 - II Switzerland
80 + IV France
88 - IV Senegal
88 - IV Madagaskar
152 + V Kosovo
152 + V Kosovo
Acknowledgments We thank the many staff members of the University of Geneva The University of Geneva (Université de Genève) is a university in Geneva, Switzerland. It was founded by John Calvin in 1559. Initially a theological seminary, it also taught law. Hospitals and the Infection Control Program who contributed to this study. In particular, G. Renzi, S. Longet, J. Alvarin, A. Agostinho, and M. Bento A data structure used to store embedded documents in an OpenDoc compound document. Bento, which stands for lunch box in Japanese, provides a "container" to hold the data and a format for defining its contents. made major contributions to this project: J. Etienne (Lyon. France) provided control strains MW2 and HT2003-0642. This work was supported by grants from the Swiss National Science Foundation The Swiss National Science Foundation is a science research support organization mandated by the Swiss Federal Government. The SNSF was established in 1952 as a foundation under private law. Its secretariat is based in Berne. nos. 404940-106296/1 (PF), 632-057950.99, PP00B--103002/1 (JS), and from the University of Geneva Hospitals, Research Program CI 70903. This study used the Multilocus Sequence Typing website (http://www.mlst.net) developed by Man-Suen Chan and David Anaensen and funded by the Wellcome Trust. This study was presented in part at the 44th Interscience Conference on Antimicrobial Agents and Chemotherapy Antimicrobial Agents and Chemotherapy (print-ISSN 0066-4804, CODEN AMACCQ; canceled ISSN 0074-9923, canceled CODEN AACHAX) is an academic journal published by the American Society for Microbiology. , Washington, D.C., USA, October 2004 (abstract L-355). References (1.) Vandenesch F, Naimi T, Enright MC, Lina G, Nimmo GR, Heffernan H, et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence. Emerg Infect Dis. 2003;9:978-84. (2.) Harbarth S, Liassine N, Dharan S, Herrault P, Auckenthaler R, Pittet D. Risk factors for persistent carriage of methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 2000;31:1380-5. (3.) Salgado CD, Farr BM, Calfee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis. 2003;36:131-9. (4.) Campbell KM, Vaughn AF, Russell KL, Smith B, Jimenez DL, Barrozo CP, et al. Risk factors for community-associated methicillin-resistant Staphylococcus aureus infections in an outbreak of disease among military trainees in San Diego, California “San Diego” redirects here. For other uses, see San Diego (disambiguation). San Diego is a coastal Southern California city located in the southwestern corner of the continental United States. As of 2006, the city has a population of 1,256,951. , in 2002. J Clin Microbiol. 2004;42:4050-3. (5.) Baggett HC, Hennessy TW, Rudolph K, Bruden D, Reasonover A, Parkinson A, et al. Community-onset methicillin-resistant Staphylococcus aureus associated with antibiotic use and the cytotoxin cytotoxin /cy·to·tox·in/ (si´to-tok?sin) a toxin or antibody having a specific toxic action upon cells of special organs. cy·to·tox·in n. Panton-Valentine leukocidin during a furunculosis furunculosis /fu·run·cu·lo·sis/ (fu-rung?ku-lo´sis) 1. the persistent sequential occurrence of furuncles over a period of weeks or months. 2. the simultaneous occurrence of a number of furuncles. outbreak in rural Alaska. J Infect Dis. 2004;189:1565-73. (6.) Ellis MW, Hospenthal DR, Dooley DP, Gray PJ, Murray CK. Natural history of community-acquired methicillin-resistant Staphylococcus aureus colonization and infection in soldiers. Clin Infect Dis. 2004;39:971-9. (7.) Grundmann H, Tami A, Hori S, Halwani M, Slack R. Nottingham Staphylococcus aureus Staphylococcus au·re·us n. A bacterium that causes furunculosis, pyemia, osteomyelitis, suppuration of wounds, and food poisoning. Staphylococcus aureus Staphylococcus pyogenes population study: prevalence of MRSA among elderly people in the community. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift . 2002;324:1365-6. (8.) Harbarth S, Schrenzel J, Fankhauser-Rodriguez C, Longet S, Sax H, Pittet D. Detecting the unrecognized reservoir of patients carrying methicillin-resistant Staphylococcus aureus at hospital admission [abstract K-1853]. Presented at the 441h Interscience Conference on Antimicrobial Agents and Chemotherapy, Washington, USA, November 2, 2004. Washington: American Society for Microbiology The American Society for Microbiology (ASM) is a scientific organization, based in the United States although with over 43,000 members throughout the world. It is the largest single life science professional organization and its members include those whose interests encompass basic ; 2004. (9.) Francois P, Renzi G, Pittet D, Bento M, Lew D, Harbarth S, et al. A novel multiplex real-time PCR assay for rapid typing of major staphylococcal cassette chromosome mec elements. J Clin Microbiol. 2004;42:3309-12. (10.) NCCLS. Performance standards for antimicrobial susceptibility testing. NCCLS document M100-S14. Wayne (PA): NCCLS; 2004. (11.) Francois P, Huyghe A, Charbonnier Y, Bento M, Herzig S, Topolski I, et al. Rapid and high throughput genotyping of Staphylococcus aureus isolates using an automated multiple-locus, variable number tandem repeat A variable number tandem repeats (VNTR) is a short nucleotide sequence ranging from 14 to 100 nucleotides long that is organized into clusters of tandem repeats, usually repeated in the range of between 4 and 40 times per occurrence. analysis. J Clin Microbiol. 2005. In press. (12.) Sabat A, Krzyszton-Russjan J, Strzalka W, Filipek R, Kosowska K, Hryniewicz W, et al. New method for typing Staphylococcus aureus strains: multiple-locus variable-number tandem repeat analysis of polymorphism polymorphism, of minerals, property of crystallizing in two or more distinct forms. Calcium carbonate is dimorphous (two forms), crystallizing as calcite or aragonite. Titanium dioxide is trimorphous; its three forms are brookite, anatase (or octahedrite), and rutile. and genetic relationships of clinical isolates. J Clin Microbiol. 2003;41:1801-4. (13.) Enright MC, Day NP, Davies CE, Peacock SJ, Spratt BG. Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J Clin Microbiol. 2000;38:1008-15. (14.) Dietrich DW, Auld auld adj. Scots Old. Adj. 1. auld - a Scottish word; "auld lang syne" old - of long duration; not new; "old tradition"; "old house"; "old wine"; "old country"; "old friendships"; "old money" DB, Mermel LA. Community-acquired methicillin-resistant Staphylococcus aureus in southern New England children. Pediatrics. 2004;113:e347-52. (15.) Kallen AJ, Driscoll TJ, Thornton S, Olson PE, Wallace MR. Increase in community-acquired methicillin-resistant Staphylococcus aureus at a naval medical center. Infect Control Hosp Epidemiol. 2000;21:223-6. (16.) Liassine N, Auckenthaler R, Descombes MC, Bes M, Vandenesch F, Etienne J. Community-acquired methicillin-resistant Staphylococcus aureus isolated in Switzerland contains the Panton-Valentine leukocidin or exfoliative ex·fo·li·a·tive adj. Marked by exfoliation, desquamation, or profuse scaling. toxin genes. J Clin Microbiol. 2004;42:825-8. Stephan Harbarth, * Patrice Francois, * Jacques Schrenzel, * Carolina Fankhauser-Rodriguez, * Stephane Hugonnet, * Thibaud Koessler, * Antoine Huyghe, * and Didier Pittet * * University of Geneva Hospitals, Geneva, Switzerland Dr. Harbarth is an associate hospital epidemiologist at the University of Geneva Hospitals, Geneva, Switzerland. His research interests include the prevention of healthcare-acquired infections and the epidemiology and control of emerging antimicrobial drug-resistant pathogens such as CA-MRSA. Address for correspondence: Stephan Harbarth, Infection Control Program, University of Geneva Hospitals, 1211 Geneva 14, Switzerland; fax: 41-22-372-3987; email: stephan.harbarth@hcuge.ch |
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