Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units.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 ) has rarely been reported in the hospital setting. We report an outbreak of 7 cases of skin and soft tissue infections due to a strain of CA-MRSA. All patients were admitted to the labor and delivery, nursery, or maternity units during a 3-week period. Genetic fingerprinting genetic fingerprinting
See DNA fingerprinting. showed that the outbreak strain was closely related to the USA 400 strain that includes the midwestern strain MW2. All isolates contained the 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. chromosome cassette mec type IV. Genes for Panton-Valentine leukocidin Panton-Valentine leukocidin
a nonhemolytic toxin produced by Staphylococcus aureus which kills segmented neutrophils and macrophages. and staphylococcal enterotoxin K were detected in all isolates, and most contained other enterotoxin enterotoxin /en·tero·tox·in/ (en´ter-o-tok?sin)
1. a toxin specific for the cells of the intestinal mucosa.
2. a toxin arising in the intestine.
3. genes. Testing of nearly 2,000 MRSA MRSA Methicillin-resistant Staphylococcus aureus. See MARSA. isolates collected during citywide surveillance studies from 1999 to 2003 showed that [approximately equal to] 1% were genetically related to MW2. CA-MRSA strain MW2 has been present in this region at least since 1999. This study documents the spread of this strain among healthy newborns at 1 hospital.
Methicillin-resistant Staphylococcus aureus (MRSA) is an established pathogen in most healthcare facilities. Recently, infections due to MRSA have been documented in children and adults who lack traditional risk factors (1-4). Most infections caused by these community-associated (CA) MRSA appear to involve the skin. However, these strains may occasionally cause pneumonia or death in previously healthy patients (5,6). In one of the initial reports of CA-MRSA, 4 deaths were reported in children infected with a prototypical strain designated MW2 (5).
Several lines of evidence suggest that the emerging CA-MRSA isolates are distinct from typical nosocomial nosocomial /noso·co·mi·al/ (nos?o-ko´me-il) pertaining to or originating in a hospital.
1. Of or relating to a hospital.
2. strains (7-9). First, CA-MRSA isolates are generally susceptible to non-[beta]-1actam antimicrobial agents and genetic fingerprinting suggests that they are unrelated to hospital-associated strains (7-9). CA-MRSA isolates possess a small (21- to 24-kb) and mobile staphylococcal chromosome cassette mec type IV (SCCmecIV)--encoding penicillin-binding protein (8). This gene cassette has been rarely found in contemporary healthcare-associated MRSA strains. Finally, most of these strains have genes that encode for multiple virulence factors, including Panton-Valentine leukocidin (PVL PVL Periventricular Leukomalacia
PVL Parameter Value Language
PVL Pade Via Lanczos (circuit modeling)
PVL Physical Volume Library
PVL Pascack Valley Line (New Jersey Transit commuter rail line) ) and superantigens (5,10).
Strains of CA-MRSA have recently caused infections in hospitalized neonates in the nonoutbreak setting (11). They have rarely been linked to nosocomial outbreaks. One report involving postpartum women documented hospital transmission of the strain MW2 (12). We describe an outbreak in a nursery and maternity unit involving the MW2 strain of CA-MRSA. The prevalence of strains resembling MW2 in Brooklyn, New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , is also reported.
Materials and Methods
Outbreak Investigation at Hospital A
From October to November 2002, a cluster of skin and soft tissue infections due to MRSA involving pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. and maternity patients occurred at a New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. hospital. The hospital has a labor and delivery unit and 2 units that house both healthy newborns and maternity patients. Healthcare workers on these units typically care for patients on all the units. After the outbreak was recognized, the following interventions were implemented: 1) nursing and medical personnel from the involved areas were informed of the outbreak and potential modes of transmission of staphylococci, 2) contact precautions were emphasized for all patients with suspected or proven skin infections, 3) alcohol-based hand sanitizers were placed in involved areas, 4) healthcare workers from involved units were screened for nasal MRSA colonization, and 5) environmental surfaces (including cord clamps, antitheft an·ti·theft
Designed to prevent theft: an antitheft automotive device. transponders, and temperature sensors of baby warmers) were tested for MRSA contamination. Healthcare workers colonized Colonized
This occurs when a microorganism is found on or in a person without causing a disease.
Mentioned in: Isolation with MRSA were treated with intranasal in·tra·na·sal
Within the nose. mupirocin and furloughed until repeat cultures were negative. To identify any other potential case-patients, letters concerning the outbreak were sent to pediatricians who cared for newborns discharged from the affected units during the outbreak period. Cases were defined as MRSA infections in patients who stayed on the labor and delivery, nursery, or maternity units at any time from October 2002 to December 2002. The medical records of the patients were reviewed for information regarding prior healthcare exposures, receipt of antimicrobial agents, underlying medical conditions, treatment, and clinical outcome.
Cultures related to the outbreak were grown on tryptic tryp·tic
Relating to or resulting from trypsin.
relating to or resulting from digestion by trypsin. soy agar plates supplemented with 3% sheep blood; colonies consistent with 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. were identified according to standard techniques. All isolates underwent susceptibility testing with the Etest method (AB Biodisk, Solna, Sweden). Ribotyping was performed with the Riboprinter Microbial microbial
pertaining to or emanating from a microbe.
the breakdown of organic material, especially feedstuffs, by microbial organisms. Characterization System (Qualicon, Wilmington, DE, USA), as previously noted (13). In addition, isolates of MRSA collected during the outbreak were fingerprinted by pulsed-field gel electrophoresis (PFGE PFGE Pulsed-Field Gel Electrophoresis ), as previously described (13). PFGE results were interpreted according to known criteria (14).
SCCmec typing was performed by using 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.
polymerase chain reaction
Polymerase chain reaction (PCR) ), under conditions described by Oliveira et al. (15). Primers to detect the mecA gene were included as an internal positive control (15). 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) ) was performed on selected isolates as described by Enright et al. (16). Bidirectional DNA sequencing of 7 amplified housekeeping genes was performed with an automated fluorescent dye-terminator sequencing system (Applied Biosystems, Foster City, CA, USA). Allelic al·lele
One member of a pair or series of genes that occupy a specific position on a specific chromosome.
[German Allel, short for Allelomorph, allelomorph, from English types were assigned by using the MLST database (available from www.mlst.net).
The presence of genetic sequences encoding several staphylococcal toxins was also investigated for the outbreak isolates. Based on the previously reported distribution of enterotoxins in CA-MRSA from the United States (7), the following toxins were selected for investigation: staphylococcal enterotoxin A (SEA), B (SEB Noun 1. SEB - a form of staphylococcal enterotoxin that has been used as an incapacitating agent in biological warfare
staphylococcal enterotoxin B ), C (SEe), H (SEH SEH Structured Exception Handling
SEH Societas Europaea Herpetologica
SEH Société d'Ecologie Humaine
SEH St Elizabeths Hospital (Anacostia, Washington, DC)
SEH Safety, Environment and Health
SEH St. ), and K (SEK SEK
In currencies, this is the abbreviation for the Swedish Krona.
The currency market, also known as the Foreign Exchange market, is the largest financial market in the world, with a daily average volume of over US $1 trillion. ). In addition, strains were screened for PVL and toxic shock syndrome toxic shock syndrome (TSS). acute, sometimes fatal, disease characterized by high fever, nausea, diarrhea, lethargy, blotchy rash, and sudden drop in blood pressure. It is caused by Staphylococcus aureus, an exotoxin-producing bacteria (see toxin). toxin-1 (TSST-1). Previously published primers and conditions were used to detect sequences encoding for SEA, SEB, SEe, SEH, PVL, and TSST-1 (17-19). Genes encoding for SEK were detected with the following primers: SEK forward: 5'-TGGATCAATGGAAATCACAAAA-3' and reverse: 5'-TTTGGTAGCCCATCATCTCC-3' (predicted product size 287 bp). The specificity of amplification was verified by bidirectional sequencing of the product.
The identification of MW2 in the outbreak of the neonatal-maternity unit prompted a retrospective investigation to determine the regional prevalence of MRSA resembling this strain. In 1999, 2001, and 2003, surveillance studies were performed in Brooklyn, New York. Each surveillance study involved collecting all single-patient isolates of S. aureus from clinical microbiology laboratories during a 3-month interval. Each study included 11-15 hospitals. Susceptibility testing was performed in the central research laboratory by using the agar dilution method according to NCCLS NCCLS National Committee for Clinical Laboratory Standards methodology (20). All MRSA isolates were then screened for a phenotype of susceptibility to clindamycin and ciprofloxacin ciprofloxacin /cip·ro·flox·a·cin/ (sip?ro-flok´sah-sin) a synthetic antibacterial effective against many gram-positive and gram-negative bacteria; used as the hydrochloride salt.
n. (typical for MW2). Isolates possessing this susceptibility pattern underwent ribotyping and SCCmec typing. The study was approved by the Institutional Review Board at the State University of New York (body) State University of New York - (SUNY) The public university system of New York State, USA, with campuses throughout the state. (SUNY SUNY - State University of New York ) Health Science Center and Maimonides Medical Center The Maimonides Medical Center is non-profit academic medical center in Brooklyn, New York. History
The institution was founded in 1911 as the New Utrecht Dispensary. .
Outbreak Investigation at Hospital A
From October 18 to November 28, 2002, a total of 8 patients with skin and soft tissue infections due to MRSA were identified. During this period, 3.5 cases of MRSA infection occurred each month in the nursery and maternity units. In contrast, no MRSA infections had been reported from the involved units in the 10 months before the outbreak. Two patients were mothers, and 6 were neonates; in no instance were both the mother and her child infected. All had been hospitalized on an involved unit at some point from October 16 to November 6, 2002. Review of medical records showed that none of the patients had prior hospital exposure, underlying chronic medical conditions, or recent antibiotic therapy.
Clinical manifestations of the infections are included in Table 1. None of the patients had evidence of infection upon admission to the hospital. The timing of hospitalization and onset of clinical symptoms are shown in Figure 1. Patients stayed on the unit for an average of 5 days (range 2-12 days). Clinical infection developed in 4 of the newborns and 1 mother while in the hospital. Symptoms developed in 2 newborns and 1 mother 2, 10, and 24 days, respectively, after discharge. [beta]-Lactam antimicrobial agents were initially administered for 6 patients. Definitive therapy generally consisted of topical or systemic antimicrobial agents active against MRSA; 1 patient required surgical drainage. All patients had clinical resolution of infection.
[FIGURE 1 OMITTED]
Two additional suspected cases were reported by pediatricians to the Infection Control Department. The first was in an infant, born in November 2002, who was seen as an outpatient for pustulosis; however, the site was not cultured. The second case involved another infant, also born in November 2002, who was readmitted to the hospital 4 days later for treatment of omphalitis. Multiple cultures yielded no growth. No additional cases were reported from December 10, 2002, to December 31, 2003.
Susceptibility testing showed that all 8 isolates were susceptible to clindamycin, ciprofloxacin, trimethoprim-sulfamethoxazole, rifampin rifampin (rĭfăm`pĭn), antibiotic used in the treatment of tuberculosis. It is also used to eliminate the meningococcus microorganism from carriers and to treat leprosy, or Hansen's disease. , doxycycline doxycycline /doxy·cy·cline/ (dok?se-si´klen) a semisynthetic broad-spectrum tetracycline antibiotic, active against a wide range of gram-positive and gram-negative organisms; used also as d. calcium and d. hyclate. , linezolid, and vancomycin. Of the 8 clinical isolates, 7 (isolates P1-P7) belonged to 1 ribotype that was identical to the prototypical MW2 strain (Figure 2). PFGE confirmed that the 7 isolates were identical and closely related to MW2 (Figure 2). All 7 contained SCCmec type IV. Since the 7 isolates appeared identical, MLST was performed on one of the isolates and showed sequence type 1. The PFGE and MLST pattern are the same as CA-MRSA clone USA 400, which also includes MW2 (21). Among these 7 isolates, all contained SEK and PVL, 6 contained SEC and SEH, and 5 contained SEA. None was found to have genes encoding SEB or TSST-1. The eighth clinical isolate, from a catheter-site infection, was distinct from the outbreak strain by ribotyping and PFGE (Figure 2). For this isolate, SCCmec was nontypable, and MLST typing confirmed a distinct allelic profile. None of the genes encoding toxins was detected.
[FIGURE 2 OMITTED]
A total of 189 healthcare workers worked on the involved units during the outbreak period. Screening cultures of the anterior nares were performed in 176 of the workers in November 2002. Three of the cultures were positive for MRSA, including 2 from the nursing staff and 1 from a pediatrician. The 3 MRSA strains possessed a susceptibility pattern typical for the multidrug-resistant hospital strains, with resistance to clindamycin and ciprofloxacin. They belonged to ribotypes distinct from the outbreak clone, and PFGE confirmed these isolates were unrelated to MW2 (Figure 2). For the 3 isolates, SCCmec was nontypable with the multiplex PCR method. None of the 27 environmental samples collected in November 2002 yielded positive cultures for MRSA.
A total of 4,345 isolates of S. aureus were collected in the 3 surveillance studies conducted in 1999, 2001, and 2003: susceptibility data for these isolates are given in Table 2. A total of 1,913 (44%) isolates were methicillin-resistant. Of the 1,913 MRSA isolates, 118 (6%) possessed the screened phenotype (susceptible to both clindamycin and fluoroquinolones). Among the 118 isolates, 40 different ribotypes were identified. A total of 11 isolates possessed the same ribotype pattern as the outbreak clone, MW2. Of the 11 isolates, 4 were known to come from children. One HIV-infected adult died of overwhelming sepsis within 24 hours of hospitalization. Sources of the cultures included skin and soft-tissue in 7 patients, blood/sterile body fluid in 3 patients, and the genital tract genital tract
The genital passages of the urogenital system.
The organs involved in reproduction. in 1 patient. Nine of the 11 isolates had SCCmecIV. The number of isolates resembling MW2 remained relatively constant during the 3 surveillances (4 in 1999, 3 in 2001, and 4 in 2003).
This report characterizes the nosocomial transmission of the CA-MRSA strain MW2 among healthy newborns and, possibly, a postpartum woman. Symptoms developed in 3 patients 2-24 days after hospitalization; 2 may have acquired the bacteria in the hospital or the community. An eighth patient, a mother with catheter-site infection, had an unrelated strain with a pattern suggestive of suggestive of Decision making adjective Referring to a pattern by LM or imaging, that the interpreter associates with a particular–usually malignant lesion. See Aunt Millie approach, Defensive medicine. a hospital-associated strain. The source of the outbreak and mechanism of transmission were not evident, as no cultures of staff members or the environment yielded this particular strain of MRSA. Transmission may have occurred after MW2 was introduced into the hospital by transient colonization of healthcare workers or by contamination of shared medical equipment. The infection control measures enacted in response to the initial cases may have had a role in controlling the outbreak. Widespread screening of healthcare workers for MRSA did not detect the outbreak strain in this and another report (12). While a potential role for this practice cannot be excluded, current evidence does not support routinely implementing widespread screening for CA-MRSA.
In the pediatric population, risk factors associated with MRSA infections include premature birth premature birth
Birth less than 37 weeks after conception. Infants born as early as 23–24 weeks may survive but many face lifelong disabilities (e.g., cerebral palsy, blindness, deafness). or low birth weight, chronic underlying diseases, prolonged hospitalization, invasive or surgical procedures, indwelling catheters, and prolonged use of antimicrobial agents (22-25). Outbreaks of S. aureus have been especially challenging in neonatal nursery units. Prior outbreaks involving the pandemic pandemic /pan·dem·ic/ (pan-dem´ik)
1. a widespread epidemic of a disease.
2. widely epidemic.
Epidemic over a wide geographic area.
n. strain phage phage: see bacteriophage.
phage - A program that modifies other programs or databases in unauthorised ways; especially one that propagates a virus or Trojan horse. See also worm, mockingbird. The analogy, of course, is with phage viruses in biology. type 80/81 were characterized by high colonization rates among infants discharged from nurseries and subsequent transmission to family members (26). In this report, infection developed in the outpatient setting for 2 patients (following an admission on the involved unit), which suggests carriage of MW2 from the hospital back into the community. Unrecognized CA-MRSA colonization during hospitalization could become an additional method of its dissemination in the community.
Increased prevalence of CA-MRSA has been reported in Chicago, Los Angeles, Texas, and Minnesota (2,3,27,28). In New York City, CA-MRSA appears less common; 1 investigation reported MRSA carriage in 0.26% of children and their guardians (29). In our present report, a retrospective analysis of isolates collected from citywide surveillance studies conducted from 1999 to 2003 suggests that [approximately equal to] 1% of all MRSA isolates in Brooklyn are genotypically related to the prototypical North American CA-MRSA, MW2. Since only MRSA isolates that were susceptible to both clindamycin and ciprofloxacin were analyzed, this analysis probably underestimates the true prevalence. Other strains of CA-MRSA (e.g., USA 300) and USA 400 strains that acquired resistance to these antimicrobial agents would have been missed by our screening methods.
The introduction of CA-MRSA strains into neonatal units represents an especially serious challenge. Many of the infections caused by these strains, including some in our report, can be unusually severe and life-threatening (11). Careful vigilance involving surveillance, identification of these dangerous strains, and implementation of infection control measures, should be helpful in preventing further transmission both within and outside of the hospital.
Table 1. Clinical information for patients with methicillin-resistant Staphylococcus aureus infection during the outbreak period Patient Age at onset Sex Strain Infection type P1, newborn 8 d F USA 400 Preseptal cellulitis P2, newborn 13 d F USA 400 Omphalitis, otitis externa P3, mother 33 y F USA 400 Breast abscess P4, newborn 2 d M USA 400 Omphalitis, pustulosis P5, newborn 4 d M USA 400 Pustulosis P6, newborn 2 d M USA 400 Pustulosis P7, newborn 1 d F USA 400 Pustulosis, mastitis P8, mother 24 y F Unique Peripheral IV catheter site Patient Initial therapy Definitive therapy P1, newborn Nafcillin, Topical gentamicin cefotaxime P2, newborn Ampicillin, Topical mupirocin cefotaxime P3, mother Cefazolin Surgical drainage, vancomycin, topical mupirocin P4, newborn Nafcillin Gentamicin, topical mupirocin Gentamicin P5, newborn Cephalexin Topical bacitracin P6, newborn None Local wound care P7, newborn Topical mupirocin Vancomycin P8, mother Cefazolin Trimethoprim-sulfamethoxazole, catheter removal Table 2. Susceptibility data on Staphylococcus aureus isolates collected from 11 to 15 hospitals in 1999, 2001, and 2003 * 1999 2001 2003 (N = 567) (N = 772) (N = 588) % MRSA 36 46 52 Antimicrobial agent (% susceptible) Azithromycin 14 5 5 Clindamycin 18 15 20 Vancomycin 100 100 100 Daptomycin ND 100 100 Tigecycline ND ND 100 Minocycline 98 ND 98 Linezolid 100 ND 100 Rifampin 88 92 95 Imipenem 37 49 56 Ciprofloxacin 10 8 7 Trimethoprim- 75 80 89 sulfamethoxazole * MRSA, methicillin-resistant Staphylococcus aureus; ND, not done.
This research was supported by grants from Merck & Co., Inc.; Elan Pharmaceuticals; Pfizer, Inc.; and Wyeth-Ayerst Pharmaceuticals.
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the muscular portion of the hindleg between the stifle and hock, corresponding to the human calf. The term is used in horses and sometimes dogs. RE, Boyle-Vavra S, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA JAMA
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Flores (flōrəs), town (1990 est. pop. 2,200), capital of Petén department, N Guatemala. Flores was built on an island in the southern part of Lake Petén Itzá and on the site of the C, Sathe S, Maccario E, Ravishankar J, et al. Molecular epidemiology of oxacillin-resistant Staphylococcus aureus in Brooklyn, New York. Eur J Clin Microbiol Infect Dis. 2003;22:58-61.
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or deoxyribonucleic acid
One of two types of nucleic acid (the other is RNA); a complex organic compound found in all living cells and many viruses. It is the chemical substance of genes. restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol. 1995;33:2233-9.
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Marked by exfoliation, desquamation, or profuse scaling. toxins, and toxic shock syndrome toxin 1 in Staphylococcus aureus by the polymerase chain reaction. J Clin Microbiol. 1991;29:426-30.
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(25.) de Almeida Silva H, Abdallah VOS An operating system used in Stratus computers. FTX is Stratus' Unix operating system. , Carneiro CL, Filho PPG PPG Points Per Game (basketball player statistic)
PPG Power Play Goals (hockey)
PPG Planning Policy Guidance (UK)
PPG Programmable Pulse Generator
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Simona Bratu, * Antonella Eramo, ([dagger]) Robert Kopec, ([double dagger]) Elizabeth Coughlin, ([double dagger]) Monica Ghitan, ([double dagger]) Robert Yost, ([double dagger]) Edward K. Chapnick, ([double dagger]) David Landman, * and John Quale qua·le
n. pl. qua·li·a
A property, such as whiteness, considered independently from things having the property.
[From Latin qu *
* State University of New York-Downstate, Brooklyn, New York, USA; ([dagger]) Long Island College Hospital Long Island College Hospital (LICH) is a teaching hospital situated in Brooklyn, New York
Founded in 1858, the hospital has 516 beds. In 1860 it introduced the practice of bedside teaching and it later became the first U.S. hospital to use stethoscopes and anesthesia. , Brooklyn, New York, USA; and ([double dagger]) Maimonides Medical Center, Brooklyn, New York, USA
Dr. Bratu is a senior research fellow in the Division of Infectious Diseases at SUNY Downstate down·state
The southerly section of a state in the United States.
adv. & adj.
To, from, or in the southerly section of a state.
down . Her research interests include virulence factors in S. aureus and mechanisms of antimicrobial resistance.
Address for correspondence: David Landman, Division of Infectious Diseases Box 77, SUNY Downstate, 450 Clarkson Ave, Brooklyn, NY 11203, USA; fax: 718-270-2465; email: firstname.lastname@example.org