Staphylococcus aureus Skin Infection Recurrences Among Household Members: An Examination of Host, Behavioral, and Pathogen-Level Predictors

Miller, Loren G.; Eells, Samantha J.; David, Michael Z.; Ortiz, Nancy; Taylor, Alexis; Kumar, Neha; Cruz, Denise; Boyle-Vavra, Susan; Daum, Robert S.

doi:10.1093/cid/ciu943

Cited by 69 publications

(76 citation statements)

References 46 publications

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“…The distribution of strain types causing infection was similar to what has been previously reported. Our finding that the CC8-300 strain accounted for nearly all MRSA infections and a large proportion of the MSSA infections mirrored the findings of previous reports, although our use of an inferred algorithm in this study does not allow a direct strain-to-strain comparison (2,22,23). In contrast to the homogeneity among infecting MRSA strains, more than 10 different strain types were encountered among infecting MSSA strains.…”

Section: Discussionsupporting

confidence: 80%

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Staphylococcus aureus Colonization and Strain Type at Various Body Sites among Patients with a Closed Abscess and Uninfected Controls at U.S. Emergency Departments

et al. 2015

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d Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a prevalent cause of skin and soft tissue infections (SSTI), but the association between CA-MRSA colonization and infection remains uncertain. We studied the carriage frequency at several body sites and the diversity of S. aureus strains from patients with and without SSTI. Specimens from the nares, throat, rectum, and groin of case subjects with a closed skin abscess (i.e., without drainage) and matched control subjects without a skin infection (n ‫؍‬ 147 each) presenting to 10 U.S. emergency departments were cultured using broth enrichment; wound specimens were cultured from abscess cases. Methicillin resistance testing and spa typing were performed for all S. aureus isolates. S. aureus was found in 85/147 (57.8%) of abscesses; 49 isolates were MRSA, and 36 were methicillin-susceptible S. aureus (MSSA). MRSA colonization was more common among cases (59/147; 40.1%) than among controls (27/147; 18.4%) overall (P < 0.001) and at each body site; no differences were observed for MSSA. S. aureus-infected subjects were usually (75/85) colonized with the infecting strain; among MRSA-infected subjects, this was most common in the groin. The CC8 lineage accounted for most of both infecting and colonizing isolates, although more than 16 distinct strains were identified. Nearly all MRSA infections were inferred to be USA300. There was more diversity among colonizing than infecting isolates and among those isolated from controls versus cases. CC8 S. aureus is a common colonizer of persons with and without skin infections. Detection of S. aureus colonization, and especially MRSA, may be enhanced by extranasal site culture. Staphylococcus aureus frequently causes invasive and life-threatening infections. While historically common in patients with significant health care exposure, community-associated methicillin-resistant S. aureus (CA-MRSA) has emerged as an important cause of disease (1). CA-MRSA is the most common cause of skin and soft tissue infections (SSTI) among people presenting to emergency departments (EDs) in much of the United States, most of which are caused by a single MRSA strain, pulsed-field type USA300 (2). S. aureus colonization with methicillin-susceptible S. aureus (MSSA) is common in the general population, especially in the anterior nares (3). Studies of MRSA pathogenesis in health care settings have demonstrated that nasal colonization typically precedes and is a risk factor for infection (4); therefore, prevention strategies in health care often involve decolonization, especially before invasive surgical procedures (5).Despite the increasing prevalence of CA-MRSA infections, nasal colonization with MRSA has been infrequently detected during CA-MRSA outbreaks or in nationally representative prevalence surveys (6, 7). One possible explanation for this observation is that CA-MRSA strains might preferentially colonize at nonnasal body sites. The throat and groin have been implicated as important sites of S. aureus and MRSA c...

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Section: Discussionsupporting

confidence: 80%

“…However, if members of the population under surveillance have a skin infection, our data suggest that the groin would be the preferred single site for detecting MRSA colonization. Other recent studies have also implicated the groin and rectum as important sites of colonization with MRSA (22,23).…”

Section: Discussionmentioning

confidence: 96%

Staphylococcus aureus Colonization and Strain Type at Various Body Sites among Patients with a Closed Abscess and Uninfected Controls at U.S. Emergency Departments

et al. 2015

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“…Recurrent and/or relapse skin infections are commonly reported after an initial S. aureus skin infection (5-7). Rates of recurrence have exceeded 50% in some populations (5,8,9).Reasons for the failure of a skin infection to resolve are poorly understood but are likely to be due to host and behavior factors, inadequate medical and/or surgical therapy, and possibly pathogen-associated factors (10). In other chronic and acute infections, medication adherence is frequently suboptimal and associated with worse clinical outcomes (11-13).…”

mentioning

confidence: 99%

Relationship between Adherence to Oral Antibiotics and Postdischarge Clinical Outcomes among Patients Hospitalized with Staphylococcus aureus Skin Infections

Eells

Nguyen

Jung

et al. 2016

Antimicrob Agents Chemother

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e Skin and soft tissue infections are common and frequently recur. Poor adherence to antibiotic therapy may lead to suboptimal clinical outcomes. However, adherence to oral antibiotic therapy for skin and soft tissue infections and its relationship to clinical outcomes have not been examined. We enrolled adult patients hospitalized with uncomplicated skin and soft tissue infections caused by Staphylococcus aureus who were being discharged with oral antibiotics to complete therapy. We fit the participants' pill bottles with an electronic bottle cap that recorded each pill bottle opening, administered an in-person standardized questionnaire at enrollment, 14 days, and 30 days, and reviewed the participants' medical records to determine outcomes. Our primary outcome was poor clinical response, defined as a change in antibiotic therapy, new incision-and-drainage procedure, or new skin infection within 30 days of hospital discharge. Of our 188 participants, 87 had complete data available for analysis. Among these participants, 40 (46%) had a poor clinical response at 30 days. The mean electronically measured adherence to antibiotic therapy was significantly different than the self-reported adherence (57% versus 96%; P < 0.0001). In a multivariable model, poor clinical response at 30 days was associated with patients having lower adherence, being nondiabetic, and reporting a lack of illicit drug use within the previous 12 months (P < 0.05). In conclusion, we found that patient adherence to oral antibiotic therapy for a skin and soft tissue infection after hospital discharge was low (57%) and associated with poor clinical outcome. Patients commonly overstate their medication adherence, which may make identification of patients at risk for nonadherence and poor outcomes challenging. Further studies are needed to improve postdischarge antibiotic adherence after skin and soft tissue infections. Skin infections are a common reason for physician visits and hospital admission (1, 2). Staphylococcus aureus is the most common cause of skin infections in the community (3, 4). Recurrent and/or relapse skin infections are commonly reported after an initial S. aureus skin infection (5-7). Rates of recurrence have exceeded 50% in some populations (5,8,9).Reasons for the failure of a skin infection to resolve are poorly understood but are likely to be due to host and behavior factors, inadequate medical and/or surgical therapy, and possibly pathogen-associated factors (10). In other chronic and acute infections, medication adherence is frequently suboptimal and associated with worse clinical outcomes (11-13). However, there are no studies to date evaluating antibiotic adherence, or the relationship between adherence and clinical outcome, among patients experiencing skin infections.Poor adherence to medication regimens is common across all disease entities. Low adherence contributes to a worsening of the patient's condition, death, and increased health care costs (14). Even in clinical trials, where study participants receive increas...

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“…Bacterial density over time was determined by taking a sample from each model at predetermined time points (0, 1, 2, 4,6,8,10,12,14,18,24,26,30,36,38,42,48,50,56,60,62,66, and 72 h) and serially diluting it in normal saline. Aliquots of diluted samples were plated for quantitative culture utilizing Trypticase soy agar plates (100-mm diameter) with 5% sheep blood.…”

Section: Methodsmentioning

confidence: 99%

“…These infections are frequently caused by Gram-positive bacteria, including Staphylococcus aureus and Streptococcus pyogenes (2). Methicillin-resistant S. aureus (MRSA) can be present in as many as 60% of cases (3,4) and has been linked with outcomes worse than those of methicillin-susceptible S. aureus (MSSA) infections (5,6). As a result of this epidemiology and the long history of vancomycin use, it is considered a first-line antibiotic for the empirical treatment of cSSSI (2,7).…”

mentioning

confidence: 99%

In Vitro Pharmacodynamics of Vancomycin against Methicillin-Susceptible and -Resistant Staphylococcus aureus: Considering the Variability in Observed Tissue Exposure

Hamada

Kuti

Nicolau

2016

Antimicrob Agents Chemother

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Vancomycin is considered a first-line antibiotic for complicated skin and skin structure infections (cSSSI) because of the risk of methicillin-resistant Staphylococcus aureus (MRSA). The vancomycin exposure of tissue can vary widely in patients with cSSSI, yet most models test only the average exposure. The in vitro pharmacodynamic model was used to simulate three tissue exposure levels attained by administering vancomycin at 1 g every 12 h (q12h), based on the median (50th), 25th, and 10th percentile tissue area under the concentration-time curve (AUC) values observed during an in vivo microdialysis study of diabetic patients. Four clinical isolates (two of MRSA [vancomycin MIC, 1 and 2 g/ml] and two of methicillin-susceptible S. aureus [MSSA] [MIC, 1 and 2 g/ml]) were evaluated. Experiments were performed over 72 h in duplicate. Time-kill curves were constructed, and the area under the bacterial killing and regrowth curve (AUBC) during the final 24-h dosing interval (48 to 72 h) (AUBC 48 -72 ) was calculated. Reductions in the 72-h number of CFU/ml and AUBC 48 -72 at the different exposure levels were compared. Target tissue vancomycin exposure levels for the 50th (AUC 0 -12 , 102.0 ؎ 9.1 g · h/ml), 25th (AUC 0 -12 , 44.3 ؎ 1.8 g · h/ml), and 10th (AUC 0 -12 , 25.3 ؎ 3.1 g · h/ml) percentiles were obtained in all studies. No differences in the 72-h number of CFU or AUBC were observed between exposure levels when all of the isolates were analyzed together. However, for the two MRSA isolates, the 10th percentile exposure level achieved a lower 72-h number of CFU/ml (؊1.4 ؎ 0.4 log 10 CFU/ml, P ‫؍‬ 0.007) and a greater AUBC 48 -72 (97.1 ؎ 20.0 log 10 CFU · h/ml, P ‫؍‬ 0.011) than the higher exposure levels. The majority of the tissue exposure levels achieved with a vancomycin dosing regimen of 1 g q12h resulted in substantial killing of MSSA and MRSA; however, the lowest exposure levels observed in a minority of the population may explain the poor vancomycin response. C omplicated skin and skin structure infections (cSSSI) are among the most common infections in hospitalized patients (1, 2). These infections are frequently caused by Gram-positive bacteria, including Staphylococcus aureus and Streptococcus pyogenes (2). Methicillin-resistant S. aureus (MRSA) can be present in as many as 60% of cases (3, 4) and has been linked with outcomes worse than those of methicillin-susceptible S. aureus (MSSA) infections (5, 6). As a result of this epidemiology and the long history of vancomycin use, it is considered a first-line antibiotic for the empirical treatment of cSSSI (2, 7).In addition to possessing in vitro microbiological activity against the causative pathogen, the treatment antibiotic must be able to penetrate to the site of infection with sufficient exposure to kill the organism. Comorbidities often present in patients with cSSSI, including diabetes mellitus and peripheral vascular disease, can result in altered and varied tissue perfusion to the site of infection, making it increasingly difficult to predict a...

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Staphylococcus aureus Skin Infection Recurrences Among Household Members: An Examination of Host, Behavioral, and Pathogen-Level Predictors

Abstract: In our longitudinal study, patients with a S. aureus skin infection were more likely to suffer a recurrence if household fomites were MRSA contaminated. Interventions to prevent recurrence may be enhanced by decontamination of household fomites.

Cited by 69 publications

References 46 publications

Staphylococcus aureus Colonization and Strain Type at Various Body Sites among Patients with a Closed Abscess and Uninfected Controls at U.S. Emergency Departments

Staphylococcus aureus Colonization and Strain Type at Various Body Sites among Patients with a Closed Abscess and Uninfected Controls at U.S. Emergency Departments

Relationship between Adherence to Oral Antibiotics and Postdischarge Clinical Outcomes among Patients Hospitalized with Staphylococcus aureus Skin Infections

In Vitro Pharmacodynamics of Vancomycin against Methicillin-Susceptible and -Resistant Staphylococcus aureus: Considering the Variability in Observed Tissue Exposure

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