Emergence of community-associated methicillin resistant Staphylococcus aureus in Hawaii, 2001–2003
Introduction
Methicillin-resistant Staphylococcus aureus (MRSA) traditionally has been considered a healthcare-associated pathogen; however, MRSA infections in individuals with no exposures to healthcare settings are being reported with increasing frequency.1, 2, 3, 4 These community-associated MRSA (CA-MRSA) strains are resistant to β-lactam antimicrobials and macrolides but often are susceptible to other drugs used to treat staphylococci, in contrast to the multi-resistant profile of healthcare-associated MRSA (HA-MRSA) strains.2, 3, 4 Skin and soft tissue infections (SSTI) are the most common clinical presentation of CA-MRSA, although some patients may progress to pneumonia, sepsis, and death.5, 6
CA-MRSA skin infections have been reported to spread in settings where crowding, skin-to-skin contact, frequent skin abrasions, poor hygiene, and environmental contamination are prevalent. These factors have been associated with several groups experiencing outbreaks of disease including sports participants,7, 8 military recruits,9 prison inmates,10 or semi-rural communities.11, 12, 13 Certain healthcare facilities and public health departments are also reporting increasing numbers of MRSA infections among ambulatory patients.14, 15, 16
Existing guidelines to treat and control transmission of MRSA infections in healthcare facilities are not always applicable for community settings. Therefore, further studies that characterize epidemiologic and clinical risk factors for CA-MRSA infections are necessary to develop and implement targeted prevention and control strategies.
From 2000 to 2002 the State of Hawaii detected an increasing prevalence of MRSA in ambulatory settings by laboratory surveillance.17 Local clinicians had also noted an increase in SSTI caused by MRSA primarily among Pacific Islanders. In September 2003, we conducted an investigation to retrospectively characterize the epidemiology and clinical outcome of patients with CA-MRSA infections in Hawaii to identify populations at risk for CA-MRSA infections. We also performed microbiologic characterization of clinical isolates to elucidate whether CA-MRSA strains causing disease in Hawaii are related to CA-MRSA strains detected in other US states.
Section snippets
Hospital enrollment
Four healthcare facilities with hospital and ambulatory clinic services were selected based on location and patient population. Three facilities were located on Oahu: a tertiary hospital for children and women (201 beds), a private outpatient/inpatient facility (250 beds), and an adult tertiary care referral hospital (535 beds). The fourth facility was a rural community hospital on Kauai (71 beds). Altogether, these facilities provide 40% of acute care bed capacity in Hawaii, and 88% of
Proportion of CA-MRSA infections by facility and over time
Between July 2001 and June 2003, MRSA was recovered from 1389 patients in the four facilities. Of these, 249 patients (18%) lacked data for classification, 739 (53%) had healthcare-associated risk factors, and 389 (28%) were considered CA-MRSA case-patients. The proportion of patients with CA-MRSA infections was 61% (126/207) at the children and women's facility; 45% (114/253) at the private center; 28% (25/90) at the community rural center; and 21% (124/590) at the university facility.
The
Discussion
We found an increasing number of MRSA infections in patients without risk factors for healthcare exposure and demonstrated that Pacific Islanders, especially Pacific Islander children, are disproportionately affected in comparison with other populations in Hawaii. Additionally, receipt of prior antimicrobials to which MRSA was resistant, (i.e., beta-lactams) was associated with a higher risk for hospitalization.
Statewide laboratory-based surveillance implemented by the Hawaii Department of
Acknowledgements
The authors would like to thank Alan Tice, MD, Scott Fridkin, MD, Jean Patel PhD, Roberta Carey PhD, Matt Arduino DrPH, and Fred Tenover PhD for their help and review of the manuscript.
References (40)
- et al.
Community-acquired, non-multiresistant oxacillin-resistant Staphylococcus aureus (NORSA) in South Western Sydney
Pathology
(2001) - et al.
An inherited defect of neutrophil motility and microfilamentous cytoskeleton associated with abnormalities in 47-Kd and 89-Kd proteins
Blood
(1991) - et al.
Re-emergence of early pandemic Staphylococcus aureus as a community-acquired methicillin-resistant clone
Lancet
(2005) - et al.
Methicillin-resistant Staphylococcus aureus disease in three communities
N Engl J Med
(2005) - et al.
Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence
Emerg Infect Dis
(2003) - et al.
Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection
JAMA
(2003) - et al.
Dissemination of new methicillin-resistant Staphylococcus aureus clones in the community
J Clin Microbiol
(2002) Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus – Minnesota and North Dakota, 1997–1999
JAMA
(1999)- et al.
Community-acquired methicillin-resistant Staphylococcus aureus infections in France: emergence of a single clone that produces Panton-Valentine leukocidin
Clin Infect Dis
(2002) - et al.
A clone of methicillin-resistant Staphylococcus aureus among professional football players
N Engl J Med
(2005)
Methicillin-resistant Staphylococcus aureus infections among competitive sports participants – Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000–2003
MMWR Morb Mortal Wkly Rep
Community-acquired methicillin-resistant Staphylococcus aureus among military recruits
Emerg Infect Dis
Methicillin-resistant Staphylococcus aureus infections in correctional facilities – Georgia, California, and Texas, 2001–2003
MMWR Morb Mortal Wkly Rep
Community-acquired methicillin-resistant Staphylococcus aureus in a rural American Indian community
JAMA
An outbreak of community-onset methicillin-resistant Staphylococcus aureus skin infections in southwestern Alaska
Infect Control Hosp Epidemiol
Epidemiology of methicillin-resistant Staphylococcus aureus in three Canadian tertiary-care centers
Infect Control Hosp Epidemiol
Community-acquired methicillin-resistant Staphylococcus aureus infections in south Texas children
Pediatr Infect Dis J
Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk
JAMA
Emergence of community-associated methicillin-resistant Staphylococcus aureus at a Memphis, Tennessee Children's Hospital
Pediatr Infect Dis J
Methicillin-resistant Staphylococcus aureus (MRSA) in Hawaii, 2000–2002
Emerg Infect Dis
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