Elsevier

Journal of Infection

Volume 54, Issue 4, April 2007, Pages 349-357
Journal of Infection

Emergence of community-associated methicillin resistant Staphylococcus aureus in Hawaii, 2001–2003

https://doi.org/10.1016/j.jinf.2006.08.002Get rights and content

Summary

Objectives

We conducted a retrospective study to determine trends and characteristics of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in Hawaii.

Methods

We reviewed medical records of patients with MRSA infections during July 2001–June 2003 in four healthcare facilities. A case was defined as a patient with MRSA infection (colonization excluded), diagnosed in ambulatory settings or ≤48 h after hospitalization, without previous MRSA or healthcare risk factors. Pulsed-field gel electrophoresis (PFGE) and typing of resistance and toxin genes was performed in 40 MRSA isolates.

Results

CA-MRSA infections increased from 28 (23% of MRSA infections) to 65 (32%) per quarter over the 2-year period (P < 0.05). Pacific islanders accounted for 51% of 389 case-patients, but only 24% of the Hawaii population. In the pediatric hospital, Pacific Islanders represented 76% of 90 case-patients versus 35% of the hospital population. Hospital admission, required for 40% (154/389), was associated with prior antimicrobial treatment (P < 0.01). The staphylococcal cassette chromosome mec type IV was detected in 38/40 isolates; 31 isolates carried Panton–Valentine leukocidin genes and 22 belonged to the same staphylococcal lineage.

Conclusions

In Hawaii, prevention strategies for CA-MRSA infections should focus on Pacific Islanders. CA-MRSA infections in Hawaii appear to be related to strains causing disease throughout the United States.

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.

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