Methicillin-resistant Staphylococcus aureus: impact at a national cystic fibrosis centre

doi:10.1016/S0195-6701(98)90138-4

Journal of Hospital Infection

Volume 40, Issue 3, November 1998, Pages 203-209

https://doi.org/10.1016/S0195-6701(98)90138-4 Get rights and content

Abstract

In many patient populations there has been a progressive increase in the prevalence of methicillin-resistant Staphylococcus aureus (MRSA). We examined the prevalence and consequences of acquiring MRSA in the adult cystic fibrosis (CF) population at Royal Brompton. Patients who became colonized by MRSA between 1965 and 1997 were identified from an existing database and case-notes were reviewed. Clinical and microbiological data were recorded. Twenty-six patients became colonized with MRSA during this period. Median age at acquisition was 23·4 years (range 11·8–43·3 years) and median FEV1 (percent predicted) was 28·9% (range 12–81%). Twenty patients (77%) had an FEV1 of ≤40% predicted. MRSA was probably acquired by four patients at Royal Brompton. In 17 patients isolates were first identified whilst under the care of a total of 11 other institutions. Since the first case of MRSA infection in 1982, there has been an increase in prevalence to a current rate of nine cases in the first seven months of 1997. The commonest site of colonization was the lower airway (96%); the nose (23%) and skin sites (15%) were more rarely affected. Duration of colonization was frequently brief with nine cases (35%) lasting less than one month. The identification of MRSA appeared to be of little clinical significance, and did not generally affect outcomes. Only three patients were MRSA positive at the time of death, and in only one of these was MRSA considered a possible contributing factor.

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Cited by (64)

Risk factors for persistent methicillin-resistant Staphylococcus aureus infection in cystic fibrosis
2017, Journal of Cystic Fibrosis
Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as an important pathogen in cystic fibrosis (CF). Over 25% of individuals in the United States with CF are found to have MRSA in respiratory culture specimens, and persistent MRSA infection has been associated with more rapid decline in lung function and increased mortality. The objective of this study was to investigate clinical and demographic characteristics that are associated with the development of persistent MRSA infection in a CF population.
This was a retrospective cohort study of individuals followed from 2002 to 2012 in the Cystic Fibrosis Foundation Patient Registry. A time-to-event analysis for the development of persistent MRSA infection was performed, and multivariable Cox proportional hazards models were constructed to identify risk factors for infection.
The study cohort included 19,434 individuals, of which 5844 would develop persistent MRSA infection. In the adjusted model, pancreatic insufficiency (HR: 1.49; 95% CI: 1.29–1.72), CF related diabetes (HR: 1.13; 95% CI: 1.05–1.20), co-infection with P. aeruginosa (HR: 1.21; 95% CI: 1.13–1.28), and number of hospitalizations/year (HR: 1.09; 95% CI: 1.06–1.12) were all associated with increased risk, whereas higher socio-economic status (HR: 0.87; 95% CI: 0.82–0.93) was associated with a lower risk. Receiving care at a CF center with increased MRSA prevalence was associated with increased risk of MRSA infection: highest quartile (HR: 2.33; 95% CI: 2.13–2.56).
No easily modifiable risk factors for persistent MRSA were identified in this study. However, several risk factors for patients at higher risk for persistent MRSA infection were identified, for example centers with a high baseline MRSA prevalence, and may be useful in designing center-specific MRSA infection prevention and control strategies and/or eradication protocols. Additional studies are needed in order to evaluate if attention to these risk factors can improve clinical outcomes.
Genetic fingerprinting and antimicrobial susceptibility profiles of Staphylococcus aureus strains isolated from children with cystic fibrosis
2012, Pediatria Polska
The pathophysiology of cystic fibrosis (CF) is associated with genetically determined abnormal chloride conductance on the apical membrane of the epithelial cell. As a result favourable environment for bacterial and fungal infections is maintained. Respiratory tract infections in CF patients are caused mainly by Staphylococcus aureus, Haemphilus influenzae, and Pseudomonas aeruginosa which is the most destructive pulmonary pathogen.
The aim of this study was to analyse genetic diversity and antimicrobial susceptibility of Staphylococcus aureus strains isolated from children with cystic fibrosis.
A total of 21 patients with confirmed cystic fibrosis were included to the study. Within 8 years 257 specimens from the respiratory tract were collected, and 201 isolates of S. aureus were cultured. Genotyping was performed using the pulsed field gel electrophoresis (PFGE) technique, and antimicrobial susceptibility was determined by the E-test method. The following data were retrieved from medical records: age at CF diagnosis, clinical signs and symptoms, respiratory function (FEV₁), frequency of hospitalization and antibiotic use.
The mean age of patients studied was 7 years (range 0.5–16 years). Over 80% of patients had pulmonary manifestations. The genotyping confirmed that Staphylococcus aureus persistently colonized the respiratory tract of patients with CF. For over 95% of strains the colonization lasted from 6 months to 8 years. Less than 5% of strains did not show a tendency for a long-term colonization, and they were isolated only once. In 34% of patients the same genotype was isolated through the study period, and it could not be eradicated despite antibiotic treatment. As many as 62% of children were persistently colonized with 2 or 3 strains simultaneously. Over 94% of strains were susceptible to β-lactams, fluoroquinolones, trimethoprim/sulfamethoxazole, aminoglycosides, and glycopeptides. The highest rates of resistance were observed for macrolides (23%) which were the second most commonly used antibiotics in bronchopulmonary exacerbations. Some of S. aureus strains were effectively transmitted among the patients. However, only methicillin-susceptible isolates (MSSA) were involved in the transmission. MRSA transmission was not detected.
Prevalence and impact on FEV <inf>1</inf> decline of chronic methicillin-resistant Staphylococcus aureus (MRSA) colonization in patients with Cystic Fibrosis. A single-center, case control study of 165 patients
2012, Journal of Cystic Fibrosis
Risk factors for methicillin-resistant Staphylococcus aureus (MRSA) in Cystic Fibrosis (CF) and the impact on CF disease progression are still under debate.
The objectives of this study were to determine clinical variables associated with MRSA colonization and examine impact on FEV₁ evolution in CF patients.
A retrospective case–control study using the University Hospital of Brussels CF clinic patient registry from 2002 to 2010, comparing clinical variables and decline of FEV₁ of MRSA positive patients with age and sex matched controls, chronically colonized with S. aureus.
Thirty of the 165 CF patients, chronically colonized with S. aureus, had cultures positive for MRSA (18.2%). Excluding patients under 4 years, the prevalence became 15.2% (23/151). Chronic colonization (i.e., three or more consecutive positive cultures) was found in 19/151 (12.6%).
The MRSA positive group showed a higher proportion of patients with genotype F508del, less pancreas sufficient patients, more bronchiectasis and more frequent hospitalization.
The FEV₁ recorded one year prior to, and at the moment of MRSA acquisition, was lower but not significantly different from that obtained in controls (72.9% ± 26.6 vs 84.3 ± 21.8 and 68.2% ± 27.1 vs 81.4% ± 24.3 respectively, p > 0.1). However, FEV₁ decline over 2- and 6-year periods, were significantly greater in the chronic MRSA group than in the controls (− 5% ± 5.5 vs −2.5 ± 2.3 over 2 years (p = 0.043) and − 1.8% ± 4.6 vs −1.0% ± 1.9 over a 6-year period (p = 0.026)).
In our center the prevalence of MRSA in CF patients, chronically colonized with S. aureus and over the age of 4 years, was 15.2% (12.6% chronic infection). MRSA colonization was shown to be associated with a genotype F508del, presence of bronchiectasis and hospitalization. Our spirometric data also show that a MRSA episode entails an FEV₁ decline that is almost double that predicted for CF patients who can remain unaffected by MRSA.
Treatment intensity and characteristics of MRSA infection in CF
2011, Journal of Cystic Fibrosis
Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and interchange of hospital-associated strains carrying the staphylococcal chromosomal cassette mec-II (SCCmec-II) with those in the community (SCCmec-IV) has increased. This study assesses the impact of MRSA and different MRSA types on clinical outcomes, medication use, and antibiotic sensitivities.
MRSA isolates from CF patients at our center were typed by SCCmec- and pv_l status. Patient characteristics, lung function and nutrition are compared between MRSA types and to age, gender and Pseudomonas aeruginosa matched patients with chronic methicillin sensitive S. aureus (MSSA) infection.
Seventy-two percent of patients carry pv_l negative SCCmec-II isolates. Seventeen percent of all MRSA were SCCmec-IV pv_l positive (USA300). These patients were younger and fewer had chronic P. aeruginosa infection, whereas pv_l-negative SCCmec-IV isolates show highest antibiotic resistance. Nutritional outcomes and FEV1 percent predicted (75.1 ± 2.7 versus 77.9 ± 2.7) did not differ in patients with MRSA compared to those with MSSA but MRSA patients received more pulmonary maintenance but not oral antibiotic medications.
Patients with chronic MRSA are treated more intensely than age, gender and Pseudomonas aeruginosa matched MSSA-positive patients but clinical characteristics within MRSA patients vary depending on MRSA types.
Challenging and emerging pathogens in cystic fibrosis
2010, Paediatric Respiratory Reviews
Citation Excerpt :
Several small studies have investigated the effect of MRSA longitudinally. Miall et al. [2001] conducted a case-control study including 10 children with MRSA and 18 controls, showing no difference in lung function change,89 whereas Thomas et al. [1998] studied 23 patients with MRSA and 69 controls and found that lower FEV1 was a risk factor for MRSA acquisition.90 In this study however, pulmonary function decline was not studied, but there appeared to be no difference in mortality between controls and MRSA positive patients.
Cystic fibrosis (CF) lung disease is characterised by chronic inflammation and infection. Patients are predominantly infected by specific pathogens, of which Staphylococcus aureus and Pseudomonas aeruginosa are the most important. In recent years however there has been an increasing number of reports on potentially emerging and challenging pathogens like Stenotrophomonas maltophilia, Non-tuberculous mycobacteria, highly prevalent P. aeruginosa clones, methicillin resistant Staphylococcus aureus and Burkholderia cepacia. Also, a role for viral infections in the pathogenesis of CF lung disease has increasingly been recognised. It is not always clear whether or how these pathogens influence the progression of CF lung disease and how they should be treated. In this review, the epidemiology and clinical impact of these pathogens is discussed. Furthermore, treatment strategies of these pathogens in a CF setting are reviewed.
Patient segregation and aggressive antibiotic eradication therapy can control methicillin-resistant Staphylococcus aureus at large cystic fibrosis centres
2010, Journal of Cystic Fibrosis
The prevalence of MRSA in patients with CF has risen in recent years. We adhere to a policy of segregation and barrier nursing to manage patients with MRSA, and we actively pursue eradication of MRSA. We have evaluated our experiences of MRSA infection in our large adult CF centre.
A retrospective review of all MRSA-positive patients from 1998 to 2008 was undertaken. Isolates were subjected to molecular identification to elucidate possible patient-to-patient transmission events. Eradication attempts were scrutinised.
We have maintained a low incidence and prevalence (below 3%) of MRSA within this large cohort. A total of 15 pulsotypes of MRSA were identified among the 24 isolates examined, epidemiological data suggested no patient–patient transmission. Based on 6 month follow-up data, successful eradication was achieved in 81% patients. This includes those who had harboured infection for some time. Twenty-one (80.8%) required only one course of treatment, 3 (11.6%) patients required two different regimes and 2 (7.5%) required three courses to fully eradicate the organism.
Strict infection control procedures can control MRSA infection and keep the prevalence low in CF clinics. Eradication is achievable in the majority of patients even when significant time has lapsed from initial isolation. In some instances, up to 3 courses of antibiotics were required to achieve eradication.

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Journal of Hospital Infection

Abstract

References (23)

Staphylococcus aureus phage typing, anti-microbial susceptibility patterns and patient data correlated using a personal computer: advantages for monitoring the epidemiology of MRSA

J Hosp Infect

Hong Kong strains of methicillin-resistant and methicillin-sensitive Staphylococcus aureus have similar virulence

Hosp Infect

Three strategies in the control of staphylococci including methicillin-resistant Staphylococcus aureus

J Hosp Infect

The management of methicillin-resistant Staphylococcus aureus in a major hospital

J Hosp Infect

Methicillin-resistant Staphylococcus aureus: report of an outbreak in a London teaching hospital

J Hosp Infect

Methicillin-resistant Staphylococcus aureus in a cystic fibrosis unit

J Hosp Infect

Methicillin-resistant Staphylococcus aureus: investigation of a hospital out-break using a case-control study

J Hosp Infect

Epidemic potential and pathogenicity in outbreaks of infection with EMRSA and EMREC

J Hosp Infect

Cystic fibrosis

Am J Respir Crit Care Med

Therapy and prognosis of fibrocystic disease of the pancreas

Pediatrics

Cystic fibrosis in adolescents and adults

Thorax

Cited by (64)

Risk factors for persistent methicillin-resistant Staphylococcus aureus infection in cystic fibrosis

Genetic fingerprinting and antimicrobial susceptibility profiles of Staphylococcus aureus strains isolated from children with cystic fibrosis

Prevalence and impact on FEV <inf>1</inf> decline of chronic methicillin-resistant Staphylococcus aureus (MRSA) colonization in patients with Cystic Fibrosis. A single-center, case control study of 165 patients

Treatment intensity and characteristics of MRSA infection in CF

Challenging and emerging pathogens in cystic fibrosis

Patient segregation and aggressive antibiotic eradication therapy can control methicillin-resistant Staphylococcus aureus at large cystic fibrosis centres

Original articleMethicillin-resistant Staphylococcus aureus: impact at a national cystic fibrosis centre

Abstract

J Hosp Infect

Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

Cystic fibrosis

Am J Respir Crit Care Med

Therapy and prognosis of fibrocystic disease of the pancreas

Pediatrics

Cystic fibrosis in adolescents and adults

Thorax

Original article
Methicillin-resistant Staphylococcus aureus: impact at a national cystic fibrosis centre