MRSA in the Community
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《新英格兰医药杂志》
To the Editor: Two articles in the April 7 issue (Fridkin et al.1 and Miller et al.2) deal with the subject of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection. Fridkin et al. found that 6 percent of cases of MRSA infection were invasive, but they reported no cases of the toxic shock syndrome. Although MRSA strains are toxigenic,3 MRSA-associated toxic shock syndrome appears rare4,5 and has not been described with community-acquired strains. We report a case of the toxic shock syndrome associated with community-acquired MRSA in an 18-year-old woman who presented with malaise, diarrhea, vomiting, and subsequently collapse. She had no risk factors for nosocomial MRSA acquisition. She was febrile, had hypotension, and was drowsy, with mucosal suffusion, widespread erythematous rash, and renal failure. Blood cultures grew MRSA that was sensitive to vancomycin, ciprofloxacin, clindamycin, gentamicin, and tetracycline. The bacterium carried the mecA gene and produced enterotoxins G and I. The patient received cefotaxime, flucloxacillin, and gentamicin and was switched to vancomycin after the microbiologic analysis became available; she recovered fully.
The unexpected microbiologic findings in this case raise concern about the empirical choice of antibiotics for patients without risk factors for nosocomial MRSA acquisition. However, true community-acquired MRSA infection remains uncommon,6 and a move from beta-lactams as first-line therapy is unnecessary and may encourage resistance to vancomycin.
Ann L.N. Chapman, M.D., Ph.D.
Julia M. Greig, M.D.
Royal Hallamshire Hospital
Sheffield S10 2JF, United Kingdom
ann.chapman@sth.nhs.uk
John A. Innes, M.D.
Heartlands Hospital
Birmingham B9 5SS, United Kingdom
References
Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352:1436-1444.
Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 2005;352:1445-1453.
Schmitz FJ, MacKenzie CR, Geisel R, et al. Enterotoxin and toxic shock syndrome toxin-1 production of methicillin resistant and methicillin sensitive Staphylococcus aureus strains. Eur J Epidemiol 1997;13:699-708.
Acland KM, Darvay A, Griffin C, Aali SAA, Russell-Jones R. Staphylococcal scalded skin syndrome in an adult associated with methicillin-resistant Staphylococcus aureus. Br J Dermatol 1999;140:518-520.
Fergie JE, Purcell K. Community-acquired methicillin-resistant Staphylococcus aureus infections in south Texas children. Pediatr Infect Dis J 2001;20:860-863.
Salgado CD, Farr BM, Calfee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis 2003;36:131-139.
Dr. Fridkin and colleagues reply: The case reported by Chapman et al. adds to other reports of severe community-associated MRSA infection with features that resemble the toxic shock syndrome1,2 and emphasizes that clinicians should consider MRSA a potential pathogen in suspected S. aureus infections. Our data clearly suggest that MRSA infections are common, and most involve only skin and soft tissue. However, the prevalence of these infections varies geographically. There are reports from some areas of the United States in which MRSA has become a predominant cause of community-associated staphylococcal disease.3,4 Although it may be premature to change empirical regimens for suspected S. aureus disease, our data support increased vigilance in the collection of appropriate diagnostic specimens and the selection of empirical agents on the basis of an understanding of local disease patterns. We agree that unnecessary use of vancomycin should be avoided. Nevertheless, in the case of a seriously ill patient who may have MRSA infection, empirical therapy with agents active against MRSA, including vancomycin and other drugs, may be necessary.
Jeffrey C. Hageman, M.H.S.
Centers for Disease Control and Prevention
Atlanta, GA 30333
Ruth Lynfield, M.D.
Minnesota Department of Health
Minneapolis, MN 55414
Scott K. Fridkin, M.D.
Centers for Disease Control and Prevention
Atlanta, GA 30333
skf0@cdc.gov
References
Mongkolrattanothai K, Boyle S, Kahana MD, Daum RS. Severe Staphylococcus aureus infections caused by clonally related community-acquired methicillin-susceptible and methicillin-resistant isolates. Clin Infect Dis 2003;37:1050-1058.
Fergie JE, Purcell K. Community-acquired methicillin-resistant Staphylococcus aureus infections in south Texas children. Pediatr Infect Dis J 2001;20:860-863.
Moran GJ, Amii RN, Abrahamian FM, Talan DA. Methicillin-resistant Staphylococcus aureus in community-acquired skin infections. Emerg Infect Dis 2005;11:928-930.
Mishaan AM, Mason EO Jr, Martinez-Aguilar G, et al. Emergence of a predominant clone of community-acquired Staphylococcus aureus among children in Houston, Texas. Pediatr Infect Dis J 2005;24:201-206.
Dr. Miller and colleagues reply: We appreciate the report by Chapman et al. regarding a case of the toxic shock syndrome caused by community-associated MRSA. The gene that encodes toxic shock syndrome toxin 1 (TSST-1) appears to be found uncommonly in community-acquired MRSA strains.1,2 Nonetheless, this case adds to growing reports of strains of MRSA causing previously unusual clinical syndromes, such as purpura fulminans,3 necrotizing community-acquired pneumonia and pulmonary septic emboli in healthy persons who do not use injection drugs,4 and empyema.5
Although Chapman et al. state that MRSA infections are "uncommon," these infections are unfortunately becoming quite prevalent globally. In many locales, including in our institutions, community-acquired S. aureus infections are more likely to be caused by MRSA than by methicillin-susceptible strains. Therefore, in the treatment of severe or invasive syndromes caused by S. aureus, it may be prudent to use vancomycin or another antibiotic that is reliably active against locally circulating MRSA strains in addition to a beta-lactam until results of cultures and susceptibilities are known.
Loren G. Miller, M.D., M.P.H.
Harbor–UCLA Medical Center
Torrance, CA 90509
Fran?oise Perdreau-Remington, Ph.D.
San Francisco General Hospital
San Francisco, CA 94110
Brad Spellberg, M.D.
Harbor–UCLA Medical Center
Torrance, CA 90509
References
Fey PD, Said-Salim B, Rupp ME, et al. Comparative molecular analysis of community- or hospital-acquired methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 2003;47:196-203.
Jamart S, Denis O, Deplano A, et al. Methicillin-resistant Staphylococcus aureus toxic shock syndrome. Emerg Infect Dis 2005;11:636-637.
Kravitz GR, Dries DJ, Peterson ML, Schlievert PM. Purpura fulminans due to Staphylococcus aureus. Clin Infect Dis 2005;40:941-947.
Gonzalez BE, Martinez-Aguilar G, Hulten KG, et al. Severe staphylococcal sepsis in adolescents in the era of community-acquired methicillin-resistant Staphylococcus aureus. Pediatrics 2005;115:642-648.
Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 2004;113:1735-1740.
The unexpected microbiologic findings in this case raise concern about the empirical choice of antibiotics for patients without risk factors for nosocomial MRSA acquisition. However, true community-acquired MRSA infection remains uncommon,6 and a move from beta-lactams as first-line therapy is unnecessary and may encourage resistance to vancomycin.
Ann L.N. Chapman, M.D., Ph.D.
Julia M. Greig, M.D.
Royal Hallamshire Hospital
Sheffield S10 2JF, United Kingdom
ann.chapman@sth.nhs.uk
John A. Innes, M.D.
Heartlands Hospital
Birmingham B9 5SS, United Kingdom
References
Fridkin SK, Hageman JC, Morrison M, et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352:1436-1444.
Miller LG, Perdreau-Remington F, Rieg G, et al. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 2005;352:1445-1453.
Schmitz FJ, MacKenzie CR, Geisel R, et al. Enterotoxin and toxic shock syndrome toxin-1 production of methicillin resistant and methicillin sensitive Staphylococcus aureus strains. Eur J Epidemiol 1997;13:699-708.
Acland KM, Darvay A, Griffin C, Aali SAA, Russell-Jones R. Staphylococcal scalded skin syndrome in an adult associated with methicillin-resistant Staphylococcus aureus. Br J Dermatol 1999;140:518-520.
Fergie JE, Purcell K. Community-acquired methicillin-resistant Staphylococcus aureus infections in south Texas children. Pediatr Infect Dis J 2001;20:860-863.
Salgado CD, Farr BM, Calfee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis 2003;36:131-139.
Dr. Fridkin and colleagues reply: The case reported by Chapman et al. adds to other reports of severe community-associated MRSA infection with features that resemble the toxic shock syndrome1,2 and emphasizes that clinicians should consider MRSA a potential pathogen in suspected S. aureus infections. Our data clearly suggest that MRSA infections are common, and most involve only skin and soft tissue. However, the prevalence of these infections varies geographically. There are reports from some areas of the United States in which MRSA has become a predominant cause of community-associated staphylococcal disease.3,4 Although it may be premature to change empirical regimens for suspected S. aureus disease, our data support increased vigilance in the collection of appropriate diagnostic specimens and the selection of empirical agents on the basis of an understanding of local disease patterns. We agree that unnecessary use of vancomycin should be avoided. Nevertheless, in the case of a seriously ill patient who may have MRSA infection, empirical therapy with agents active against MRSA, including vancomycin and other drugs, may be necessary.
Jeffrey C. Hageman, M.H.S.
Centers for Disease Control and Prevention
Atlanta, GA 30333
Ruth Lynfield, M.D.
Minnesota Department of Health
Minneapolis, MN 55414
Scott K. Fridkin, M.D.
Centers for Disease Control and Prevention
Atlanta, GA 30333
skf0@cdc.gov
References
Mongkolrattanothai K, Boyle S, Kahana MD, Daum RS. Severe Staphylococcus aureus infections caused by clonally related community-acquired methicillin-susceptible and methicillin-resistant isolates. Clin Infect Dis 2003;37:1050-1058.
Fergie JE, Purcell K. Community-acquired methicillin-resistant Staphylococcus aureus infections in south Texas children. Pediatr Infect Dis J 2001;20:860-863.
Moran GJ, Amii RN, Abrahamian FM, Talan DA. Methicillin-resistant Staphylococcus aureus in community-acquired skin infections. Emerg Infect Dis 2005;11:928-930.
Mishaan AM, Mason EO Jr, Martinez-Aguilar G, et al. Emergence of a predominant clone of community-acquired Staphylococcus aureus among children in Houston, Texas. Pediatr Infect Dis J 2005;24:201-206.
Dr. Miller and colleagues reply: We appreciate the report by Chapman et al. regarding a case of the toxic shock syndrome caused by community-associated MRSA. The gene that encodes toxic shock syndrome toxin 1 (TSST-1) appears to be found uncommonly in community-acquired MRSA strains.1,2 Nonetheless, this case adds to growing reports of strains of MRSA causing previously unusual clinical syndromes, such as purpura fulminans,3 necrotizing community-acquired pneumonia and pulmonary septic emboli in healthy persons who do not use injection drugs,4 and empyema.5
Although Chapman et al. state that MRSA infections are "uncommon," these infections are unfortunately becoming quite prevalent globally. In many locales, including in our institutions, community-acquired S. aureus infections are more likely to be caused by MRSA than by methicillin-susceptible strains. Therefore, in the treatment of severe or invasive syndromes caused by S. aureus, it may be prudent to use vancomycin or another antibiotic that is reliably active against locally circulating MRSA strains in addition to a beta-lactam until results of cultures and susceptibilities are known.
Loren G. Miller, M.D., M.P.H.
Harbor–UCLA Medical Center
Torrance, CA 90509
Fran?oise Perdreau-Remington, Ph.D.
San Francisco General Hospital
San Francisco, CA 94110
Brad Spellberg, M.D.
Harbor–UCLA Medical Center
Torrance, CA 90509
References
Fey PD, Said-Salim B, Rupp ME, et al. Comparative molecular analysis of community- or hospital-acquired methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother 2003;47:196-203.
Jamart S, Denis O, Deplano A, et al. Methicillin-resistant Staphylococcus aureus toxic shock syndrome. Emerg Infect Dis 2005;11:636-637.
Kravitz GR, Dries DJ, Peterson ML, Schlievert PM. Purpura fulminans due to Staphylococcus aureus. Clin Infect Dis 2005;40:941-947.
Gonzalez BE, Martinez-Aguilar G, Hulten KG, et al. Severe staphylococcal sepsis in adolescents in the era of community-acquired methicillin-resistant Staphylococcus aureus. Pediatrics 2005;115:642-648.
Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 2004;113:1735-1740.