Epidemiology, Treatment, and Prevention of Community-Acquired Methicillin-Resistant Staphylococcus aureus Infections
2005; Elsevier BV; Volume: 80; Issue: 9 Linguagem: Inglês
10.4065/80.9.1201
ISSN1942-5546
AutoresTodd J. Kowalski, Elie F. Berbari, Douglas R. Osmon,
Tópico(s)Bacterial Identification and Susceptibility Testing
ResumoSince first described in 1961, methicillin-resistant Staphylococcus aureus (MRSA) has become a common nosocomial pathogen. Substantial increases in MRSA infections among nonhospitalized patients are being reported. Methicillin-resistant S aureus is the most common isolate from skin and soft tissue infections in selected centers in the United States. Community-acquired MRSA strains differ from nosocomial strains in clinically relevant ways, such as in their propensity to cause skin and soft tissue infection and severe necrotizing pneumonia. Clinicians in numerous specialties, particularly primary care physicians, will likely evaluate patients presenting with community-acquired MRSA and should become familiar with the epidemiology and clinical characteristics of and evolving therapeutic and preventive strategies for this infection. Since first described in 1961, methicillin-resistant Staphylococcus aureus (MRSA) has become a common nosocomial pathogen. Substantial increases in MRSA infections among nonhospitalized patients are being reported. Methicillin-resistant S aureus is the most common isolate from skin and soft tissue infections in selected centers in the United States. Community-acquired MRSA strains differ from nosocomial strains in clinically relevant ways, such as in their propensity to cause skin and soft tissue infection and severe necrotizing pneumonia. Clinicians in numerous specialties, particularly primary care physicians, will likely evaluate patients presenting with community-acquired MRSA and should become familiar with the epidemiology and clinical characteristics of and evolving therapeutic and preventive strategies for this infection. Accumulating evidence reveals the emergence of methicillin-resistant Staphylococcus aureus (MRSA) in the community.1Chambers HF The changing epidemiology of Staphylococcus aureus?.Emerg Infect Dis. 2001; 7: 178-182Crossref PubMed Scopus (1193) Google Scholar Many of these community isolates are distinctly different from nosocomial strains. The emergence of these distinct MRSA isolates in the community, coined community-acquired MRSA (CA-MRSA), has become a topic of intense interest. The incidence of CA-MRSA infection seems to be increasing in the United States and worldwide. Primary care clinicians will need to be knowledgeable about the epidemiology, clinical syndromes, treatments, and preventive strategies associated with CA-MRSA. Shortly after the introduction of penicillin in the 1940s, penicillin-resistant S aureus isolates were described first in hospitals and subsequently in the community.1Chambers HF The changing epidemiology of Staphylococcus aureus?.Emerg Infect Dis. 2001; 7: 178-182Crossref PubMed Scopus (1193) Google Scholar Today, the vast majority of staphylococcal isolates carry plasmids encoding a penicillinase-rendering penicillin resistance. Methicillin, a penicillinase-resistant semisynthetic penicillin, was introduced in 1961. Less than 1 year later, MRSA was reported.1Chambers HF The changing epidemiology of Staphylococcus aureus?.Emerg Infect Dis. 2001; 7: 178-182Crossref PubMed Scopus (1193) Google Scholar Today, MRSA is a common nosocomial isolate and accounts for more than 50% of S aureus isolates from intensive care units in the United States.2National Nosocomial Infections Surveillance System National Nosocomial Infections Surveillance (NNIS) System Report, data summary from January 1992 to June 2002, issued August 2002.Am J Infect Control. 2002; 30: 458-475Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar In 1982, MRSA was first reported outside of the hospital among intravenous drug users in Detroit, Mich.3Saravolatz LD Markowitz N Arking L Pohlod D Fisher E Methicillin-resistant Staphylococcus aureus: epidemiologic observations during a community-acquired outbreak.Ann Intern Med. 1982; 96: 11-16Crossref PubMed Scopus (291) Google Scholar Subsequently, MRSA was described in Polynesian populations in western Australia and in pediatric populations in the southern and midwestern United States.4Riley TV Rouse IL Methicillin-resistant Staphylococcus aureus in Western Australia, 1983-1992.J Hosp Infect. 1995; 29: 177-188Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 5Adcock PM Pastor P Medley F Patterson JE Murphy TV Methicillin-resistant Staphylococcus aureus in two child care centers.J Infect Dis. 1998; 178: 577-580Crossref PubMed Scopus (223) Google Scholar, 6Herold BC Immergluck LC Maranan MC et al.Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified pre-disposing risk.JAMA. 1998; 279: 593-598Crossref PubMed Scopus (1261) Google Scholar In 1999, a report of the deaths of 4 children due to severe MRSA infections in Minnesota and North Dakota garnered much attention.7Centers for Disease Control and Prevention Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus—Minnesota and North Dakota, 1997-1999.MMWR Morb Mortal Wkly Rep. 1999; 48: 707-710PubMed Google Scholar A burgeoning body of literature continues to detail the emergence of CA-MRSA. These community isolates are composed of a heterogeneous mix of strains, some apparently well suited to survival and propagation in the community. There is no universally accepted definition of what constitutes CA-MRSA. Epidemiologically oriented studies base the definition on the timing of MRSA isolation in culture relative to hospital admission (ie, <24–72 hours), with or without excluding patients with established MRSA risk factors (recent hospitalization, hemodialysis, indwelling catheters, etc).8Salgado CD Farr BM Calfee DP Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors.Clin Infect Dis. 2003; 36: 131-139Crossref PubMed Scopus (715) Google Scholar Numerous epidemiological studies have suggested that hospitals were the primary MRSA reservoir and that hospital contact accounted for most MRSA infections in the community.8Salgado CD Farr BM Calfee DP Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors.Clin Infect Dis. 2003; 36: 131-139Crossref PubMed Scopus (715) Google Scholar In contrast, outbreaks and small case series of MRSA infections in the community were notable for the lack of any health care exposure among cases.5Adcock PM Pastor P Medley F Patterson JE Murphy TV Methicillin-resistant Staphylococcus aureus in two child care centers.J Infect Dis. 1998; 178: 577-580Crossref PubMed Scopus (223) Google Scholar, 6Herold BC Immergluck LC Maranan MC et al.Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified pre-disposing risk.JAMA. 1998; 279: 593-598Crossref PubMed Scopus (1261) Google Scholar These reports elucidated characteristics differentiating CA-MRSA from local nosocomial strains. Molecular analysis (eg, pulse-field gel electrophoresis analysis) revealed distinct strains compared with local nosocomial isolates.7Centers for Disease Control and Prevention Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus—Minnesota and North Dakota, 1997-1999.MMWR Morb Mortal Wkly Rep. 1999; 48: 707-710PubMed Google Scholar These distinct community strains often expressed resistance to β-lactams alone, in contrast to the multidrug-resistance pattern that typified nosocomial strains. Clinicians also noted a predilection for skin and soft tissue infection in these outbreaks.9Frank AL Marcinak JF Mangat PD Schreckenberger PC Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children.Pediatr Infect Dis J. 1999; 18: 993-1000Crossref PubMed Scopus (142) Google Scholar The discovery of a novel resistance element in CA-MRSA, in conjunction with molecular epidemiological insights, has added substantially to our understanding of these apparent differences. Methicillin resistance is mediated via a chromosomally incorporated resistance gene, mecA, which confers altered binding of β-lactams to penicillin binding protein 2a. The mecA gene is packaged in a cassette called the staphylococcal cassette cartridge (SCC), which aids in successful chromosomal incorporation.10Katayama Y Ito T Hiramatsu K A new class of genetic element, staphylococcus cassette chromosome mec, encodes methicillin resistance in Staphylococcus aureus.Antimicrob Agents Chemother. 2000; 44: 1549-1555Crossref PubMed Scopus (746) Google Scholar Until 2002, only 3 SCC types (I-III) were known, but a novel fourth type has been isolated from CA-MRSA.11Ma XX Ito T Tiensasitorn C et al.Novel type of staphylococcal cassette chromosome mec identified in community-acquired methicillin-resistant Staphylococcus aureus strains.Antimicrob Agents Chemother. 2002; 46: 1147-1152Crossref PubMed Scopus (501) Google Scholar It is becoming clear that the smaller type IV cassette, which usually does not include multiple other resistance elements, predominates among CA-MRSA strains.12Charlebois ED Perdreau-Remington F Kreiswirth B et al.Origins of community strains of methicillin-resistant Staphylococcus aureus [published correction appears in Clin Infect Dis. 2004;39:291].Clin Infect Dis. 2004; 39: 47-54Crossref PubMed Scopus (158) Google Scholar Rapid molecular diagnostics are available to test for the mecA gene in vitro and eventually will likely be available to directly test clinical specimens. These tests may prove useful to more rapidly diagnose MRSA infections.13Huletsky A Giroux R Rossbach V et al.New real-time PCR assay for rapid detection of methicillin-resistant Staphylococcus aureus directly from specimens containing a mixture of staphylococci.J Clin Microbiol. 2004; 42: 1875-1884Crossref PubMed Scopus (346) Google Scholar A recent San Francisco-based study used both epidemiological and molecular techniques to characterize CA-MRSA.14Carleton HA Diep BA Charlebois ED Sensabaugh GF Perdreau-Remington F Community-adapted methicillin-resistant Staphylococcus aureus (MRSA): population dynamics of an expanding community reservoir of MRSA.J Infect Dis. 2004; 190: 1730-1738Crossref PubMed Scopus (207) Google Scholar The strong association between type IV cassettes and CA-MRSA was confirmed. Furthermore, the study suggested that most MRSA infections in the community were related to a growing community reservoir, not a hospital reservoir, of MRSA. Methicillin-resistant S aureus infections in the community are composed of escaped nosocomial isolates (particularly among people with traditional MRSA risk factors) and novel community isolates of MRSA, the latter of which we deem to be true CA-MRSA. Regardless of origin, the growing community reservoir of MRSA poses daunting new challenges to the control and treatment of MRSA infections. Currently, CA-MRSA sensu stricto can be distinguished by the following characteristics: (1) the lack of multidrug-resistant phenotype, (2) the presence of exotoxin virulence factors, (3) type IV SCC, and (4) molecular distinction from nosocomial strains. Only an isolate's lack of multidrug-resistant phenotype is readily available to practicing clinicians outside of research settings. Table 115Naimi TS LeDell KH Como-Sabetti K et al.Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003; 290: 2976-2984Crossref PubMed Scopus (1505) Google Scholar shows representative resistance patterns among CA-MRSA compared with nosocomial strains. These susceptibility patterns are dynamic and may vary markedly by region. Already, CA-MRSA strains have encroached on health care settings to cause nosocomial outbreaks, and increasing antimicrobial resistance patterns have been observed among type IV isolates.14Carleton HA Diep BA Charlebois ED Sensabaugh GF Perdreau-Remington F Community-adapted methicillin-resistant Staphylococcus aureus (MRSA): population dynamics of an expanding community reservoir of MRSA.J Infect Dis. 2004; 190: 1730-1738Crossref PubMed Scopus (207) Google Scholar, 16Saiman L O'Keefe M Graham III, PL et al.Hospital transmission of community-acquired methicillin-resistant Staphylococcus aureus among post-partum women.Clin Infect Dis. 2003; 37: 1313-1319Crossref PubMed Scopus (333) Google Scholar Table 24Riley TV Rouse IL Methicillin-resistant Staphylococcus aureus in Western Australia, 1983-1992.J Hosp Infect. 1995; 29: 177-188Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 5Adcock PM Pastor P Medley F Patterson JE Murphy TV Methicillin-resistant Staphylococcus aureus in two child care centers.J Infect Dis. 1998; 178: 577-580Crossref PubMed Scopus (223) Google Scholar, 6Herold BC Immergluck LC Maranan MC et al.Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified pre-disposing risk.JAMA. 1998; 279: 593-598Crossref PubMed Scopus (1261) Google Scholar, 9Frank AL Marcinak JF Mangat PD Schreckenberger PC Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children.Pediatr Infect Dis J. 1999; 18: 993-1000Crossref PubMed Scopus (142) Google Scholar, 15Naimi TS LeDell KH Como-Sabetti K et al.Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003; 290: 2976-2984Crossref PubMed Scopus (1505) Google Scholar, 17Vandenesch F Naimi T Enright MC et al.Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence.Emerg Infect Dis. 2003; 9: 978-984Crossref PubMed Scopus (1520) Google Scholar, 18Moreillon P Que Y-A Glauser MP Staphylococcus aureus (including staphylococcal toxic shock).in: Mandell GL Bennett JE Dolin R 6th ed. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Vol 2. Elsevier, Philadelphia, Pa2005: 2321-2351Google Scholar, 19Centers for Disease Control and Prevention Community-associated methicillin-resistant Staphylococcus aureus infections in Pacific Islanders—Hawaii, 2001-2003.MMWR Morb Mortal Wkly Rep. 2004; 53: 767-770PubMed Google Scholar highlights differences between CA-MRSA and nosocomial MRSA.TABLE 1Representative Antimicrobial Susceptibilities (%) of Community-Associated and Health Care–Associated MRSA*Resistance data vary by geographic region. MRSA = methicillin-resistant Staphylococcus aureus.†See Table 2 and text for treatment recommendations; susceptibility does not necessarily indicate appropriate monotherapy.Adapted from JAMA,15Naimi TS LeDell KH Como-Sabetti K et al.Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003; 290: 2976-2984Crossref PubMed Scopus (1505) Google Scholar with permission. Copyrighted 2003, American Medical Association. All rights reservedAntimicrobialCommunity-associatedHealth care– associatedOxacillin00Ciprofloxacin7916Clindamycin8321Erythromycin449Gentamicin9480Rifampin9694Tetracycline9292Trimethoprim-sulfamethoxazole9590Vancomycin100100* Resistance data vary by geographic region. MRSA = methicillin-resistant Staphylococcus aureus.† See Table 2 and text for treatment recommendations; susceptibility does not necessarily indicate appropriate monotherapy. Open table in a new tab TABLE 2Characteristics of CA-MRSA vs Health Care–Associated MRSA*CA = community-acquired; MRSA = methicillin-resistant Staphylococcus aureus; PVL = Panton-Valentine leukocidin; SCC = staphylococcal cassette cartridge.4Riley TV Rouse IL Methicillin-resistant Staphylococcus aureus in Western Australia, 1983-1992.J Hosp Infect. 1995; 29: 177-188Abstract Full Text PDF PubMed Scopus (44) Google Scholar, 5Adcock PM Pastor P Medley F Patterson JE Murphy TV Methicillin-resistant Staphylococcus aureus in two child care centers.J Infect Dis. 1998; 178: 577-580Crossref PubMed Scopus (223) Google Scholar, 6Herold BC Immergluck LC Maranan MC et al.Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified pre-disposing risk.JAMA. 1998; 279: 593-598Crossref PubMed Scopus (1261) Google Scholar, 9Frank AL Marcinak JF Mangat PD Schreckenberger PC Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children.Pediatr Infect Dis J. 1999; 18: 993-1000Crossref PubMed Scopus (142) Google Scholar, 15Naimi TS LeDell KH Como-Sabetti K et al.Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003; 290: 2976-2984Crossref PubMed Scopus (1505) Google Scholar, 17Vandenesch F Naimi T Enright MC et al.Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence.Emerg Infect Dis. 2003; 9: 978-984Crossref PubMed Scopus (1520) Google Scholar, 18Moreillon P Que Y-A Glauser MP Staphylococcus aureus (including staphylococcal toxic shock).in: Mandell GL Bennett JE Dolin R 6th ed. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Vol 2. Elsevier, Philadelphia, Pa2005: 2321-2351Google Scholar, 19Centers for Disease Control and Prevention Community-associated methicillin-resistant Staphylococcus aureus infections in Pacific Islanders—Hawaii, 2001-2003.MMWR Morb Mortal Wkly Rep. 2004; 53: 767-770PubMed Google ScholarCA-MRSAHealth care–associated MRSAAt-risk groups or conditionsChildren, competitive athletes, prisoners, soldiers, selected ethnic populations (Native Americans/Alaska Natives, Pacific Islanders), intravenous drug users, men who have sex with menResidents in long-term care facility, patients with diabetes mellitus, patients undergoing hemodialysis/peritoneal dialysis, prolonged hospitalization, intensive care unit admission, indwelling intravascular cathetersSCC typeType IVTypes I, II, and IIIAntimicrobial resistanceβ-Lactam resistance alone, common (Table 1)Multidrug resistance, common (Table 1)PVL toxinFrequentRareAssociated clinical syndromesSkin and soft tissue infections (furuncles, skin abscesses), postinfluenza necrotizing pneumonia (see text)Nosocomial pneumonia, nosocomial- or catheter-related urinary tract infections, intravascular catheter or bloodstream infections, surgical-site infections* CA = community-acquired; MRSA = methicillin-resistant Staphylococcus aureus; PVL = Panton-Valentine leukocidin; SCC = staphylococcal cassette cartridge. Open table in a new tab Community-acquired MRSA strains tend to have associated exotoxins. The most common is the Panton-Valentine leukocidin (PVL) toxin, which is lethal to neutrophils and is associated with skin and soft tissue infections (specifically cellulitis, cutaneous abscesses, and furuncles) as well as severe necrotizing pneumonia.20Lina G Piemont Y Godail-Gamot F et al.Involvement of Panton-Valentine leukocidin-producing Staphylococcus aureus in primary skin infections and pneumonia.Clin Infect Dis. 1999; 29: 1128-1132Crossref PubMed Scopus (2087) Google Scholar Historically an uncommon virulence factor (present in <5% of isolates), PVL is emerging with CA-MRSA and probably in part explains the predilection for skin and soft tissue infections.17Vandenesch F Naimi T Enright MC et al.Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence.Emerg Infect Dis. 2003; 9: 978-984Crossref PubMed Scopus (1520) Google Scholar Recent in vitro work revealed that PVL-positive strains of Staphylococcus bind preferentially to damaged respiratory epithelium.21Gauduchon V Cozon G Vandenesch F et al.Neutralization of Staphylococcus aureus Panton Valentine leukocidin by intravenous immunoglobulin in vitro.J Infect Dis. 2004; 189: 346-353Crossref PubMed Scopus (176) Google Scholar This correlates clinically with data showing that PVL-associated pneumonias are associated with prior influenzalike illnesses.22Gillet Y Issartel B Vanhems P et al.Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients.Lancet. 2002; 359: 753-759Abstract Full Text Full Text PDF PubMed Scopus (1271) Google Scholar It is postulated that PVL contributes to enhanced community fitness, perhaps through enhanced transmission from draining wounds. Other exotoxins, including that responsible for staphylococcal scalded skin syndrome, have been described in community strains.23Liassine N Auckenthaler R Descombes MC Bes M Vandenesch F Etienne J Community-acquired methicillin-resistant Staphylococcus aureus isolated in Switzerland contains the Panton-Valentine leukocidin or exfoliative toxin genes.J Clin Microbiol. 2004; 42: 825-828Crossref PubMed Scopus (118) Google Scholar A recent prospective study24Ellis MW Hospenthal DR Dooley DP Gray PJ Murray CK Natural history of community-acquired methicillin-resistant Staphylococcus aureus colonization and infection in soldiers.Clin Infect Dis. 2004; 39: 971-979Crossref PubMed Scopus (395) Google Scholar suggests that CA-MRSA possesses enhanced infectivity and virulence. This report showed at least a 12-fold greater attack rate among MRSA nasally colonized soldiers compared with methicillin-sensitive S aureus (MSSA) colonized soldiers over an 8-to 10-week period. Furthermore, PVL-positive strains were found in all patients whose illness was severe enough to require hospitalization. The incidence of CA-MRSA varies regionally, but comprehensive epidemiological studies have not been published recently. Local prevalence data and antibiograms should be updated and monitored. Attendant to this, clinicians need to culture appropriate sources (furuncles, soft tissue abscesses, etc). The incidence of CA-MRSA varies also by age and is reported consistently in younger patients than is nosocomial MRSA.15Naimi TS LeDell KH Como-Sabetti K et al.Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection.JAMA. 2003; 290: 2976-2984Crossref PubMed Scopus (1505) Google Scholar Outbreaks have occurred in several discrete patient populations. Identified at-risk populations include children (particularly those in day care centers), soldiers, prisoners, homeless persons, intravenous drug users, and men who have sex with men.3Saravolatz LD Markowitz N Arking L Pohlod D Fisher E Methicillin-resistant Staphylococcus aureus: epidemiologic observations during a community-acquired outbreak.Ann Intern Med. 1982; 96: 11-16Crossref PubMed Scopus (291) Google Scholar, 6Herold BC Immergluck LC Maranan MC et al.Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified pre-disposing risk.JAMA. 1998; 279: 593-598Crossref PubMed Scopus (1261) Google Scholar, 24Ellis MW Hospenthal DR Dooley DP Gray PJ Murray CK Natural history of community-acquired methicillin-resistant Staphylococcus aureus colonization and infection in soldiers.Clin Infect Dis. 2004; 39: 971-979Crossref PubMed Scopus (395) Google Scholar, 25Centers for Disease Control and Prevention Methicillin-resistant Staphylococcus aureus infections in correctional facilities—Georgia, California, and Texas, 2001-2003.MMWR Morb Mortal Wkly Rep. 2003; 52: 992-996PubMed Google Scholar, 26Young DM Harris HW Charlebois ED et al.An epidemic of methicillin-resistant Staphylococcus aureus soft tissue infections among medically underserved patients.Arch Surg. 2004; 139: 947-951Crossref PubMed Scopus (152) Google Scholar Certain ethnic groups also have been associated with outbreaks including Pacific Islanders, Native Americans/Alaska Natives, and Pacific and Canadian aboriginals.19Centers for Disease Control and Prevention Community-associated methicillin-resistant Staphylococcus aureus infections in Pacific Islanders—Hawaii, 2001-2003.MMWR Morb Mortal Wkly Rep. 2004; 53: 767-770PubMed Google Scholar Competitive athletes, specifically those who participate in fencing, rugby, football, and wrestling, have been involved in outbreaks among high school, college, and professional teams.27Centers for Disease Control and Prevention Methicillin-resistant staphylococcus aureus infections among competitive sports participants—Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000-2003.MMWR Morb Mortal Wkly Rep. 2003; 52: 793-795PubMed Google Scholar Recently, an outbreak occurred in a group of divers.28Wang J Barth S Richardson M Corson K Mader J An outbreak of Methicillin-resistant Staphylococcus aureus cutaneous infection in a saturation diving facility.Undersea Hyperb Med. Winter 2003; 30: 277-284PubMed Google Scholar A lack of personal hygiene and a lack of basic infection-control principles probably contribute considerably to these outbreaks.27Centers for Disease Control and Prevention Methicillin-resistant staphylococcus aureus infections among competitive sports participants—Colorado, Indiana, Pennsylvania, and Los Angeles County, 2000-2003.MMWR Morb Mortal Wkly Rep. 2003; 52: 793-795PubMed Google Scholar Patients with recent or frequent antimicrobial use or persons who were recently hospitalized, have contact with others who have skin and soft tissue infections, or live in crowded quarters are also at risk.12Charlebois ED Perdreau-Remington F Kreiswirth B et al.Origins of community strains of methicillin-resistant Staphylococcus aureus [published correction appears in Clin Infect Dis. 2004;39:291].Clin Infect Dis. 2004; 39: 47-54Crossref PubMed Scopus (158) Google Scholar, 25Centers for Disease Control and Prevention Methicillin-resistant Staphylococcus aureus infections in correctional facilities—Georgia, California, and Texas, 2001-2003.MMWR Morb Mortal Wkly Rep. 2003; 52: 992-996PubMed Google Scholar, 29Baggett HC Hennessy TW Rudolph K et al.Community-onset methicillin-resistant Staphylococcus aureus associated with antibiotic use and the cytotoxin Panton-Valentine leukocidin during a furunculosis outbreak in rural Alaska.J Infect Dis. 2004; 189: 1565-1573Crossref PubMed Scopus (227) Google Scholar Skin and soft tissue infections and lower respiratory infections account for much of the current clinical literature about CA-MRSA. Community-acquired MRSA has been reported less frequently in endocarditis, brain abscesses, bacteremia, sinusitis, and musculoskeletal infections.30Lin JC Wu JS Chang FY Community-acquired methicillin-resistant Staphylococcus aureus endocarditis with septic embolism of popliteal artery: a case report.J Microbiol Immunol Infect. 2000; 33: 57-59PubMed Google Scholar, 31Khan MA Greig JR Jayamohan J Community-acquired methicillin-resistant Staphylococcus aureus brain abscess in an immunocompetent individual.Scand J Infect Dis. 2000; 32: 423-424Crossref PubMed Scopus (13) Google Scholar, 32Murray RJ Lim TT Pearson JC Grubb WB Lum GD Community-onset methicillin-resistant Staphylococcus aureus bacteremia in Northern Australia.Int J Infect Dis. 2004; 8: 275-283Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar, 33Collins M Tami TA Methicillin-resistant Staphylococcus aureus (MRSA) in the practice of otolaryngology—an emerging community acquired organism?.Curr Opin Otolaryngol Head Neck Surg. 2003; 11: 179-183Crossref PubMed Scopus (12) Google Scholar, 34Gwynne-Jones DP Stott NS Community-acquired methicillin-resistant Staphylococcus aureus: a cause of musculoskeletal sepsis in children.J Pediatr Orthop. 1999; 19: 413-416PubMed Google Scholar Recent reports about CA-MRSA causing necrotizing fasciitis, myositis, osteomyelitis, prosthetic joint infection, and complicated parapneumonic effusions highlight the various clinical settings and syndromes with which this pathogen has been associated.35Miller LG Perdrau-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: 1445-1453Crossref PubMed Scopus (870) Google Scholar, 36Martinez-Aguilar G Avalos-Mishaan A Hulten K Hammerman W Mason Jr, EO Kaplan SL Community-acquired, methicillin-resistant and methicillin-susceptible Staphylococcus aureus musculoskeletal infections in children.Pediatr Infect Dis J. 2004; 23: 701-706Crossref PubMed Scopus (306) Google Scholar, 37Kourbatova EV, Halvosa JS, King MD, Ray SM, White N, Blumberg HM. Community-associated (CA) methicillin-resistant Staphylococcus aureus (MRSA) USA 300 clone as a cause of nosocomial prosthetic joint infections [abstract]. In: Program and abstracts of the Infectious Diseases Society of America 42nd Annual Meeting; Boston, Mass; September 30-October 3, 2004: 135. Abstract 496.Google Scholar, 38Alfaro C, Patel D, Newaskar M, Fergie J, Purcell K. Emergence of community-acquired methicillin-resistant Staphylococcus aureus in complicated parapneumonic effusions [abstract]. In: Program and abstracts of the Infectious Diseases Society of America 42nd Annual Meeting; Boston, Mass; September 30-October 3, 2004: 135. Abstract 494.Google Scholar Such diverse manifestations may become recognized more frequently over time as the prevalence and physician awareness of this pathogen increase. Community-acquired MRSA should be considered in the differential diagnosis of skin and soft tissue infections, particularly among patients at risk or slow to respond to β-lactam therapy. Furunculosis and cutaneous skin abscesses are the most common manifestations, but simple cellulitis also can occur. Recurrent furunculosis and transmission to close contacts (family members, teammates, etc) occur frequently.39Faden H Ferguson S Community-acquired methicillin-resistant Staphylococcus aureus and intrafamily spread of pustular disease [letter].Pediatr Infect Dis J. 2001; 20: 554-555Crossref PubMed Scopus (38) Google Scholar The dermonecrotic lesions encountered may be misdiagnosed as spider bites, and such lesions should suggest CA-MRSA.40Cente
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