Community-acquired methicillin-resistant Staphylococcus aureus in institutionalized adults with developmental disabilities - 1

Emerging Infectious Diseases, Sept, 2002 by Abraham Borer, Jacob Gilad, Pablo Yagupsky, Nechama Peled, Nurith Porat, Ronit Trefler, Hannah Shprecher-Levy, Klaris Riesenberg, Miriam Shipman, Francisc Schlaeffer

Elimination of carriage was achieved by intranasal antibiotics (either mupirocin or fusidic acid); the aim was to control the outbreak and prevent recurrence. We also treated the great majority of infections topically, in addition to bathing with chlorhexidine and appropriate drainage with the intention of maximally reducing systemic antibiotic use.

While mupirocin is a well-accepted eradication regimen (24), the possible emergence of mupirocin resistance during therapy (especially with skin application) should be considered. Fusidic acid, widely used in Israel, has been shown to be a convenient and risk-free method for eradication of nasal S. aureus carriage (36), but currently no comparative data evaluate both agents. In our population, only five cases required systemic therapy, according to study indications, and mupirocin resistance was not detected during follow-up. However, persistent nasal MRSA carriage, 2 years after the onset of the outbreak, demonstrates a continued potential threat for both the reemergence of MRSA in the institution and perhaps, dissemination to the community.

Our essential goal was to achieve maximal infection control while maintaining selective pressure at the minimum. Critical factors, which are difficult to achieve in nosocomial settings, allowed us to achieve nearly total eradication of MRSA: 1) only one resident appeared to be a persistent nasal MRSA carrier; 2) all residents were exposed during a specific time frame without mingling between newly admitted or discharged residents; 3) enforcement of strict environmental cleansing and infection control measures; and 4) selective antibiotic pressure owing to minimal use of systemic agents (only 5 courses).

In conclusion, massive, and perhaps unjustified, systemic antibiotic use in communities, particularly those involving close interaction between members, may permit the emergence of multiresistant bacteria such as MRSA, with a high risk for disease. Implementation of antibiotic control strategies is crucial to prevent the dissemination of MRSA in the community as a whole.

(1) This work has been presented in part at the 38th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC), San Diego, California, USA, September 24-27, 1998.

References

(1.) Andersen BM, Bergh K, Steinbakk M, Syversen G, Magnaes B, Dalen H, et al. A Norwegian nosocomial outbreak of methicillin-resistant Staphylococcus aureus resistant to fusidic acid and susceptible to other antistaphylococcal agents. J Hosp Infect 1999;41:123-32.

(2.) Goetz MB, Mulligan ME, Kwok R, O'Brien H, Caballes C, Garcia JP. Management and epidemiologic analyses of an outbreak due to methicillin-resistant Staphylococcus aureus. Am J Med 1992;92:607-14.

(3.) Barrett FF, McGehee RF Jr, Finland M. Methicillin resistant Staphylococcus aureus at Boston City Hospital. N Engl J Med 1968;279:441-8.

(4.) Thompson RL, Cabezudo I, Wenzel RP. Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann Intern Med 1982;97:309-17.