The nose is not the only relevant MRSA screening site

Ide, Lucy Eberechukwu Yaguo; Lootens, J.; Thibo, P.

doi:10.1111/j.1469-0691.2009.02954.x

Cited by 15 publications

(17 citation statements)

References 5 publications

(16 reference statements)

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“…This theory is not borne out by data from the USA, where community-acquired PVL-positive MRSA infection is common but most individuals are colonised with PVL-negative MSSA strains 1 . This finding suggests that disease can occur in the absence of nasal colonisation, 74 and evidence increasingly suggests that non-nasal sites such as the throat 75 and inguinal areas might be important colonisation sites for PVL-positive S aureus 76 . Results of a large study 77 of S aureus transmission in the household suggest interplay between colonisation and disease-causing isolates is complex and might depend on bacterial strain.…”

Section: Discussionmentioning

confidence: 99%

The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis

Shallcross

Fragaszy

Johnson

et al. 2013

The Lancet Infectious Diseases

385

332

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SummaryBackgroundInvasive community-onset staphylococcal disease has emerged worldwide associated with Panton-Valentine leucocidin (PVL) toxin. Whether PVL is pathogenic or an epidemiological marker is unclear. We investigate the role of PVL in disease, colonisation, and clinical outcome.MethodsWe searched Medline and Embase for original research reporting the prevalence of PVL genes among Staphylococcus aureus pneumonia, bacteraemia, musculoskeletal infection, skin and soft-tissue infection, or colonisation published before Oct 1, 2011. We calculated odds ratios (ORs) to compare patients with PVL-positive colonisation and each infection relative to the odds of PVL-positive skin and soft-tissue infection. We did meta-analyses to estimate odds of infection or colonisation with a PVL-positive strain with fixed-effects or random-effects models, depending on the results of tests for heterogeneity.ResultsOf 509 articles identified by our search strategy, 76 studies from 31 countries met our inclusion criteria. PVL strains are strongly associated with skin and soft-tissue infections, but are comparatively rare in pneumonia (OR 0·37, 95% CI 0·22–0·63), musculoskeletal infections (0·44, 0·19–0·99), bacteraemias (0·10, 0·06–0·18), and colonising strains (0·07, 0·01–0·31). PVL-positive skin and soft-tissue infections are more likely to be treated surgically than are PVL-negative infections, and children with PVL-positive musculoskeletal disease might have increased morbidity. For other forms of disease we identified no evidence that PVL affects outcome.InterpretationPVL genes are consistently associated with skin and soft-tissue infections and are comparatively rare in invasive disease. This finding challenges the view that PVL mainly causes invasive disease with poor prognosis. Population-based studies are needed to define the role of PVL in mild, moderate, and severe disease and to inform control strategies.FundingNone.

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Section: Discussionmentioning

confidence: 99%

The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis

Shallcross

Fragaszy

Johnson

et al. 2013

The Lancet Infectious Diseases

385

332

View full text Add to dashboard Cite

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“…A cross-sectional study of adults and children with S. aureus skin infections and their household contacts indicated that a nare-only survey would have missed 38% of MSSA and 51% of MRSA colonized persons [20]. Overall, most studies focus on patient populations with a history of ongoing skin infection or substantial risk factors of MRSA colonization; however, the literature increasingly supports the role of extra-nare site screening, especially the oropharynx [24-26]. …”

Section: Discussionmentioning

confidence: 99%

Staphylococcus aureus colonization of healthy military service members in the United States and Afghanistan

et al. 2013

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BackgroundStaphylococcus aureus [methicillin-resistant and methicillin-susceptible (MRSA/MSSA)] is a leading cause of infections in military personnel, but there are limited data regarding baseline colonization of individuals while deployed. We conducted a pilot study to screen non-deployed and deployed healthy military service members for MRSA/MSSA colonization at various anatomic sites and assessed isolates for molecular differences.MethodsColonization point-prevalence of 101 military personnel in the US and 100 in Afghanistan was determined by swabbing 7 anatomic sites. US-based individuals had received no antibiotics within 30 days, and Afghanistan-deployed personnel were taking doxycycline for malaria prophylaxis. Isolates underwent identification and testing for antimicrobial resistance, virulence factors, and pulsed-field type (PFT).Results4 individuals in the US (4 isolates- 3 oropharynx, 1 perirectal) and 4 in Afghanistan (6 isolates- 2 oropharynx, 2 nare, 1 hand, 1 foot) were colonized with MRSA. Among US-based personnel, 3 had USA300 (1 PVL+) and 1 USA700. Among Afghanistan-based personnel, 1 had USA300 (PVL+), 1 USA800 and 2 USA1000. MSSA was present in 40 (71 isolates-25 oropharynx, 15 nare) of the US-based and 32 (65 isolates- 16 oropharynx, 24 nare) of the Afghanistan-based individuals. 56 (79%) US and 41(63%) Afghanistan-based individuals had MSSA isolates recovered from extra-nare sites. The most common MSSA PFTs were USA200 (9 isolates) in the US and USA800 (7 isolates) in Afghanistan. MRSA/MSSA isolates were susceptible to doxycycline in all but 3 personnel (1 US, 2 Afghanistan; all were MSSA isolates that carried tetM).ConclusionMRSA and MSSA colonization of military personnel was not associated with deployment status or doxycycline exposure. Higher S. aureus oropharynx colonization rates were observed and may warrant changes in decolonization practices.

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“…In various studies, the sensitivity of an anterior nares culture for MRSA nasal colonization ranged from 41 to 93% (7-11, 19, 21-24, 26-30), while the sensitivity of combined nose and throat cultures ranged from 80 to 100% (8,9,11,19,22,23,26). The NPV of a nasal culture alone varied from 87 to 98.8%, while the NPV of nasal plus throat cultures ranged from 92 to 100% (Table 1) (7)(8)(9)(10)(11). Given the fact that aspiration of pathogens from the oropharynx is the primary route of bacteria entering the lower respiratory tract (2), the data described above provide strong evidence that MRSA pneumonia is unlikely in patients who are not colonized in the nose and throat and have no evidence of MRSA bacteremia.…”

Section: Discussionmentioning

confidence: 99%

“…We requested that care givers screen patients for both throat and nasal MRSA colonization, because previous studies have found that from 5 to 20% of patients may be colonized in the throat but not the nose (7,(9)(10)(11)(18)(19)(20)(21)(22)(23)(24)(25). In various studies, the sensitivity of an anterior nares culture for MRSA nasal colonization ranged from 41 to 93% (7-11, 19, 21-24, 26-30), while the sensitivity of combined nose and throat cultures ranged from 80 to 100% (8,9,11,19,22,23,26).…”

Section: Discussionmentioning

confidence: 99%

“…The fact that the combination of a nasal plus a throat culture negative for MRSA has a negative predictive value (NPV) of 92 to 100% for MRSA colonization (Table 1) (7)(8)(9)(10)(11) suggests that MRSA pneumonia is unlikely to be present in patients who do not have MRSA nasal or throat colonization. This concept is supported by a recent study which found that a negative nasal swab using PCR methods had an NPV of 98% for estimating the risk of having a clinical respiratory specimen culture positive for MRSA (12).…”

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confidence: 99%

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A Trial of Discontinuation of Empiric Vancomycin Therapy in Patients with Suspected Methicillin-Resistant Staphylococcus aureus Health Care-Associated Pneumonia

Boyce

Pop

Abreu-Lanfranco³

et al. 2013

Antimicrob Agents Chemother

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f Healthcare-associated pneumonia (HCAP) guidelines recommend de-escalating initial antibiotic therapy based on results from lower-respiratory-tract cultures. In the absence of adequate lower respiratory cultures, physicians are sometimes reluctant to discontinue empirical vancomycin, which is given for suspected methicillin-resistant Staphylococcus aureus (MRSA) HCAP. We evaluated a strategy of discontinuing vancomycin if both nasal and throat cultures were negative for MRSA when lower-respiratory-tract cultures were not available. An antimicrobial stewardship team identified patients receiving empirical vancomycin for suspected or proven HCAP but for whom adequate lower-respiratory-tract cultures were not available. Nasal and throat swab specimens were obtained and plated on MRSA selective media. If both nasal and throat MRSA cultures were negative, the stewardship team recommended discontinuation of empirical vancomycin. Demographic and clinical aspects, a clinical pulmonary infection score (CPIS) on the day of the stewardship recommendation, and mortality of patients for whom vancomycin was discontinued were obtained by retrospective chart review. A convenience sample of 91 patients with nasal and throat cultures negative for MRSA in the absence of adequate respiratory cultures had empirical vancomycin therapy discontinued. A retrospective review revealed that 88 (97%) patients had a CPIS of <6 on the day of the stewardship recommendation. In-hospital mortality (7.7%) was similar to that of a previous study of de-escalation of antibiotics in pneumonia patients without adequate cultures. In the absence of adequate lower-respiratory-tract cultures, it is reasonable to discontinue empirical vancomycin HCAP therapy in patients with negative MRSA nasal and throat cultures and a CPIS of <6.

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The nose is not the only relevant MRSA screening site

Cited by 15 publications

References 5 publications

The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis

The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis

Staphylococcus aureus colonization of healthy military service members in the United States and Afghanistan

A Trial of Discontinuation of Empiric Vancomycin Therapy in Patients with Suspected Methicillin-Resistant Staphylococcus aureus Health Care-Associated Pneumonia

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