884 infection control & hospital epidemiology july 2017, vol. 38, no. 7
to PVL-positive S. aureus nasal colonization3,4 and (2) nosoco- mial outbreaks of epidemic PVL+ CA-MRSA other than USA300 being fueled by colonized individuals that suffer from recurrent SSTI.9 Although the impact of the proposed approach has not been systematically evaluated, these observations in conjunction with our report suggests that a history of recurrent SSTI is a potent marker for colonization with epidemic CA- MRSA and could thus prove useful for its early detection and timely eradication in newly admitted patients before invasion of epidemic CA-MRSA into European hospitals becomes an unchangeable fact. A recent report of a USA300 outbreak in a Belgium hospital demonstrates the urgency of this issue10 and justifies taking measures before direct evidence is available. Finally, European surveillance activities must address the silent invasion by USA300-LV and must monitor the import and spread of ACME-neg,MLST 8, SCCmec IVc MRSA.
acknowledgments
Financial support: No financial support was provided relevant to this article. Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.
Dennis Nurjadi, MD;1 Sabrina Klein, MD;1
Stefan Zimmermann, MD;1 Klaus Heeg, MD;1
Philipp Zanger, MD1,2
Affiliation: 1. Department of Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany; 2. Institute of Public Health, Heidelberg University Hospital, Heidelberg, Germany. Address correspondence to Dennis Nurjadi, MD, Heidelberg University Hospital, Department of Infectious Diseases, Im Neuenheimer Feld 324, Heidelberg 69120, Germany (
dennis.nurjadi@
uni-heidelberg.de). Infect Control Hosp Epidemiol 2017;38:883–885 © 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3807-0023. DOI: 10.1017/ice.2017.88
references
1. Nimmo GR. USA300 abroad: global spread of a virulent strain of community-associated methicillin-resistant aureus. Clin Microbiol Infect 2012;18:725–734.
Staphylococcus
2. Reyes J, Rincon S, Diaz L, et al. Dissemination of methicillin- resistant Staphylococcus aureus USA300 sequence type 8 lineage in Latin America. Clin Infect Dis 2009;49:1861–1867.
3. Nurjadi D, Friedrich-Janicke B, Schafer J, et al. Skin and soft tissue infections in intercontinental travellers and the import of multi-resistant Staphylococcus aureus to Europe. Clin Microbiol Infect 2015;21:567e1–e10.
4. Zanger P, Nurjadi D, Schleucher R, et al. Import and spread of Panton-Valentine Leukocidin-positive Staphylococcus aureus through nasal carriage and skin infections in travelers returning from the tropics and subtropics. Clin Infect Dis 2012;54:483–492.
5. Conde-AgudeloA,Diaz-Rossello JL.Kangaroomother care to reduce morbidity and mortality in low birthweight infants. Cochrane Data- base Syst Rev 2016. doi: 10.1002/
14651858.CD002771.
table 1. Characteristics of the Index Case, Contact Persons, and Staphylococcus aureus Isolates of a USA300 Latin American Variant Outbreaka Screened Subject, Site (Time Point) Newborn (index case)
mecA Nasal (pp day 11) Mother Father Sister
Nasal, preoperative (pp day 16) Nasal (pp day 18)
Breast milk (pp day 18)
Cesarean section wound (pp day 24) Nasal (pp day 18)
Wound (pp day 18) Nasal (pp day 18)
Resolving SSTI wound (pp day 18) +
+ +
+ +
+
+ +
+ +
+ + PVL spa
t008 t008
t008 t008
t008 t008 MLST
Negative for S. aureus ST8
ST8 ST8 ST8
ST8 ST8 SCCmecb
IVc IVc
IVc IVc
IVc
No acute infection at day of sample collection Negative
IVc Neg NOTE. MRSA, methicillin-resistant S. aureus; PVL, Panton-Valentine leukocidin; MLST, multilocus sequence type; SCCmec, staphylococcal cassette chromosome mec; ACME, arginine
catabolic mobile element; NICU, neonatal intensive care unit; pp, post partum; DORV, double outlet right ventricle; neg, negative. aNo coresistance to quinolones, aminoglycosides, tetracyclines, trimethoprim-sulfamethoxazole, clindamycin, erythromycin, rifampicin, vancomycin, teicoplanin, linezolid, dapto-
mycin, fosfomycin, tigecyclin, fusidic acid and mupirocin in any of the MRSA isolates. All strains bear the copper- and mercury-resistant characteristics (COMER). bMolecular characterization revealed SCCmec type IVc, ACME negative MRSA, consistent with the USA300-Latin American Variant, and not SCCmec IVa and ACME-positive MRSA, characteristic for USA300, which is highly prevalent in the United States.
ACMEb
Neg Neg
Neg Neg
Neg
History of recurrent SSTI; return from travel to Spain>12 mo prior; no history of travel outside Europe
History of recurrent SSTI; no history of travel outside Europe Clinical Characteristics Preterm infant with DORV; kangaroo mother care on NICU
Source of MRSA (putative primary case); MRSA colonization detected after identification of index case; no history of travel outside Europe
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