title: Nosocomial antibiotic-associated diarrhea associated with enterotoxin-producing strains of methicillin-resistant Staphylococcus aureus.
abstract: OBJECTIVE
  The aim of this study is to present new evidence that enterotoxin-producing strains of methicillin-resistant Staphylococcus aureus may cause nosocomial antibiotic-associated diarrhea.
  
  
  METHODS
  We conducted a prospective study that utilized standard methods to exclude other bacterial, parasitic, and viral pathogens as causes of nosocomial diarrhea in patients with heavy growth of methicillin-resistant S. aureus in their stool. Staphylococcal enterotoxin assays were performed on S. aureus strains recovered from patients' stools and on stool specimens from affected patients. Retrospective cohort studies compared the severity of diarrhea in patients with methicillin-resistant S. aureus-associated diarrhea with that of patients whose stool did not contain the organism and with patients colonized or infected with enterotoxin-negative methicillin-resistant S. aureus strains.
  
  
  RESULTS
  During an 18-month period, 11 patients had nosocomial antibiotic-associated diarrhea associated with enterotoxin-producing strains of methicillin-resistant S. aureus. Other common bacterial, parasitic, and viral pathogens were excluded. S. aureus strains from the 11 patients produced staphylococcal enterotoxin A, A and B, or D. Eighty-nine percent of patients had the same enterotoxin(s) in stool specimens as produced by the strain recovered from their stool. Case patients had a greater number of days of diarrhea than patients without methicillin-resistant S. aureus in their stool (p < 0.001), or randomly selected patients colonized or infected with enterotoxin-negative methicillin-resistant S. aureus (p < 0.001).
  
  
  CONCLUSIONS
  Our findings provide evidence that enterotoxin-producing strains of methicillin-resistant S. aureus may cause nosocomial antibiotic-associated diarrhea. Greater recognition of this disease should result in more rapid and appropriate treatment of affected patients.
authors.affiliation: Department of Medicine, Hospital of Saint Raphael; and Yale University School of Medicine New Haven, Connecticut 06511, USA.
authors.forename: John M
authors.initials: JM
authors.lastname: Boyce
authors.forename: Nancy L
authors.initials: NL
authors.lastname: Havill
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D003428:Cross Infection / Q000382:microbiology*; D003967:Diarrhea / Q000139:chemically induced* / Q000382:microbiology*; D004768:Enterotoxins / Q000096:biosynthesis*; D005243:Feces / Q000382:microbiology; D005260:Female; D006801:Humans; D008297:Male; D016106:Methicillin Resistance; D013203:Staphylococcal Infections / Q000150:complications / Q000382:microbiology*; D013211:Staphylococcus aureus / Q000187:drug effects / Q000302:isolation & purification / Q000378:metabolism*
chemical_list: D000900:Anti-Bacterial Agents; D004768:Enterotoxins