Is methicillin-resistant Staphylococcus aureus an emerging community pathogen? A review of the literature.
OBJECTIVE
To discuss the historical epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) and review the literature suggesting that MRSA has become a community pathogen.


METHODS
A search of the MEDLINE database was performed, encompassing all English or French language citations from 1966 to 1999 and containing the subjects and/or text words: 'Staphylococcus aureus', 'methicillin resistance', 'endocarditis', 'cellulites', 'pneumonia' and 'community-acquired'. Articles published in other languages that provided English or French abstracts were included. All relevant references cited in articles obtained from the MEDLINE database and book chapters were also included.


METHODS
All articles obtained from the above sources were examined and were included in the review if a laboratory or epidemiological study of community-acquired MRSA was presented.


CONCLUSIONS
MRSA has emerged over the past 30 years to become a worldwide nosocomial pathogen and has recently been reported as a cause of community-acquired infections. The changing epidemiology of MRSA is likely because of two mechanisms: the movement of nosocomial MRSA strains into the community and the de novo appearance of community strains resulting from the transfer of genetic material from methicillin-resistant Gram-positive organisms to sensitive S aureus strains. The emergence of MRSA as a community pathogen has occurred at a slower rate than it did for penicillin-resistant S aureus (PRSA) in the 1950s and 1960s, possibly because the mechanism of methicillin resistance does not exhibit the same ease of transferability as that of penicillin resistance. Four case reports, seven case series, 10 case-control studies and two cohort studies on community-acquired MRSA were analyzed. Determining whether these reports involve new community-acquired strains rather than previously acquired nosocomial strains can be problematic. It appears, however, that MRSA strains of both nosocomial and community origin are now endemic in certain communities in different parts of the world. Few surveillance studies of nonhospitalized patient populations have been performed to date; thus, the true prevalence of MRSA in the community at large is essentially unknown, although it appears to be low. At present, the empirical treatment of community-acquired S aureus infections with a beta-lactamase-stable beta-lactam antibiotic is appropriate for most populations. However, empirical vancomycin therapy for serious S aureus infections should be strongly considered for patients with significant risk factors for previously-acquired nosocomial MRSA or for patients belonging to outpatient populations with a proven high prevalence of MRSA. Increasing vancomycin use will likely have a significant impact on the development of resistance in Gram-positive organisms.
Gardam
M A
MA
Infection Prevention and Control Unit and the Division of Infectious Disease, Department of Medicine, The University Health Network, University of Toronto, Toronto, Ontario.