title: Methicillin-sensitive Staphylococcus aureus bacteraemia and endocarditis among injection drug users and nonaddicts: host factors, microbiological and serological characteristics.
abstract: BACKGROUND
  Endocarditis has been associated with lower mortality and fewer complications among injection drug users (IDUs) than nonaddicts in Staphylococcus aureus bacteraemia (SAB). The better prognosis of IDUs has not been clarified but it has generally been explained by younger age and other host factors. In this study, bacterial strains, their virulence factors, and host immune responses were compared among IDUs and nonaddicts with SAB, including those with and without endocarditis.
  
  
  METHODS
  A total of 430 consecutive adult patients with methicillin-sensitive SAB were followed prospectively for 3 months. All 44 IDUs were included, and 44 nonaddicts as controls for them. According to the modified Duke criteria, 20 patients in both groups had endocarditis. For each addict without endocarditis, an age and sex matched nonaddict was selected as a control. S. aureus isolates were assigned a genotype by PFGE, Panton-Valentine leukocidin (PVL), staphylokinase (SAK), protease, and haemolysin production. Acute and convalescent sera were tested for antibodies to alpha-haemolysin (ASTA) and teichoic acid (TAA).
  
  
  RESULTS
  There were no differences between IDUs and nonaddicts with SAB in the proportion of patients with a deep infection (98% vs 86%, P=0.06) or a thromboembolic complication (30% vs 14%, P=0.12). Endocarditis among IDUs was not associated with any specific strains, and only the FIN-4 strain was observed more often in IDUs than in nonaddicts (21% vs 5%, P=0.03). The majority of isolates (98%) were PVL negative, and there were no differences in the numbers of SAK, protease and haemolysin production among strains between IDUs and nonaddicts. However, haemolytic properties were found more frequently in strains from IDUs without endocarditis than those with endocarditis (88% vs 47%, P=0.007). IDUs displayed more often elevated TAA titers than nonaddicts, especially in endocarditis at acute phase (33% vs 5%, P=0.04) and at convalescent phase (50% vs 10%, P=0.01). The ASTA titer was more frequently initially positive among IDUs without endocarditis than with endocarditis (44% vs 6%, P=0.01).
  
  
  CONCLUSIONS
  Characterization of the bacterial strains and their virulence factors, and host immune responses did not reveal significant differences between IDUs and nonaddicts with similar clinical picture of SAB. Serological tests were not helpful in identifying patients with endocarditis.
authors.affiliation: Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland. eeva.ruotsalainen@hus.fi
authors.forename: Eeva
authors.initials: E
authors.lastname: Ruotsalainen
authors.forename: Minna
authors.initials: M
authors.lastname: Kardén-Lilja
authors.forename: Pentti
authors.initials: P
authors.lastname: Kuusela
authors.forename: Jaana
authors.initials: J
authors.lastname: Vuopio-Varkila
authors.forename: Anni
authors.initials: A
authors.lastname: Virolainen-Julkunen
authors.forename: Seppo
authors.initials: S
authors.lastname: Sarna
authors.forename: Ville
authors.initials: V
authors.lastname: Valtonen
authors.forename: Asko
authors.initials: A
authors.lastname: Järvinen
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000890:Anti-Infective Agents / Q000627:therapeutic use; D016470:Bacteremia / Q000150:complications / Q000188:drug therapy / Q000382:microbiology*; D016022:Case-Control Studies; D016521:Electrophoresis, Gel, Pulsed-Field; D004697:Endocarditis, Bacterial / Q000150:complications / Q000188:drug therapy / Q000382:microbiology*; D024841:Fluoroquinolones / Q000627:therapeutic use; D005838:Genotype; D006801:Humans; D008712:Methicillin / Q000494:pharmacology; D008875:Middle Aged; D009287:Naphthyridines / Q000627:therapeutic use; D015242:Ofloxacin / Q000627:therapeutic use; D012698:Serologic Tests; D013203:Staphylococcal Infections / Q000150:complications / Q000188:drug therapy / Q000382:microbiology*; D013211:Staphylococcus aureus / Q000187:drug effects / Q000276:immunology* / Q000302:isolation & purification*; D015819:Substance Abuse, Intravenous / Q000150:complications / Q000382:microbiology*; D013682:Teichoic Acids / Q000276:immunology
chemical_list: D000900:Anti-Bacterial Agents; D000890:Anti-Infective Agents; D024841:Fluoroquinolones; D009287:Naphthyridines; D013682:Teichoic Acids; C044340:ribitol teichoic acid; C080163:trovafloxacin; D015242:Ofloxacin; D008712:Methicillin