Impact of traditional hospital strain of methicillin-resistant Staphylococcus aureus (MRSA) and community strain of MRSA on mortality in patients with community-onset S aureus bacteremia.
Community-associated methicillin-resistant Staphylococcus aureus (MRSA) has become an important pathogen in community and nosocomial infections. The impact of these emerging MRSA strains on mortality in adult patients with community-onset S aureus bacteremia remains uncertain. We defined community strain MRSA (CoSt-MRSA) and hospital strain MRSA (HoSt-MRSA) according to the results of staphylococcus cassette chromosome mec (SCCmec) molecular typing: CoSt-MRSA isolates had SCCmec type IV or V genes, and HoSt-MRSA isolates had SCCmec type I, II, or III genes. We quantitatively evaluated the impact of the MRSA strain on mortality in patients with CoSt-MRSA or HoSt-MRSA bacteremia by comparison with mortality in patients with methicillin-susceptible S aureus (MSSA) bacteremia.We studied an observational cohort of 500 patients with MSSA bacteremia, 111 patients with CoSt-MRSA, and 133 patients with HoSt-MRSA bacteremia from January 1, 2001, through December 31, 2007. The 90-day cumulative probability of survival in patients with MSSA, CoSt-MRSA, and HoSt-MRSA bacteremia was 71%, 70%, and 55%, respectively (p = 0.014, by Wilcoxon rank-sum test).Compared to patients with MSSA bacteremia, patients with HoSt-MRSA bacteremia were associated with an increased risk of mortality in the first multivariate analysis model adjusting for all potential confounders (hazard ratio [HR], 1.525; 95% confidence interval [CI], 1.091-2.131), in the second model adjusting for all confounders except acute severity of bacteremia (HR, 1.489; 95% CI, 1.071-2.070), and in stratified analysis in patients with low Charlson comorbidity scores (score 0-2) (HR, 3.093; 95% CI, 1.507-6.350).Compared to patients with MSSA bacteremia, patients with CoSt-MRSA bacteremia did not show significant differences in mortality rate in the 2 multivariate analysis models (first model: HR, 1.106; 95% CI, 0.748-1.637; second model: HR, 1.028; 95% CI, 0.697-1.516) or in stratified analysis (HR, 1.092; 95% CI, 0.539-2.214).In conclusion, using MSSA as reference, traditional hospital strain MRSA had a higher impact on bacteremia mortality than community strain MRSA.
Chen
Shey-Ying
SY
From Department of Emergency Medicine (SYC); Division of Infectious Diseases (JTW, SCC), Department of Internal Medicine; and Department of Laboratory Medicine (PRH), National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei; Institute of Preventive Medicine (SYC, JTW, MSL, WCC, KLC); and Institute of Epidemiology (THHC), College of Public Health, National Taiwan University, Taipei; and Department of Internal Medicine (JLW), E-Da Hospital, I-Shou University, Kaohsiung, Taiwan.
Wang
Jann-Tay
JT
Chen
Tony Hsiu-Hsi
TH
Lai
Mei-Shu
MS
Chie
Wei-Chu
WC
Chien
Kuo-Liong
KL
Hsueh
Po-Ren
PR
Wang
Jiun-Ling
JL
Chang
Shan-Chwen
SC
D000328:Adult; D000368:Aged; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D016470:Bacteremia / Q000382:microbiology* / Q000401:mortality*; D017714:Community-Acquired Infections / Q000401:mortality*; D003428:Cross Infection / Q000382:microbiology* / Q000401:mortality*; D005260:Female; D006801:Humans; D008297:Male; D055624:Methicillin-Resistant Staphylococcus aureus / Q000302:isolation & purification*; D008875:Middle Aged; D013203:Staphylococcal Infections / Q000382:microbiology* / Q000401:mortality*; D015996:Survival Rate; D055815:Young Adult
D000890:Anti-Infective Agents
Blot SI, Vandewoude KH, Hoste EA, Colardyn FA. Outcome and attributable mortality in critically ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus. Arch Intern Med. 2002;162:2229-2235.
Boyle-Vavra S, Daum RS. Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine leukocidin. Lab Invest. 2007;87:3-9.
Charlson ME, Pompei P, Ales KL, Mackenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373-383.
Chua T, Moore CL, Perri MB, Donabedian SM, Masch W, Vager D, Davis SL, Lulek K, Zimnicki B, Zervos MJ. Molecular epidemiology in methicillin-resistant Staphylococcus aureus bloodstream isolates in urban Detroit. J Clin Microbiol. 2008;46:2345-2352.
Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible Staphylococcus aureus bacteremia: a meta-analysis. Clin Infect Dis. 2003;36:53-59.
Deresinski S. Methicillin-resistant Staphylococcus aureus: an evolutionary, epidemiologic, and therapeutic odyssey. Clin Infect Dis. 2005;40:562-573.
Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICO-9-CM administrative databases. J Clin Epidemiol. 1992;45:613-619.
Enright MC, Day NP, Davies CE, Peacock SJ, Spratt BG. Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J Clin Microbiol. 2000;38:1008-1015.
Enright MC, Robinson DA, Randle G, Feil EJ, Grundmann H, Spratt BG. The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA). Proc Natl Acad Sci USA. 2002;99:7687-7692.
Fang CT, Shau WY, Hsueh PR, Chen YC, Wang JT, Hung CC, Huang LY, Chang SC. Early empirical glycopeptide therapy for patients with methicillin-resistant Staphylococcus aureus bacteremia: impact on the outcome. J Antimicrob Chemother. 2006;57:511-519.
Gillet Y, Issartel B, Vanhems P, Fournet JC, Lina G, Bes M, Vandenesch F, Piemont Y, Brousse N, Floret D, Etienne J. Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients. Lancet. 2002;359:753-759.
Harbarth S, Francois P, Shrenzel J, Fankhauser-Rodriguez C, Hugonnet S, Koessler T, Huyghe A, Pittet D. Community-associated methicillin-resistant Staphylococcus aureus, Switzerland. Emerg Infect Dis. 2005;11:962-965.
Harbarth S, Rutschmann O, Sudre P, Pittet D. Impact of methicillin resistance on the outcome of patients with bacteremia caused by Staphylococcus aureus. Arch Intern Med. 1998;158:182-189.
Hurley JC. Comparison of mortality associated with methicillin-susceptible and methicillin-resistant Staphylococcus aureus bacteremia: an ecological analysis. Clin Infect Dis. 2003;37:866-868.
Ito T, Katayama Y, Asada K, Mori N, Tsutsumimoto K, Tiensasitorn C, Hiramatus K. Structural comparison of three types of staphylococcal cassette chromosome mec integrated in the chromosome in methicillin-resistant Staphylococcus aureus. Antimicrob Agents Chemother. 2001;45:1323-1336.
Ito T, Ma XX, Takeuchi F, Okuma K, Yuzawa H, Hiramatsu K, Novel type V. staphylococcal cassette chromosome mec driven by a novel cassette chromosome recombinase, ccrC. Antimicrob Agents Chemother. 2004;48:2637-2651.
Jevons MP. "Celbenin"-resistant staphylococci. Br Med J. 1961;1:124-125.
Kaplan SL, Hulten KG, Gonzalez BE, Hammerman WA, Lamberth L, Versalovic J, Mason EO Jr. Three-year surveillance of community-acquired Staphylococcus aureus infections in children. Clin Infect Dis. 2005;40:1785-1791.
Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999;115:462-474.
Kuint J, Barzilai A, Regev-Yochay G, Rubinstein E, Keller N, Maayan-Metzger A. Comparison of community-acquired methicillin-resistant Staphylococcus aureus bacteremia to other staphylococcal species in a neonatal intensive care unit. Eur J Pediatr. 2007;166:319-325.
Labandeira-Rey M, Couzon F, Boisset S, Brown EL, Bes M, Benito Y, Barbu EM, Vazquez V, Hook M, Etienne J, Vandenesch F, Bowden MG. Staphylococcus aureus Panton-Valentine leukocidin causes necrotizing pneumonia. Science. 2007;315:1130-1133.
Laupland KB, Ross T, Gregson DB. Staphylococcus aureus bloodstream infections: risk factors, outcomes, and the influence of methicillin resistance in Calgary, Canada, 2000-2006. J Infect Dis. 2008;198:336-343.
Lesens O, Methlin C, Hansmann Y, Remy V, Martinot M, Berqin C, Meyer P, Christmann D. Role of comorbidity in mortality related to Staphylococcus aureus bacteremia: a prospective study using the Charlson weighted index of comorbidity. Infect Control Hosp Epidemiol. 2003;24:890-896.
Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis. 2003;36:1418-1423.
Maree CL, Daum RS, Boyle-Vavra S, Matayoshi K, Miller LG. Community-associated methicillin-resistant Staphylococcus aureus isolates causing healthcare-associated infections. Emerg Infect Dis. 2007;13:236-242.
Moellering RC Jr. Current treatment options for community-acquired methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46:1032-1037.
Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE, McDougal LK, Carey RB, Talan DA; EMERGEncy ID Net Study Group. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355:666-674.
Murray RJ, Lim TT, Pearson JC, Grubb WB, Lum GD. Community-onset methicillin-resistant Staphylococcus aureus bacteremia in Northern Australia. Int J Infect Dis. 2004;8:275-283.
Naimi TS, LeDell KH, Como-Sabetti K, Borchardt SM, Boxrud DJ, Etienne J, Johnson SK, Vandenesch F, Fridkin S, O'Boyle C, Danila RN, Lynfield R. Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection. JAMA. 2003;290:2976-2984.
Okuma K, Iwakawa K, Turnidge JD, Grubb WB, Bell JM, O'Brien FG, Coombs GW, Pearman JW, Tenover FC, Kapi M, Tiensasitorn C, Ito T, Hiramatsu K. Dissemination of new methicillin-resistant Staphylococcus aureus clones in the community. J Clin Microbiol. 2002;40:4289-4294.
Perencevich EN. Excess shock and mortality in Staphylococcus aureus related to methicillin resistance. Clin Infect Dis. 2000;31:1311-1313.
Popovich KJ, Weinstein RA, Hota B. Are community-associated methicillin-resistant Staphylococcus aureus (MRSA) strains replacing traditional nosocomial MRSA strains? Clin Infect Dis. 2008;46:787-794.
Roghmann MC. Predicting methicillin resistance and the effect of inadequate empiric therapy on survival in patients with Staphylococcus aureus bacteremia. Arch Intern Med. 2000;160:1001-1004.
Romero-Vivas J, Rubio M, Fernandez C, Picazo JJ. Mortality associated with nosocomial bacteremia due to methicillin-resistant Staphylococcus aureus. Clin Infect Dis. 1995;21:1417-1423.
Selvey LA, Whitby M, Johnson B. Nosocomial methicillin-resistant Staphylococcus aureus bacteremia: is it any worse than nosocomial methicillin-sensitive Staphylococcus aureus bacteremia? Infect Control Hosp Epidemiol. 2002;21:645-648.
Soriano A, Martinez JA, Mensa J, Marco F, Almela M, Moreno-Martinez A, Sanchez F, Munoz I, Jimenez de Anta MT, Soriano E. Pathogenic significance of methicillin resistance for patients with Staphylococcus aureus bacteremia. Clin Infect Dis. 2000;30:368-373.
Takano T, Higuchi W, Otsuka T, Baranovich T, Enany S, Saito K, Isobe H, Dohmae S, Ozaki K, Takano M, Iwao Y, Shibuya M, Okubo T, Yabe S, Shi D, Reva I, Teng LJ, Yamamoto T. Novel characteristics of community-acquired methicillin-resistant Staphylococcus aureus strains belonging to multilocus sequence type 59 in Taiwan. Antimicrob Agents Chemother. 2008;52:837-845.
Valles J, Rello J, Ochagavia A, Garnacho J, Alcala MA. Community-acquired bloodstream infection in critically ill adult patients: impact of shock and inappropriate antibiotic therapy on survival. Chest. 2003;123:1615-1624.
Vandenesch F, Naimi T, Enright MC, Lina G, Nimmo GR, Heffernan H, Liassine N, Bes M, Greenland T, Reverdy ME, Etienne J. Community-acquired methicillin-resistant Staphylococcus aureus carrying Panton-Valentine leukocidin genes: worldwide emergence. Emerg Infect Dis. 2003;9:978-984.
Wang JL, Chen SY, Wang JT, Wu GH, Chiang WC, Hsueh PR, Chen YC, Chang SC. Comparison of both clinical features and mortality risks associated with bacteremia due to community-acquired methicillin-resistant Staphylococcus aureus and methicillin-susceptible S. aureus. Clin Infect Dis. 2008;46:799-806.
Whitby M, McLaws ML, Berry G. Risk of death from methicillin-resistant Staphylococcus aureus bacteremia: a meta-analysis. Med J Aust. 2001;175:264-267.
Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275-286.