title: Neglect of skin wounds and the risk of becoming a Staphylococcus aureus nasal carrier: a cohort study.
abstract: BACKGROUND
  Nasal carriers of Staphylococcus aureus have an increased risk of acquiring skin and soft tissue infections, which could manifest as outbreaks, especially in crowded settings. Current prevention programs are ineffective, antibiotic resistance is rising and risk factors for becoming a carrier are incompletely understood. We aimed to examine whether a behavior, the neglect of skin wounds, is a risk factor for becoming a Staphylococcus aureus carrier during training.
  
  
  METHODS
  We conducted a field-based cohort study among male infantry trainees in three seasons in Israel during 2011-12. Participants underwent anterior nares cultures and answered structured questionnaires on potential risk factors on two occasions: before and 3 weeks after start of training (N = 542). Attitudes and practices toward neglect of skin wounds were defined as perseverance in training at all costs, despite having a wound. Samples were processed within 18 hours for identification of Staphylococcus aureus. Univariable and multivariable logistic regression analyses were performed to assess risk factors for becoming a carrier.
  
  
  RESULTS
  Carriage prevalence increased by 43.3% during training, from 33.2% to 47.6% (p < 0.01). One-fourth (25.4%) of those with a negative culture before training became carriers. None of the socio-demographic characteristics was a risk factor for becoming a carrier while the risk was lower in the winter (Odds ratio [OR] = 0.42; 95% confidence interval [CI]: 0.23-0.78, p < 0.01) and spring (OR = 0.46; 0.26-0.81, p < 0.01) seasons compared to the summer season. Neglect of skin wounds in practice and attitude was a risk factor for becoming a carrier (OR = 2.40; 1.13-5.12, p = 0.02), as well as neglect in practice or attitude (OR = 1.86; 1.04-3.34, p = 0.04) compared to no neglect when controlled for season. The preventable fraction in the population attributed to neglect of skin wounds was 33%.
  
  
  CONCLUSIONS
  Neglect of skin wounds is an independent, common and strong risk factor for becoming a Staphylococcus aureus carrier during training. This preventable behavior should not be ignored and should be addressed in public health programs during training and in other settings. Further research on behavioral determinants of Staphylococcus aureus carriage and infection is warranted.
authors.affiliation: Braun School of Public Health and Community Medicine, Hebrew University-Hadassah, Jerusalem, Israel. hlevine@hadassah.org.il.|Israel Defence Forces Medical Corps, Tel Hashomer, Israel. hlevine@hadassah.org.il.
authors.forename: Hagai
authors.initials: H
authors.lastname: Levine
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. rkayouf@gmail.com.
authors.forename: Raid
authors.initials: R
authors.lastname: Kayouf
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. vladiro81@gmail.com.
authors.forename: Vladislav
authors.initials: V
authors.lastname: Rozhavski
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. tamars@actcom.co.il.
authors.forename: Tamar
authors.initials: T
authors.lastname: Sela
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. inbalraj@gmail.com.
authors.forename: Inbal
authors.initials: I
authors.lastname: Rajuan-Galor
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. anat.tf@gmail.com.
authors.forename: Anat Tzurel
authors.initials: AT
authors.lastname: Ferber
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. barhatz.padam@gmail.com.
authors.forename: Shiraz
authors.initials: S
authors.lastname: Yona
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. olga267@gmail.com.
authors.forename: Olga
authors.initials: O
authors.lastname: Gorochovski
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. halperintami@gmail.com.
authors.forename: Tami
authors.initials: T
authors.lastname: Halperin
authors.affiliation: Israel Defence Forces Medical Corps, Tel Hashomer, Israel. hartal4@gmail.com.|Department of Military Medicine, Hebrew University Faculty of Medicine, Jerusalem, Israel. hartal4@gmail.com.
authors.forename: Michael
authors.initials: M
authors.lastname: Hartal
mesh_terms: D015331:Cohort Studies; D017714:Community-Acquired Infections / Q000382:microbiology* / Q000517:prevention & control; D006801:Humans; D007557:Israel; D008297:Male; D009296:Nasal Cavity / Q000382:microbiology*; D016017:Odds Ratio; D015995:Prevalence; D012306:Risk; D012307:Risk Factors; D018461:Soft Tissue Infections / Q000382:microbiology* / Q000517:prevention & control; D013203:Staphylococcal Infections / Q000175:diagnosis* / Q000517:prevention & control; D013211:Staphylococcus aureus / Q000302:isolation & purification*; D055815:Young Adult