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[Experiences of postoperative staphylococcal enteritis caused by methicillin-cephem resistant Staphylococcus aureus (MRSA) and the state of the isolation of MRSA].

During the last 12 months, three cases of postoperative staphylococcal enteritis were experienced in our surgical ward. Kanamycin, Clindamycin and Latamoxef were given prophylactically in all cases. They developed dehydration with severe diarrhea and paralytic ileus in three to ten days after abdominal surgery. MRSA was cultured from the intestinal fluid or feces and Minocycline, sensitive anti-microbial agent to the organism, was administered intravenously and their conditions improved dramatically. Since the nosocomial infections of MRSA are believed to be the cause of these cases, following items were investigated; 1) the frequency of MRSA among Staphylococcus aureus clinically isolated from patients in surgical ward, 2) the state of nasal carriage of MRSA in medical staffs and inpatients without infections in surgical ward, 3) drug sensitivity of MRSA to ten kinds of antibiotics. The results were as follows; 1) the frequency of MRSA was 83% of all the strains of Staphylococcus aureus, 2) the nasal carrier status was 2 in 46 medical staffs and 4 in 17 inpatients, 3) 124 strains of MRSA, 114 isolated from patients and 10 from nasal carriers, showed the identical drug sensitivity, that is, MRSA is sensitive to Minocycline and resistant to every other antibiotics. It is believed that these three cases were due to nosocomial infections of MRSA, and early diagnosis of MRSA enteritis should lead to early antibiotic therapy and to a cure of this serious postoperative complication.

Adult

[Analysis of methicillin-cephem resistant Staphylococcus aureus (MRSA) hospital infection and toxigenicity of MRSA].

MRSA infectious diseases were often observed in our ward including general, pediatric and neurosurgery during recent two years. Following items were investigated for analysing a prevalence of the infections; 1) the frequency of MRSA in Staphylococcus aureus isolates from clinical materials, 2) the monthly number of patients with MRSA infectious diseases, 3) the biologic types and the toxigenicity of MRSA isolates from clinical materials, nasal carriers and an environmental material in the ward. The results were as follows. 1) Methicillin-cephem resistant strain was determined in 204 of 247 Staphylococcus aureus isolates (83%). 2) Monthly registration showed a trend that an increased number of the patient in one unit was followed by an increase in other units. 3) Most of MRSA isolates were classified into type II coagulase and two kinds of strains were predominantly found in isolates from clinical materials by plasmid DNA analysis. Most of MRSA isolates had capabilities of producing type C enterotoxin and toxic shock syndrome toxin-1 (TSST-1). The results suggested that the frequent MRSA infectious diseases attributed to hospital infection. Since hospital infection of virulent MRSA may cause serious infectious diseases, much concern to inhibit the spread of this organism should be required.

Bacterial Toxins

[Nosocomial infections due to methicillin-resistant S. aureus (MRSA) at the Kagoshima University Hospital (1). Coagulase typing of MRSA].

Nosocomial infection due to MRSA at the Kagoshima University Hospital and their coagulase typing were examined using S. aureus (349 strains) clinically isolated in 1989. The results were as follows: 1) S. aureus consisted of 43.6% of MRSA and 56.7% of Methicillin-sensitive S. aureus (MSSA). 2) MRSAs were recovered most frequently from the specimens from the respiratory tract (47.8%). 3) The isolation of MRSA gradually increased in frequency from January to August; however, that of MSSA did not show a similar tendency. 4) The isolation of MRSA was higher in frequency in the surgical wards, the ICU and the pediatric ward. 5) When classified into 8 coagulase types, MRSAs (133 strains) consisted of only 3 types (54.1% of type II, 32.3% of type VII, and 12.0% of type IV), whereas MSSAs contained all coagulase types. As compared with the results of coagulase typing at other institutions, the incidence of type VII was much more frequent at our hospital. 6) A few coagulase types of MRSA appeared in each ward. Also, type II MRSA strains increased in June and July, and type VII MRSA increased in August. However, MSSA strains did not show any similar tendency.

Bacterial Typing Techniques

[Methicillin-resistant Staphylococcus aureus (MRSA) infection--significance of MRSA in respiratory tract infection].

We have examined background factors in MRSA infection in cases in which S. aureus had been isolated from sputa. The incidence of isolation of S. aureus was high and still increasing in expectorated sputa, and causative organisms in the cases of pneumonia and autopsied lungs. A significant correlation was observed between high incidence of isolation of S. aureus and abuse of third-generation cephems. MRSA isolation rates of inpatients was higher than that of outpatients. Among the inpatients such cases with severe underlying diseases and prolonged admission showed the highest incidence of isolation of MRSA. There seemed to be a correlation between distribution of patients with S. aureus and that of rooms with S. aureus in the air. This suggests nosocomial infection. Although MRSA was frequently isolated from sputa, most cases showed no signs of infection, and this suggested that they had been transient colonization. Such antimicrobial agents as rifampicin, teicoplanin, vancomycin reveal excellent antibacterial activity against MRSA and minocycline, ofloxacin were moderately effective. The physician must be informed of the significance of MRSA, because their understanding of MRSA still remains insufficient.

Anti-Bacterial Agents

[Isolation of methicillin-resistant Staphylococcus aureus (MRSA) from sputum and clinical features of bronchopulmonary infection due to MRSA during 4 years (1985-1988)].

Clinical and bacteriological studies were carried out to investigate the isolation of MRSA from sputa and 13 cases with bronchopulmonary infections due to MRSA, during 4 years from 1985 to 1988 at the Hokusyo Central Hospital. The isolation rate of MRSA in Staphylococcus aureus from sputum increased from 0% in 1985 to 51.4% in 1988, and especially from patients in wards for aged people. Most of the MRSA strains were isolated from patients with underlying diseases, or bed sores. The roentgenographic appearances in bronchopulmonary infection patients due to MRSA, showed infiltration and cavitation. Seven out of 13 cases of bronchopulmonary infection due to MRSA died, in spite of therapy with current antibiotics, suggesting poor prognosis of this infection.

Adult

Postoperative complications due to methicillin-resistant Staphylococcus aureus (MRSA) in an elderly patient: management and control of MRSA.

An elderly lady was admitted to hospital for elective resection of an adenocarcinoma of the colon. Following an anastomotic leak she developed intra-abdominal sepsis and underwent abdominal drainage of pus. During recovery from her second operation, she developed pneumonia and a bacteraemia due to methicillin-resistant Staphylococcus aureus (MRSA). She was treated with vancomycin and co-trimoxazole and survived without further sequelae. Details of the development and treatment of this case are discussed. Procedures for the control and eradication of MRSA infections in hospitals are reviewed.

Adenocarcinoma

MRSA revisited.

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Humans

An epidemiological study of methicillin-resistant Staphylococcus aureus (MRSA) isolated from medical staff, inpatients, and hospital environment in one ward at our hospital.

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most important causative microorganisms for nosocomial infections. Recently, the incidence of isolation of MRSA has been increasing every year in Japan and is, notably, much more frequently found in inpatients than in outpatients. Therefore, we have done epidemiological studies of MRSA isolated from medical staff, inpatients, and the hospital environment in one ward of our hospital. Thereafter, we examined the antibiotic susceptibility (ABPC, DMPPC, CET, CMZ, IPM, GM, MINO, OFLX, EM, CLDM, VCM), phage typing, and coagulase typing of these MRSA. MRSA were isolated more frequently from anterior nares of inpatients than from doctors and nurses. MRSA were isolated more frequently from the environment near carriers of MRSA. Coagulase type II and phage type N.T. (not typable) were the dominant types of MRSA in our hospital (69% and 61%). MRSA strains were resistant to most antibiotics with a few exceptions (VCM, IPM, CMZ, CET). The high isolation frequency of MRSA in our hospital seems to suggest that inpatients who are carrying MRSA spread MRSA throughout the hospital environment and that the anterior nares of inpatients are the major MRSA harbor.

Air Microbiology

Emergence of SCCmec variants causing false-negative MRSA results by Xpert SA Nasal Complete: a need for culture back-up?

BACKGROUND: Staphylococcus aureus (SA) is a major human pathogen and an important cause of healthcare-associated infections. Hospital-acquired methicillin-resistant S. aureus (MRSA) is associated with increased morbidity and mortality. Screening for nasal carriage of SA followed by decolonization has been shown to reduce healthcare-associated MRSA transmission and infection. Nucleic acid amplification assays (NAATs) are widely used for MRSA screening and are associated with shorter turnaround times, fewer isolation days, reduced MRSA-related infections, and improved clinical outcomes and cost savings. CASE SUMMARY: Two patients underwent preoperative nasal screening using Xpert SA Nasal Complete, and corresponding culture results were discordant with the molecular results. In both cases, the Xpert SA assay reported "SA detected and MRSA not detected," whereas culture and antimicrobial susceptibility testing (AST) demonstrated the presence of MRSA. Additional testing supported the culture-based identification of MRSA. Whole-genome sequencing and molecular typing revealed that both MRSA isolates harbored SCCmec variants that were not detected by the Xpert assay, leading to false-negative (FN) MRSA results. CONCLUSION: While NAATs remain highly sensitive and reliable tools for MRSA screening and the overall risk of FN MRSA detection may be low, our cases highlight the importance of ongoing surveillance of local MRSA epidemiology and understanding the genetic inclusivity of the molecular assays used for detection. In high-risk or targeted patients, consideration of reflex culture may be warranted.

MRSA screening

[An epidemiological study of methicillin-resistant Staphylococcus aureus (MRSA) isolated from medical staffs, inpatients and hospital environments at our hospital].

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most important microorganisms which is causative of the nosocomial infections. Recently the incidence of isolation of MRSA is increasing from year to year in Japan. Especially MRSA isolated from inpatients are much higher than from outpatients. Therefore we have done epidemiological studies about MRSA isolated from medical staffs, inpatients and hospital environments in our hospital. Thereafter we examined phage typing and coagulase typing of those MRSA. MRSA were isolated more frequently from anterior nares of inpatients in compare with doctors and nurses. MRSA were isolated more frequently from the environments of MRSA carriers. Coagulase type II and phage type N.T. (not typable) were dominant type of MRSA in our hospital (69% and 61%). Our studies have revealed that the isolation frequency of MRSA is very high in our hospital. It seems to suggest that inpatients who are carrying MRSA are spreading MRSA out hospital environments and medical staffs.

Cross Infection

[Isolation and antimicrobial susceptibility of methicillin-resistant Staphylococcus aureus (MRSA) at Kumamoto University Hospital].

An increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has created a serious therapeutic problem. During the period from July to December 1987, the prevalence of MRSA was only 72 strains (35.8%) of 201 total staphylococcal isolates. Since then, the frequency of MRSA has markedly increased to 67.3% in 1989, and at that time it was estimated that 30 patients (3.5%) of 850 total inpatients became infected with MRSA. In an early study in 1987, the majority of the MRSA came from post-operative patients; however in 1989, nearly 40% of MRSA were from internal medicine, mainly from immunocompromised patients. The major source of MRSA isolates was sputum (40%) throughout the years, but the MRSA from blood cultures was first recovered in 1989. Also, the major coagulase serotype of MRSA was type IV (18 of 30) in the 1987-study, then shifted to type II (24 of 40) in 1989. Among the several antimicrobials evaluated, four agents; erythromycin, minocycline, ofloxacin, and gentamicin revealed increasing MICs when compared with the results obtained for the MRSA isolates in 1987 and 1989. In particular, the most of the MICs to minocycline and ofloxacin were categorized to be highly susceptible (less than or equal to 0.39 micrograms/ml) or resistant (greater than or equal to 25 micrograms/ml). Vancomycin, currently licensed for the MRSA infection, will be highly effective both in vitro and in vivo; however, it examinative of the MRSA isolates in the clinical laboratories, especially to prevent hospital-acquired infections and to follow up the vancomycin susceptibility will be required.

Anti-Bacterial Agents

[A study of resistance to antiseptics of methicillin resistant Staphylococcus aureus (MRSA) in gastroenterological surgery].

Highly methicillin-resistant Staphylococcus aureus (H-MRSA, MIC greater than 100 micrograms/ml) was prevalent from 1986 in our institution. The failure of povidone-iodine to reduce the prevalence of MRSA led us to choose chlorhexidine-ethanol solution as an antiseptic, and then the isolation frequency of H-MRSA decreased significantly in 1988. When H-MRSA began to increase again recently, we studied the resistance to antiseptics of MRSA in order to investigate the cause of this re-increase. Common antiseptics were tested against 45 strains of H-MRSA and 22 strains of methicillin sensitive S. aureus (MSSA, MIC less than 12.5 micrograms/ml). Dilute preparations (1:100) of povidone-iodine and chlorhexidine-ethanol solution were more effective on H-MRSA than the other antiseptics. Though there was no significant difference between H-MRSA and MSSA in their sensitivity to povidone-iodine, the killing of H-MRSA strains was more delayed than the killing of MSSA strains in chlorhexidine. Even after a 120-second exposure, 13.3% of H-MRSA strains were resistant to chlorhexidine (more than 1000 colonies were recovered). These highly chlorhexidine-resistant strains have been isolated since 1987 when we chose chlorhexidine-ethanol solution as the antiseptic in our institution. Therefore we suspect that the acquirement of resistance to antiseptics by H-MRSA caused the re-increase of this strain.

Anti-Infective Agents, Local

Comparison of enterotoxins and haemolysins produced by methicillin-resistant (MRSA) and sensitive (MSSA) Staphylococcus aureus.

A collection of 201 isolates of Staphylococcus aureus was examined: 152 methicillin-sensitive S. aureus (MSSA) comprised 48 blood culture isolates (BC) and 58 isolates from routine diagnostic specimens (RD) from Glasgow Royal Infirmary (GRI), and 46 strains from nasal swabs of patients attending a general practitioner (GP); 49 isolates were of methicillin-resistant S. aureus (MRSA) from GRI. We have previously shown that the MRSA could be divided into two sub-groups on the basis of sensitivity or resistance to aminoglycoside antibiotics. Production of enterotoxins A, B, C and D, and alpha-, beta-, gamma- and delta- haemolysins was detected by reverse passive latex agglutination (RPLA) and agar overlay methods respectively: 60% of BC MSSA and a similar proportion of MSSA from other sources produced enterotoxin; 87% of aminoglycoside-sensitive MRSA produced enterotoxin (89% of these produced enterotoxin A alone) whereas only 27% of aminoglycoside-resistant MRSA were enterotoxin-positive, significantly less than either MSSA or aminoglycoside-sensitive MRSA. The proportion of haemolysin-producing isolates did not differ amongst the isolates of MSSA and MRSA; there was no difference in the distributions of haemolysins between aminoglycoside-sensitive and -resistant strains of MRSA. GP MSSA had higher and lower numbers of gamma- and delta-haemolysin producers respectively than other S. aureus isolates. alpha-Haemolysin producers were commoner amongst MRSA isolates, which were also more likely than MSSA isolates to produce several haemolysins. Differences in enterotoxin production between aminoglycoside-sensitive and -resistant MRSA isolates reflect subgroups previously defined by biotype, phage type, immunoblot and restriction enzyme fragmentation pattern data, and provide further evidence for the existence of two major MRSA clones in GRI.

Aminoglycosides

[A study of methicillin-resistant Staphylococcus aureus (MRSA) infection in the urological field].

Clinical backgrounds of 35 patients with urogenital infection, from whom methicillin-resistant Staphylococcus aureus (MRSA) was isolated, were analyzed. Susceptibilities of these MRSA strains to various antimicrobial agents were also measured. Out of 35 MRSA strains, 29, 4 and 2 were isolated from urine, pus and sputum specimens, respectively, showing a definitely high isolation rate from urine. As for underlying diseases, 22 patients (62.8%), 11 (31.4%) and one each had a malignant tumor of the urinary tract or genital organ, prostatic hypertrophy, urolithiasis and vesicoureteral reflux, respectively. Patients aged at over 60 years numbered 20 (57%), and 32 patients (91.4%) were treated with some antimicrobial agent at the time of MRSA isolation. Out of 35 strains, 17 were isolated after total cystectomy with urinary diversion or transurethral surgery. As for the state of MRSA infection, 9 and 26 patients had single and polymicrobial infections, respectively, but none of patients had serious symptoms definitely thought to be caused by MRSA. On evaluation of susceptibilities of MRSA to various antimicrobial agents, the MRSA strains were found to be sensitive to minocycline, netilmicin and ofloxacin. From these results, MRSA strains isolated from patients treated in the field of urology were thought to rarely cause serious infectious symptoms, especially true for those isolated from the urine.

Adolescent

[Methicillin-resistant Staphylococcus aureus (MRSA) infection in urological field--clinical backgrounds and clinical course].

The Staphylococcus aureus in this study were isolated from 33 outpatients and 38 inpatients of the Department of Urology from August 1989 to April 1991. Twenty one patients (29.5%), three outpatients, had the MRSA type. Significant correlations were found between the incidence of MRSA infection and such factors as diabetes mellitus and the isolation of MRSA within 7 days of the administration of antibiotic agents. Out of 14 MRSA which were investigated for coagulase type, 9 were type VII. This indicates an outbreak of MRSA in the urological ward. Seven cases of MRSA and 5 cases of MRSA had high grade fever (over 38 degrees C), but all patients experienced much relief by using susceptible antibiotic agents. Our study shows that the isolation frequency of MRSA has increased in urological field. Therefore, we think it is important to treat patients with MRSA infection adequately, especially when there are compromised hosts in the same room.

Adult