A trial of the use of mupirocin in the nasal carriage of Staphylococcus aureus in medical personnel]

Many hospital-acquired purulent diseases and wound infections are due to multiresistant hospital strains of Staphylococcus aureus. The role of S. aureus nasal carriage in development of wound infections due to autoinfection is confirmed. Not only inpatients but also hospital staff can be highly colonized with coagulase positive staphylococci. The S. aureus persistence in hospital personnel results in distribution of the microorganisms in the environment. Therefore, detection of S. aureus carriers without signs of the infection among the hospital personnel and eradication of the pathogen make it possible to control outbreaks of S. aureus infection in hospitals. Clinical efficacy of nasal ointment of mupirocin in the treatment of S. aureus carriers among the intensive care personnel of the N. N.Blokhin Cancer Research Center was evaluated. S. aureus nasal carriage was diagnosed in 17 (26 per cent) out of 65 persons. All the isolates were susceptible to oxacillin. 5-7 days after discontinuation of the mupirocin nasal ointment use eradication of S. aureus was stated in 100 per cent of the cases. The effect was still observed in 94 per cent of the cases in 1 month, in 76 per cent of the cases in 5-6 months and in 60 per cent of the cases in 8-9 months. It is believed that mupirocin nasal ointment (Bactroban) is convenient to use, low toxic and highly active in the treatment of persons with S. aureus nasal carriage.     

The results and characteristics of the mupirocin (Bactroban) sanative treatment of intranasal Staphylococcus carriers in a large hospital]

The action of mupirocin as a nasal ointment (Bactroban) was studied on intranasal carriers of the hospital staphylococcal strains. The study included 37 medical workers from different and mainly problem units of the large general hospital. The tolerability of the ointment was good. After the Bactroban use no complications of the patients were recorded. The efficacy of Bacroban by the microbiological criteria in total amounted to 100 per cent. The eradication of methicillin resistant Staphylococcus aureus (MRSA) was observed in 93 per cent of the cases. A decrease of the level of the nasal passages dissemination by MRSA and methicillin resistant coagulase-negative staphylococci (MRSC) up to such low titers as 100 and 90 per cent was stated. No difference in the action of Bactroban on MRSA, MSSA and MRSC was noted. The bacteriological monitoring for 3 to 4 months revealed a change of the staphylococcal strains in 94 per cent of the cases, recolonization by the same staphylococcal strain in 19 per cent, recolonization by some another staphylococcal strains in 33 per cent and no recolonization in 14 per cent. A stable decrease of staphylococcal strains was possible with simultaneous Bactroban sanitation of all the bacterial carriers of the hospital or its isolated unit.     

Use of nasal mupirocin for Staphylococcus aureus: effect on nasal carriers and nosocomial infections

Staphylococcus aureus is the agent of community-acquired and nosocomial infections. Twenty to 35% of the population permanently carries it in the nose and oropharynx, and additional 50%, carries it intermittently. Topical calcium mupirocin is an antibacterial agent against Staphylococcus aureus recommended to eradicate nasal and hand colonization in patients and health care workers. The prevalence of nasal S. aureus was determined in patients undergoing cardiovascular surgery. In addition, the effect of mupirocine on the number of carriers and rate of nosocomial infections was evaluated. An experimental prospective study was undertaken with two groups of patients: one treated with mupirocin (n = 96), and the other without treatment (n = 95). Tests for presence of nasal S. aureus and nosocomial infections were conducted in all patients. A 34% prevalence of S. aureus carriers was found. A decrease of the prevalence was found in both treated (87%) and untreated patients (33%), but in significantly different proportions (p = 0.0002, RR = 0.22, 95%CI = 0.09-0.054). This result demonstrated the effectiveness of a mupirocin treatment program to decrease numbers of nasal carriers. With regard to nosocomial infection, S. aureus prevalence was 3.6%, occurring mostly in control patients (6 of 7). Total nosocomial infection prevalence was 17.3%, evenly distributed in treated and untreated patients. This suggested that mupirocin use did not decrease the number of nosocomial infections.     

Direct detection of nasal Staphylococcus aureus carriage via helicase-dependent isothermal amplification and chip hybridization

ABSTRACT: BACKGROUND: The bacterium Staphylococcus aureus constitutes one of the most important causes of nosocomial infections. One out of every three individuals naturally carries S. aureus in their anterior nares, and nasal carriage is associated with a significantly higher infection rate in hospital settings. Nasal carriage can be either persistent or intermittent, and it is the persistent carriers who, as a group, are at the highest risk of infection and who have the highest nasal S. aureus cell counts. Prophylactic decolonization of S. aureus from patients' noses is known to reduce the incidence of postsurgical infections, and there is a clear rationale for rapid identification of nasal S. aureus carriers among hospital patients. FINDINGS: A molecular diagnostic assay was developed which is based on helicase-dependent target amplification and amplicon detection by chip hybridization to a chip surface, producing a visible readout. Nasal swabs from 70 subjects were used to compare the molecular assay against culturing on "CHROMagar Staph aureus" agar plates. The overall relative sensitivity was 89%, and the relative specificity was 94%. The sensitivity rose to 100% when excluding low-count subjects (<100 S. aureus colony-forming units per swab). CONCLUSIONS: This molecular assay is much faster than direct culture and has sensitivity that is appropriate for identification of high-count (>100 S. aureus colony-forming units per swab) nasal S. aureus carriers who are at greatest risk for nosocomial infections.     

Antibiotic resistance dynamics and isolation rate of staphylococci and enterococci from patients of reconstructive surgery units

The dynamics of isolation of staphylococci and enterococci from clinical material of patients and their antibiotic susceptibility within a 5-year period (2005-2009) was analysed. 5990 isolates were tested: 1250 isolates of Staphylococcus aureus, 3268 isolates of S. epidermidis, 1005 isolates of Enterococcus faecalis and 467 isolates of E. faecium. Grampositive infections were shown to be prevailing within the last 2-3 years, the nosocomial epidermal staphylococci more and more replacing S. aureus (the ratio of S. epidermidis and S. aureus in 2009 was 3.3). The isolation rate of E. faecalis significantly increased (by 3.5 times) and the ratio of E. faecalis and E. faecium in 2009 was 4.3. The microflora composition with respect to the isolation source was analysed and its clinical significance was estimated. The study of the antibiotic susceptibility showed that oxacillin had its own specific niche, while antibiotics active against resistant grampositive cocci, such as rifampicin, fusidic acid, fluoroquinolones (moxifloxacin), cefoxitin, as well as amoxicillin/clavulane in infections due to E. faecalis, might be considered as the drugs of choice. In the treatment of nosocomial infections, when the etiological role of MRSA or VRE is suspected or confirmed, the complex therapy should obligatory include the most active antibiotics (vancomycin or linezolid among them).     

Rhesus macaques (Macaca mulatta) are natural hosts of specific Staphylococcus aureus lineages

Currently, there is no animal model known that mimics natural nasal colonization by Staphylococcus aureus in humans. We investigated whether rhesus macaques are natural nasal carriers of S. aureus. Nasal swabs were taken from 731 macaques. S. aureus isolates were typed by pulsed-field gel electrophoresis (PFGE), spa repeat sequencing and multi-locus sequence typing (MLST), and compared with human strains. Furthermore, the isolates were characterized by several PCRs. Thirty-nine percent of 731 macaques were positive for S. aureus. In general, the macaque S. aureus isolates differed from human strains as they formed separate PFGE clusters, 50% of the isolates were untypeable by agr genotyping, 17 new spa types were identified, which all belonged to new sequence types (STs). Furthermore, 66% of macaque isolates were negative for all superantigen genes. To determine S. aureus nasal colonization, three nasal swabs from 48 duo-housed macaques were taken during a 5 month period. In addition, sera were analyzed for immunoglobulin G and A levels directed against 40 staphylococcal proteins using a bead-based flow cytometry technique. Nineteen percent of the animals were negative for S. aureus, and 17% were three times positive. S. aureus strains were easily exchanged between macaques. The antibody response was less pronounced in macaques compared to humans, and nasal carrier status was not associated with differences in serum anti-staphylococcal antibody levels. In conclusion, rhesus macaques are natural hosts of S. aureus, carrying host-specific lineages. Our data indicate that rhesus macaques are useful as an autologous model for studying S. aureus nasal colonization and infection prevention.     

Cost-effectiveness of preoperative screening and eradication of Staphylococcus aureus carriage

Background

Preoperative screening for nasal S. aureus carriage, followed by eradication treatment of identified carriers with nasal mupirocine ointment and chlorhexidine soap was highly effective in preventing deep-seated S. aureus infections. It is unknown how cost-effectiveness of this intervention is affected by suboptimal S. aureus screening. We determined cost-effectiveness of different preoperative S. aureus screening regimes.

Methods

We compared different screening scenarios (ranging from treating all patients without screening to treating only identified S. aureus carriers) to the base case scenario without any screening and treatment. Screening and treatment costs as well as costs and mortality due to deep-seated S. aureus infection were derived from hospital databases and prospectively collected data, respectively.

Results

As compared to the base case scenario, all scenarios are associated with improved health care outcomes at reduced costs. Treating all patients without screening is most cost-beneficial, saving €7339 per life year gained, as compared to €3330 when only identified carriers are treated. In sensitivity analysis, outcomes are susceptible to the sensitivity of the screening test and the efficacy of treatment. Reductions in these parameters would reduce the cost-effectiveness of scenarios in which treatment is based on screening. When only identified S. aureus carriers are treated costs of screening should be less than €6.23 to become the dominant strategy.

Conclusions

Preoperative screening and eradication of S. aureus carriage to prevent deep-seated S. aureus infections saves both life years and medical costs at the same time, although treating all patients without screening is the dominant strategy, resulting in most health gains and largest savings.     

Distinctive patterns in the human antibody response to Staphylococcus aureus bacteremia in carriers and non-carriers

Staphylococcus aureus is both a prominent cause of nosocomial infections with significant morbidity and mortality and a commensal with nasal carriage in around 30% of the population. The rapid spread of multi-resistant strains necessitates novel therapeutic strategies, a challenging task because the species S. aureus and the host response against it are highly variable. In a prospective study among 2023 surgical and non-surgical patients, 12 patients developed S. aureus bacteremia. They were analysed in detail using a personalized approach. For each patient, the extracellular proteins of the infecting S. aureus strain were identified and the developing antibody response was assessed on 2-D immunoblots. S. aureus carriers showed clear evidence of strain-specific pre-immunization. In all immune-competent bacteremia patients, antibody binding increased strongly, in most cases already at diagnosis. In endogenous infections, the pattern of antibody binding was similar to the pre-infection pattern. In exogenous infections, in contrast, the pre-infection pattern was radically altered with the acquisition of new specificities. These were characteristic for individual patients. Nevertheless, a common signature of 11 conserved S. aureus proteins, recognized in at least half of the bacteremic patients, was identified. All patients mounted a dynamic antibody response to a subset of these proteins.     

Occurrence of high-level mupirocin resistant coagulase-negative staphylococci in hospitals and their characterization

Occurrence of high-level mupirocin resistant coagulase-negative staphylococci in 5 hospitals in the region of Gdansk was determined. The study was carried out on 192 staphylococcal strains isolated from patients and medical staff. The mupirocin resistant strains were detected by 5 microgram mupirocin disc. The minimal inhibitory concentration (MIC) for mupirocin was estimated by E-tests. The mupirocin resistant strains were characterised by antibiotic sensitivity, including MIC for glycopeptides and oxacillin. Biotypes of resistant strains were also determined. Eight high-level mupirocin resistant strains (4.7%) were found. Only one strain expressed low-level resistance. All but one of high-level mupirocin resistant strains were resistant to methicillin. Six of them belonged to the S. epidermidis species but differences in the biotypes and antibiotic resistance patterns of these strains suggest they did not have a common origin.     

Frequency of nasal and wound isolates of Staphylococcus aureus associated with TSST-1 production in Jordanian population

A total of 110 Staphylococcus aureus isolates were obtained from nasal carriers and wound infections of Jordanian population. The isolates were identified by cultural and biochemical methods. The nasal carrier rate of S. aureus among individuals was 22.7%. In comparison with the nasal S. aureus isolates the wound isolates did not produce significantly more virulence factors except DNase. Toxic shock syndrome toxin-1 production was higher among the S. aureus nasal isolates (40%) as compared with the wound isolates (26%) detected by an ELISA method which proved to be uniformly more sensitive than the immunodiffusion optimal sensitivity plate (OSP) method.     

Experimental endocarditis model of methicillin resistant Staphylococcus aureus (MRSA) in rat

Endovascular infections, including endocarditis, are life-threatening infectious syndromes. Staphylococcus aureus is the most common world-wide cause of such syndromes with unacceptably high morbidity and mortality even with appropriate antimicrobial agent treatments. The increase in infections due to methicillin-resistant S. aureus (MRSA), the high rates of vancomycin clinical treatment failures and growing problems of linezolid and daptomycin resistance have all further complicated the management of patients with such infections, and led to high healthcare costs. In addition, it should be emphasized that most recent studies with antibiotic treatment outcomes have been based in clinical settings, and thus might well be influenced by host factors varying from patient-to-patient. Therefore, a relevant animal model of endovascular infection in which host factors are similar from animal-to-animal is more crucial to investigate microbial pathogenesis, as well as the efficacy of novel antimicrobial agents. Endocarditis in rat is a well-established experimental animal model that closely approximates human native valve endocarditis. This model has been used to examine the role of particular staphylococcal virulence factors and the efficacy of antibiotic treatment regimens for staphylococcal endocarditis. In this report, we describe the experimental endocarditis model due to MRSA that could be used to investigate bacterial pathogenesis and response to antibiotic treatment.     

NK cells play a critical protective role in host defense against acute extracellular Staphylococcus aureus bacterial infection in the lung

Staphylococcus aureus remains a common cause of nosocomial bacterial infections and are often antibiotic resistant. The role of NK cells and IL-15 and their relationship in host defense against extracellular bacterial pathogens including S. aureus remain unclear. We have undertaken several approaches to address this issue using wild type (WT), IL-15 gene knock-out (KO), and NK cell-depleted mouse models. Upon pulmonary staphylococcal infection WT mice had markedly increased activated NK cells, but not NKT or gammadelta T cells, in the airway lumen that correlated with IL-15 production in the airway and with alveolar macrophages. In vitro exposure to staphylococcal products and/or coculture with lung macrophages directly activated NK cells. In contrast, lung macrophages better phagocytosed S. aureus in the presence of NK cells. In sharp contrast to WT controls, IL-15 KO mice deficient in NK cells were found to be highly susceptible to pulmonary staphylococcal infection despite markedly increased neutrophils and macrophages in the lung. In further support of these findings, WT mice depleted of NK cells were similarly susceptible to staphylococcal infection while they remained fully capable of IL-15 production in the lung at levels similar to those of NK-competent WT hosts. Our study thus identifies a critical role for NK cells in host defense against pulmonary extracellular bacterial infection and suggests that IL-15 is involved in this process via its indispensable effect on NK cells, but not other innate cells. These findings hold implication for the development of therapeutics in treating antibiotic-resistant S. aureus infection.     

Association between nasal carriage of Staphylococcus aureus and the human complement cascade activator serine protease C1 inhibitor (C1INH) valine vs. methionine polymorphism at amino acid position 480

Staphylococcus aureus produces compounds that interfere with complement deposition. We hypothesized that humans have developed countermeasures to staphylococcal complement evasion and we screened for single nucleotide polymorphisms in the serine protease C1 inhibitor (C1INH) gene at amino acid position 480 (valine vs. methionine) and nasal carriage of S. aureus. In our study cohort, 38 individuals were persistently colonized by S. aureus, whereas 50 were invariably culture-negative. A trend was observed towards an increased prevalence of the Val/Val genotype in noncarriers compared to persistent carriers (OR 0.50, P=0.07). The Val/Val genotype was significantly overrepresented in noncarriers compared to 463 Caucasian blood donors (OR 0.52, P=0.02). These findings suggest that susceptibility to S. aureus nasal carriage is associated with the C1INH V480M polymorphism.     

Quorum-sensing control in Staphylococci -- a target for antimicrobial drug therapy?

Today, we find ourselves in an urgent need for novel antibacterial drugs, as many important human pathogens have acquired multiple antibiotic resistance factors. Among those, Staphylococcus aureus and S. epidermidis play a major role as the leading sources of nosocomial infections. Recently, it has been suggested to develop therapeutics that attack bacterial virulence rather than kill bacteria. Such drugs are called "antipathogenic" and are believed to reduce the development of antibiotic resistance. Specifically, cell-density-dependent gene regulation (quorum-sensing) in bacteria has been proposed as a potential target. While promising reports exist about quorum-sensing blockers in gram-negative bacteria, the use of the staphylococcal quorum-sensing system as a drug target is now seen in an increasingly critical way. Inhibition of quorum-sensing in Staphylococcus has been shown to enhance biofilm formation. Furthermore, down-regulation or mutation of the Staphylococcus quorum-sensing system increases bacterial persistence in device-related infection, suggesting that interference with quorum-sensing would enhance rather than suppress this important type of staphylococcal disease. The chemical nature and biological function of another proposed staphylococcal quorum-sensing inhibitor, named "RIP", are insufficiently characterized. Targeting quorum-sensing systems might in principle constitute a reasonable way to find novel antibacterial drugs. However, as outlined here, this approach requires careful investigation in every specific pathogen and type of infection.     

Characterisation of Staphylococcus aureus nasal and skin carriage among patients undergoing haemodialysis treatment

The aim of the study was to investigate the rate of Staphylococcus aureus nasal and skin carriage in patients undergoing haemodialysis. The cultured staphylococcal isolates were subsequently characterized by molecular methods. The study group comprised 43 haemodialysed patients from whom nasal and skin swabs from the vascular access sites were collected. The identification of staphylococcal isolates and antibiotic susceptibility testing were performed on the basis of conventional diagnostic procedures. The staphylococci were further characterized using Pulsed-Field Gel Electrophoresis (PFGE). S. aureus was cultured from 12 (27.9%) patients. Only one (8.3%) patient was colonized with the microorganism both in the anterior nares and the vascular access site representing a single strain, as evidenced by PFGE analysis. Antibiotic susceptibility testing identified one (7.6%) methicillin-resistant S. aureus (MRSA) strain. PFGE typing identified several S. aureus genotypes with the lack of one specific strain responsible for colonization. However, it should be noted that among two (A and D) PFGE patterns genetically indistinguishable and closely related isolates (two isolates for each pattern) were identified. The obtained results revealed a relatively low rate of S. aureus carriage accompanied by low methicillin resistance rate and a significant genetic diversity of cultured isolates with the lack of one predominant strain responsible for colonization.     

Auxotrophic mutant of Staphylococcus aureus interferes with nasal colonization by the wild type

Staphylococcus aureus nasal carriage is a risk factor for infection in humans, particularly in the hospital setting. Bacterial interference was used as an alternative strategy for the prevention of upper respiratory, urogenital and gastrointestinal tract infections. This study was designed to assess if the administration of a live-attenuated aroA mutant of S. aureus is useful as a potential approach to prevent transient staphylococcal nasal carriage by virulent strains. We constructed an aroA mutant of S. aureus Newman strain by homologous recombination. The auxotrophic NK41 mutant was attenuated as determined by the increase of the LD(50) after intraperitoneal challenge. In mice, previous nasal colonization with the NK41 mutant significantly reduced the number of CFU of S. aureus (HU-71 and Hde288) clinical isolates and the parental Newman strain. The NK41 mutant was unable to induce a pro-inflammatory response and to damage the invaded human respiratory epithelial cells. Moreover, the cells previously or simultaneously infected with the NK41 mutant were invaded by virulent strains in a significantly lower degree than those of the control group. In conclusion, the attenuated NK41 mutant interfered with the colonization and establishment of pathogenic strains of S. aureus, which produce severe infections.     

Simultaneous PCR detection of ica cluster and methicillin and mupirocin resistance genes in catheter-isolated Staphylococcus.

Recent data show that more than 50% of catheter-associated bloodstream infections are caused by staphylococci. Staphylococcal infections produced by intercellular-adhesion cluster (ica) carriers can be even more problematic due to the presence of methicillin and mupirocin resistance genes. In the present study, a multiplex PCR protocol that allows the simultaneous identification of staphylococci and detection of both the ica and methicillin and/or mupirocin resistance genes was developed. Furthermore, the method allows differential detection of the ica locus from Staphylococcus aureus and Staphylococcus epidermidis.     

Anti-biofilm properties of a mupirocin spray formulation against Escherichia coli wound infections

Mupirocin ointment is a widely used topical drug for the treatment of bacterial skin infections. However, ointments have some limitations which motivated the development of a film forming spray of mupirocin. Mupirocin spray (2%) was formulated with Eudragit E100 as a film forming agent and tested for its antibacterial and anti-biofilm activities against Escherichia coli, a skin pathogen causing wound and surgical site infections. Treatment with mupirocin spray resulted in significant antibacterial and anti-biofilm activities (inhibition and disruption) with single spray and sub-actual dose concentrations at par with the commercial ointment concentration. The spray formulation was found to be non-toxic to fibroblast cells and greatly resisted removal from the site of application upon washing, in contrast to the ointment which was significantly removed after a single wash. This is the first study to develop and evaluate a spray formulation for mupirocin that forms a stable thin film for sustained release of the drug.     

Role of teichoic acids in Staphylococcus aureus nasal colonization, a major risk factor in nosocomial infections

Colonization of the anterior nares in approximately 37% of the population is a major risk factor for severe Staphylococcus aureus infections. Here we show that wall teichoic acid (WTA), a surface-exposed staphylococcal polymer, is essential for nasal colonization and mediates interaction with human nasal epithelial cells. WTA-deficient mutants were impaired in their adherence to nasal cells, and were completely unable to colonize cotton rat nares. This study describes the first essential factor for S. aureus nasal colonization.     

Epidemiological analysis of Staphylococcus aureus strains from nasal carriers in a teaching hospital

The present study was conducted to assess the epidemiological relation of Staphylococcus aureus isolates from nasal carriers of hospital staff. Nasal swabs were taken from each of 327 personnel. After culturing on blood agar for overnight, probable staphylococcal isolates were identified and subjected to tube coagulase test. After a two-week interval, second nasal swabs were taken from the subjects whose first cultures were positive for S. aureus. Nasal carriage was defined in 58 (17.7%) personnel with positive culture for both sampling time. Antibiogram typing and arbitrarily-primed polymerase chain reaction (AP-PCR) with M13 primer were used for typing of the strains. Antibiotyping distinguished seven types and three subtypes, and 85% of the isolates were clustered in one group. AP-PCR, in contrast, identified 12 distinct patterns with 13 variants. A specific profile was not found among the isolates obtained from the personnel in a particular clinic. These results indicate that antibiotyping has poor discrimination power and heterogeneity among the nasal S. aureus strains in the hospital personnel screened is high.