Georgia epidemiology report, Vol. 20, no. 6 (June 2004)

June 2004

volume 20 number 06

Community-Associated Methicillin resistant Staphylococcus aureus (MRSA)

Introduction
MRSA (Methicillin resistant Staphylococcus aureus) infections have been common in hospitals and other health care facilities since the 1960's. In the healthcare setting, risk factors for MRSA infections include broad-spectrum antibiotic use, surgery, indwelling catheters, exposure to MRSA patients, colonization, and prolonged hospital or ICU stay. Infection control measures for healthcare-associated MRSA (HAMRSA) have been defined (1). Community-associated MRSA (CAMRSA) includes cases of MRSA infection with no exposure to the healthcare system in the previous year. Since the 1990's, reports of MRSA infections in injecting drug users (2), children (3, 14), families (5), athletic teams (6-7), military personnel (8-9), and American Indian/ Alaska Native populations (10-11) have been published. More recently, CAMRSA infections have been reported in numerous correctional facilities (12, 13), and in men who have sex with men (14). The majority of reported infections have been skin or soft tissue infections with a range of severity, but some infections have been invasive (Box 1). Molecular studies suggest that strains of MRSA causing community-associated disease are distinct from HAMRSA strains (15). Among the genetic characteristics of CAMRSA strains are genes encoding Panton-Valentine Leukocidin (PVL), an enzyme that enhances the ability to cause skin infections, and a shortened cassette of genes coding for antibiotic resistance, such that most CAMRSA are beta-lactam and macrolide-resistant, but are susceptible to all other antibiotics. Studies of affected populations have identified certain risk factors for CAMRSA infection (Table 1).
Surveillance A study to define the burden of CAMRSA in Georgia was conducted in 2001-2002 by the Emerging Infections Program in the 8-county (Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnett, Newton, Rockdale) metropolitan Atlanta area (16). All laboratory reports of MRSA (n=9896) were reviewed and characterized as healthcareassociated, community-associated, or indeterminate. CAMRSA were defined as MRSA isolates from any culture taken within 48 hours after hospital admission, where the patient had a) no previous MRSA colonization or infection b) no history of percutaneous device or indwelling catheter, and c) no history of dialysis, surgery, hospitalization, or residence in a long term care facility in the past year. At least 592 (6%) MRSA infections met the definition for CAMRSA, with an additional 10% that were indeterminate (unable to interview to evaluate fulfillment of case

definition). The proportion of MRSA infections that were CAMRSA increased from 4% in 2001 to 8% in 2002. Patients with CAMRSA were younger than those with HAMRSA (37.9 years vs. 66.8 years), and were more likely to have reported an insect bite or spider bite, (9% vs. 0.6%). Most (66%) CAMRSA patients were treated empirically with antibiotics, and, of these, 75% received betalactams, which are not effective against MRSA. Some CAMRSA patients were hospitalized, required ICU care, and / or died as a result of the infection.
GA Populations affected by CAMRSA: Inmates in correctional facilities: The Georgia Division of Public Health (GDPH) first investigated an outbreak of CAMRSA affecting a correctional population in 2001 (17) Since then, clusters of cases have been reported and investigated in many other Georgia correctional facilities. A common misconception identified in this and other CAMRSA investigations was that patients and caregivers initially thought the skin infections were "spider bites." A combination of contributing factors including poor hygiene, sharing personal items, and inadequate clinical and infection control practices were discovered during investigations. Since 2002, the GDPH has received reports of MRSA from 30 correctional facilities (jails, prisons, detention centers, etc.) and, in 2002, the Georgia Department of Corrections and the Division of Public Health collaboratively developed provisional guidelines for prevention and control of correctional cases*. These guidelines were based on rational, feasible measures for infection control in correctional settings, given the limited information on effective prevention measures and treatment outside the healthcare setting. Subsequently, the Federal Bureau of Prisons developed guidelines for Federal correctional facilities (18).
Athletes participating in team sports: In 2003, a Georgia baseball team reported 7 cases of MRSA skin infections over 2 months. All infections occurred on the lower extremities among "position players" (non-pitching staff). Investigations of MRSA outbreaks in other types of sports teams have identified risk factors for MRSA including sharing towels and having
* Available on request.

breaks in the skin due to "turf burns" or shaving (7). We speculate that the pattern of lesions in the Georgia baseball team may have resulted from skin abrasions on the lower extremities due to sliding to a plate, although a formal investigation was not conducted. Identified risk factors for CAMRSA in athletes and other persons at risk are found in Table 1.
Neonates: During a three-week period in 2004, a hospital infection control practitioner identified 3 cases of MRSA mastitis in babies under the age of 2 months. The 3 babies were born at 2 hospitals on 3 different days. The birth hospitals were experiencing no MRSA problems in their labor and delivery areas or nurseries at the time. None of the births were complicated by intensive care unit stays. None of the babies attended daycare. Ages ranged from 17 days to 7 weeks at the time of hospital admission. Symptoms included nipple erythema, tenderness and warmth, irritability, and fever. Incision and drainage was required in one case. All 3 isolates were erythromycin resistant. The isolate from the baby born at hospital A was not tested for inducible clindamycin resistance, while one isolate from a baby born at hospital B had inducible clindamycin resistance and one did not.
Military: In 2003, an infection control practitioner at a large Georgia military base began prospective CAMRSA surveillance, and retrospectively collected data on skin infections since 2001. Cases increased markedly between 2001-2003, suggesting a growing problem, but surveillance artifact cannot be ruled out.
Families: Several clusters of CAMRSA skin infections have been reported in families with children. Following is one such report, demonstrating the difficulty in eradicating MRSA. The likely index case was the father, whose skin infection was treated empirically with cephalexin (a betalactam antibiotic), but worsened on therapy. Ten days later, the teenage son was seen for a "bite and cellulitis" but was not cultured. Two weeks later, the same son had a skin infection

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on the leg, which was treated with topical care and cephalexin. A culture grew MRSA resistant to tetracycline and clindamycin. Therapy was changed to trimethoprim-sulfamethoxazole and cleaning with topical chlorhexidine was added. Meanwhile, the mother sought care for a skin papule, was diagnosed with an insect bite and cellulitis, and was given azithromycin. She returned for care after the infection worsened; by that time she knew her child had MRSA, and she was given empiric trimethoprim/ sulfamethoxazole. The next day, the father was cultured for a new lesion that grew MRSA sensitive to tetracycline, and was treated with clindamycin. A 5-year-old son was not affected. The entire family used topical chlorhexidine on the skin and mupirocin in the nares for 3 days. On follow up 2 months later, they had all healed with no recurrences, but subsequently recurrences in the father and child were reported.
Conclusion and Plan Given the potential severity of these infections, challenges in controlling transmission in closed settings, the expanding burden of CAMRSA and the need to define risk factors and control measures for CAMRSA, the Georgia Division of Public Health plans to request reports of severe disease or death caused by CAMRSA by adding these infections to the list of notifiable diseases. To address infection control measures, we also ask that clusters of disease limited to skin and soft tissues be reported (clusters of any disease are notifiable). Because MRSA is a common laboratory isolate, and because the great majority of MRSA are not communityassociated, information documenting no recent history of hospitalization, dialysis, residence in a long-term care facility, or an indwelling medical device will be required to distinguish CAMRSA cases.

Box 1: Georgia Case Reports of Severe CAMRSA
CAMRSA carbuncle, toxic shock syndrome, and lung abscesses: A 40-year-old man with HIV infection for 14 years presented with 4 to 5 days of increasing lower back pain. He reported a painful swollen area on the back of his neck that had drained spontaneously two weeks earlier. His temperature was 39.1C, with tachycardia and normal blood pressure. A 4-5 cm carbuncle was noted on the neck with overlying eschar. While in the ED, the patient developed a diffuse blanching erythroderma and hypotension, obtundation and labored respiration; he was intubated. Gram stain of purulence from his neck showed PMNs and grampositive cocci in clusters. CT scan of the chest showed multiple pulmonary nodules. He was initially treated with vancomycin, clindamycin, gentamicin and IVIG. Blood cultures grew MRSA, resistant to erythromycin but susceptible to clindamycin, trimethoprim/ sulfamethoxazole, gentamicin, and doxycycline and intermediate to levofloxacin. Despite aggressive support, he developed refractory shock and multi-organ failure and died the day following admission. Post-mortem examination confirmed the presence of multiple lung abscesses.
CAMRSA tenosynovitis and pneumonia in family members: A 32-year-old woman with no prior illness presented with 10 to 14 days of progressive swelling and pain in her left index finger. The patient thought she may have been bitten by a spider. On exam there was a sausage digit held in a flexed position with pain to palpation and on passive extension. She was admitted and treated with IV cefazolin. The finger was incised, revealing tenosynovitis and a deep abscess, which was drained. A second surgical procedure was required after two days because

of persistent drainage. After surgery, the original culture was reported to grow MRSA, resistant to erythromycin but susceptible to other non-beta-lactam antibiotics. She received vancomycin for several days and recovered uneventfully on oral trimethoprimsulfamethoxazole.
Two months later, the 64 year-old mother of this patient, with a history of adult-onset diabetes and hypothyroid goiter, presented with 1 week of cough, myalgias, fever, and shortness of breath. She was hypoxemic with elevated WBC at 29,000. A CXR showed a left hilar pneumonia. Blood cultures were positive for MRSA with the same susceptibility pattern as above. The patient did not recall any skin lesions and none were observed. She did not use injectable insulin and had not been hospitalized in the preceding year. The patient's initial empiric therapy (levofloxacin) was changed to vancomycin, which led to rapid improvement. She was treated with vancomycin for 4 weeks.
CAMRSA causing multiple soft tissue abscesses: A 32 year-old man with AIDS (CD4 277 on HAART) presented with painful swollen lesions of the right gluteus and left calf, and a draining right thigh. There was a history of a spontaneously draining lesion in the right axilla 4 weeks before admission, which had resolved. The new lesions had been present for approximately 3 weeks and the thigh had been draining for two weeks. When the thigh lesion first drained, he had been treated with cephalexin through an ER, but no cultures had been taken. MRSA grew from a surgical specimen after incision and drainage. Following initial treatment with vancomycin, his CAMRSA was treated with clindamycin and rifampin and he recovered.

TABLE 1: Risk Factors for CAMRSA in Various Study Populations

Reference Study population

Risk factors

19

Men who have sex

Hospitalization, hot tubs

with men in LA County

11

Alaska Natives

Recent antibiotic use, skin contact with shared wooden benches in steam saunas

12, 13

U.S. correctional facilities

Prolonged incarceration, infrequent clothing changes, recent antibiotic use, loss of skin integrity, sharing soap, washing clothing by hand, previous skin infection, recent close contact with MRSA-infected inmate

5

Families

Unknown

6, 7

Various sports teams

Loss of skin integrity, sharing personal items, poor hygiene

8, 9

Military

Unknown -2 -

Reported in GA Yes No Many
Yes Yes Yes

Article written by Melissa Tobin-d'Angelo M.D.,

Colorado, Indiana, Pennsylvania, and Los

M.P.H., and Kathryn Arnold M.D. Case reports

Angeles County, 2000-2003. 2003;52:793.

courtesy of Jay Steinberg M.D. and Susan Ray M.D. 8. LaMar JE, Carr RB, Zinderman C, McDonald K.

Sentinel cases of community-acquired methicillin-

1. CDC MRSA fact sheet http://www.cdc.gov/

resistant Staphylococcus aureus onboard a naval ship.

ncidod/hip/ARESIST/mrsafaq.htm

Mil Med. 2003;168:135-8.

2. Saravolatz LD, Markowitz N, Arking L,

9. Kallen AJ, Driscoll TJ, Thornton S, Olson

Pohloh D, Fisher E. Methicillin-resistant

PE, Wallace MR. Increase in community-

Staphylococcus aureus. Epidemiologic

acquired methicillin-resistant Staphylococcus

observations during a community-acquired

aureus at a Naval Medical Center. Infect

outbreak. Ann Intern Med. 1982;96:11-16.

Control Hosp Epidemiol 2000;21:223-6.

3. Hussain FM, Boyle-Vavra S, Bethel CD,

10. Groom AV, et al. Community-acquired

Daum RS. Current trends in community-

methicillin-resistant Staphylococcus aureus in a

acquired methicillin-resistant Staphylococcus

rural American Indian community. JAMA

aureus at a tertiary care pediatric facility.

2001, 286:1201-5.

Pediatr Infect Dis J 2000; 19: 1163-6.

11. Baggett HC et al. An outbreak of community-

4. Fergie JE, Purcell K. Community-acquired

onset methicillin resistant Staphylococcus aureus skin

methicillin-resistant Staphylococcus aureus infections

infections in southwestern Alaska. Infect

in south Texas children. Pediatr Infect Dis J.

Control Hosp Epidemiol 2003; 24:392-6.

2001;20:260-3.

12. Centers for Disease Control and Prevention.

5. Hollis RJ, Barr JL, Doebbeling BN, Pfaller MA,

Methicillin-resistant Staphylococcus aureus skin

Wenzel RP. Familial carriage of methicillin-

or soft tissue infections in a state prison--

resistant Staphylococcus aureus and subsequent

Mississippi, 2000. MMWR 2001; 50 (42):

infection in a premature neonate.

919-22.

Clin Infect Dis. 1995 Aug;21(2):328-32.

13. Centers for Disease Control and Prevention.

6. Lindenmayer JM, Schoenfeld S, O'Grady R,

Methicillin-resistant Staphylococcus aureus

Carney JK. Methicillin-resistant Staphylococcus

infections in correctional facilities--

aureus in a high school wrestling team and the

Georgia, California, and Texas, 2001-2003.

surrounding community. Arch Int Med

MMWR 2003; 52:992-995.

1998;158:895-9.

14. Centers for Disease Control and Prevention.

7. Centers for Disease Control and Prevention.

Outbreaks of community-associated

Methicillin-resistant Staphylococcus aureus infections

methicillin-resistant Staphylococcus aureus skin

among competitive sports participants--

infections--Los Angeles County, California,

2002-2003. MMWR 2003;52:88.

15. Eady EA, Cove JH. Staphylococcal resistance revisited: community-acquired methicillin resistant Staphylococcus aureus--an emerging problem for the management of skin and soft tissue infections. Curr Opin Infect Dis 16:103124.
16. Hageman J. et al. Multiple state-based surveillance for community-associated methicillin-resistant Staphylococcus aureus (CAMRSA) disease: Maryland, Minnesota, and Georgia 2001-2002. Unpublished data, presented in part at International Conference of Emerging Infectious Diseases, Atlanta, GA, March 1, 2004.
17. Wootton SH et al. Intervention to reduce the incidence of methicillin resistant Staphylococcus aureus skin infections in a correctional facility in Georgia. Infect Control Hosp Epidemiol 2004;25:402-407.
18. Federal Bureau of Prisons. Clinical practice guidelines for the management of methicillinresistant Staphylococcus aureus (MRSA) infections. July 2003. Available at http://www.bop.gov/ hsdpg/hsdcpgstaph.pdf
19. Lee NE et al. Community-associated methicillin resistant Staphylococcus aureus infections among HIV-positive men who have sex with men Los Angeles County 2002-2003. Presented at 53rd Annual Epidemic Intelligence Service Conference, April 19-23, 2004.

Listeriosis Reporting
Last year, we expanded the Georgia Listeria case definition so that a listeriosis case is defined as a person from whom L. monocytogenes is isolated from blood, cerebrospinal fluid, or other normally sterile site, or from placenta or products of conception in conjunction with fetal

death or newborn illness. We have found that some clinically significant cases may not quite fit in any of these categories. Therefore, we plan to further broaden our reporting definition to include isolation of L. monocytogenes from any source.
Unlike infections with other common foodborne pathogens such as Salmonella,

which rarely result in fatalities, listeriosis is associated with a mortality rate of approximately 20%. This high case-fatality rate, heightened awareness of foodborne listeriosis, and increasing clinical concern about listeriosis in the expanding population of highly susceptible persons, has increased attention to the importance of L. monocytogenes as a human pathogen.

Division of Public Health http://health.state.ga.us
Kathleen E. Toomey, M.D., M.P.H. Director
State Health Officer

Epidemiology Branch http://health.state.ga.us/epi
Paul A. Blake, M.D., M.P.H. Director
State Epidemiologist
Mel Ralston Public Health Advisor

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. - Editor Kathryn E. Arnold, M.D.
Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H.
Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer

Georgia Department of Human Resources
Division of Public Health

-3 -

The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186

PRESORTED STANDARD U.S. POSTAGE
PAID ATLANTA, GA PERMIT NO. 4528

June 2004

Volume 20 Number 06

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for March 2004

Selected Notifiable Diseases
Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis

Total Reported for March 2004
2004 38 1496 5 1 50 674 12 24 59 2 0 0 0 2 0 60 35 3 18 39 37 0 12

Previous 3 Months Total

Ending March

2002

2003 2004

115

115

110

8726

9252

5833

28

27

45

7

4

3

181

188

163

4456

4485

2659

29

20

32

150

146

99

105

128

158

3

6

3

1

3

1

8

12

5

0

0

0

5

6

4

0

0

1

228

207

205

261

349

137

34

23

27

59

110

73

183

213

116

215

230

116

6

4

0

92

115

79

Previous 12 Months Total

Ending in March

2002

2003

2004

623

667

617

33237

35370

32543

158

123

140

50

45

26

912

933

828

18420

18859

15946

113

76

93

915

507

744

434

513

696

12

22

31

2

7

8

43

35

30

4

2

3

23

30

34

0

0

1

1739

1936

2055

942

1930

957

101

105

132

293

386

439

707

738

635

854

789

713

24

13

7

571

552

490

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.

AIDS Profile Update

Report Period
Latest 12 Months: 06/03-05/04 Five Years Ago: 06/99-05/00 Cumulative: 07/81-05/04

Total Cases Reported* <13yrs >=13yrs Total

5

2,093 2,098

10

1,282 1,292

216

28,231 28,447

Percent Female
27.6
27.2
18.6

Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown

34.5

6.5

1.6

14.6

1.5

41.3

33.1

14.1

3.4

21.4

1.6

26.4

46.6

16.5

5.2

14.3

1.9

15.6

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

- 4 -

Race Distribution (%) White Black Other

21.1 74.3

3.6

19.5 77.5

3.0

32.7 64.7

2.6