Georgia epidemiology report, Vol. 23, no. 12 (Dec. 2007)

December 2007

volume 23 number 12

Community-Associated Methicillin-Resistant Staphylococcus aureus in Georgia, 2004-2007

Since the late 1990s, methicillin-resistant Staphylococcus aureus (MRSA) has become a widespread cause of disease in community settings in many U.S. states (including Georgia), associated with the emergence of a new and virulent genotype known as USA300 (1-3). Community-associated MRSA (CA-MRSA) often affects otherwise healthy individuals, and is defined as community-associated by causing disease among persons without exposure to healthcare settings (excludes those with recent hospitalization or surgery, dialysis, percutaneous medical devices, or long-term residential care). CA-MRSA frequently causes purulent skin or soft tissue infections (SSTI). Although most infections are uncomplicated, CA-MRSA can also cause severe disease, including sepsis, necrotizing pneumonia, osteomyelitis, pyomyositis, septic arthritis, endocarditis, necrotizing fasciitis, and Waterhouse-Friderichsen syndrome. Recent media reports have increased public awareness of CA-MRSA in school settings, providing opportunities to enhance prevention measures and healthcare-seeking behaviors, although the disease is actually more common among other age groups.
In June 2004, the Georgia Epidemiology Report focused on the newly emerging problem of CA-MRSA infections and Georgia's plan to enhance CA-MRSA surveillance (available at http://health.state. ga.us/pdfs/epi/gers/ger0604.pdf). In this issue, we present updated active surveillance information from the Georgia Emerging Infections Program (EIP) and severe CA-MRSA disease reports from the state's notifiable disease surveillance system.

Figure 1: Invasive CA-MRSA disease rates*, by race, during three 12-month acRtiavteessuorvfeIinllvaanscievepeCriAo-dMs RduSrAinbgy20R0a1-c2e, 2in0084-C5,oaunndty2M00e5t-r6oinAttlhaen8ta-county Atlanta Metropolitan Statistical Area.

8

Invasive CA-MRSA - all races

7.1

Invasive CA-MRSA - Black race

6.8

Invasive CA-MRSA - White race

6

5.2

5.2

4.3 4
3.2

Cases per 100,000 Population

2 1.5

1.1

1

0
2001-2

2002-3

2003-4

2004-5

2005-6

12 Month Periods of Active Surveillance

*Incidence rates were calculated using annualized case numbers and population denominators from the earlier year (i.e., 2001, 2004, 2005) of each period.

Figure 2: Invasive CA-MIRnvSasAivedCiAse-MaRsSeA rbaytAegse Gbryouapg, e200g4r-5oup, 2004-5, 8-county Atlanta Metropolitan Statistical AMerteroap.olitan Atlanta
14

12

Cases per 100,000 Population

Active Surveillance for Invasive CA-MRSA, 8-county Atlanta Metropolitan Statistical Area (Health District 3) The Georgia Emerging Infections Program conducts populationbased active surveillance for MRSA disease in the 8-county Atlanta Metropolitan Statistical Area (MSA, population 3.5 million). Disease rates for CA-MRSA are shown for three 12-month time periods, beginning in 2001 (Figure 1). Cases had positive MRSA cultures from normally sterile sites and were considered communityassociated if the MRSA culture was obtained from an outpatient or within 48 hours of hospital admission, and chart review identified no prior MRSA infection, or surgery, hospitalization, dialysis, invasive device, or residence in a long-term care facility during the past 12 months. As shown, the overall incidence of invasive CA-MRSA disease increased from 1.1 to 5.2/100,000 between 2001 and 2005, then remained stable in 2006, although race-specific trends differed for black and white racial groups. Figure 2 shows that in the MSA rates of invasive CA-MRSA disease are higher at the extremes of age and lowest among school aged children.

10

8

6

4

2

0
<1 yr

1-3 yrs

4-11 yrs

12-19 yrs 20-49 yrs 50-64 yrs

>65 yrs

Severe CA-MRSA Disease Reporting in Georgia In October 2004, the Georgia Department of Human Resources, Division of Public Health made severe CA-MRSA infections notifiable by law. Severe CA-MRSA infection is defined as MRSA isolated from a sterile body site or resulting in intensive care, operative debridement, or death in a person with no history of MRSA infection, recent hospitalization or surgery, dialysis, percutaneous medical devices, or history of long term residential care. Figures 3 and 4 show reported cases of severe MRSA SSTI and pneumonia in Georgia from November 2004 through February 2007.

The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file.
If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. | Please visit, http://health.state.ga.us/epi/manuals/ger.asp for all current and past pdf issues of the GER.

Figure 3: Severe CA-MRSA skin and soft tissue infections (statewide) by month, November 2004 through February 2007, Georgia.

80

Survived Died

70

Total Number of Cases

60

50

40

30

20

10

Although subject to reporting artifact, notifiable disease reporting demonstrates that severe CA-MRSA SSTIs are common statewide, occur more often in summer, and are rarely fatal (Figure 3). By comparison, severe CA-MRSA pneumonia is less common but associated with higher mortality, occurs more often during the winter months, and is sometimes proven to be a complication of influenza (Figure 4, Table 1). Five of 11 patients listed in Table 1 developed sepsis following CA-MRSA skin or soft tissue infection which resulted in death. The remaining six deaths were due to CA-MRSA pneumonia; all six reported previous influenza-like illness (ILI) varying in duration from 2 to 6 days (with one unknown). Five of six were tested for influenza by rapid test, by viral culture and immunohistochemical stain, respectively; three of which were positive.

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb

0

2004

2005

2006

2007

Month of Onset

Figure 4: Severe CA-MRSA pneumonia cases (statewide) by month, November 2004 through February 2007, Georgia.

9

Survived

Died

8

MRSA genotype USA300 is the most widespread CA-MRSA clone in Georgia (2). Although invariably resistant to penicillins and cephalosporins, CA-MRSA strains are typically multi-drug susceptible due to a shortened resistance chromosome (SCCmec typeIV). Ten of the 11 fatal cases of CA-MRSA described in this report had isolates with antimicrobial resistance patterns typical of USA300; five isolates were fully characterized as USA300.

Total Number of Cases

7 6 5 4 3 2 1 0

Nov Dec Jan Feb Mar Apr May Jun
Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May Jen
Jul Aug Sept Oct Nov Dec Jan Feb

2004

2005

2006

2007

Month of Onset

Review of Severe CA-MRSA Cases Resulting in Death among Young Persons Chart reviews were performed for cases of severe CA-MRSA disease resulting in death among previously healthy young persons (< 25 years of age) occurring in Georgia between October 2004 and February 2007. Eleven cases are summarized in Table 1. Five deaths were presumed due to primary sepsis following CA-MRSA SSTI, and six were due to primary CA-MRSA pneumonia.

Discussion This report illustrates the rapid emergence and increasing importance of CA-MRSA statewide, while highlighting only the most severely affected patients. Laboratory-confirmed invasive infections are a small subset of all CA-MRSA disease; invasive disease constituted only 6% of laboratory-confirmed MRSA infections during EIP baseline surveillance (2001-2) which included surveillance of all body sites (1). Laboratory-confirmed MRSA infections are also a subset of uncomplicated infections, many of which may not present for medical attention or be cultured on presentation. Evidence suggests that CA-MRSA is widespread in Georgia and of significant public health concern, despite the fact that most disease occurs as uncomplicated skin and soft tissue infections which are easily treated.

Recent media attention has focused on the problem of CA-MRSA among school-aged children, but EIP surviellance in the MSA suggests that invasive disease rates are lowest in this age group. Prevention measures are important for all ages. Following multiple outbreak investigations, CDC has characterized risk factors ("the 5 C's") associated with CA-MRSA disease, which include Crowding, Close contact, Compromised skin, Contaminated surfaces and shared personal items, lack of Cleanliness, and in some outbreaks, prior antimicrobial use. Among the 11 fatal cases we studied, there was little evidence that prior antimicrobial use contributed to MRSA infection; only one patient was thought to have taken systemic antimicrobials immediately preceding hospital admission. Of the five fatal cases with SSTI, the significance of failure to comply with outpatient antibiotic therapy after diagnosis (two patients), and self-manipulation of the skin lesion (three patients) is unknown. None of the 6 fatal cases with CA-MRSA pneumonia preceded by ILI were known to have received an influenza vaccine.
Staphylococcus bacteria are primarily spread through skin-to-skin contact. Patients with skin lesions should be diligent in preventing spread to other persons or the environment. Because there is no anti-staphylococcal vaccine, prevention of CA-MRSA infection relies on personal hygiene, and specifically, excellent hand hygiene, with environmental cleaning as a supplementary measure. Advice includes not sharing personal items that contact skin such as towels, razors, or bar soap. The role of influenza vaccine in prevention of influenza virus co-infecting staphylococcal pneumonia is under investigation; no specific vaccine recommendations have been made for patients with MRSA colonization or active disease.
Expert guidance for clinical management of CA-MRSA SSTIs is available on the CDC website at http://www.cdc.gov/ncidod/dhqp/pdf/ar/ CAMRSA_ExpMtgStrategies.pdf. Current guidelines and several clinical studies suggest that for purulent skin lesions, incision and drainage constitutes a primary therapy, and that only some patients require empiric anti-

Division of Public Health http://health.state.ga.us
Stuart T. Brown, M.D. Director |State Health Officer
Martha N. Okafor, Ph.D. Deputy Director

Epidemiology Branch http://health.state.ga.us/epi
Susan Lance, D.V.M., Ph.D. State Epidemiologist John M. Horan, MD, MPH
Acting Director Epidemiology Branch

Georgia Epidemiology Report Editorial Board
Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D.
Cherie Drenzek, D.V.M., M.S. Susan Lance, D.V.M., Ph.D.
Stuart T. Brown, M.D. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer
-2 -

Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588
Fax: (404) 657-7517

Georgia Department of Human Resources
Division of Public Health

Please send comments to: gaepinfo@dhr.state.ga.us

microbial therapy (4). The decision to use empiric antimicrobials for SSTI requires clinical judgment with assessment of lesion severity, size, location, patient co-morbidities and other factors. All patients with potentially infectious skin lesions should be educated regarding infection control measures that can protect family members and other contacts.
To address the emergence of CA-MRSA, The Georgia DHR Division of Public Health formed a MRSA Task Force and is working with partners to address MRSA prevention and control. Projects include 1) clinician outreach to enhance recognition of CA-MRSA and patient management, 2) development of tools for patient education, and 3) needs assessment and partnering to address groups at risk (for example, persons in schools, athletic programs and correctional facilities) to identify prevention measures that may be implemented or enhanced in these settings (5). Educational tools and resources can be found at: http://health.state.ga.us/MRSA/, and http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca.html
Article written by Jessica Tuttle M.D., Kathryn Arnold M.D., and Melissa Tobin-d'Angelo M.D., M.P.H. Data collection and analysis courtesy of Sandra N. Bulens M.P.H. and Susan Ray M.D.

References 1) Fridkin SK, Hageman JC, Morrison M, Sanza LT, Como-Sabetti K,
Jernigan JA, Harriman K, Harrison LH, Lynfield R, Farley MM. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005;352:1436-44.
2) King MD, Humphrey BJ, Wang YF, Kourbatova EV, Ray SM, Blumberg
HM. Emergence of community-acquired methicillin-resistant Staphlococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue
infections. Ann Intern Med 2006;144:309-17.
3) Okuma k, Iwakawa K, Turnidge JD, et al. Dissemination of new methicillin-resistant Staphylococcus aureus clones in the community. Jour Clin Micro 2002; 40:4289-4294.
4) Lee MC, Rios AM, Aten MF, et al. Management and outcome of children with skin and soft tissue abscesses caused by communityacquired methicillin-resistant Staphylococcus aureus. Pediatr Infect Dis J. 2004; 23(2):123-127.
5) Wootten SH, Arnold K, Hill HA, et al. Intervention to reduce the incidence of methicillin-resistent Staphylococcus aureus skin infections in a correctional facility in Georgia. Infect Control Hosp Epidemiol 2004;25:402-7.

Table 1. Deaths among Previously Healthy Young Persons with Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA) Infections in Georgia, October 2004- February 2007.

Patient Description

Symptoms-Prior to Hospital Admission (pta)

Antimicrobials (pta)

Presentation to Hospital

MRSA Disease Syndrome(s)

MRSA Isolate Source(s) Influenza testing (if done)

Presumed portal of entry

Time from Admission to Death

18 yo WF 9 yo BF 17 yo BF

6 days pta: axillary abscess drained in emergency department 2 days pta: fever, back pain, vomiting
4 days pta: knee abrasion 2 days pta: fever, difficulty walking
3-6 days pta: sore throat, cough, fever 1 day pta: negative strep and flu testing in ED

Cephalexin given but not filled
None
None

Fever, back and leg pain
Fulminant respiratory failure, left calf swelling

Sepsis, necrotizing pneumonia with bullae, coagulopathy
Sepsis, pulmonary artery embolus, intracranial hemorrhage

Blood*, Sputum
Blood*, Skin, Internal organs (autopsy specimens)

Hemoptysis, respiratory distress, sepsis

Necrotizing pneumonia, respiratory failure

Bronchoalveolar lavage fluid**

Skin

29 days

Skin

4 days

Respiratory tract 9 days

23 mo WM 20 yo WM 14 yo BM

14 days pta: R buttock pustule (drained at home) 4 days pta: nausea, vomiting, diarrhea 2 days pta: fever 104F, headache

None

2 days pta: fever, myalgias, cough None

14 days pta: forearm pustule (drained at home) 6 days pta: low-grade fever, progressive leg weakness

Topical antimicrobials

Fever, dehydration, altered mental status, respiratory arrest
Fever, dyspnea, sore throat, leukopenia

Meningitis, sepsis, brain death
Pneumonia, anoxic brain injury due to self-extubation during helicopter transport

Septic shock, generalized pustular rash, coagulopathy

Purpura fulminans, sepsis, brain death

CSF**

Skin

Blood*, Sputum; Sputum negative for influenza by Cx and PCR

Respiratory tract

Blood, Urine, Skin**

Skin

2 days 3 days 7days

18 mo BM

3 days pta: low-grade fever

21 yo BM, history of incarceration, R thigh pustule two months pta
11 yo BF

6 days pta: pustule L scrotum, (drained at home) 5 days pta: scrotal lesion drained in emergency department
2 days pta: cold symptoms, pharyngitis, fever 1 day pta: positive flu testing given oseltarnivir

None

Fever 104F, seizures, dyspnea; no flu testing

TMP-SMZ prescribed but not filled

8" by 6" scrotal abscess, multiple pulmonary nodules

None

Unresponsive, apneic for 10 minutes. Intubated, resuscitated.

Sepsis, pulmonary edema
Abscess, sepsis, multiple septic pulmonary emboli, respiratory failure
Respiratoy failure. Cardiac arrest during transport to tertiary care center.

Blood*
Blood*, Sputum, Scrotal exudates
Blood**

8 yo WF 13 yo WM

3 days pta: pharyngitis, fever, cough, rhinorrhea, dyspnea, posttussive vomiting

None

Several day history of fever. Outpatient treatment included unknown antibiotic

Yes, unknown

Respiratory failure, septic shock, fever, cardiac arrest
Cardiopulmonary arrest at home

Pneumonia with pleural effusion, septic shock supported by ECMO until death
Necrotizing pneumonia, severe sepsis

Sputum** (sputum also positive for influenza A by viral culture)
No isolate. Postmortem pathology showed immunohistochemical evidence of Staph aureus and influenza B in lung tissue

*Isolate genotype USA 300 by PFGE; PVL and SCCmec type IV genes detected by PCR. **Antibiogram showed resistance to Beta-lactams and erythromycin, but susceptible to other antibiotics.

Respiratory tract

5 days

Skin

5 days

Respiratory tract

3 hours

Respiratory tract 21 days

Respiratory tract Dead on arrival

-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

December 2007

Volume23Number12

Reported Cases of Selected Notifiable Diseases in Georgia, Profile* for September 2007

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 September 2007
2007 54 13 37 11 57 10 10 3 11 0 0 3 0 1 0 294 113 4 26 8 35 0 29

Previous 3 Months Total Ending in September

2005

2006

2007

194

178

221

8615

10079

1571

58

103

98

12

18

26

216

240

190

4286

5782

621

18

21

19

44

21

13

43

58

36

12

14

5

3

3

4

2

3

9

0

0

0

15

12

3

0

0

0

785

814

750

185

339

346

43

25

19

138

140

100

98

98

72

240

248

165

0

1

1

132

147

100

Previous 12 Months Total Ending in September

2005

2006

2007

611

560

671

33163

38919

32885

148

246

265

32

44

41

786

712

655

15773

19764

14122

113

114

127

146

64

67

270

198

146

32

38

37

5

8

9

17

18

25

2

5

0

51

31

19

0

0

0

1843

1932

1874

587

1043

1823

129

129

87

513

489

468

372

401

357

971

1004

900

3

8

9

518

517

463

* 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.

Report Period

Disease

Total Cases Reported*

Classification <13yrs

>=13yrs Total

Percent

AIDS Profile Update
Risk Group Distribution (%)

MSM

IDU

MSM&IDU HS

Unknown Perinatal

Race Distribution (%)

White Black

Hispanic

Other

Latest 12 Months

HIV, non-AIDS

23

3,101

3,124

26

27

3

1

10

59

<1

22

72

5

1

11/06-10/07 AIDS

6

949

955

25

22

2

1

7

68

<1

23

70

6

1

Five Years Ago:**

HIV, non-AIDS

-

-

-

-

-

-

-

-

-

-

-

-

-

-

11/02-10/03 AIDS

0

1,633

1,633

26

37

7

2

15

39

-

19

75

5

1

Cumulative: HIV, non-AIDS 204

10,365

10,569

32

28

7

2

11

50

2

22

74

3

1

07/81-10/07 AIDS

236

31,474

31,710

20

44

15

5

14

21

<1

31

66

3

<1

Yrs - Age at diagnosis in years

MSM - Men having sex with men

IDU - Injection drug users

HS - Heterosexual

* Counted as Georgia cases only when the individual resided in Georgia at the time of earliest diagnosis of HIV or AIDS. NOTE: Previous reports may not have been restricted by this

methodology. This month's report includes only those cases, in order to avoid duplication with other states. For this reason an apparent decrease in Georgia case counts may be noted in some

instances. All future reports will be based on the more restricted methodology.

** HIV (non-AIDS) data was not collected until 12/31/2003.

- 4 -