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CommunityAssociated MRSA
Maha Assi, MD, MPH
MRSA Hits the Media
October 16, 2007
Lead story on MRSA
“superbug killing
many in US”
MRSA Kills High School
17 year old Ashton
Bonds died of
disseminated MRSA
Prompts closing of
school for cleaning
MRSA kills Football Player
20 year old college football player who
developed a skin infection. He was seen and
treated with antibiotics. MRSA was not
suspected. He died within days of disseminated
An Epidemic
A great deal of
media attention
Public concern
MRSA and the Media
How Common is CA-MRSA
colonization ?
General population analysis of data from the
Colonized with Staph aureus 31.6%
84 million
Colonized with MRSA 0.84%
2 million
Annals of Internal Medicine. 2006 March 7;144(5):318-25
How common is disease due
In 2005 in US 94,360 cases of invasive
MRSA infection with 18,650 deaths.
Of those, 14% were community-acquired
Traditional MRSA Risk
Newborns, elderly, hospital workers, HD,
IVDU, Diabetics, patients with chronic
Hospitalized patients, antibiotic receipt,
chronic illness of any kind
Community-Associated MRSA
without Identifiable Risk
Herold 1988- reported 25 fold increase in
MRSA colonization in children at a
Chicago Hospital
Adcock 1998-2 day care centers with from
3-24% colonization- 40% in children with
no contact with health care system
Deaths of 4 children in MN/ND 1999
Herold et al JAMA 1998:279:593-8
Adcock et al JID 1998:178:577-80
MMWR 1999;48:707-10
Community outbreaks
Native and aboriginal communities
Sports teams
Child care centers
Military personnel
Men who have sex with men
Prison inmates and guards
Risk factors
Skin trauma (e.g. lacerations, abrasions,
tattoos, injection drug use), cosmetic body
shaving, incarceration, sharing equipment
that is not cleaned or laundered between
users, and close contact with others who
have MRSA colonization or infection.
Animals can also carry MRSA and
function as a source of transmission.
What about me?
Importantly, many patients with CA-MRSA
have no risk factors.
Is that all?
CA-MRSA may cause disease without
previous nasal colonization, and/or favor
other sites of colonization over the nares
(such as the skin, throat, or
gastrointestinal tract).
The Molecular Biology of
Resistance to Penicillin=B-lactamases
Resistance to Methicillin=Penicillin binding
protein 2a (PBP 2a)
Alterations in PBP 2a carried on SCCmec
Nosocomial MRSA=SCCmec II and III
The USA300 strain
Necrotizing pneumonia
caused by CA-MRSA
Outcomes in Patients Treated
33% nonresponse at day 30
Failure related to lack of I & D (p=.005)
Failure not associated with wrong
antibiotic choice
Trend for close contacts to develop a
similar infection by day 30
Clin Infec Dis. 2007;44:483-92
Eradication of MRSA
The role of decolonization in the control of
methicillin-resistant Staphylococcus
aureus (MRSA) spread is uncertain.
Decolonization does not appear to be
consistently effective for eliminating MRSA
The optimal regimen and duration of
therapy for eradicating MRSA colonization
is uncertain.
Topical regimen
Chlorhexidine washes
Mupirocin or Bactroban ointment applied
to nares with a cotton-tipped applicator
two to three times daily
Prevention of CA-MRSA
Vaccine for Staph aureus
Capsular polysaccharides serotypes 5 and 8
Conjugated with protein from Pseudomonas
Randomized trial in hemodialysis patients
Partial immunity, decreased Staph aureus
bacteremias at 40 weeks
By 54 weeks no difference
?booster doses
Passive immunization