Under a microscope, staph bacteria look like bunches of grapes. Yet what looks pretty can turn ugly fast. Harmless Staphylococcus aureus lives in many people’s noses and on their skin. But it sometimes causes pus-filled boils and other skin infections. When eaten in tainted food, it can cause food poisoning. Staphylococcus aureus shows looks really can be deceiving.
- “Staphylococcus aureus.” Wikipedia, The Free Encyclopedia. Available from: http://en.wikipedia.org/wiki/Staphylococcus_aureus
- “Staph Infection.” Wikipedia, The Free Encyclopedia. Available from:http://en.wikipedia.org/wiki/Staph_infection
Staphylococcus aureus is a bacterium that is a member of the Firmicutes, and is frequently found in the human respiratory tract and on the skin. Although S. aureus is not always pathogenic, it is a common cause of skin infections (e.g. boils), respiratory disease (e.g. sinusitis), and food poisoning. Disease-associated strains often promote infections by producing potent protein toxins, and expressing cell-surface proteins that bind and inactivate antibodies. The emergence of antibiotic-resistant forms of pathogenic S. aureus (e.g. MRSA) is a worldwide problem in clinical medicine.
Staphylococcus was first identified in Aberdeen, Scotland (1880) by the surgeon Sir Alexander Ogston in pus from a surgical abscess in a knee joint. This name was later appended to Staphylococcus aureus by Rosenbach who was credited by the official system of nomenclature at the time. It is estimated that 20% of the human population are long-term carriers of S. aureus which can be found as part of the normal skin flora and in anterior nares of the nasal passages. S. aureus is the most common species of staphylococcus to cause Staph infections and is a successful pathogen due to a combination of nasal carriage and bacterial immuno-evasive strategies. S. aureus can cause a range of illnesses, from minor skin infections, such as pimples, impetigo, boils (furuncles), cellulitis folliculitis, carbuncles, scalded skin syndrome, and abscesses, to life-threatening diseases such as pneumonia, meningitis, osteomyelitis, endocarditis, toxic shock syndrome (TSS), bacteremia, and sepsis. Its incidence ranges from skin, soft tissue, respiratory, bone, joint, endovascular to wound infections. It is still one of the five most common causes of nosocomial infections and is often the cause of postsurgical wound infections. Each year, some 500,000 patients in American hospitals contract a staphylococcal infection.
|Classification and external resources|
S. aureus (pron.: / /, Greek σταφυλόκοκκος, "grape-cluster berry", Latin aureus, "golden") is a facultative anaerobic Gram-positive coccal bacterium, also known as "golden staph" and Oro staphira.
In medical literature the bacteria is often referred to as S. aureus or Staph aureus. Staphylococcus should not be confused with the similarly named and medically relevant genus Streptococcus. S. aureus appears as grape-like clusters when viewed through a microscope, and has large, round, golden-yellow colonies, often with hemolysis, when grown on blood agar plates. S. aureus reproduces asexually by binary fission. The two daughter cells do not fully separate and remain attached to one another. This is why the cells are observed in clusters.
S. aureus is catalase-positive (meaning it can produce the enzyme catalase), so is able to convert hydrogen peroxide (H2O2) to water and oxygen. This test is sometimes used to distinguish staphylococci from enterococci and streptococci. Previously S. aureus was differentiated from other staphylococci by the coagulase test. However it is now known that not all S. aureus are coagulase positive and that incorrect species identification can impact effective treatment and control measures.
Role in disease 
S. aureus is responsible for many infections but it may also occur as a commensal. The presence of S. aureus does not always indicate infection. S. aureus can survive from hours to weeks, or even months, on dry environmental surfaces, depending on strain.
S. aureus can infect tissues when the skin or mucosal barriers have been breached. This can lead to many different types of infections including furuncles and carbuncles (a collection of furuncles). In infants, S. aureus infection can cause a severe disease — staphylococcal scalded skin syndrome (SSSS).
S. aureus infections can spread through contact with pus from an infected wound, skin-to-skin contact with an infected person by producing hyaluronidase that destroys tissues, and contact with objects such as towels, sheets, clothing, or athletic equipment used by an infected person. Deeply penetrating S. aureus infections can be severe. Prosthetic joints put a person at particular risk of septic arthritis, and staphylococcal endocarditis (infection of the heart valves) and pneumonia. S. aureus can host phages, such as Panton-Valentine leukocidin, that increase its virulence.
Atopic dermatitis 
S. aureus is extremely prevalent in atopic dermatitis patients. It is mostly found in fertile, active places, including the armpits, hair, and scalp. Large pimples that appear in those areas may exacerbate the infection if lacerated. This can lead to staphylococcal scalded skin syndrome (SSSS). A severe form of this, Ritter's disease, can be observed in neonates.
Animal infections 
S. aureus can survive on dogs, cats, and horses, and can cause bumblefoot in chickens. S. aureus is one of the causal agents of mastitis in dairy cows. Its large polysaccharide capsule protects the organism from recognition by the cow's immune defenses.
Virulence factors 
|This section needs additional citations for verification. (March 2012)|
 It produces various enzymes such as coagulase (bound and free coagulases) which clots plasma and coats the bacterial cell which probably prevent phagocytosis. Hyaluronidase also known as spreading factor that breakdown hyaluronic acid and help in spreading of Staphylococcus aureus. S.aureus also produces DNAse (deoxyribonuclease) which breakdown the DNA.
- (PTSAgs) have superantigen activities that induce toxic shock syndrome (TSS). This group includes the toxin TSST-1, which causes TSS associated with tampon use. This is characterized by fever, erythematous rash, hypotension, shock, multiple organ failure, and skin desquamation. Lack of antibody to TSST-1 plays a part in the pathogenesis of toxic shock syndrome. Other strains of S. aureus can produce an enterotoxin that is the causative agent of S. aureus gastroenteritis. This gastroenteritis is self-limiting, characterized by vomiting and diarrhea one to six hours after ingestion of the toxin with recovery in eight to 24 hours. Symptoms include nausea, vomiting, diarrhea, and major abdominal pain.
- Exfoliative toxins
- EF toxins are implicated in the disease staphylococcal scalded-skin syndrome (SSSS), which occurs most commonly in infants and young children. It also may occur as epidemics in hospital nurseries. The protease activity of the exfoliative toxins causes peeling of the skin observed with SSSS.
- Other toxins
- Staphylococcal toxins that act on cell membranes include alpha toxin, beta toxin, delta toxin, and several bicomponent toxins. The bicomponent toxin Panton-Valentine leukocidin (PVL) is associated with severe necrotizing pneumonia in children. The genes encoding the components of PVL are encoded on a bacteriophage found in community-associated methicillin-resistant S. aureus (MRSA) strains.
Other immunoevasive strategies 
- Protein A
Protein A is anchored to staphylococcal peptidoglycan pentaglycine bridges (chains of five glycine residues) by the transpeptidase sortase A. Protein A, an IgG-binding protein, binds to the Fc region of an antibody. In fact, studies involving mutation of genes coding for protein A resulted in a lowered virulence of S. aureus as measured by survival in blood, which has led to speculation that protein A-contributed virulence requires binding of antibody Fc regions.
Protein A in various recombinant forms has been used for decades to bind and purify a wide range of antibodies by immunoaffinity chromatography. Transpeptidases, such as the sortases responsible for anchoring factors like Protein A to the staphylococcal peptidoglycan, are being studied in hopes of developing new antibiotics to target MRSA infections.
- Staphylococcal Pigments
Some strains of S. aureus are capable of producing staphyloxanthin — a golden coloured carotenoid pigment. This pigment acts as a virulence factor, primarily by being a bacterial antioxidant which helps the microbe evade the reactive oxygen species which the host immune system uses to kill pathogens.
Mutant strains of S. aureus modified to lack staphyloxanthin are less likely to survive incubation with an oxidizing chemical, such as hydrogen peroxide than pigmented strains. Mutant colonies are quickly killed when exposed to human neutrophils, while many of the pigmented colonies survive. In mice, the pigmented strains cause lingering abscesses when inoculated into wounds, whereas wounds infected with the unpigmented strains quickly heal.
These tests suggest the Staphylococcus strains use staphyloxanthin as a defence against the normal human immune system. Drugs designed to inhibit the production of staphyloxanthin may weaken the bacterium and renew its susceptibility to antibiotics. In fact, because of similarities in the pathways for biosynthesis of staphyloxanthin and human cholesterol, a drug developed in the context of cholesterol-lowering therapy was shown to block S. aureus pigmentation and disease progression in a mouse infection model.
Classical diagnosis 
Depending upon the type of infection present, an appropriate specimen is obtained accordingly and sent to the laboratory for definitive identification by using biochemical or enzyme-based tests. A Gram stain is first performed to guide the way, which should show typical Gram-positive bacteria, cocci, in clusters. Second, the isolate is cultured on mannitol salt agar, which is a selective medium with 7–9% NaCl that allows S. aureus to grow, producing yellow-colored colonies as a result of mannitol fermentation and subsequent drop in the medium's pH.
Furthermore, for differentiation on the species level, catalase (positive for all Staphylococcus species), coagulase (fibrin clot formation, positive for S. aureus), DNAse (zone of clearance on DNase agar), lipase (a yellow color and rancid odor smell), and phosphatase (a pink color) tests are all done. For staphylococcal food poisoning, phage typing can be performed to determine whether the staphylococci recovered from the food were the source of infection.
Rapid diagnosis and typing 
Diagnostic microbiology laboratories and reference laboratories are key for identifying outbreaks and new strains of S. aureus. Recent genetic advances have enabled reliable and rapid techniques for the identification and characterization of clinical isolates of S. aureus in real time. These tools support infection control strategies to limit bacterial spread and ensure the appropriate use of antibiotics. Real-time PCR is being increasingly employed in clinical laboratories as a technique to identifying outbreaks.
Treatment and antibiotic resistance 
The treatment of choice for S. aureus infection is penicillin; in most countries, however, penicillin resistance is extremely common, and first-line therapy is most commonly a penicillinase-resistant β-lactam antibiotic (for example, oxacillin or flucloxacillin). Combination therapy with gentamicin may be used to treat serious infections, such as endocarditis, but its use is controversial because of the high risk of damage to the kidneys. The duration of treatment depends on the site of infection and on severity.
Antibiotic resistance in S. aureus was uncommon when penicillin was first introduced in 1943. Indeed, the original petri dish on which Alexander Fleming of Imperial College London observed the antibacterial activity of the Penicillium fungus was growing a culture of S. aureus. By 1950, 40% of hospital S. aureus isolates were penicillin-resistant; and, by 1960, this had risen to 80%.
Methicillin-resistant S. aureus, abbreviated MRSA and often pronounced // or / /, is one of a number of greatly feared strains of S. aureus which have become resistant to most β-lactam antibiotics. MRSA strains are most often found associated with institutions such as hospitals, but are becoming increasingly prevalent in community-acquired infections. A recent study by the Translational Genomics Research Institute showed that nearly half (47%) of the meat and poultry in U.S. grocery stores were contaminated with S. aureus, with more than half (52%) of those bacteria resistant to antibiotics.
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- The article Methicillin-resistant Staphylococcus aureus contains related information on this topic
Mechanisms of antibiotic resistance 
Staphylococcal resistance to penicillin is mediated by penicillinase (a form of β-lactamase) production: an enzyme that cleaves the β-lactam ring of the penicillin molecule, rendering the antibiotic ineffective. Penicillinase-resistant β-lactam antibiotics, such as methicillin, nafcillin, oxacillin, cloxacillin, dicloxacillin, and flucloxacillin, are able to resist degradation by staphylococcal penicillinase.
Resistance to methicillin is mediated via the mec operon, part of the staphylococcal cassette chromosome mec (SCCmec). Resistance is conferred by the mecA gene, which codes for an altered penicillin-binding protein (PBP2a or PBP2') that has a lower affinity for binding β-lactams (penicillins, cephalosporins, and carbapenems). This allows for resistance to all β-lactam antibiotics, and obviates their clinical use during MRSA infections. As such, the glycopeptide vancomycin is often deployed against MRSA.
Aminoglycoside antibiotics, such as kanamycin, gentamicin, streptomycin, etc., were once effective against staphylococcal infections until strains evolved mechanisms to inhibit the aminoglycosides' action, which occurs via protonated amine and/or hydroxyl interactions with the ribosomal RNA of the bacterial 30S ribosomal subunit There are three main mechanisms of aminoglycoside resistance mechanisms which are currently and widely accepted: aminoglycoside modifying enzymes, ribosomal mutations, and active efflux of the drug out of the bacteria.
Aminoglycoside-modifying enzymes inactivate the aminoglycoside by covalently attaching either a phosphate, nucleotide, or acetyl moiety to either the amine or the alcohol key functional group (or both groups) of the antibiotic. This changes the charge or sterically hinders the antibiotic, decreasing its ribosomal binding affinity. In S. aureus, the best-characterized aminoglycoside-modifying enzyme is aminoglycoside adenylyltransferase 4' IA (ANT(4')IA). This enzyme has been solved by x-ray crystallography. The enzyme is able to attach an adenyl moiety to the 4' hydroxyl group of many aminoglycosides, including kamamycin and gentamicin.
Glycopeptide resistance is mediated by acquisition of the vanA gene. The vanA gene originates from the enterococci and codes for an enzyme that produces an alternative peptidoglycan to which vancomycin will not bind.
Today, S. aureus has become resistant to many commonly used antibiotics. In the UK, only 2% of all S. aureus isolates are sensitive to penicillin, with a similar picture in the rest of the world. The β-lactamase-resistant penicillins (methicillin, oxacillin, cloxacillin, and flucloxacillin) were developed to treat penicillin-resistant S. aureus, and are still used as first-line treatment. Methicillin was the first antibiotic in this class to be used (it was introduced in 1959), but, only two years later, the first case of MRSA was reported in England.
MRSA infections in both the hospital and community setting are commonly treated with non-β-lactam antibiotics, such as clindamycin (a lincosamine) and co-trimoxazole (also commonly known as trimethoprim/sulfamethoxazole). Resistance to these antibiotics has also led to the use of new, broad-spectrum anti-Gram-positive antibiotics, such as linezolid, because of its availability as an oral drug. First-line treatment for serious invasive infections due to MRSA is currently glycopeptide antibiotics (vancomycin and teicoplanin). There are number of problems with these antibiotics, such as the need for intravenous administration (there is no oral preparation available), toxicity, and the need to monitor drug levels regularly by blood tests. There are also concerns glycopeptide antibiotics do not penetrate very well into infected tissues (this is a particular concern with infections of the brain and meninges and in endocarditis). Glycopeptides must not be used to treat methicillin-sensitive S. aureus (MSSA), as outcomes are inferior.
Because of the high level of resistance to penicillins and because of the potential for MRSA to develop resistance to vancomycin, the U.S. Centers for Disease Control and Prevention has published guidelines for the appropriate use of vancomycin. In situations where the incidence of MRSA infections is known to be high, the attending physician may choose to use a glycopeptide antibiotic until the identity of the infecting organism is known. After the infection is confirmed to be due to a methicillin-susceptible strain of S. aureus, treatment can be changed to flucloxacillin or even penicillin, as appropriate.
Vancomycin-resistant S. aureus (VRSA) is a strain of S. aureus that has become resistant to the glycopeptides. The first case of vancomycin-intermediate S. aureus (VISA) was reported in Japan in 1996; but the first case of S. aureus truly resistant to glycopeptide antibiotics was only reported in 2002. Three cases of VRSA infection had been reported in the United States as of 2005.
Carriage of Staphylococcus aureus 
The carriage of Staphylococcus aureus is an important source of nosocomial infection and community-acquired methicillin-resistant S. aureus (MRSA). Although S. aureus can be present on the skin of the host, a large proportion of its carriage is through the anterior nares of the nasal passages. The ability of the nasal passages to harbour S. aureus results from a combination of a weakened or defective host immunity and the bacteria's ability to evade host innate immunity.
Infection control 
Spread of S. aureus (including MRSA) generally is through human-to-human contact, although recently some veterinarians have discovered the infection can be spread through pets, with environmental contamination thought to play a relatively unimportant part. Emphasis on basic hand washing techniques are, therefore, effective in preventing its transmission. The use of disposable aprons and gloves by staff reduces skin-to-skin contact and, therefore, further reduces the risk of transmission. Please refer to the article on infection control for further details.
Recently, there have been myriad reported cases of S. aureus in hospitals across America. The pathogen has had facilitated transportation in medical facilities mainly because of insufficient healthcare worker hygiene. S. aureus is an incredibly hardy bacterium, as was shown in a study where it survived on polyester for just under three months; polyester is the main material used in hospital privacy curtains.
The bacteria are transported on the hands of healthcare workers, who may pick them up from a seemingly healthy patient carrying a benign or commensal strain of S. aureus, and then pass it on to the next patient being treated. Introduction of the bacteria into the bloodstream can lead to various complications, including, but not limited to, endocarditis, meningitis, and, if it is widespread, sepsis.
Ethanol has proven to be an effective topical sanitizer against MRSA. Quaternary ammonium can be used in conjunction with ethanol to increase the duration of the sanitizing action. The prevention of nosocomial infections involves routine and terminal cleaning. Nonflammable alcohol vapor in CO2 NAV-CO2 systems have an advantage, as they do not attack metals or plastics used in medical environments, and do not contribute to antibacterial resistance.
An important and previously unrecognized means of community-associated MRSA colonization and transmission is during sexual contact.
Staff or patients who are found to carry resistant strains of S. aureus may be required to undergo "eradication therapy", which may include antiseptic washes and shampoos (such as chlorhexidine) and application of topical antibiotic ointments (such as mupirocin or neomycin) to the anterior nares of the nose.
Biological control might be a new possible way to control Staphylococcus aureus in body surfaces. Colonization of body surfaces (especially in the nose) by Staphylococcus epidermidis(inhibitory strain JK16) impairs the establishment of S. aureus.
A 2011 study points to this new possible way to control S.aureus. This study was performed from observations of the nasal microbial flora of a diverse group of people. It was discovered that there are two different strains of S. epidermidis, one that inhibits biofilm formation by S. aureus, S. epidermidis strain JK16 (inhibitory type), and one that does not (non-inhibitory type) S. epidermidis strain JK11. In this study they observed that there were some patients that were not affected by Staphylococcus aureus; this was because these patients had S. aureus together with S. epidermis (inhibitory type), in their nasal microbial flora. This is due to an amensalistic relationship between these microorganisms, the inhibitory strain of S. epidermidis and Staphylococcus aureus.
These findings open the way to a biological control therapy to help in the treatment of S. aureus infections which are becoming a growing threat due to the rise of resistance to conventional antibiotic treatments.
See also 
- Facultative anaerobic organism
- Gram-positive bacteria
- List of cutaneous conditions
- Staphylococcal infection
- Vancomycin-resistant Staphylococcus aureus
- Ogston A (1984). ""On Abscesses". Classics in Infectious Diseases". Rev Infect Dis 6 (1): 122–28. PMID 6369479.
- Kluytmans J, van Belkum A, Verbrugh H (July 1997). "Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks". Clin. Microbiol. Rev. 10 (3): 505–20. PMC 172932. PMID 9227864.
- Cole, A. M.; Tahk, S.; Oren, A.; Yoshioka, D.; Kim, Y. H.; Park, A.; Ganz, T (November 2001). "Determinants of Staphylococcus aureus nasal carriage". Clin Diagn Lab Immunol 8 (6): 1064–9. doi:10.1128/CDLI.8.6.1064-1069.2001. PMC 96227.
- Bowersox, John (27 May 1999). "Experimental Staph Vaccine Broadly Protective in Animal Studies". NIH. Archived from the original on 5 May 2007. Retrieved 28 July 2007.
- Ryan KJ, Ray CG (editors) (2004). Sherris Medical Microbiology (4th ed.). McGraw Hill. ISBN 0-8385-8529-9.
- "Staphylococcus aureus: Reproduction". palexander13.webs.com.
- PreTest, Surgery, 12th ed., p.88
- Matthews KR, Roberson J, Gillespie BE, Luther DA, Oliver SP (1997). "Identification and Differentiation of Coagulase-Negative Staphylococcus aureus by Polymerase Chain Reaction". Journal of Food Protection 60 (6): 686–8.
- Cimolai N (July 2008). "MRSA and the environment: implications for comprehensive control measures". Eur. J. Clin. Microbiol. Infect. Dis. 27 (7): 481–93. doi:10.1007/s10096-008-0471-0. PMID 18273652.
- Curran JP, Al-Salihi FL (1980). "Neonatal staphylococcal scalded skin syndrome: massive outbreak due to an unusual phage type". Pediatrics 66 (2): 285–90. PMID 6447271.
- Cenci-Goga BT, Karama M, Rossitto PV, Morgante RA, Cullor JS (September 2003). "Enterotoxin production by Staphylococcus aureus isolated from mastitic cows". Journal of food protection 66 (9): 1693–6. PMID 14503727.
- Medical Laboratory Manual For Tropical Countries vol two
- Schneewind O, Fowler A, Faull KF (April 1995). "Structure of the cell wall anchor of surface proteins in Staphylococcus aureus". Science 268 (5207): 103–6. doi:10.1126/science.7701329. PMID 7701329.
- Patel AH, Nowlan P, Weavers ED, Foster T (December 1987). "Virulence of protein A-deficient and alpha-toxin-deficient mutants of Staphylococcus aureus isolated by allele replacement". Infect. Immun. 55 (12): 3103–10. PMC 260034. PMID 3679545.
- Zhu J, Lu C, Standland M et al. (February 2008). "Single mutation on the surface of Staphylococcus aureus Sortase A can disrupt its dimerization". Biochemistry 47 (6): 1667–74. doi:10.1021/bi7014597. PMID 18193895.
- Clauditz A, Resch A, Wieland KP, Peschel A, Götz F (August 2006). "Staphyloxanthin plays a role in the fitness of Staphylococcus aureus and its ability to cope with oxidative stress". Infection and immunity 74 (8): 4950–3. doi:10.1128/IAI.00204-06. PMC 1539600. PMID 16861688.
- Liu GY, Essex A, Buchanan JT, Datta V, Hoffman HM, Bastian JF, Fierer J, Nizet V (2005). "Staphylococcus aureus golden pigment impairs neutrophil killing and promotes virulence through its antioxidant activity". J Exp Med 202 (2): 209–15. doi:10.1084/jem.20050846. PMC 2213009. PMID 16009720.
- Liu CI, Liu GY, Song Y, Yin F, Hensler ME, Jeng WY, Nizet V, Wang AH, Oldfield E (2008). "A cholesterol biosynthesis inhibitor blocks Staphylococcus aureus virulence". Science 319 (5868): 391–94. doi:10.1126/science.1153018. PMC 2747771. PMID 18276850.
- Francois P and Schrenzel J (2008). "Rapid Diagnosis and Typing of Staphylococcus aureus". StaphylococcuWEINERs: Molecular Genetics. Caister Academic Press. ISBN 978-1-904455-29-5.
- Mackay IM, ed. (2007). Real-Time PCR in Microbiology: From Diagnosis to Characterization. Caister Academic Press. ISBN 978-1-904455-18-9.
- Korzeniowski O, Sande MA (1982). "Combination antimicrobial therapy for Staphylococcus aureus endocarditis in patients addicted to parenteral drugs and in nonaddicts: a prospective study". Ann Intern Med 97 (4): 496–503. PMID 6751182.
- Bayer AS, Bolger AF, Taubert KA et al. (1998). "Diagnosis and management of infective endocarditis and its complications". Circulation 98 (25): 2936–48. PMID 9860802.
- Cosgrove SE, Vigliani GA, Campion M et al. (2009). "Initial low‐dose gentamicin for Staphylococcus aureus bacteremia and endocarditis is nephrotoxic". Clin Infect Dis 48 (6): 713–721. doi:10.1086/597031. PMID 19207079.
- Chambers HF (2001). "The changing epidemiology of Staphylococcus aureus?". Emerg Infect Dis 7 (2): 178–82. doi:10.3201/eid0702.010204. PMC 2631711. PMID 11294701.
- "US Meat and Poultry Is Widely Contaminated With Drug-Resistant Staph Bacteria". ScienceDaily. 15 April 2011.
- "Phage Therapy May Control Staph Infections In Humans Including MRSA". Sciencedaily. 22 August 2007. Retrieved 18 September 2009.
- Carter AP, Clemons WM, Brodersen DE, Morgan-Warren RJ, Wimberly BT, Ramakrishnan V (September 2000). "Functional insights from the structure of the 30S ribosomal subunit and its interactions with antibiotics". Nature 407 (6802): 340–8. doi:10.1038/35030019. PMID 11014183.
- Sakon J, Liao HH, Kanikula AM, Benning MM, Rayment I, Holden HM (November 1993). "Molecular structure of kanamycin nucleotidyltransferase determined to 3.0-A resolution". Biochemistry 32 (45): 11977–84. doi:10.1021/bi00096a006. PMID 8218273.
- Jevons MP (1961). "Celbenin-resistant staphylococci". BMJ 1 (5219): 124–5. doi:10.1136/bmj.1.5219.124-a.
- Johnson AP, Aucken HM, Cavendish S, Ganner M, Wale MC, Warner M, Livermore DM, Cookson BD (2001). "Dominance of EMRSA-15 and -16 among MRSA causing nosocomial bacteraemia in the UK: analysis of isolates from the European Antimicrobial Resistance Surveillance System (EARSS)". J Antimicrob Chemother 48 (1): 143–4. doi:10.1093/jac/48.1.143. PMID 11418528.
- [verification needed]Blot SI, Vandewoude KH, Hoste EA, Colardyn FA (2002). "Outcome and attributable mortality in critically Ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus". Arch Intern Med 162 (19): 22293–5. doi:10.1001/archinte.162.19.2229. PMID 12390067.
- Hiramatsu K, Hanaki H, Ino T, Yabuta K, Oguri T, Tenover FC (1997). "Methicillin-resistant Staphylococcus aureus clinical strain with reduced vancomycin susceptibility". J Antimicrob Chemother 40 (1): 135–6. doi:10.1093/jac/40.1.135. PMID 9249217.
- Chang S, Sievert DM, Hageman JC, Boulton ML, Tenover FC, Downes FP, Shah S, Rudrik JT, Pupp GR, Brown WJ, Cardo D, Fridkin SK (2003). "Infection with vancomycin-resistant Staphylococcus aureus containing the vanA resistance gene". N Engl J Med 348 (14): 1342–7. doi:10.1056/NEJMoa025025. PMID 12672861.
- Menichetti F (2005). "Current and emerging serious Gram-positive infections". Clin Microbiol Infect 11 (Suppl 3): 22–8. doi:10.1111/j.1469-0691.2005.01138.x. PMID 15811021.
- Quinn, G. A.; Cole, A. M (September 2007). "Suppression of innate immunity by a nasal carriage strain of Staphylococcus aureus increases its colonization on nasal epithelium". Immunology 122 (1): 80–9. doi:10.1111/j.1365-2567.2007.02615.x. PMC 2265977.
- Sing A, Tuschak C, Hoermansdorfer S (March 2008). "Methicillin-Resistant Staphylococcus aureus in a Family and Its Pet Cat". N Engl J Med 358: 1200–1. doi:10.1056/NEJMc0706805.
- Neely AN, Maley MP (February 2000). "Survival of enterococci and staphylococci on hospital fabrics and plastic". J. Clin. Microbiol. 38 (2): 724–6. PMC 86187. PMID 10655374.
- Cook H, Furuya E, Larson E, Vasquez G, Lowy F (2007). "Heterosexual transmission of community-associated methicillin-resistant Staphylococcus aureus". Clin Infect Dis 44 (3): 410–3. doi:10.1086/510681. PMID 17205449.
- Shafiei Y, Razavilar V, Javadi A (2011). "Thermal Death Time of Staphylococcus Aureus (PTCC=29213) and Staphylococcus Epidermidis (PTCC=1435) in Distilled Water" (PDF). Australian Journal of Basic and Applied Sciences 5 (11): 1551–4.
- Iwase, Tadayuki; Uehara, Yoshio; Shinji, Hitomi; Tajima, Akiko; Seo, Hiromi; Takada, Koji; Agata, Toshihiko; Mizunoe, Yoshimitsu (20 May 2010). "Staphylococcus epidermidis Esp inhibits Staphylococcus aureus biofilm formation and nasal colonization". Nature 465 (7296): 346–9. doi:10.1038/nature09074. PMID 20485435.
|It has been suggested that this article or section be merged into Methicillin-resistant Staphylococcus aureus. (Discuss) Proposed since November 2011.|
ST8:USA300 is a strain of community-associated MRSA that has emerged as a particularly antibiotic resistant epidemic that is responsible for rapidly progressive, fatal diseases including necrotizing pneumonia, severe sepsis and necrotizing fasciitis. The epidemiology of infections caused by MRSA is rapidly changing: in the past 10 years, infections caused by this organism have emerged in the community. The 2 MRSA clones in the United States most closely associated with community outbreaks, USA400 (MW2 strain, ST1 lineage) and USA300, often contain Panton-Valentine leukocidin (PVL) genes and, more frequently, have been associated with skin and soft tissue infections. Outbreaks of community-associated (CA)-MRSA infections have been reported in correctional facilities, among athletic teams, among military recruits, in newborn nurseries, and among active homosexual men. CA-MRSA infections now appear to be endemic in many urban regions and cause most MRSA infections. 
- Boyle-Vavra S, Daum RS (2007). "Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine leukocidin". Lab. Invest. 87 (1): 3–9. doi:10.1038/labinvest.3700501. PMID 17146447.
- Maree CL, Daum RS, Boyle-Vavra S, Matayoshi K, Miller LG (2007). "Community-associated methicillin-resistant Staphylococcus aureus isolates causing healthcare-associated infections". Emerging Infect. Dis. 13 (2): 236–42. doi:10.3201/eid1302.060781. PMC 2725868. PMID 17479885. http://www.cdc.gov/eid/content/13/2/236.htm?s_cid=eid236_e.
- Diep BA, Chambers HF, Graber CJ, et al. (February 2008). "Emergence of multidrug-resistant, community-associated, methicillin-resistant Staphylococcus aureus clone USA300 in men who have sex with men". Ann. Intern. Med. 148 (4): 249–57. PMID 18283202.
Methicillin-resistant Staphylococcus aureus
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium responsible for several difficult-to-treat infections in humans. It is also called multidrug-resistant Staphylococcus aureus and oxacillin-resistant Staphylococcus aureus (ORSA). MRSA is any strain of Staphylococcus aureus that has developed resistance to beta-lactam antibiotics, which include the penicillins (methicillin, dicloxacillin, nafcillin, oxacillin, etc.) and the cephalosporins. Strains unable to resist these antibiotics are classified as methicillin-sensitive Staphylococcus aureus, or MSSA. The development of such resistance does not cause the organism to be more intrinsically virulent than strains of Staphylococcus aureus that have no antibiotic resistance, but resistance does make MRSA infection more difficult to treat with standard types of antibiotics and thus more dangerous.
Signs and symptoms
S. aureus most commonly colonizes the anterior nares (the nostrils). The rest of the respiratory tract, open wounds, intravenous catheters, and the urinary tract are also potential sites for infection. Healthy individuals may carry MRSA asymptomatically for periods ranging from a few weeks to many years. Patients with compromised immune systems are at a significantly greater risk of symptomatic secondary infection.
In most patients, MRSA can be detected by swabbing the nostrils and isolating the bacteria found inside. Combined with extra sanitary measures for those in contact with infected patients, screening patients admitted to hospitals has been found to be effective in minimizing the spread of MRSA in hospitals in the United States, Denmark, Finland, and the Netherlands.
MRSA may progress substantially within 24–48 hours of initial topical symptoms. After 72 hours, MRSA can take hold in human tissues and eventually become resistant to treatment. The initial presentation of MRSA is small red bumps that resemble pimples, spider bites, or boils; they may be accompanied by fever and, occasionally, rashes. Within a few days, the bumps become larger and more painful; they eventually open into deep, pus-filled boils. About 75 percent of community-associated (CA-) MRSA infections are localized to skin and soft tissue and usually can be treated effectively. But some CA-MRSA strains display enhanced virulence, spreading more rapidly and causing illness much more severe than traditional healthcare-associated (HA-) MRSA infections, and they can affect vital organs and lead to widespread infection (sepsis), toxic shock syndrome, and necrotizing ("flesh-eating") pneumonia. This is thought to be due to toxins carried by CA-MRSA strains, such as PVL and PSM, though PVL was recently found to not be a factor in a study by the National Institute of Allergy and Infectious Diseases (NIAID) at the NIH. It is not known why some healthy people develop CA-MRSA skin infections that are treatable while others infected with the same strain develop severe infections or die.
The most common manifestations of CA-MRSA are skin infections, such as necrotizing fasciitis and pyomyositis (most commonly found in the tropics), necrotizing pneumonia, infective endocarditis (which affects the valves of the heart), and bone and joint infections. CA-MRSA often results in abscess formation that requires incision and drainage. Before the spread of MRSA into the community, abscesses were not considered contagious, because it was assumed that infection required violation of skin integrity and the introduction of staphylococci from normal skin colonization. However, newly emerging CA-MRSA is transmissible (similar, but with very important differences) from Hospital-Associated MRSA. CA-MRSA is less likely than other forms of MRSA to cause cellulitis.
Some of the populations at risk:
- People with weak immune systems (people living with HIV/AIDS, people living with lupus, cancer patients, transplant recipients, severe asthmatics, etc.)
- Intravenous drug users 
- Users of quinolone antibiotics
- Young children
- The elderly
- College students living in dormitories
- People staying or working in a health care facility for an extended period of time
- People who spend time in coastal waters where MRSA is present, such as some beaches in Florida and the west coast of the United States
- People who spend time in confined spaces with other people, including occupants of homeless shelters and warming centers, prison inmates, military recruits in basic training, and individuals who spend considerable time in changerooms or gyms.
- Urban under-served
- Indigenous populations, including Native Americans, Native Alaskans, and Australian Aboriginals
- Men who have sex with men
- Veterinarians, Livestock handlers, and Pet owners
Many MRSA infections occur in hospitals and healthcare facilities, with a higher incidence rate in nursing homes or long-term care facilities. When infections occur in this manner it is known as healthcare acquired MRSA or HA-MRSA. These Rates of MRSA infection are also increased in hospitalized patients who are treated with quinolones. Healthcare provider-to-patient transfer is common, especially when healthcare providers move from patient to patient without performing necessary hand-washing techniques between patients.
Prison inmates, Military recruits, and the Homeless
Prisons, military barracks, and homeless shelters can be crowded and confined, and poor hygiene practices may proliferate, thus putting inhabitants at increased risk of contracting MRSA. Cases of MRSA in such populations were first reported in the United States, and then in Canada. The earliest reports were made by the CDC in state prisons. Subsequently reports of a massive rise in skin and soft tissue infections were reported by the CDC in the Los Angeles County Jail system in 2001, and this has continued. Pan et al. reported on the changing epidemiology of MRSA skin infection in the San Francisco County Jail, noting the MRSA accounted for more than 70% of S. aureus infection in the jail by 2002. Lowy and colleagues reported on frequent MRSA skin infections in New York State Prisons. Two reports on inmates in Maryland have demonstrated frequent colonization with MRSA.
In the news media hundreds of reports of MRSA outbreaks in prisons appeared between 2000 and 2008. For example, in February 2008, The Tulsa County Jail in the U.S. State of Oklahoma started treating an average of twelve Staphylococcus cases per month. A report on skin and soft tissue infections in the Cook County Jail in Chicago in 2004–05 demonstrated that MRSA was the most common cause of these infections among cultured lesions and furthermore that few risk factors were more strongly associated with MRSA infections than infections caused by methicillin-susceptible S. aureus. In response to these and many other reports on MRSA infections among incarcerated and recently incarcerated persons, the Federal Bureau of Prisons has released guidelines for the management and control of the infections although few studies provide an evidence base for these guidelines.
People in contact with live food-producing animals
Cases of MRSA have increased in livestock animals. CC398 is a new clone of MRSA that has emerged in animals and is found in intensively reared production animals (primarily pigs, but also cattle and poultry), where it can be transmitted to humans. Though dangerous to humans, CC398 is often asymptomatic in food-producing animals.
A 2011 study reported 47% of the meat and poultry sold in surveyed U.S. grocery stores was contaminated with S. aureus and, of those, 52%—or 24.4% of the total—were resistant to at least three classes of antibiotics. "Now we need to determine what this means in terms of risk to the consumer," said Dr. Keim, a co-author of the paper. Some samples of commercially sold meat products in Japan were also found to harbor MRSA strains.
In the United States, there have been increasing numbers of reports of outbreaks of MRSA colonization and infection through skin contact in locker rooms and gyms, even among healthy populations. A study published in the New England Journal of Medicine linked MRSA to the abrasions caused by artificial turf. Three studies by the Texas State Department of Health found that the infection rate among football players was 16 times the national average. In October 2006, a high school football player was temporarily paralyzed from MRSA-infected turf burns. His infection returned in January 2007 and required three surgeries to remove infected tissue, as well as three weeks of hospital stay.
MRSA is also becoming a problem in pediatric settings, including hospital nurseries. A 2007 study found that 4.6% of patients in U.S. health care facilities were infected or colonized with MRSA.
Diagnostic microbiology laboratories and reference laboratories are key for identifying outbreaks of MRSA. New rapid techniques for the identification and characterization of MRSA have been developed. This notwithstanding, the bacterium generally must be cultured via blood, urine, sputum, or other body fluid cultures, and cultured in the lab in sufficient quantities to perform these confirmatory tests first. Consequently, there is no quick and easy method to diagnose a MRSA infection. Therefore, initial treatment is often based upon 'strong suspicion' by the treating physician, since any delay in treating this type of infection can have fatal consequences. These techniques include Real-time PCR and Quantitative PCR and are increasingly being employed in clinical laboratories for the rapid detection and identification of MRSA strains.
Another common laboratory test is a rapid latex agglutination test that detects the PBP2a protein. PBP2a is a variant penicillin-binding protein that imparts the ability of S. aureus to be resistant to oxacillin.
Antimicrobial resistance is genetically based; resistance is mediated by the acquisition of extrachromosomal genetic elements containing resistance genes. Exemplary are plasmids, transposable genetic elements, and genomic islands, which are transferred between bacteria via horizontal gene transfer. A defining characteristic of MRSA is its ability to thrive in the presence of penicillin-like antibiotics, which normally prevent bacterial growth by inhibiting synthesis of cell wall material. This is due to a resistance gene, mecA, which stops β-lactam antibiotics from inactivating the enzymes (transpeptidases) that are critical for cell wall synthesis.
Staphylococcal cassete chromosome mec (SCCmec) is a genomic island of unknown origin containing the antibiotic resistance gene mecA. SCCmec contains additional genes beyond mecA, including the cytolysin gene psm-mec, which may suppress virulence in hospital-acquired MRSA strains. SCCmec also contains ccrA and ccrB; both genes encode recombinases that mediate the site-specific integration and excision of the SCCmec element from the S. aureus chromosome. Currently, six unique SCCmec types ranging in size from 21-67 kb have been identified; they are designated types I-VI and are distinguished by variation in mec and ccr gene complexes. Owing to the size of the SCCmec element and the constraints of horizontal gene transfer, a limited number of clones is thought to be responsible for the spread of MRSA infections.
Different SCCmec genotypes confer different microbiological characteristics, such as different antimicrobial resistance rates. Different genotypes are also associated with different types of infections. Types I-III SCCmec are large elements that typically contain additional resistance genes and are characteristically isolated from HA-MRSA strains. Conversely, CA-MRSA is associated with types IV and V, which are smaller and lack resistance genes other than mecA.
mecA is responsible for resistance to methicillin and other β-lactam antibiotics. After acquisition of mecA, the gene must be integrated and localized in the S. aureus chromosome. mecA encodes penicillin-binding protein 2a (PBP2a), which differs from other penicillin-binding proteins as its active site does not bind methicillin or other β-lactam antibiotics. As such, PBP2a can continue to catalyze the transpeptidation reaction required for peptidoglycan cross-linking, enabling cell wall synthesis in the presence of antibiotics. As a consequence of the inability of PBP2a to interact with β-lactam moieties, acquisition of mecA confers resistance to all β-lactam antibiotics in addition to methicillin.
mecA is under the control of two regulatory genes, mecI and mecR1. MecI is usually bound to the mecA promoter and functions as a repressor. In the presence of a β-lactam antibiotic, MecR1 initiates a signal transduction cascade that leads to transcriptional activation of mecA. This is achieved by MecR1-mediated cleavage of MecI, which alleviates MecI repression. mecA is further controlled by two co-repressors, BlaI and BlaR1. blaI and blaR1 are homologous to mecI and mecR1, respectively, and normally function as regulators of blaZ, which is responsible for penicillin resistance. The DNA sequences bound by MecI and BlaI are identical; therefore, BlaI can also bind the mecA operator to repress transcription of mecA.
Acquisition of SCCmec in methicillin-sensitive staphylococcus aureus (MSSA) gives rise to a number of genetically different MRSA lineages. These genetic variations within different MRSA strains possibly explain the variability in virulence and associated MRSA infections. The first MRSA strain, ST250 MRSA-1 originated from SCCmec and ST250-MSSA integration. Historically, major MRSA clones: ST2470-MRSA-I, ST239-MRSA-III, ST5-MRSA-II, and ST5-MRSA-IV were responsible for causing hospital-acquired MRSA (HA-MRSA) infections. ST239-MRSA-III, known as the Brazilian clone, was highly transmissible compared to others and distributed in Argentina, Czech Republic, and Portugal.
In the UK, where MRSA is commonly called "Golden Staph", the most common strains of MRSA are EMRSA15 and EMRSA16. EMRSA16 is the best described epidemiologically: it originated in Kettering, England, and the full genomic sequence of this strain has been published. EMRSA16 has been found to be identical to the ST36:USA200 strain, which circulates in the United States, and to carry the SCCmec type II, enterotoxin A and toxic shock syndrome toxin 1 genes. Under the new international typing system, this strain is now called MRSA252. EMRSA 15 is also found to be one of the common MRSA strains in Asia. Other common strains include ST5:USA100 and EMRSA 1. These strains are genetic characteristics of HA-MRSA.
It is not entirely certain why some strains are highly transmissible and persistent in healthcare facilities. One explanation is the characteristic pattern of antibiotic susceptibility. Both the EMRSA15 and EMRSA16 strains are resistant to erythromycin and ciprofloxacin. It is known that Staphylococcus aureus can survive intracellularly, for example in the nasal mucosa  and in the tonsil tissue ,. Erythromycin and Ciprofloxacin are precisely the antibiotics that best penetrate intracellularly; it may be that these strains of S. aureus are therefore able to exploit an intracellular niche.
Community-acquired MRSA (CA-MRSA) strains emerged in late 1990 to 2000, infecting healthy people; who have not been in contact with health care facilities. Researchers suggests that CA-MRSA did not evolved from the HA-MRSA. This is further proven by molecular typing of CA-MRSA strains and genome comparison between CA-MRSA and HA-MRSA, which indicate that novel MRSA strains integrated SCCmec into MSSA separately on its own. By mid 2000, CA-MRSA is introduced into the health care systems and distinguishing between CA-MRSA from HA-MRSA became a difficult process. Community-acquired MRSA (CA-MRSA) is more easily treated and more virulent, than hospital-acquired MRSA (HA-MRSA). The genetic mechanism for the enhanced virulence in CA-MRSA remains as an active area of research. Especially, the Panton-Valentine leukocidin (PVL) genes are of interest because they are a unique feature of CA-MRSA.
In the United States, most cases of CA-MRSA are caused by a CC8 strain designated ST8:USA300, which carries SCCmec type IV, Panton-Valentine leukocidin, PSM-alpha and enterotoxins Q and K, and ST1:USA400. ST8:USA300 strain results in skin infections, necrotizing fasciitis, toxic shock syndrome. Whereas, ST1:USA400 strain results in necrotizing pneumonia and pulmonary sepsis. Other community-acquired strains of MRSA are ST8:USA500 and ST59:USA1000. In many nations of the world, MRSA strains with different predominant genetic background types have come to predominate among CA-MRSA strains; USA300 easily tops the list in the U. S. and is becoming more common in Canada after its first appearance there in 2004. For example, in Australia ST93 strains are common, while in continental Europe ST80 strains predominate (Tristan et al., Emerging Infectious Diseases, 2006), which carries SCCmec type IV. In Taiwan, ST59 strains, some of which are resistant to many non-beta-lactam antibiotics, have arisen as common causes of skin and soft tissue infections in the community. In a remote region of Alaska, unlike most of the continental U. S., USA300 was found rarely in a study of MRSA strains from outbreaks in 1996 and 2000 as well as in surveillance from 2004–06 (David et al., Emerg Infect Dis 2008).
In June 2011, the discovery of a new strain of MRSA was announced by two separate teams of researchers in the UK. Its genetic make-up was reportedly more similar to strains found in animals, and testing kits designed to detect MRSA were unable to identify it. This MRSA strain, Clonal Complex 398 (CC398), is responsible for Livestock-associated MRSA (LA-MRSA) infections. Although it is known to be more persistent in colonizing pigs and calves, there has been cases of LA-MRSA carriers with pneumonia, endocarditis, and necrotising fasciitis.
Prevention in Healthcare Settings
Patient screening upon hospital admission, with nasal cultures, prevents the cohabitation of MRSA carriers with non-carriers, and exposure to infected surfaces. The test used (whether a rapid molecular method or traditional culture) is not as important as the implementation of active screening. In the United States and Canada, the Centers for Disease Control and Prevention issued guidelines on October 19, 2006, citing the need for additional research, but declined to recommend such screening.
In some UK hospitals screening for MRSA is performed in every patient and all NHS surgical patients, except for minor surgeries, are previously checked for MRSA. There is no community screening in the UK, however screening of individuals is offered by some private companies.
In a US cohort of 1300 healthy children, 2.4% carried MRSA in their nose.
Alcohol has been proven to be an effective surface sanitizer against MRSA. Quaternary ammonium can be used in conjunction with alcohol to extend the longevity of the sanitizing action. The prevention of nosocomial infections involves routine and terminal cleaning. Non-flammable Alcohol Vapor in Carbon Dioxide systems (NAV-CO2) do not corrode metals or plastics used in medical environments and do not contribute to antibacterial resistance.
In healthcare environments, MRSA can survive on surfaces and fabrics, including privacy curtains or garments worn by care providers. Complete surface sanitation is necessary to eliminate MRSA in areas where patients are recovering from invasive procedures. Testing patients for MRSA upon admission, isolating MRSA-positive patients, decolonization of MRSA-positive patients, and terminal cleaning of patients' rooms and all other clinical areas they occupy is the current best practice protocol for nosocomial MRSA.
Studies published from 2004-2007 reported hydrogen peroxide vapor could be used to decontaminate busy hospital rooms, despite taking significantly longer than traditional cleaning. One study noted rapid recontamination by MRSA following the hydrogen peroxide application
Also tested, in 2006, was a new type of surface cleaner, incorporating accelerated hydrogen peroxide, which was pronounced "a potential candidate" for use against the targeted microorganisms.
In September 2004,  after a successful pilot scheme to tackle MRSA, the UK National Health Service announced its Clean Your Hands campaign. Wards were required to ensure that alcohol-based hand rubs are placed near all beds so that staff can hand wash more regularly. It is thought that even if this cuts infection by no more than 1%, the plan will pay for itself many times over.
As with some other bacteria, MRSA is acquiring more resistance to some disinfectants and antiseptics. Although alcohol-based rubs remain somewhat effective, a more effective strategy is to wash hands with running water and an anti-microbial cleanser with persistent killing action, such as Chlorhexidine. In another study chlorohexidine (Hibiclens), p-chloro-m-xylenol (Acute-Kare), hexaclorophene (Phisohex), and povidone-iodine (Betadine) were evaluated for their effectiveness. Of the four most commonly used antiseptics, povidone-iodine, when diluted 1:100, was the most rapidly bactericidal against both MRSA and methicillin-susceptible S. aureus.
A June 2008 report, centered on a survey by the Association for Professionals in Infection Control and Epidemiology, concluded that poor hygiene habits remain the principal barrier to significant reductions in the spread of MRSA.
Use of surgical respirator
The U.S. Food and Drug Administration (FDA) announced on 8 April 2011 that it had cleared a novel type of N95 Surgical Respirator, the SpectraShield 9500, that kills methicillin-resistant Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae. This mask is manufactured by Nexera Medical Ltd. of Richmond, British Columbia The mask blocks at least 95% of small particles in a standardized test. The FDA clearance also included evaluation by the National Institute of Occupational Safety and Health.
Proper disposal of hospital gowns
Current US guidance does not require workers in the general workplace (excluding medical facilities) with MRSA infections to be routinely excluded from going to work. Therefore, unless directed by a health care provider, exclusion from work should be reserved for those with wound drainage that cannot be covered and contained with a clean, dry bandage and for those who cannot maintain good hygiene practices. Workers with active infections should be excluded from activities where skin-to-skin contact is likely to occur until their infections are healed. Health care workers should follow the Centers for Disease Control and Prevention's Guidelines for Infection Control in Health Care Personnel.
To prevent the spread of staph or MRSA in the workplace, employers should ensure the availability of adequate facilities and supplies that encourage workers to practice good hygiene; that surface sanitizing in the workplace is followed; and that contaminated equipment are sanitized with Environmental Protection Agency (EPA)-registered disinfectants.
Restricting antibiotic use
Glycopeptides, cephalosporins and in particular quinolones are associated with an increased risk of colonisation of MRSA. Reducing use of antibiotic classes that promote MRSA colonisation, especially fluoroquinolones, is recommended in current guidelines.
Public health considerations
Mathematical models describe one way in which a loss of infection control can occur after measures for screening and isolation seem to be effective for years, as happened in the UK. In the "search and destroy" strategy that was employed by all UK hospitals until the mid-1990s, all patients with MRSA were immediately isolated, and all staff were screened for MRSA and were prevented from working until they had completed a course of eradication therapy that was proven to work. Loss of control occurs because colonised patients are discharged back into the community and then readmitted; when the number of colonised patients in the community reaches a certain threshold, the "search and destroy" strategy is overwhelmed. One of the few countries not to have been overwhelmed by MRSA is the Netherlands: An important part of the success of the Dutch strategy may have been to attempt eradication of carriage upon discharge from hospital.
The Centers for Disease Control and Prevention (CDC) estimated that about 1.7 million nosocomial infections occurred in the United States in 2002, with 99,000 associated deaths. The estimated incidence is 4.5 nosocomial infections per 100 admissions, with direct costs (at 2004 prices) ranging from $10,500 (£5300, €8000 at 2006 rates) per case (for bloodstream, urinary tract, or respiratory infections in immunocompetent patients) to $111,000 (£57,000, €85,000) per case for antibiotic-resistant infections in the bloodstream in patients with transplants. With these numbers, conservative estimates of the total direct costs of nosocomial infections are above $17 billion. The reduction of such infections forms an important component of efforts to improve healthcare safety. (BMJ 2007) MRSA alone was associated with 8% of nosocomial infections reported to the CDC National Healthcare Safety Network from January 2006 to October 2007.
This problem is not unique to one country; the British National Audit Office estimated that the incidence of nosocomial infections in Europe ranges from 4% to 10% of all hospital admissions. As of early 2005, the number of deaths in the United Kingdom attributed to MRSA has been estimated by various sources to lie in the area of 3,000 per year. Staphylococcus bacteria account for almost half of all UK hospital infections. The issue of MRSA infections in hospitals has recently been a major political issue in the UK, playing a significant role in the debates over health policy in the United Kingdom general election held in 2005.
On January 6, 2008, half of 64 non-Chinese cases of MRSA infections in Hong Kong in 2007 were Filipino domestic helpers. Ho Pak-leung, professor of microbiology at the University of Hong Kong, traced the cause to high use of antibiotics. In 2007, there were 166 community cases in Hong Kong compared with 8,000 hospital-acquired MRSA case (155 recorded cases—91 involved Chinese locals, 33 Filipinos, 5 each for Americans and Indians, and 2 each from Nepal, Australia, Denmark and England).
Worldwide, an estimated 2 billion people carry some form of S. aureus; of these, up to 53 million (2.7% of carriers) are thought to carry MRSA. In the United States, 95 million carry S. aureus in their noses; of these, 2.5 million (2.6% of carriers) carry MRSA. A population review conducted in three U.S. communities showed the annual incidence of CA-MRSA during 2001–2002 to be 18–25.7/100,000; most CA-MRSA isolates were associated with clinically relevant infections, and 23% of patients required hospitalization.
One possible contribution to the increased spread of MRSA infections comes from the use of antibiotics in intensive pig farming. A 2008 study in Canada found MRSA in 10% of tested pork chops and ground pork; a U.S. study in the same year found MRSA in the noses of 70% of the tested farm pigs and in 45% of the tested pig farm workers. There have also been anecdotal reports of increased MRSA infection rates in rural communities with pig farms.
Healthcare facilities with high bed occupancy rates, high levels of temporary nursing staff, or low cleanliness scores no longer have significantly higher MRSA rates. Simple tabular evidence helps provide a clear picture of these changes, showing, for instance, that hospitals with occupancy over 90% had, in 2006–2007, MRSA rates little above those in hospitals with occupancy below 85%, in contrast to the period 2001–2004. In one sense, the disappearance of these relationships is puzzling. Reporters now blame IV cannula and catheters for spreading MRSA in hospitals. (Hospital organisation and speciality mix, 2008)
Care should be taken when trying to drain boils, as disruption of surrounding tissue can lead to larger infections, or even infection of the blood stream (often with fatal consequences). Any drainage should be disposed of very carefully. After the drainage of boils or other treatment for MRSA, patients can shower at home using chlorhexidine (Hibiclens) or hexachlorophene (Phisohex) antiseptic soap (available over-the-counter at many pharmacies) from head to toe. Alternatively, a dilute bleach bath can be taken at a concentration of 1/2 cup bleach per 1/4-full bathtub of water. Care should be taken to use a clean towel, and to ensure that nasal discharge (i.e. snot) doesn't infect the towel (see below).
All infectious lesions should be kept covered with a dressing (band-aids etc.). Mupirocin (Bactroban) 2% ointment can be effective at reducing the size of lesions. A secondary covering of clothing is preferred. As shown in an animal study with diabetic mice, the topical application of a mixture of sugar (70%) and 3% povidone-iodine paste is an effective agent for the treatment of diabetic ulcers with MRSA infection.
The nose is a common refuge for MRSA, and a test swab can be taken of the nose to indicate whether MRSA is present. Mupirocin (Bactroban) If MRSA is detected via nasal culture, 2% ointment can be applied inside each nostril twice daily for 7 days, using a cotton-tipped swab. However, care should be taken so that the swab doesn't penetrate into the sinus. Household members are recommended to follow the same decolonization protocol. After treatment, the nose should be swabbed again to ensure that the treatment was effective. If not, the process should be repeated.
Toilet seats are a common vector for infection, and wiping seats clean before and/or after use can help to prevent the spread of MRSA. Door handles, faucets, light switches (with care!), etc. can be disinfected regularly with disinfectant wipes. Spray disinfectants can be used on upholstery. Carpets can be washed with disinfectant, and hardwood floors can be scrubbed with diluted tea tree oil (e.g. Melaleuca). Laundry soap containing tea tree oil may be effective at decontaminating clothing and bedding, especially if hot water and heavy soil cycles are used, however tea tree oil may cause a rash which MRSA can re-colonize. Alcohol-based sanitizers can be placed near bedsides, near sitting areas, in vehicles etc. to encourage their use.
Prevention in Community Settings
The CDC offers suggestions for preventing the contraction and spread MRSA infection which are applicable to those in community settings, including incarcerated populations, childcare center employees, and athletes. To prevent MRSA infection, individuals should regularly wash hands using soap and water or an alcohol-based sanitizer, keep wounds clean and covered, avoid contact with other people's wounds, avoid sharing personal items such as razors or towels, shower after exercising at athletic facilities (including gyms, weight rooms, and school facilities), shower before using swimming pools or whirlpools, and maintain a clean environment.
Both CA-MRSA and HA-MRSA are resistant to traditional anti-staphylococcal beta-lactam antibiotics, such as cephalexin. CA-MRSA has a greater spectrum of antimicrobial susceptibility, including to sulfa drugs (like co-trimoxazole/trimethoprim-sulfamethoxazole), tetracyclines (like doxycycline and minocycline) and clindamycin, but the drug of choice for treating CA-MRSA is now believed to be vancomycin, according to a Henry Ford Hospital Study. Linezolid is now felt to be the best drug for treating patients with MRSA pneumonia. HA-MRSA is resistant even to these antibiotics and often is susceptible only to vancomycin. Newer drugs, such as linezolid (belonging to the newer oxazolidinones class) and daptomycin, are effective against both CA-MRSA and HA-MRSA. Ceftaroline and ceftabiparole, a new fifth generation cephalosporins, are the first beta-lactam antibiotics approved in the US to treat MRSA infections (skin and soft tissue only).
Vancomycin and teicoplanin are glycopeptide antibiotics used to treat MRSA infections. Teicoplanin is a structural congener of vancomycin that has a similar activity spectrum but a longer half-life. Because the oral absorption of vancomycin and teicoplanin is very low, these agents must be administered intravenously to control systemic infections. Drugs are administered via a peripherally inserted central catheter, or a Picc Line, which is inserted by radiologists, doctors, physician assistants (in the U.S.), radiologist assistants (in the U.S.), or specially trained certified registered nurses. Treatment of MRSA infection with vancomycin can be complicated, due to its inconvenient route of administration. Moreover, many clinicians believe that the efficacy of vancomycin against MRSA is inferior to that of anti-staphylococcal beta-lactam antibiotics against methicillin-susceptible Staphylococcus aureus (MSSA).
Several newly discovered strains of MRSA show antibiotic resistance even to vancomycin and teicoplanin. These new evolutions of the MRSA bacterium have been dubbed Vancomycin intermediate-resistant Staphylococcus aureus (VISA).  Linezolid, quinupristin/dalfopristin(synercid), daptomycin, and tigecycline are used to treat more severe infections that do not respond to glycopeptides such as vancomycin.
Initial studies at the University of East London have demonstrated that allicin (a compound found in garlic) exhibits a strong antimicrobial response to the bacteria, indicating that it may one day lead to more effective treatments.
A report released in 2010 details the efficacy of the active ingredients of a new composite dressing (hydrogen peroxide, tobramycin, chlorhexidine digluconate, chlorhexidine gluconate, levofloxacin, and silver) against MRSA.
A 1990 study tested MRSA isolates obtained from veterans and found they could be killed by several substances, including bacitracin, nitrofurantoin, hydrogen peroxide, novobiocin, netilmicin and vancomycin. The study went on to conclude that netilmicin might be useful as an alternative to intravenous vancomycin, and suggested that topical applications of hydrogen peroxide may be useful to reduce MRSA on skin and some mucous membranes.
|The examples and perspective in this article may not represent a worldwide view of the subject. Please improve this article and discuss the issue on the talk page. (December 2010)|
US and UK
In 1959 methicillin was licensed in England to treat penicillin-resistant S. aureus infections. Just as bacterial evolution had allowed microbes to develop resistance to penicillin, strains of S. aureus evolved to become resistant to methicillin. In 1961 the first MRSA isolates were reported in a British study, and between 1961-1967 there were infrequent hospital outbreaks in Western Europe and Australia. The first United States hospital outbreak of MRSA occurred at the Boston City Hospital in 1968. Between 1968-mid 1990s the percent of S. aureus infections that were caused by MRSA increased steadily, and MRSA became recognized as an endemic pathogen. In 1974 2% of hospital-acquired S. aureus infections could be attributed to MRSA. The rate had increased to 22% by 1995, and by 1997 the percent of hospital S. aureus infections attributable to MRSA had reached 50%.
The first report of CA-MRSA occurred in 1981, and in 1982 there was a large outbreak of CA-MRSA among intravenous drug users in Detroit, Michigan. Additional outbreaks of CA-MRSA were reported through the 1980s and 1990s, including outbreaks among Australian Aboriginal populations that had never been exposed to hospitals. In the mid 1990s there were scattered reports of CA-MRSA outbreaks among US children. While HA-MRSA rates stabilized between 1998-2008, CA-MRSA rates continued to rise. A report released by The University of Chicago Children's Hospital comparing two time periods (1993-1995 and 1995-1997) found a 25-fold increase in the rate of hospitalizations due to MRSA among children in the United States. In 1999 The University of Chicago reported the first deaths from invasive MRSA among otherwise healthy children in the United States. By 2004 MRSA accounted for 64% of hospital-acquired S. aureus infections in the United States.
The Office for National Statistics reported 1,629 MRSA-related deaths in England and Wales during 2005, indicating a MRSA-related mortality rate half the rate of that in the United States for 2005, even though the figures from the British source were explained to be high because of "improved levels of reporting, possibly brought about by the continued high public profile of the disease" during the time of the 2005 United Kingdom General Election. MRSA is thought to have caused 1,652 deaths in 2006 in UK up from 51 in 1993.
It has been argued that the observed increased mortality among MRSA-infected patients may be the result of the increased underlying morbidity of these patients. Several studies, however, including one by Blot and colleagues, that have adjusted for underlying disease still found MRSA bacteremia to have a higher attributable mortality than methicillin-susceptible S. aureus (MSSA) bacteremia.
A population-based study of the incidence of MRSA infections in San Francisco during 2004–05 demonstrated that nearly 1 in 300 residents suffered from such an infection in the course of a year and that greater than 85% of these infections occurred outside of the healthcare setting. A 2004 study showed that patients in the United States with S. aureus infection had, on average, three times the length of hospital stay (14.3 vs. 4.5 days), incurred three times the total cost ($48,824 vs $14,141), and experienced five times the risk of in-hospital death (11.2% vs 2.3%) than patients without this infection. In a meta-analysis of 31 studies, Cosgrove et al., concluded that MRSA bacteremia is associated with increased mortality as compared with MSSA bacteremia (odds ratio = 1.93; 95% CI = 1.93±0.39). In addition, Wyllie et al. report a death rate of 34% within 30 days among patients infected with MRSA, a rate similar to the death rate of 27% seen among MSSA-infected patients.
According to the CDC, the most recent estimates of the incidence of healthcare-associated infections that are attributable to MRSA in the United States indicate a decline in such infection rates. Incidence of MRSA central line-associated blood stream infections as reported by hundreds of intensive care units decreased 50-70% from 2001-2007. A separate system tracking all hospital MRSA bloodstream infections found an overall 34% decrease between 2005-2008.
MRSA is sometimes sub-categorised as community-acquired MRSA (CA-MRSA) or healthcare-associated MRSA (HA-MRSA), although the distinction is complex. Some researchers have defined CA-MRSA by the characteristics of patients whom it infects, while others define it by the genetic characteristics of the bacteria themselves. By 2005, identified CA-MRSA risk factors included athletes, military recruits, incarcerated people, emergency room patients, urban children, HIV-positive individuals, men who have sex with men, and indigenous populations.
The first reported cases of CA-MRSA began to appear in the mid-1990s in Australia, New Zealand, the United States, the United Kingdom, France, Finland, Canada and Samoa, and were notable because they involved people who had not been exposed to a healthcare setting.
Because measurement and reporting varies, it is difficult to compare rates of MRSA in different countries. An international comparison of 2004 MRSA-attributable S. arueus rates in middle and high income countries released by the Center For Disease Dynamics, Economics, and Policy in showed that Iceland had the lowest rate of infection, and Romania had the highest at over 70%.
It has been reported that maggot therapy to clean out necrotic tissue of MRSA infection has been successful. Studies in diabetic patients reported significantly shorter treatment times than those achieved with standard treatments.
Many antibiotics against MRSA are in phase II and phase III clinical trials. e.g.:
- Phase III : ceftobiprole, Ceftaroline, Dalbavancin, Telavancin, Aurograb, torezolid, iclaprim...
- Phase II : nemonoxacin.
An entirely different and promising approach is phage therapy (e.g., at the Eliava Institute in Georgia), which in mice had a reported efficacy against up to 95% of tested Staphylococcus isolates.
A 2010 study noted significant antimicrobial action of Ulmo 90 and manuka UMF 25+ honey against several microorganisms, including MRSA. The investigators noted the superior antimicrobial action of Ulmo 90 honey, and suggested it be investigated further. A separate 2010 study examined the use of medical-grade honey against several antibiotic-resistant strains of bacteria, including MRSA. The study concluded that the antimicrobial action of the honey studied was due to the activity of hydrogen peroxide, methylglyoxal, and a novel compound named bee defensin-1.
Ocean-dwelling living sponges produce compounds that may make MRSA more susceptible to antibiotics.
Some semi-toxic fungi/mushrooms excrete broad spectrum antibiotics, not all of which have been fully identified.
Cannabinoids (components of Cannabis sativa), including cannabidiol (CBD), cannabinol (CBN), cannabichromene (CBC), Δ9-tetrahydrocannabinol (THC) and cannabigerol (CBG), show activity against a variety of MRSA strains.
- Study at the Veterans Affairs hospital in Pittsburgh: "Science Daily". http://www.sciencedaily.com/upi/index.php?feed=Science&article=UPI-1-20070727-15235200-bc-us-infections.xml. [dead link]
- McCaughey B. "Unnecessary Deaths: The Human and Financial Costs of Hospital Infections" (PDF). Archived from the original on July 11, 2007. http://web.archive.org/web/20070711030535/http://www.tufts.edu/med/apua/Patients/ridbooklet.pdf. Retrieved 2007-08-05.
- "Symptoms". Mayo Clinic. http://www.mayoclinic.com/health/mrsa/DS00735/DSECTION=symptoms.
- "MRSA Toxin Acquitted: Study Clears Suspected Key to Severe Bacterial Illness". NIH news release. National Institute of Health. 2006-11-06. http://www3.niaid.nih.gov/news/newsreleases/2006/staphtoxin.htm.
- Raygada JL and Levine DP (March 30, 2009). "Managing CA-MRSA Infections: Current and Emerging Options". Infections in Medicine 26 (2). http://www.consultantlive.com/infection/article/1145625/1393856.
- Lipsky et al (2010). "Skin and soft tissue infections in hospitalised patients with diabetes: culture isolates and risk factors associated with mortality, length of stay and cost". Diabetologia. http://www.springerlink.com/content/508667p3k4625375/fulltext.pdf.
- "MRSA Infections: People at Risk of Acquiring MRSA Infections". Centers for Disease Control and Prevention. 9 August 2010. http://www.cdc.gov/mrsa/riskfactors/index.html. Retrieved 13 May 2012.
- Tacconelli, E.; De Angelis, G.; Cataldo, MA.; Pozzi, E.; Cauda, R. (Jan 2008). "Does antibiotic exposure increase the risk of methicillin-resistant Staphylococcus aureus (MRSA) isolation? A systematic review and meta-analysis.". J Antimicrob Chemother 61 (1): 26–38. doi:10.1093/jac/dkm416. PMID 17986491. http://jac.oxfordjournals.org/cgi/content/full/61/1/26.
- Reuters (2009-02-16). "Study: Beachgoers More Likely to Catch MRSA". FoxNews.com. http://www.foxnews.com/story/0,2933,493604,00.html.
- Marilynn Marchione (2009-09-12). "Dangerous staph germs found at West Coast beaches". AP. http://www.foxnews.com/story/0,2933,549601,00.html.
- Zinderman, C.; Conner, B.; Malakooti, M.; LaMar, J.; Armstrong, A.; Bohnker, A. (May 2004). "Community-Acquired Methicillin-Resistant Staphylococcus aureus Among Military Recruits". Emerging Infectious Diseases. http://www.medscape.com/viewarticle/474843.
- David, Micheal Z. and Daum, Robert S. (2010). Community-Associated Methicillin-Resistant Staphylococcus aureus: Epidemiology and Clinical Consequences of an Emerging Epidemic. 23. American Society for Microbiology. pp. 616-687. http://cmr.asm.org/content/23/3/616.full.pdf+html.
- Muto, CA.; Jernigan, JA.; Ostrowsky, BE.; Richet, HM.; Jarvis, WR.; Boyce, JM.; Farr, BM. (May 2003). "SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus". Infect Control Hosp Epidemiol 24 (5): 362–86. doi:10.1086/502213. PMID 12785411.
- Staph (MRSA) Infection Eradicated For 14 Months
- "Joint scientific report of ECDC, EFSA and EMEA on meticillin resistant Staphylococcus aureus (MRSA) in livestock, companion animals and food". 2009-06-16. http://www.efsa.europa.eu/EFSA/Report/biohaz_report_301_joint_mrsa_en,0.pdf. Retrieved 2009-09-19.
- US meat and poultry is widely contaminated with drug-resistant Staph bacteria, study finds
- Ogata, K; Narimatsu, H, Suzuki, M, Higuchi, W, Yamamoto, T, Taniguchi, H (2012 Feb 3). "Commercially distributed meat as a potential vehicle for community-acquired methicillin-resistant Staphylococcus aureus.". Applied and environmental microbiology 78 (8): 2797–802. doi:10.1128/AEM.07470-11. PMID 22307310.
- Kazakova, SV; Hageman, JC, Matava, M, Srinivasan, A, Phelan, L, Garfinkel, B, Boo, T, McAllister, S, Anderson, J, Jensen, B, Dodson, D, Lonsway, D, McDougal, LK, Arduino, M, Fraser, VJ, Killgore, G, Tenover, FC, Cody, S, Jernigan, DB (2005 Feb 3). "A clone of methicillin-resistant Staphylococcus aureus among professional football players.". The New England Journal of Medicine 352 (5): 468–75. doi:10.1056/NEJMoa042859. PMID 15689585. http://www.nejm.org/doi/full/10.1056/NEJMoa042859.
- Epstein, Victor (21 December 2007). "Texas Football Succumbs to Virulent Staph Infection From Turf". Bloomberg. http://www.bloomberg.com/apps/news?pid=newsarchive&sid=alxhrJDn.cdc. Retrieved 10 June 2010.
- Gray JW (April 2004). "MRSA: the problem reaches paediatrics". Arch. Dis. Child. 89 (4): 297–8. doi:10.1136/adc.2003.045534. PMC 1719885. PMID 15033832. http://adc.bmjjournals.com/cgi/content/full/89/4/297.
- Bratu S, Eramo A, Kopec R, et al. (June 2005). "Community-associated methicillin-resistant Staphylococcus aureus in hospital nursery and maternity units". Emerging Infect. Dis. 11 (6): 808–13. PMID 15963273. http://www.cdc.gov/ncidod/EID/vol11no06/04-0885.htm.
- Association for Professionals in Infection Control & Epidemiology (June 25, 2007). "National Prevalence Study of Methicillin-Resistant Staphylococcus aureus (MRSA) in U.S. Healthcare Facilities". Archived from the original on September 7, 2007. http://web.archive.org/web/20070907201425/http://www.apic.org/Content/NavigationMenu/ResearchFoundation/NationalMRSAPrevalenceStudy/MRSA_Study_Results.htm. Retrieved 2007-07-14.
- Francois P and Schrenzel J (2008). "Rapid Diagnosis and Typing of Staphylococcus aureus". Staphylococcus: Molecular Genetics. Caister Academic Press. ISBN 978-1-904455-29-5. http://www.horizonpress.com/staph.
- Mackay I M (editor). (2007). Real-Time PCR in Microbiology: From Diagnosis to Characterization. Caister Academic Press. ISBN 978-1-904455-18-9. http://www.horizonpress.com/rtmic.
- Seiken, Denka. "MRSA latex test for PBP2". http://www.hardydiagnostics.com/catalog2/hugo/MRSALatexTest.htm.
- Jensen, S. O., Lyon, B. R. (2009). "Genetics of antimicrobial resistance in "Staphylococcus aureus"". Future Microbiology 4: 565–582.
- Lowy, F. D. (2003). "Antimicrobial resistance: the example of Staphylococcus aureus". The Journal of Clinical Investigation 111: 1265–1273.
- Monaco, M., Pantosti, A., Sanchini, A. (2007). "Mechanisms of antibiotic resistance in Staphylococcus aureus". Future Microbiology 2: 323–334.
- Kaito, Chikara; Saito, Yuki, Nagano, Gentaro, Ikuo, Mariko, Omae, Yosuke, Hanada, Yuichi, Han, Xiao, Kuwahara-Arai, Kyoko, Hishinuma, Tomomi, Baba, Tadashi, Ito, Teruyo, Hiramatsu, Keiichi, Sekimizu, Kazuhisa, Cheung, Ambrose (Feb 2011). "Transcription and Translation Products of the Cytolysin Gene psm-mec on the Mobile Genetic Element SCCmec Regulate Staphylococcus aureus Virulence". PLoS Pathogens 7 (2): e1001267. doi:10.1371/journal.ppat.1001267.
- Jensen, S. O., Lyon, B. R. (2009). "Genetics of antimicrobial resistance in Staphylococcus aureus". Future Microbiology 4: 565–582.
- Kuo, S., Chiang, M., Lee, W., Chen, L., Wu, H., Yu, K., Fung, C., Wang, F. (2012). "Comparison of microbiological and clinical characteristics based in SCCmec typing in patients with community-onset meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia". International Journal of Antimicrobial Agents 39: 22–26.
- Berger-Bächi, B. (1999). "Genetic basis of methicillin resistance in Staphylococcus aureus". Cellular and Molecular Life Sciences 56: 764–770.
- Gordon, Rachel J.; Lowy, Franklin D. (2008). "Pathogenesis of Methicillin‐ResistantStaphylococcus aureusInfection". Clinical Infectious Diseases 46 (S5): S350–S359. doi:10.1086/533591. ISSN 1058-4838.
- Johnson AP, Aucken HM, Cavendish S, et al. (2001). "Dominance of EMRSA-15 and -16 among MRSA causing nosocomial bacteraemia in the UK: analysis of isolates from the European Antimicrobial Resistance Surveillance System (EARSS)". J Antimicrob Chemother 48 (1): 143–4. doi:10.1093/jac/48.1.143. PMID 11418528. http://jac.oxfordjournals.org/cgi/content/full/48/1/143.
- Holden MTG, Feil EJ, Lindsay JA, et al. (2004). "Complete genomes of two clinical Staphylococcus aureus strains: Evidence for the rapid evolution of virulence and drug resistance". Proc Natl Acad Sci USA 101 (26): 9786–91. doi:10.1073/pnas.0402521101. PMC 470752. PMID 15213324. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=470752.
- Diep B, Carleton H, Chang R, Sensabaugh G, Perdreau-Remington F (2006). "Roles of 34 virulence genes in the evolution of hospital- and community-associated strains of methicillin-resistant Staphylococcus aureus". J Infect Dis 193 (11): 1495–503. doi:10.1086/503777. PMID 16652276.
- Stefani, Stefania; Chung, Doo Ryeon; Lindsay, Jodi A.; Friedrich, Alex W.; Kearns, Angela M.; Westh, Henrik; MacKenzie, Fiona M. (2012). "Meticillin-resistant Staphylococcus aureus (MRSA): global epidemiology and harmonisation of typing methods". International Journal of Antimicrobial Agents. doi:10.1016/j.ijantimicag.2011.09.030. ISSN 09248579.
- Calfee, David P. (2011). "The Epidemiology, Treatment, and Prevention of Transmission of Methicillin-Resistant Staphylococcus aureus". Journal of Infusion Nursing 34 (6): 359–364. doi:10.1097/NAN.0b013e31823061d6. ISSN 1533-1458.
- von Eiff C, Becker K, Metze D, et al. (2001). "Intracellular persistence of Staphylococcus aureus small-colony variants within keratinocytes: a cause for antibiotic treatment failure in a patient with Darier's disease". Clin Infect Dis 32 (11): 1643–7. doi:10.1086/320519. PMID 11340539.
- Clement S, Vaudaux P, François P, et al. (2005). "Evidence of an intracellular reservoir in the nasal mucosa of patients with recurrent Staphylococcus aureus rhinosinusitis". J Infect Dis 192 (6): 1023–8. doi:10.1086/432735. PMID 16107955.
- Zautner AE, Krause M, Stropahl G, et al. (2010). Bereswill, Stefan. ed. "Intracellular persisting Staphylococcus aureus is the major pathogen in recurrent tonsillitis". PloS One 5 (3): e9452. doi:10.1371/journal.pone.0009452. PMC 2830486. PMID 20209109. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2830486.
- Daum, Robert S. (2007). "Skin and Soft-Tissue Infections Caused by Methicillin-ResistantStaphylococcus aureus". New England Journal of Medicine 357 (4): 380–390. doi:10.1056/NEJMcp070747. ISSN 0028-4793. PMID 17652653.
- Wang R, Braughton KR, Kretschmer D, et al. (December 2007). "Identification of novel cytolytic peptides as key virulence determinants for community-associated MRSA". Nat. Med. 13 (12): 1510–4. doi:10.1038/nm1656. PMID 17994102.
- Gould, Ian M.; David, Michael Z.; Esposito, Silvano; Garau, Javier; Lina, Gerard; Mazzei, Teresita; Peters, Georg (2012). "New insights into meticillin-resistant Staphylococcus aureus (MRSA) pathogenesis, treatment and resistance". International Journal of Antimicrobial Agents 39 (2): 96–104. doi:10.1016/j.ijantimicag.2011.09.028. ISSN 09248579.
- Ahlstrom, Dick (2011-06-03). "New strain of MRSA superbug discovered in Dublin hospitals". The Irish Times. http://www.irishtimes.com/newspaper/frontpage/2011/0603/1224298323851.html.
- Graveland, Haitske; Duim, Birgitta; van Duijkeren, Engeline; Heederik, Dick; Wagenaar, Jaap A. (2011). "Livestock-associated methicillin-resistant Staphylococcus aureus in animals and humans". International Journal of Medical Microbiology 301 (8): 630–634. doi:10.1016/j.ijmm.2011.09.004. ISSN 14384221.
- Tacconelli E, De Angelis G, de Waure C, et al. (2009). "Rapid screening tests for meticillin-resistant Staphylococcus aureus at hospital admission: systematic review and meta-analysis". Lancet Infect Dis 9 (9): 546–554. doi:10.1016/S1473-3099(09)70150-1.
- "To Catch a Deadly Germ," New York Times opinion
- CDC Guideline "Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006"
- "MRSA test for surgical patients". BBC News. 2009-03-31. http://news.bbc.co.uk/1/hi/health/7974964.stm. Retrieved 2010-04-05.
- Home Mrsa Test - Home
- Fritz SA, Garbutt J, Elward A, et al. (2008). "Prevalence of and risk factors for community-acquired methicillin-resistant and methicillin-sensitive Staphylococcus aureus colonization in children seen in a practice-based research network". Pediatrics 121 (6): 1090–8. doi:10.1542/peds.2007-2104. PMID 18519477.
- Otter JA, Puchowicz M, Ryan D, et al. (June 2009). "Feasibility of routinely using hydrogen peroxide vapor to decontaminate rooms in a busy United States hospital". Infect Control Hosp Epidemiol 30 (6): 574–7. doi:10.1086/597544. PMID 19415969. http://www.journals.uchicago.edu/doi/abs/10.1086/597544?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
- Bartels MD, Kristoffersen K, Slotsbjerg T, Rohde SM, Lundgren B, Westh H (September 2008). "Environmental meticillin-resistant Staphylococcus aureus (MRSA) disinfection using dry-mist-generated hydrogen peroxide". J. Hosp. Infect. 70 (1): 35–41. doi:10.1016/j.jhin.2008.05.018. PMID 18621434. http://linkinghub.elsevier.com/retrieve/pii/S0195-6701(08)00216-8.
- French GL, Otter JA, Shannon KP, Adams NM, Watling D, Parks MJ (May 2004). "Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination". J. Hosp. Infect. 57 (1): 31–7. doi:10.1016/j.jhin.2004.03.006. PMID 15142713. http://linkinghub.elsevier.com/retrieve/pii/S019567010400101X.
- Otter JA, Cummins M, Ahmad F, van Tonder C, Drabu YJ (October 2007). "Assessing the biological efficacy and rate of recontamination following hydrogen peroxide vapour decontamination". J. Hosp. Infect. 67 (2): 182–8. doi:10.1016/j.jhin.2007.07.019. PMID 17884250. http://linkinghub.elsevier.com/retrieve/pii/S0195-6701(07)00255-1.
- Hardy KJ, Gossain S, Henderson N, et al. (August 2007). "Rapid recontamination with MRSA of the environment of an intensive care unit after decontamination with hydrogen peroxide vapour". J. Hosp. Infect. 66 (4): 360–8. doi:10.1016/j.jhin.2007.05.009. PMID 17655975. http://linkinghub.elsevier.com/retrieve/pii/S0195-6701(07)00173-9.
- Omidbakhsh N, Sattar SA (June 2006). "Broad-spectrum microbicidal activity, toxicologic assessment, and materials compatibility of a new generation of accelerated hydrogen peroxide-based environmental surface disinfectant". Am J Infect Control 34 (5): 251–7. doi:10.1016/j.ajic.2005.06.002. PMID 16765201. http://linkinghub.elsevier.com/retrieve/pii/S0196-6553(05)00575-4.
- "NPSA - About us". http://www.npsa.nhs.uk/cleanyourhands/about-us/.
- Demarco, E.; Cushing, A.; Frempong-Manso, E.; Seo, M.; Jaravaza, A.; Kaatz, W. (Sep 2007). "Efflux-Related Resistance to Norfloxacin, Dyes, and Biocides in Bloodstream Isolates of Staphylococcus aureus" (Free full text). Antimicrobial Agents and Chemotherapy 51 (9): 3235–3239. doi:10.1128/AAC.00430-07. ISSN 0066-4804. PMC 2043220. PMID 17576828. http://aac.asm.org/cgi/pmidlookup?view=long&pmid=17576828.
- Haley C.E., Marling-Cason M., Smith J.W., Luby J.P., Mackowiak P.A. (1985). "Bactericidal Activity of Antiseptics Against Methicillin-Resistant Staphylococcus aures". Journal of Clinical Microbiology 21: 991–992.
- Gever J.Senior Editor, MedPage Today. Germicidal Surgical Mask Approved Published: April 09, 2011 http://www.medpagetoday.com/HospitalBasedMedicine/InfectionControl/25819
- "Simple techniques slash hospital infections: meeting". Reuters. 2009-03-21. http://www.reuters.com/article/healthNews/idUSTRE52K1O920090321.
- "NIOSH MRSA and the Workplace". United States National Institute for Occupational Safety and Health. http://www.cdc.gov/niosh/topics/mrsa/. Retrieved 2007-10-29.
- CDC (1998). "Guidelines for Infection Control in Health Care Personnel, 1998". Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/dhqp/gl_hcpersonnel.html. Retrieved December 18, 2007.
- Cooper BS, Medley GF, Stone SP, et al. (2004). "Methicillin-resistant Staphylococcus aureus in hospitals and the community: stealth dynamics and control catastrophes". Proceedings of the National Academy of Sciences 101 (27): 10223–8. doi:10.1073/pnas.0401324101. PMC 454191. PMID 15220470. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=454191.
- Bootsma MC, Diekmann O, Bonten MJ (2006). "Controlling methicillin-resistant Staphylococcus aureus: quantifying the effects of interventions and rapid diagnostic testing". Proc Natl Acad Sci USA 103 (14): 5620–5. doi:10.1073/pnas.0510077103. PMC 1459403. PMID 16565219. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1459403.
- Klevens RM, Edwards JR, Richards CL, et al. (2007). "Estimating health care-associated infections and deaths in U.S. hospitals, 2002". Public Health Rep 122 (2): 160–6. PMC 1820440. PMID 17357358. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1820440.
- Hidron AI, Edwards JR, Patel J, et al. (November 2008). "NHSN annual update: antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006-2007". Infect Control Hosp Epidemiol 29 (11): 996–1011. doi:10.1086/591861. PMID 18947320.
- Johnson AP, Pearson A, Duckworth G (2005). "Surveillance and epidemiology of MRSA bacteraemia in the UK". J Antimicrob Chemother 56 (3): 455–62. doi:10.1093/jac/dki266. PMID 16046464.
- Inquirer.net, Cases of RP maids with 'superbug' infection growing in HK
- "MRSA Infections". Keep Kids Healthy. http://www.keepkidshealthy.com/welcome/infectionsguide/mrsa.html.
- Graham P, Lin S, Larson E (2006). "A U.S. population-based survey of Staphylococcus aureus colonization". Ann Intern Med 144 (5): 318–25. PMID 16520472.
- Jernigan JA, Arnold K, Heilpern K, Kainer M, Woods C, Hughes JM (2006-05-12). "Methicillin-resistant Staphylococcus aureus as community pathogen". Symposium on Community-Associated Methicillin-resistant Staphylococcus aureus (Atlanta, Georgia, U.S.). Cited in Emerg Infect Dis. Centers for Disease Control and Prevention. http://www.cdc.gov/ncidod/EID/vol12no11/06-0911.htm. Retrieved 2007-01-27.
- First study finds MRSA in U.S. pigs and farmers, seattlepi.com, 4 June 2008
- Our Pigs, Our Food, Our Health, The New York Times, 12 March 2009
- "PubMed Health". US National Institutes of Health. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004520/. Retrieved 20 November 2011.
- "Optimal Bleach Concentration Required to Kill MRSA in Bath Water". American Academy of Pediatrics.
- "Living With MRSA". Group Health Cooperative/Tacoma-Pierce County Health Dept./Washington State Dept. of Health. http://www.tpchd.org/files/library/2357adf2a147d1aa.pdf. Retrieved 20 November 2011.
- Shi, C., Nakao, H., Yamazaki, M., Tsuboi, R., Ogawa, H. (2007), Arch Dermatol Res, 299: 499-456
- "THE NOSE – "GROUND ZERO" FOR MRSA COLONIZATION". Ondine Biomedical Inc. http://mrsatopic.com/2011/01/the-nose-ground-zero-for-mrsa-colonization/. Retrieved 20 November 2011.
- "Personal Prevention of MRSA Skin Infections". CDC. 9 August 2010. http://www.cdc.gov/mrsa/prevent/personal.html.
- Wunderink RG, Rello J, Cammarata SK, Croos-Dabrera RV, Kollef MH., Linezolid vs vancomycin: analysis of two double-blind studies of patients with methicillin-resistant Staphylococcus aureus nosocomial pneumonia. Chest 2003 Nov;124(5):1789-97.
- Schentag JJ, Hyatt JM, Carr JR, Paladino JA, Birmingham MC, Zimmer GS, Cumbo TJ (1998). "Genesis of methicillin-resistant Staphylococcus aureus (MRSA), how treatment of MRSA infections has selected for vancomycin-resistant Enterococcus faecium, and the importance of antibiotic management and infection control". Clin. Infect. Dis. 26 (5): 1204–14. doi:10.1086/520287. PMID 9597254.
- Rybak MJ, Lerner SA, Levine DP, Albrecht LM, McNeil PL, Thompson GA, Kenny MT, Yuh L (1991). "Teicoplanin pharmacokinetics in intravenous drug abusers being treated for bacterial endocarditis". Antimicrob. Agents Chemother. 35 (4): 696–700. PMC 245081. PMID 1829880. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=245081.
- Janknegt R (1997). "The treatment of staphylococcal infections with special reference to pharmacokinetic, pharmacodynamic, and pharmacoeconomic considerations". Pharmacy world & science : PWS 19 (3): 133–41. doi:10.1023/A:1008609718457. PMID 9259029.
- Kirsten Edwards
- Chang FY, Peacock JE Jr, Musher DM, et al. (2003). "Staphylococcus aureus bacteremia: recurrence and the impact of antibiotic treatment in a prospective multicenter study". Medicine (Baltimore) 82 (5): 333–9. doi:10.1097/01.md.0000091184.93122.09. PMID 14530782.
- Siegman-Igra Y, Reich P, Orni-Wasserlauf R, Schwartz D, Giladi M. (2005). "The role of vancomycin in the persistence or recurrence of Staphylococcus aureus bacteraemia". Scand J Infect Dis 37 (8): 572–8. doi:10.1080/00365540510038488. PMID 16138425.
- Sieradzki K, Tomasz A (1997). "Inhibition of cell wall turnover and autolysis by vancomycin in a highly vancomycin-resistant mutant of Staphylococcus aureus". J. Bacteriol. 179 (8): 2557–66. PMC 179004. PMID 9098053. //www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=179004.
- Schito GC (2006). "The importance of the development of antibiotic resistance in Staphylococcus aureus". Clin Microbiol Infect 12 Suppl 1: 3–8. doi:10.1111/j.1469-0691.2006.01343.x. PMID 16445718.
- Mongkolrattanothai K, Boyle S, Kahana MD, Daum RS (2003). "Severe Staphylococcus aureus infections caused by clonally related community-associated methicillin-susceptible and methicillin-resistant isolates". Clin. Infect. Dis. 37 (8): 1050–8. doi:10.1086/378277. PMID 14523769.
- Phage International - Subsidiaries - Phage Therapy Center
- "Wired 11.10: How Ravenous Soviet Viruses Will Save the World". Wired. http://www.wired.com/wired/archive/11.10/phages.html.
- Suay I, Arenal F, Asensio FJ, Basilio A, Cabello MA, Díez MT, García JB, González del Val A, Gorrochategui J, Hernández P, Peláez F, Vicente MF. (2000). "Screening of basidiomycetes for antimicrobial activities" (PDF). Antonie van Leeuwenhoek 78 (2): 129–39. doi:10.1023/A:1026552024021. PMID 11204765. http://www.springerlink.com/content/p65r2660651u7k76/fulltext.pdf.
- Cutler R.R.; Wilson, P (2004). "Antibacterial activity of a new, stable, aqueous extract of allicin against methicillin-resistant Staphylococcus aureus". British journal of biomedical science 61 (2): 71–4. PMID 15250668.
- Echague CG, Hair PS, Cunnion KM (September 2010). "A comparison of antibacterial activity against Methicillin-Resistant Staphylococcus aureus and gram-negative organisms for antimicrobial compounds in a unique composite wound dressing". Adv Skin Wound Care 23 (9): 406–13. doi:10.1097/01.ASW.0000383213.95911.bc. PMID 20729646. http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1527-7941&volume=23&issue=9&spage=406.
- Flournoy DJ, Robinson MC (October 1990). "In vitro antimicrobial susceptibilities of 349 methicillin-resistant Staphylococcus aureus isolates from veterans". Methods Find Exp Clin Pharmacol 12 (8): 541–4. PMID 2093132.
- "MRSA History Timeline: The First Half-Century, 1959-2009". The University of Chicago Medical Center. 2010. http://mrsa-research-center.bsd.uchicago.edu/timeline.html.
- "MRSA Surveillance". Centers for Disease Control and Prevention. April 8, 2011. http://www.cdc.gov/mrsa/statistics/MRSA-Surveillance-Summary.html.
- UK Office for National Statistics Online (February 22, 2007), "MRSA Deaths continue to rise in 2005"
- Hospitals struck by new killer bug An article by Manchester free newspaper 'Metro', May 7, 2008
- Blot S, Vandewoude K, Hoste E, Colardyn F (2002). "Outcome and attributable mortality in critically Ill patients with bacteremia involving methicillin-susceptible and methicillin-resistant Staphylococcus aureus". Arch Intern Med 162 (19): 2229–35. doi:10.1001/archinte.162.19.2229. PMID 12390067.
- Liu C, Graber CJ, Karr M, et al. (June 2008). "A population-based study of the incidence and molecular epidemiology of methicillin-resistant Staphylococcus aureus disease in San Francisco, 2004–2005". Clin. Infect. Dis. 46 (11): 1637–46. doi:10.1086/587893. PMID 18433335. http://www.cid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=18433335.
- Noskin GA, Rubin RJ, Schentag JJ, Kluytmans J, Hedblom EC, Smulders M, Lapetina E, Gemmen E (2005). "The Burden of Staphylococcus aureus Infections on Hospitals in the United States: An Analysis of the 2000 and 2001 Nationwide Inpatient Sample Database". Arch Intern Med 165 (15): 1756–1761. doi:10.1001/archinte.165.15.1756. PMID 16087824.
- Cosgrove SE, Qi Y, Kaye KS, Harbarth S, Karchmer AW, Carmeli Y (2005). "The impact of Methicillin Resistance in Staphylococcus aureus Bacteremia on Patient Outcomes: Mortality, Length of Stay, and Hospital Charges" (– Scholar search). Infection Control and Hospital Epidemiology 26 (2): 166–174. doi:10.1086/502522. PMID 15756888. http://www.journals.uchicago.edu/ICHE/journal/issues/v26n2/9885/9885.html. [dead link]
- Hardy KJ, Hawkey PM, Gao F, Oppenheim BA (2004). "Methicillin resistant Staphylococcus aureus in the critically ill". British Journal of Anaesthesia 92 (1): 121–30. doi:10.1093/bja/aeh008. PMID 14665563.
- Wyllie D, Crook D, Peto T (2006). "Mortality after Staphylococcus aureus bacteraemia in two hospitals in Oxfordshire, 1997–2003: cohort study". BMJ 333 (7562): 281. doi:10.1136/bmj.38834.421713.2F. PMC 1526943. PMID 16798756. http://bmj.bmjjournals.com/cgi/content/abstract/333/7562/281.
- CDDEP "MRSA Infection Rates by Country" (2004)
- Bowling FL, Salgami EV, Boulton AJ (2007). "Larval therapy: a novel treatment in eliminating methicillin-resistant Staphylococcus aureus from diabetic foot ulcers". Diabetes Care 30 (2): 370–1. doi:10.2337/dc06-2348. PMID 17259512.
- "Maggots help cure MRSA patients". BBC News. 2007-05-02. http://news.bbc.co.uk/2/hi/uk_news/england/manchester/6614471.stm.
- "Maggots rid patients of MRSA". EurekAlert!/AAAS. 2007-05-03. http://www.eurekalert.org/pub_releases/2007-05/uom-mrp050307.php.
- ClinicalTrials.gov NCT00685698
- Murphy, Clare (2007-08-13). "'Red Army' virus to combat MRSA". BBC News. http://news.bbc.co.uk/2/hi/health/6943779.stm.
- Matsuzaki S, Yasuda M, Nishikawa H, Kuroda M, Ujihara T, Shuin T, Shen Y, Jin Z, Fujimoto S, Nasimuzzaman MD, Wakiguchi H, Sugihara S, Sugiura T, Koda S, Muraoka A, Imai S (2003). "Experimental protection of mice against lethal Staphylococcus aureus infection by novel bacteriophage phi MR11". J. Infect. Dis. 187 (4): 613–24. doi:10.1086/374001. PMID 12599078.
- Bayston R, Ashraf W, Smith T (2007). "Triclosan resistance in methicillin-resistant Staphylococcus aureus expressed as small colony variants: a novel mode of evasion of susceptibility to antiseptics". J. Antimicrob. Chemother. 59 (5): 848–53. doi:10.1093/jac/dkm031. PMID 17337510.
- Wang J; Soisson, SM; Young, K; Shoop, W; Kodali, S; Galgoci, A; Painter, R; Parthasarathy, G et al (May 2006). "Platensimycin is a selective FabF inhibitor with potent antibiotic properties". Nature 441 (7091): 358–361. doi:10.1038/nature04784. PMID 16710421.
- Sherlock O, Dolan A, Athman R, et al. (2010). "Comparison of the antimicrobial activity of Ulmo honey from Chile and Manuka honey against methicillin-resistant Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa". BMC Complement Altern Med 10: 47. doi:10.1186/1472-6882-10-47. PMC 2942791. PMID 20813024. http://www.biomedcentral.com/1472-6882/10/47.
- Kwakman PH, te Velde AA, de Boer L, Speijer D, Vandenbroucke-Grauls CM, Zaat SA (July 2010). "How honey kills bacteria". FASEB J. 24 (7): 2576–82. doi:10.1096/fj.09-150789. PMID 20228250. http://www.fasebj.org/cgi/pmidlookup?view=long&pmid=20228250.
- Sponge's secret weapon restores antibiotics' power
- Appendino G, Gibbons S, Giana A, Pagani A, Grassi G, Stavri M, Smith E, Rahman M (2008). "Antibacterial Cannabinoids from Cannabis sativa: A Structure-Activity Study". J. Nat. Prod. 71 (8): 1427–30. doi:10.1021/np8002673. PMID 18681481. http://pubs.acs.org/doi/pdf/10.1021/np8002673.
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