Molecular Epidemiology and Antimicrobial Resistance of Methicillin-resistant Staphylococcus aureus Isolated from Nasal Swab at Intensive Care Unit

중환자실 입원 환자의 비강 도말에서 메티실린 내성 황색포도알균의 분자역학, 항생제 내성 연구

  • Kwak, Om Sub (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Kwon, Mee Hye (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Jeong, Ji Hyun (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Kang, Mi-il (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Cheun, Ji Young (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Lee, Go Eun (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Kim, Young Keun (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Choi, Eu Gene (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Na, Moon Jun (Department of Internal Medicine, College of Medicine, Konyang University) ;
  • Kwon, Hee Uk (Department of Anesthesiology and Pain Medicine, College of Medicine, Konyang University) ;
  • Son, Ji Woong (Department of Internal Medicine, College of Medicine, Konyang University)
  • 곽엄섭 (건양대학교 의과대학 내과학교실) ;
  • 권미혜 (건양대학교 의과대학 내과학교실) ;
  • 정지현 (건양대학교 의과대학 내과학교실) ;
  • 강미일 (건양대학교 의과대학 내과학교실) ;
  • 천지영 (건양대학교 의과대학 내과학교실) ;
  • 이고은 (건양대학교 의과대학 내과학교실) ;
  • 김영근 (건양대학교 의과대학 내과학교실) ;
  • 최유진 (건양대학교 의과대학 내과학교실) ;
  • 나문준 (건양대학교 의과대학 내과학교실) ;
  • 권희욱 (건양대학교 의과대학 마취통증의학교실) ;
  • 손지웅 (건양대학교 의과대학 내과학교실)
  • Received : 2008.03.12
  • Accepted : 2008.06.18
  • Published : 2008.08.30

Abstract

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most common organism associated with nosocomial infections. MRSA infections are becoming increasing important because they have emerged no only as healthcare-associated (HA) infections but also as community-associated (CA) ones. This study examined the moleculo-epidemiology of MRSA, which was isolated from nasal swabs in the intensive care unit (ICU) at Konyang University Hospital. MRSA are classified into HA-MRSA and CA-MRSA. Methods: From June to September 2006, 353 patients who were admitted to the ICU in Konyang University Hospital were enrolled in this study. Single nasal swabs were obtained for culture in the ICU on the 1st day. Pulsed-field gel electrophoresis and the antimicrobial resistant patterns were analyzed between HA- and CA-MRSA. An antimicrobial sensitivity test was also performed. Results: Forty two strains of MRSA were isolated from 353 patients (11.9%). Among the 42 isolates, HA-MRSA and CA-MRSA were found in 33 (78.6%), and 9 (21.4%), respectively. Eleven different PFGE types (type A to K) were identified. Types A (n=9) and B (n=7) were the most common for HA-MRSA, and types A (n=2) and B (n=2) were identified in CA-MRSA. The proportion of types A and B in CA-MRSA (44.4%) was similar to that in HA-MRSA (48.5%). The rates of resistance rates to erythromycin and ciprofloxacin were higher in HA-MRSA than in CA-MRSA. Conclusion: The rate of isolation of MRSA in an ICU setting was 11.9%. HA-MRSA was isolated more frequently than CA-MRSA. The rate of resistance of HA-MRSA to erythromycin and ciprofloxacin was higher than that of CA-MRSA. Despite the small number of subjects, the main isolates (type A and B) of CA-MRSA were similar to those of HA-MRSA.

연구배경: 메티실린 내성 황색포도알균은 의료기관 관련 감염 뿐 아니라 지역사회 감염에서도 나타나 이에 저자들은 한 대학병원 중환자실에 입원한 환자의 비강 도말 배양을 통해 MRSA의 의료기관 관련 감염 및 지역사회 감염의 빈도와 분자 역학 및 항생제 내성을 연구하였다. 방 법: 2006년 6월에서 9월까지 건양대학교 병원 중환자실 환자 353명을 대상으로 입실 첫날 비강 도말 배양을 시행하여 MRSA 획득 위험인자에 따라 HA-MRSA와 CA-MRSA로 나누어 Pulsed-Field Gel Electrophorosis (PFGE)로 분류하여 각각의 항생제 내성 검사를 시행하였다. 결 과: 353명 중 비강 도말 배양에서 동정된 MRSA는 42명(11.9%)이며, 동정된 MRSA 중 HA-MRSA는 33명(78.6%), CA-MRSA는 9명(21.4%)이다. PFGE에서 type A에서 type K까지 11형으로 구분하였고 HA-MRSA는 type A (n=9), B (n=7)가, CA-MRSA는 type A (n=2), B (n=2)가 주로 나타났다. 항생제 내성률은 erythromycin, ciprofloxacin에서 HA-MRSA가 CA-MRSA보다 높게 나타났다. 결 론: MRSA의 집락률은 11.9%이며 HA-MRSA의 균주가 CA-MRSA보다 많고, CA-MRSA는 9예로 적은 예지만 PFGE type에서 대부분의 type이 HA-MRSA에서 동정된 type과 같은 경향을 보여 지역사회전파를 시사한다.

Keywords

References

  1. Diederen BM, Kluytmans JA. The emergence of infections with community-associated methicillin resistant Staphylococcus aureus. J Infect 2006;52:157-68. https://doi.org/10.1016/j.jinf.2005.09.001
  2. Kim JM, Park ES, Jeong JS, Kim KM, Kim JM, Oh HS, et al. Multicenter surveillance study for nosocomial infections in major hospitals in Korea. Am J Infect Control 2000;28:454-8. https://doi.org/10.1067/mic.2000.107592
  3. From the Centers for Disease Control and Prevention. Four pediatric deaths from community-acquired methi cillin-resistant Staphylococcus aureus--Minnesota and North Dakota, 1997-1999. JAMA 1999;282:1123-5. https://doi.org/10.1001/jama.282.12.1123
  4. Beam JW, Buckley B. Community-acquired methicillin- resistant Staphylococcus aureus: prevalence and risk factors. J Athl Train 2006;41:337-40.
  5. Wijaya L, Hsu LY, Kurup A. Community-associated methicillin- resistant Staphylococcus aureus: overview and local situation. Ann Acad Med Singapore 2006;35:479-86.
  6. Park JY, Kim HO, Jeong YG, Kim S, Bae IG. Clinical characteristics and risk factors of community-acquired methicillin-resistant Staphylococcus aureus infections: comparison of community-acquired methicillin-susceptible staphylococcus aureus infections. Infect Chemother 2006;38:109-15.
  7. Kluytmans J, van Belkum A, Verbrugh H. Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev 1997;10:505-20.
  8. Wertheim HF, Vos MC, Ott A, van Belkum A, Voss A, Kluytmans JA, et al. Risk and outcome of nosocomial Staphylococcus aureus bacteraemia in nasal carriers versus non-carriers. Lancet 2004;364:703-5. https://doi.org/10.1016/S0140-6736(04)16897-9
  9. National Commitiee for Clinical Laboratory Standards (NCCLS). Standard M2-A4. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. Villanova, PA: NCCLS; 1990.
  10. Matushek MG, Bonten MJ, Hayden MK. Rapid preparation of bacterial DNA for pulsed-field gel electrophoresis. J Clin Microbiol 1996;34:2598-600.
  11. Tenover FC, Arbeit RD, Goering RV, Mickelsen PA, Murray BE, Persing DH, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol 1995;33:2233-9.
  12. Mest DR, Wong DH, Shimoda KJ, Mulligan ME, Wilson SE. Nasal colonization with methicillin-resistant Staphylococcus aureus on admission to the surgical intensive care unit increased with the risk of infection. Anesth Analg 1994;78:644-50.
  13. Jung SI, Heo ST, Kim YS, Kim S, Peck KR, Kwon OJ, et al. Prevention of Methicillin-resistant Staphylococcus aureus nasal carriage and infection by conventional method and intranasal fusidic acid. Korean J Nosocomial Infect Control 2001;6:33-40.
  14. Kim S, Kim CK, Lee H, Peck KR, Kwon J, Lee JH, et al. A study on modes of transmission and role of nasal carriage to subsequent infection with Methicillin-Resistant Staphylococcus aureus in medical ICU using PFGE. Korean J Nosocomial Infect Control 1998;3:1-10.
  15. Corbella X, Dominguez MA, Pujol M, Ayats J, Sendra M, Pallares R, et al. Staphylococcus aureus nasal carriage as a marker for subsequent staphylococcal infections in intensive care unit patients. Eur J Clin Microbiol Infect Dis 1997;16:351-7. https://doi.org/10.1007/BF01726362
  16. Lim MS, Marshall CL, Spelman D. Carriage of multiple subtypes of methicillin-resistant Staphylococcus aureus by intensive care unit patients. Infect Control Hosp Epidemiol 2006;27:1063-7. https://doi.org/10.1086/507959
  17. Kim OS, Yoon SW, Kang YJ, Kim YK, Lee NY, Lee JH, et al. Rate of nasal colonization of methicillin-resistant Staphylococcus aureus at admission to a medical intensive care unit. Korean J Nosocomial Infect Control 2007;12:42-9.
  18. Song W, Lee TJ, Kim SJ, Park MJ, Lee KM. Methicillin- resistant Staphylococcus aureus infections in intensive care unit (ICU) patients: relation to nasal carriage of patients or ICU personnels. Korean J Clin Microbiol 2001;4:45-51.
  19. Pujol M, Pena C, Pallares R, Ariza J, Ayats J, Dominguez MA, et al. Nosocomial Staphylococcus aureus bacteremia among nasal carriers of methicillin-resistant and methicillin-susceptible strains. Am J Med 1996;100:509-16. https://doi.org/10.1016/S0002-9343(96)00014-9
  20. Garrouste-Orgeas M, Timsit JF, Kallel H, Ben Ali A, Dumay MF, Paoli B, et al. Colonization with methicillin-resistant Staphylococcus aureus in ICU patients: morbidity, mortality, and glycopeptide use. J Infect Control Hosp Epidemiol 2001;22:687-92. https://doi.org/10.1086/501846
  21. Porter R, Subramani K, Thomas AN, Chadwick P. Nasal carriage of Staphylococcus aureus on admission to intensive care: incidence and prognostic significance. Intensive Care Med 2003;29:655-8. https://doi.org/10.1007/s00134-003-1679-1
  22. Faria NA, Oliveira DC, Westh H, Monnet DL, Larsen AR, Skov R, et al. Epidemiology of emerging methicillin- resistant Staphylococcus aureus (MRSA) in Denmark: a nationwide study in a country with low prevalence of MRSA infection. J Clin Microbiol 2005;43:1836-42. https://doi.org/10.1128/JCM.43.4.1836-1842.2005
  23. Wylie JL, Nowicki DL. Molecular epidemiology of community- and health care-associated methicillin-resistant Staphylococcus aureus in Manitoba, Canada. J Clin Microbiol 2005;43:2830-6. https://doi.org/10.1128/JCM.43.6.2830-2836.2005
  24. Salgado CD, Farr BM, Calfee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a metaanalysis of prevalence and risk factors. Clin Infect Dis 2003;36:131-9. https://doi.org/10.1086/345436
  25. Onorato M, Borucki MJ, Baillargeon G, Paar DP, Freeman DH, Cole CP, et al. Risk factors for colonization or infection due to methicillin-resistant Staphylococcus aureus in HIV-positive patients: a retrospective case-control study. Infect Control Hosp Epidemiol 1999;20:26-30. https://doi.org/10.1086/501556
  26. Merrer J, Santoli F, Appere de Vecchi C, Tran B, De Jonghe B, Outin H. "Colonization pressure" and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit. Infect Control Hosp Epidemiol 2000;21:718-23. https://doi.org/10.1086/501721
  27. Shopsin B, Kreiswirth BN. Molecular epidemiology of methicillin-resistant Staphylococcus aureus. Emerg Infect Dis 2001;7:323-6. https://doi.org/10.3201/eid0702.010236
  28. Trindade PA, McCulloch JA, Oliveira GA, Mamizuka EM. Molecular techniques for MRSA typing: current issues and perspectives. Braz J Infect Dis 2003;7:32-43.
  29. McDougal LK, Steward CD, Killgore GE, Chaitram JM, McAllister SK, Tenover FC. Pulsed-field gel electrophoresis typing of oxacillin-resistant Staphylococcus aureus isolates from the United States: establishing a national database. J Clin Microbiol 2003;41:5113-20. https://doi.org/10.1128/JCM.41.11.5113-5120.2003
  30. Huang H, Flynn NM, King JH, Monchaud C, Morita M, Cohen SH. Comparisons of community-associated methicillin- resistant Staphylococcus aureus (MRSA) and hospital-associated MSRA infections in Sacramento, California. J Clin Microbiol 2006;44:2423-7. https://doi.org/10.1128/JCM.00254-06
  31. Davis SL, Perri MB, Donabedian SM, Manierski C, Singh A, Vager D, et al. Epidemiology and outcomes of community- associated methicillin-resistant Staphylococcus aureus infection. J Clin Microbiol 2007;45:1705-11. https://doi.org/10.1128/JCM.02311-06
  32. Park CW, Lee JS, Song JY, Kim CH, Eom JS, Cheong HJ, et al. Clinical and molecular epidemiologic study of community-acquired and hospital-acquired methicillin- resistant Staphylococcus aureus (MRSA) infection. J Korean Soc Chemother 2002;20;77-90.
  33. Jeong HY, Lee JE, Choi BK, Seo KW, Park SH, Kim YL, et al. Molecular epidemiology of community-associated antimicrobial-resistant Staphylococcus aureus in Seoul, Korea (2003): pervasiveness of multidrug-resistant SCCmec type II methicillin-resistant S. aureus. Microb Drug Resist 2007;13:178-85. https://doi.org/10.1089/mdr.2007.709
  34. Hiramatsu K. Elucidation of mechanism of antibiotic resistance acquisition of methicillin-resistant Staphylococcus aureus (MRSA) and determination of its whole genome nucleotide sequence. JMAJ 2004;47:153-9.
  35. Vandenesch F, Naimi T, Enright MC, Lina G, Nimmo GR, Heffernan H, et al. Community-acquired methicillin- resistant Staphylococcus aureus carrying Panton- Valentine leukocidin genes: worldwide emergence. Emerg Infect Dis 2003;9:978-84. https://doi.org/10.3201/eid0908.030089
  36. Lowy FD. Antimicrobial resistance: the example of Staphylococcus aureus. J Clin Invest 2003;111:1265-73. https://doi.org/10.1172/JCI18535