STAPHYLOCOCCI in Hawaii

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STAPHYLOCOCCI - in Hawaii

• Alan D Tice, MD, FACP
• Infectious Diseases Specialist
• JABSOM
• alantice_at_idlinks.com

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Staphylococcus aureus in the Community
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CA-MRSA Definitions

• Epidemiologic
• Culture within 48 hours
• In past year, no hospitalization, no surgery, no
  LTCF, no dialysis
• No indwelling catheters
• No history of MRSA disease or colonization
• Bacteriologic
• Susceptibility patterns
• Molecular typing
• PFGE USA 300 most prevalent
• Toxin profile PVL, ACME associated
• Other spa typing, gene detection

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CA-MRSA Findings
Community-Wide Emergence
Outbreaks among Groups
Microbiological Characteristics
Thanks to Matt Arduino of CDC
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Trends in S. aureus Antimicrobial Resistance
Penicillinase-producing S. aureus
Hospital
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Trends in S. aureus Antimicrobial Resistance
Penicillinase-producing S. aureus
Hospital
Community
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Trends in S. aureus Antimicrobial Resistance
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Trends in S. aureus Antimicrobial Resistance
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CA-MRSA Prevalence is Increasing
2001 2002
2003
CA-MRSA cases in Four Facilities in Hawaii,
2001-2003
Estivariz EIS, Hawaii EpiAid Trip Report
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CA-MRSA Causing Infections In the Hospital
Number of infections by quarter for Asocacion
Espanola, Uruguay July 2002-July 2004
Benoit, Estivariz EIS Uruguay Trip Report
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Staphylococcus aureus - resistance

• Methicillin resistance
• Complex, needs chromosome plus plasmid
• Nosocomial strains for 25 years
• Community-acquired (Panton-Valentine Leukocidin
  gene associated)
• Vancomycin intermediate resistance (VISA)
• Japan, Detroit, related to cell wall
• Vancomycin resistance (VRSA)
• Genotypic van A gene from enterococcus

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Local antibiograms vary

• Diagnostic Laboratory Services
• QMC Gram negative rods
• QMC Gram positive cocci
• Outpatient cultures
• Extended Care facilities
• http//www.dlslab.com/dls/attachment/58C9A2F2B41F3
  2B510DD7B018F2/QMCgrampos.pdf

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CA-MRSA Outbreaks

• Often first detected as clusters of abscesses or
  spider bites
• Various settings
• Sports participants football, wrestlers, fencers
• Correctional facilities prisons, jails
• Military recruits
• Daycare and other institutional centers
• Newborn nurseries and other healthcare settings
• Men who have sex with men

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St. Louis RamsCA-MRSA Abscesses

• Association with
• BMIgt30
• Recent Abx use
• Lineman/Linebacker
• Abx use
• 2.6 scripts/yr for Rams
• 0.2 scripts/yr for gen popn
• Common USA 300 clone

Kazakova et al NEJM 2005352468-75.
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CA-MRSA Factors for Transmission
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Staph Transmission Dynamics
Colonized
Infected
Susceptible
Environment
ESEM of bench seat sauna
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CA-MRSA Incidence Differs by Race and Age
MRSA disease in three communities. Fridkin et
al NEJM 20053521436-44
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CA-MRSA PrevalenceVaries by RaceEstivariz EIS
03


Asian Pacific White Others
Islanders
Plt0.05 for CA-MRSA vs expected by Census.
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S. aureus ColonizationNHANES Nasal Swab Survey
2001-2, Kuehnert et al.
S. aureus 32 89.4 million people MRSA
0.8 2.3 million people
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Host Range

• Humans
• Pets (cats, dogs, etc)
• Companion animals (cows, horses, chickens)
• Psittacine birds
• Ceteceans (Harbour porpoises, dolphins, Orcinus
  orca)
• Harbor seals and elephant seals (captive wild)
• Fresh water fish (silver carp)
• Marine fish (Lopes CA, Moreno G, 1973)

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Environmental Persistence

• Surfaces and fomites lt 9 weeks
• Hydrotherapy pools and spas-long periods between
  uses (Meldrun R, 2001)
• Phosphate buffered saline years
• Sand years
• Sterile sewage lt15 days
• Sterile and nonsterile lake water lt3 days
• Sea water, 9.8C gt 7days (EPA, 1976)

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Human Infections from the Sea?

• Paddlers report skin infections related to
  seawater use
• Some swimmers and surfers report ocean waters
  heal infections
• Some swimmers and surfers report ocean waters
  cause infections

Chang W, Pien F, Fujioka R Post Grad Med 1986
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PEW Commission Report (1999)

• One million bacteria per cubic centimeter
  (milliliter) of ocean water around the world!
• Most not characterized and cannot subculture
• Ten million viruses per ml.!
• Very competitive environment!

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Kuhio a swimmer beach along Waikiki
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Human infections from the Sea?

• Sampling of beach water in Oahu
• Up to 100 colonies/100 ml water
• Staph correlate with people using water
• More people, more staph
• Where people swim not out at sea
• Colony counts go down at night
• Higher concentrations with sand
• Fujioka 1995

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JABSOM dept of Molecular Biology Steve Seifried,
PhD, A Tice

• Characterize Staph aureus (clones, lineage)
• Pulse field gel electrophoresis, ribotyping, spa
  typing, (MLST)
• Virulence factors
• Antibiotic resistance antibiogram
• Mecc genes
• Toxins like TSST, enterotoxins,
• Panton-Valentine leukocidin
• Found wide variety of S. aureus and some unique
  strains never reported

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31 USA 300 strains

• 13 human source (clinical lab)
• 3 different spa types, 10 different ribotypes
• 10 carried SCCmec type IVa, 3 had no mec A gene
• 11 had PVL, one had TSST
• 18 environmental (recreational seawater)
• 8 different spa types
• 3 different SCCmec types (II, IV, untypable)
• 4 had mecA gene
• 1 had PVL

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Growth Curve of Pre-conditioned CA-MRSA in a
Minimal Simulated Seawater Medium
Peterson, Arduino
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Survival of CA-MRSA in water Obtained from the
Atlantic Ocean
Log10
Peterson, A
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The Phage Connection
Bacteriophages code for virulence factors in S.
aureus and many other pathogens
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Microbiologic Characterization

• Clones PFGE, spa, other
• Virulence factors
• Antibiotic resistance

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Staphylococcus aureus - virulence factors

• Enzymes
• Catalase, coagulase, hyaluronidase, clumping
  factor, beta-lactamases
• Toxins
• Alpha through delta and leukocidin
• Other toxins
• Epidermolytic, enterotoxins, exotoxins, toxic
  shock syndrome toxin, superantigens
• Growth factors
• Resistance mechanisms for antibiotics
• METHICILLIN RESISTANCE NOT A VIRULENCE FACTOR IN
  ITSELF

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CA-MRSA Differs from HA-MRSA

• HA-MRSA
• SCCmec II
• USA 100, 200
• PVL Rare
• Resistant to
• multiple agents

Res. Gene PFGE Type PVL Susceptibility

• CA-MRSA
• SCCmec IV
• USA 300, 400
• PVL Common
• Resistant mainly
• to oxacillin and
• erythromycin

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Clinical Considerations

• History of infection, other medical problems
• Physical exam
• Admission, surgery?
• Antibiotic decisions
• Route of therapy, duration
• Epidemiology and exposure history
• Microbiology
• Gram stain
• Culture
• Antibiotic susceptibilities
• Need for follow-up if not admitted
• Sharing of information among health care
  facilities

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Antibiotic Decisions about MRSA

• No antibiotic
• Colonization, not infection
• Admit for intravenous antibiotic therapy
• Oral antibiotic
• Linezolid (Zyvox)
• Cephalexin (Keflex)
• Trimeth/sulfa (Bactrim, Septra)
• Clindamycin
• Tetracyclines
• Topical antibiotic

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Topical antibiotics

• Triple Antibiotic Ointment
• Bacitracin, neomycin, polymixin B
• Mupirocin (Bactroban)
• Clindamycin
• Gentamicin
• Metronidazole

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Local Laboratory Resources

• Identification and antibiogram - 2 days
• Clinical labs
• PBP-2 assay for methicillin resistance
• within a few hours
• JABSOM Steve Seifried, PhD
• Spa (staph protein A) detection
• Within minutes
• Rapid clone determination by spa
• within a few hours
• Rapid detection of virulence factors
• within a few hours

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Laboratory Excellence Can and Could

• Determine need for quarantine and isolation
• Determine nosocomial and nosohusial spread
• Help in antibiotic decisions and choice
• Help in specific intervention for virulence
  factors
• clindamycin, IVIG, immune modulators, etc.
• Alert us when new invasive species arrive
• Assist in research into this formidable pathogen

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Approaches to Control of MRSA

• Epidemiologic and microbiological differences
  between HA-MRSA and CA-MRSA
• Approach to control of MRSA must now include
  community interventions as well

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Key Prevention Strategies

• Prevent infection
• Diagnose and treat infection effectively
• Use antimicrobials wisely
• Prevent transmission

www.cdc.gov
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Clinical Considerations

• Increase Awareness
• Use Local Data for Treatment
• Collect Diagnostic Specimens
• ID Should Be Routine
• Adequate Follow-up Required
• Empiric Abxs MAY be needed
• Target Tx with Alternative Abxs
• Educate Patients, Parents, Providers

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How to determine if seawater staph a risk to
people?

• Should we study people or seawater?
• How about marine mammals?
• Should we study MSSA or MRSA?
• Should we study strep as well?
• How about vibrio, aeromonas, enterococcus, E.
  coli, leptospirosis, coag-neg staph, viruses,
  bacteriophage, etc.?

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Relationship of the Sea and People

• People contaminating seawater?
• Seawater contaminating people?
• What is level of risk?
• What staphylococci are in the sea?
• Do they harbor resistance and virulence factors?
• Opportunity for drug discovery

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CONCLUSION GO SWIMMING -
- and help us study the sea
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STAPHYLOCOCCI - in Hawaii

• Alan D Tice, MD, FACP
• Infectious Diseases Specialist
• JABSOM
• alantice_at_idlinks.com

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Questions

• What are the concentrations of S. aureus in
  Oahus coastal waters?
• Are phages common among S. aureus isolates from
  these waters?

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S. aureus at Kuhio Beach
Range 1 to 448 CFU/100ml Highest values
nearshore
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Prophage Content Comparison
Sequenced Genomes n 6
TIGR/Genbank web sites
No. of Prophages per Isolate
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Development of Reasonable Approaches for CA-MRSA

• Data are lacking for many aspects of CA-MRSA
  prevention and control
• Numerous strategies have been reported to be
  successful however, little is known about the
  independent benefit of components of the
  strategies
• Given these limitations, what is a reasonable
  approach to CA-MRSA prevention and control
• Invited experts to CDC for two day meeting

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Prophage Content Comparison
Sequenced Genomes n 6
TIGR/Genbank web sites
No. of Prophages per Isolate
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Preliminary data on 20 strains

• All resistant to bacitracin and polymixin
• One resistant to clindamycin
• One resistant to mupirocin and clindamycin

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Background
The average milliliter of ocean water worldwide
contains one million bacteria and ten million
viruses (1). Among these organisms are recognized
human pathogens although the role the oceans play
in human infections is largely unknown.
Associations of Staphylococcus aureus (S. aureus)
infections with water sports in Hawaii was noted
ten years ago with studies then that demonstrated
up to 100 colony forming units of S. aureus per
100 ml. of sea water(2,3).
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Methods
To confirm and expand on the prior findings,
seawater samples were collected from 16 different
locations in Oahu.
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Aliquots of 25 and 100 ml. were collected and
processed promptly. Bacteria were concentrated
by membrane filtration method then plated on agar
with sodium azide added to increase selectivity.
S. aureus was enumerated based on growth of
mauve-colored colonies using CHROMagar SA media.
Presumptive colonies were confirmed as S. aureus
by coagulase activity and tested for
susceptibility to oxacillin. This methodology
has been recently presented at the American
Society of Microbiology annual meeting
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Findings
76 samples were collected from a depth of one
foot in water approximately 2 feet deep. They
were obtained at peak swimming times on a monthly
or bimonthly basis. Specimens were collected from
10 swimming and 4 non-swimming (fewer than 10
people per 250 square meters of beach or no
swimmers) beaches.
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An average of more than 1000 colony forming
units of Gram-positive organisms was recovered on
the selective agar plates from both types of
beaches. An average of 25 (geometric mean 9)
strains of S. aureus per 100 ml of seawater was
recovered from swimmer beaches whereas an average
of only 7 (geometric mean of 1) strains were
recovered from non-swimmer beaches. Of 380 S.
aureus strains tested, 16 were found to be
resistant to oxacillin (4.2). All ORSA strains
were recovered from beaches with swimmers. Other
types of Gram-positive organisms were not
identified.
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Additional studies were carried out by the
Centers for Disease Control using pulsed-field
gel electrophoresis. The seawater strains were
compared with outbreak strains previously
collected and evaluated (5). The original 8
groups have been expanded to 11. Of the 8 typed
strains of ORSA, 4 were not groupable.
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Pulsed-field gel electrophoresis typing of
seawater isolates
Contributed by Matthew Arduino and Bette
Jensen (a)       HAHosptial-associated,
CACommunity-associated (b)       Location of
outbreaks EAEurope and Asia, U SUnited
States (c)       Resistant to 3 or more classes
of antibiotics
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Discussion
Seawater in a tropical climate harbors a variety
of microorganisms, including S. aureus, which
appears to be related to human use with secondary
contamination of the water. The variety and
spectrum of these organisms has yet to be
determined. Their relationship to human disease
and the potential for the ocean to serve as a
reservoir for antimicrobial resistance needs to
be considered, especially as the oceans become
more affected by human use and abuse. The risk
of acquiring S. aureus or ORSA from recreational
use of seawater is not clear but bears further
study.   The finding of types of S. aureus
strains similar to those found in outbreaks in
Europe and Asia may reflect the large number of
foreign visitors to Hawaii from those continents.
The source and significance of the 13 other
typed strains is not known. Further study is
needed.
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Summary
   A practical method has been developed to
identify and enumerate concentrations of S.
aureus and MRSA in marine recreational
waters.    Gram-positive bacteria are found in
abundance in the recreational seawaters of Hawaii
with significant numbers of S. aureus, including
methicillin-resistant strains.    Concentrations
of S. aureus are associated with human use of
these ocean waters.     The presence of S.
aureus and ORSA in recreational seawater may pose
a risk of infection that needs further
investigation,
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How to determine if seawater staph a risk to
people?

• Identify people infected with staph and ask if
  seawater exposure
• QMC ED wounds and survey
• Not initiated yet IRB issues
• A problem with denominator

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How to determine if seawater staph a risk to
people?

• Identify people colonized with staph and ask if
  seawater exposure
• KCC student noses
• Tourist trap
• Sample noses and look for infections days 0,2,5?
• Surfrider Foundation
• Free surfing lessons?
• QMC ED wounds and survey
• Not initiated yet IRB issues

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Do we want to know more?

• Should we do surveillance?
• Spa detection?
• Are fecal indicators more important?
• Should we be monitoring vibrios and aeromonas?
• Hard to get a frequency (numerator and
  denominator)
• Can we establish standards?
• How to determine?

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What should we look to fund?

• More studies at Queens with survey of risk
  factors?
• Necrotizing fasciitis
• Emergency Department cultures
• Hospital patient cultures
• More studies of seawater?
• Tourist trap for colonization changes?
• Longitudinal studies with risk factors?
  students, other
• Make MRSA a reportable disease?

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References
(1)      Pew Institute. (2003). America's Living
Oceans Charting a Course for Sea Change.
Commission, P. O. June 4, 2003 or
http//www.pewoceans.org/. (2)     Chang W, Pien
FD. Marine-acquired infections Hazards of the
ocean environment. Postgrad Med,
19868030-33. (3)     Charoenca N, Fujioka RS,
Association of staphylococcal skin infections and
swimming. Wat Sci Tech 19953111-17. (4)     Fow
ler TL, Fujioka RS, Tice AD, et al. Modification
of CHROMagar Staph. aureus to enumerate
Staphylococcus aureus from marine recreational
waters in Hawaii. Abstract Q-516. Annual
meeting of American Society for Microbiology, New
Ornleans, LA, May, 2004. (5)     McDougal LK,
Steward CD, Killgore GE, et al. Pulsed-field Gel
Electrophoresis Typing of oxacillin-resistant
Staphylococcus aureus isolates from the United
States establishing a national database. J Clin
Micro. 2003415113-5120.
Funding is gratefully acknowledged from Sea
Grant College, University of Hawaii Queen Emma
Research Fund, Honolulu, Hawaii
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