Length of stay, hospitalisation costs and in-hospital mortality of methicillin-susceptible and methicillin-resistant Staphylococcus aureus bacteremia in Japan

OBJECTIVES

To examine the length of stay, hospitalisation costs and case fatality of methicillin-susceptible and -resistant Staphylococcus aureus (MSSA and MRSA) bacteremia in Japan.

STUDY DESIGN

Retrospective cohort study. Patients with a diagnosis of S. aureus bacteremia who were admitted to a tertiary care hospital (the National Centre for Global Health and Medicine [NCGM]) in Tokyo, Japan, between 1st January 2016 and 31st December 2020 were included in the study.

METHODS

We combined Japan Nosocomial Infections Surveillance data and Diagnosis Procedure Combination data at NCGM from 2016 to 2020. The data were stratified into MSSA and MRSA groups. Length of stay (LoS), LoS after submission of a blood culture specimen (LoS-after), hospitalisation cost, hospitalisation costs per day and clinical outcome were compared after propensity score matching.

RESULTS

Median LoS was 46 (interquartile range [IQR] 28.5-64.5) days in the MSSA group and 66 (IQR 40-91) days in the MRSA group (P = 0.020). Median LoS-after was 38 (IQR 25-62.5) days and 45 (IQR 24-63) days (P = 0.691) in the MSSA and MRSA groups, respectively. Median hospitalisation cost was significantly higher in the MRSA group (26,035 [IQR 18,154-47,362] USD) than in the MSSA group (19,823 [IQR 13,764-32,042] USD) (P = 0.036), but cost per day was not (MRSA: 528.9 [IQR 374.9-647.4] USD; MSSA: 455.6 [IQR 359.2-701.7] USD; P = 0.990). Case fatality rate was higher in the MRSA group than in the MSSA group (22/60 vs 9/60, P = 0.012).

CONCLUSIONS

Patients with MRSA bacteremia had longer LoS and higher costs than those with MSSA bacteremia. However, LoS-after and hospitalisation costs per day were not different. The longer LoS of patients in Japan compared with other countries might contribute to the higher disease burden of S. aureus bacteremia in Japan.

Cellulitis: A Review of Pathogenesis, Diagnosis, and Management

Cellulitis is a common skin infection resulting in increasing hospitalizations and health care costs. There is no gold standard diagnostic test, making cellulitis a potentially challenging condition to distinguish from other mimickers. Physical examination typically demonstrates poorly demarcated unilateral erythema with warmth and tenderness. Thorough history and clinical examination can narrow the differential diagnosis of cellulitis and minimize unnecessary hospitalization. Antibiotic selection is determined by patient history and risk factors, severity of clinical presentation, and the most likely microbial culprit.

Validation of a More Reliable Method of Eye Drop Self-Administration

SIGNIFICANCE

We propose an alternative method for eye drop self-administration. Similar IOP reductions were found with this method compared with clinician instillation. The alternative method of self-administration potentially benefits patients who have trouble successfully instilling drops.

PURPOSE

The purpose of this study was to validate the efficacy of an alternative method of drop instillation.

METHODS

This study is a randomized controlled crossover clinical trial. Thirty participants were recruited. A drop of 0.5% timolol maleate was instilled into subject's eye on two separate visits. On one visit, eye drop instillation was by a trained clinician, and on the other, self-instillation using an alternative method was used. The order was randomly chosen. Intraocular pressure was measured before drop instillation and 2 hours after drop instillation. The investigator was masked during measurement, and an observer recorded the IOP measurements.

RESULTS

Mean ± SD IOP measurement before 0.5% timolol maleate instillation measured 13.89 ± 2.29 mmHg. An average reduction 3.75 ± 2.36 mmHg was found with clinician administration, and an average reduction of 3.32 ± 2.31 mmHg was recorded with the new method. No significance was found in IOP reduction between two groups P < .45. Percent reduction was 25.17 ± 16.21% and 24.38 ± 16.31% in clinician instillation and alternative instillation method group, respectively. No significant difference was found. This percentage reduction was similar to previously reported studies. No reported cases of eye infection or irritation were found in any case, within a 3-month follow-up period.

CONCLUSIONS

We have proposed a more reliable method for instillation that provides a larger area for instillation and lessen the risk of contamination and patient's fear for eye drops. Similar efficacy was found compared with that of having a clinician directly administer the drop. This alternative method could potentially benefit patients who require topical eye drop therapy and result in increased compliance.

Nosocomial keratitis caused by methicillin-resistant Staphylococcus aureus: case report and preventative measures

A 47-year-old African-American woman was admitted to the intensive care unit of our community hospital for respiratory failure secondary to severe decompensated heart failure, requiring intubation. In the ensuing days, she developed a methicillin-resistant Staphylococcus aureus (MRSA) infection of the cornea, despite no growth of MRSA in multiple blood, sputum, and urine cultures. This unexpected corneal infection complicated her hospital stay, and increased morbidity and disease-related cost. Risk factors, warning signs, and preventative measures for MRSA keratitis secondary to lagophthalmos (inability to completely close one's eyelids) are outlined in this case report. Implementing simple precautions such as taping eyelids shut or using artificial lubrication may reduce patient morbidity and disease-related costs. These recommendations are directed to non-ophthalmic clinicians who provide care to patients in settings where MRSA colonization is widespread.

Protective effect of methicillin-susceptible Staphylococcus aureus carriage against methicillin-resistant S. aureus acquisition in nursing homes: a prospective cross-sectional study

OBJECTIVE

To evaluate whether an ecologic inverse association exists between methicillin-susceptible Staphylococcus aureus (MSSA) prevalence and methicillin-resistant S. aureus (MRSA) prevalence in nursing homes.

METHODS

We conducted a secondary analysis of a prospective cross-sectional study of S. aureus prevalence in 26 nursing homes across Orange County, California, from 2008-2011. Admission prevalence was assessed using bilateral nares swabs collected from all new residents within 3 days of admission until 100 swabs were obtained. Point prevalence was assessed from a representative sample of 100 residents. Swab samples were plated on 5% sheep blood agar and Spectra MRSA chromogenic agar. If MRSA was detected, no further tests were performed. If MRSA was not detected, blood agar was evaluated for MSSA growth. We evaluated the association between MRSA and MSSA admission and point prevalence using correlation and linear regression testing.

RESULTS

We collected 3,806 total swabs. MRSA and MSSA admission prevalence were not correlated (r = -0.40, P = .09). However, MRSA and MSSA point prevalence were negatively correlated regardless of whether MSSA prevalence was measured among all residents sampled (r = -0.67, P = .0002) or among those who did not harbor MRSA (r = -0.41, P = .04). This effect persisted in regression models adjusted for the percentage of residents with diabetes (β = -0.73, P = .04), skin lesions (β = -1.17, P = .002), or invasive devices (β = -1.4, P = .0006).

CONCLUSIONS

The inverse association between MRSA and MSSA point prevalence and minimal association on admission prevalence suggest MSSA carriage may protect against MRSA acquisition in nursing homes. The minimal association on admission prevalence further suggests competition may occur during nursing home stays.

Impact of inappropriate empiric antimicrobial therapy on mortality of septic patients with bacteremia: a retrospective study

Background. Inappropriate empiric antimicrobials could be a major cause of unfavorable mortality rates in co-morbid patients. This study aimed to assess the prevalence and impact of first-dose and 24-hour inappropriate antimicrobials on mortality rates of bacteremic septic patients. Methods. A retrospective cohort study was employed. Case record forms of patients diagnosed as sepsis, severe sepsis, or septic shock with positive hemoculture during 2009 were retrieved from the medical wards, Siriraj Hospital. Demographic data, antimicrobial use, types of bacteria isolated from blood and susceptibilities, patients' comorbidities, 28-day and overall mortality rates were collected and analyzed. Results. There were 229 cases, mean age (SD) of 63.5 (17.2) years and mean (SD) APACHE II score of 24.7 (6.8). The prevalence of first-dose and 24-hour inappropriate antimicrobials was 29.7% and 25.3%, respectively. The 28-day and overall mortality rates between first-dose inappropriate and appropriate antimicrobial were 67.6% versus 60.2% (P = 0.301) and 75.0% versus 68.3% (P = 0.345), consequently. Patients with septic shock and inappropriate first-dose antimicrobials significantly had higher 28-day mortality rate (61.6% versus 41.9%; P = 0.017). Conclusion. Higher mortality rates in bacteremic septic patients were substantially associated with inappropriate first-dose antimicrobials and 3-hour delayed antimicrobial administration after sepsis diagnosis.

Methicillin resistant Staphylococcus aureus in a Japanese community hospital: 5-year experience

Methicillin resistant Staphylococcus aureus (MRSA) is exceptionally critical to infection treatment and control in the health-care setting. MRSA has been detected at high levels in Japan, and the frequency of MRSA infection must be ascertained to provide a baseline with which to assess various infection control efforts. We studied MRSA infection rate at a general hospital in Japan in all 65,135 inpatients of Sendai Kousei Hospital from January 2004 to December 2008. MRSA's prevalence among strains of S. aureus and the rate of MRSA detection were studied. Identification of MRSA infection is according to the laboratory-based ward liaison surveillance. The minimal inhibitory concentrations (MICs) of vancomycin, teicoplanin, and arbekacin for the various isolates were determined. During the period studied, there were 621 MRSA-positive patients. MRSA prevalence among strains of S. aureus was 45.5% (621/1,365). The rate of MRSA detection in inpatients was 0.953/100 inpatients. Of the 621 patients from whom MRSA was isolated, 51 (8.2%) had an MRSA infection (MRSA infection rate 0.078/100 inpatients). MRSA was often detected from the respiratory tract, but this seldom led to infection, since many of those affected were merely carriers. MICs against MRSA was 0.5-4 μg/ml for vancomycin, 0.5-16 μg/ml for teicoplanin, and 0.5 to >16 μg/ml for arbekacin, with no tendency for tolerance observed for these drugs. Findings suggest that whereas MRSA remains prevalent, there is a low incidence of infection in a general hospital in Japan.

Longitudinal trends in antimicrobial susceptibilities across long-term-care facilities: emergence of fluoroquinolone resistance

BACKGROUND

Antibiotic resistance in the longterm-care facility (LTCF) setting is of increasing concern due to both the increased morbidity and mortality related to infections in this debilitated population and the potential for transfer of resistant organisms to other healthcare settings. Longitudinal trends in antibiotic resistance in LTCFs have not been well described.

DESIGN

Correlational longitudinal survey study.

SETTING

Four LTCFs in Pennsylvania.

SUBJECTS

All clinical cultures of residents of the participating LTCFs (700 total beds) from 1998 through 2003. We assessed the annual prevalence of resistance to various antimicrobials of interest for the following organisms: Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Staphylococcus aureus, and enterococcus species.

RESULTS

A total of 4,954 clinical isolates were obtained during the study. A high prevalence of antimicrobial resistance was noted for many organism-drug combinations. This was especially true for fluoroquinolone susceptibility among the Enterobacteriaceae (susceptibility range, 51.3% to 92.2%). In addition, the prevalence of resistance to various agents differed significantly across study sites. Finally, significant increasing trends in resistance were noted over time and were most pronounced for fluoroquinolone susceptibility among the Enterobacteriaceae.

CONCLUSIONS

The prevalence of antimicrobial resistance has increased significantly in LTCFs, although trends have varied substantially across different institutions. These trends have been particularly pronounced for fluoroquinolone resistance among the Enterobacteriaceae. These findings demonstrate that antimicrobial resistance is widespread and increasing in LTCFs, highlighting the need for future studies to more clearly elucidate the risk factors for, and potential interventions against, emerging resistance in these settings.

External ocular infections due to methicillin-resistant Staphylococcus aureus (MRSA)

PURPOSE

To determine the prevalence and clinical characteristics of external ocular infections caused by methicillin-resistant Staphylococcus aureus (MRSA) in an ophthalmic hospital in the UK.

METHODS

A retrospective analysis of the case notes of patients who had culture proven external ocular Staphylococcal infections during a 44-month period was undertaken.

RESULTS

There were a total of 548 external eye infections caused by Staphylococcus aureus. Of these, 17 (3%) were MRSA positive. The most common presentation was conjunctivitis seen in six patients. All MRSA isolates were sensitive to chloramphenicol. Ofloxacin resistance was observed in all isolates from patients over the age of 50 years. All patients had an underlying history of either an ocular surface disease, malignancy, or a debilitating medical illness.

CONCLUSIONS

MRSA is as yet an infrequent cause of external ocular infections. Patients typically have underlying ocular risk factors and/or are medically debilitated. Different strains infect young and old age groups with characteristic antimicrobial sensitivity. This study highlights the need for more work to establish the role of MRSA commensals and ocular infections.

Staphylococcus aureus bacteremic pneumonia: differences between community and nosocomial acquisition

OBJECTIVE

The aim of the study was to ascertain the clinical and epidemiologic characteristics of patients with nosocomial or community-acquired Staphylococcus aureus bacteremic pneumonia.

METHODS

A prospective study of 134 cases diagnosed between January 1990 and December 1995 was performed.

RESULTS

Fifty cases involved primary bacteremic pneumonias, of which 80% were nosocomial (the majority, 72%, in intensive care unit patients, of whom 57% were post-surgery). Of the 84 cases of secondary pneumonia, 36 were non-intravenous drug users (78% nosocomial, of whom 43% were in the intensive care unit), and 48 cases were intravenous drug users (98% community-acquired).

CONCLUSIONS

Nosocomial S. aureus bacteremic pneumonia was especially frequent in intensive care unit patients (68.1%), and community-acquired pneumonia in intravenous drug users (72.3%). In non-intravenous drug users, clinical outcome and mortality were similar for nosocomial and community-acquired pneumonia.

Mupirocin-resistant, methicillin-resistant Staphylococcus aureus: does mupirocin remain effective?

OBJECTIVE

To determine the efficacy of mupirocin ointment in reducing nasal colonization with mupirocin-susceptible, methicillin-resistant Staphylococcus aureus (MS MRSA) as well as mupirocin-resistant MRSA (MR MRSA).

DESIGN

Prospective evaluation in which patients colonized with MRSA were treated twice daily with 2% topical mupirocin ointment for 5 days.

SETTING

James H. Quillen Veterans' Affairs Medical Center.

PATIENTS

Forty hospitalized patients with two anterior nares cultures positive for MRSA within a 7-day period.

METHODS

Treated patients had post-treatment cultures at day 3 and weeks 1, 2, and 4. Isolates underwent mupirocin-susceptibility testing and DNA typing. MRSA clearance and type turnover were assessed for isolates that were mupirocin-susceptible, low-level (LL) MR MRSA and high-level (HL) MR MRSA.

RESULTS

Post-treatment nares cultures on day 3 were negative for 78.5%, 80%, and 27.7% of patients with MS MRSA, LL-MR MRSA, and HLMR MRSA, respectively. Sustained culture negativity at 1 to 4 weeks was more common in the MS MRSA group (91%) than in the LL-MR MRSA group (25%) or the HL-MR MRSA group (25%). Positive post-treatment cultures usually showed the same DNA pattern relative to baseline. Plasmid curing of 18 HL-MR MRSA resulted in 15 MS MRSA and 3 LL-MR MRSA.

CONCLUSIONS

Mupirocin was effective in eradicating MS MRSA, but strains of MR MRSA often persisted after treatment. This appeared to reflect treatment failure rather than exogenous recolonization. MR MRSA is now more prevalent and it is appropriate to sample MRSA populations for mupirocin susceptibility prior to incorporating mupirocin into infection control programs.

Infectious disease outbreaks in nursing homes: an unappreciated hazard for frail elderly persons

The common occurrence and dire consequences of infectious disease outbreaks in nursing homes often go unrecognized and unappreciated. Nevertheless, these facilities provide an ideal environment for acquisition and spread of infection: susceptible residents who share sources of air, food, water, and health care in a crowded institutional setting. Moreover, visitors, staff, and residents constantly come and go, bringing in pathogens from both the hospital and the community. Outbreaks of respiratory and gastrointestinal infection predominate in this setting, but outbreaks of skin and soft-tissue infection and infections caused by antimicrobial-resistant bacteria also occur with some frequency.

Antibiotic-resistant gram-negative organisms in pediatric chronic-care facilities

This study was designed to define the prevalence of colonization with antibiotic-resistant gram-negative rectal specimens were obtained from subjects residing in 2 pediatric extended-care facilities and were processed to identify gram-negative organisms resistant to ceftazidime, gentamicin, meropenem, and piperacillin-tazobactam. Horizontal transmission was assessed by analyzing all resistant isolates by pulsed-field gel electrophoresis. Forty percent of subjects were colonized with >/=1 resistant bacillus; >60% of organisms were resistant to >/=2 of the antibiotics tested. Colonization was disproportionate among residents with a tracheostomy or other prosthesis. More than 65% of colonized subjects shared 1 organism with another resident, with cross-colonization occurring among both enteric and nonenteric species. Children residing in chronic-care facilities represent a large reservoir for resistant bacilli. Such colonization may be amenable to simple barrier infection-control procedures.

Colonization of skilled-care facility residents with antimicrobial-resistant pathogens

OBJECTIVES

To determine the frequency of and risk factors for colonization of skilled-care unit residents by several antimicrobial-resistant bacterial species, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), or extended-spectrum-beta-lactamase-producing (ESBL-producing) (ceftazidime resistant) Klebsiella pneumoniae or Escherichia coli.

DESIGN

Point-prevalence survey and medical record review.

SETTING

The skilled-care units in one healthcare facility.

PARTICIPANTS

120 skilled-care unit residents.

MEASUREMENTS

Colonization by each of the four antimicrobial-resistant pathogens during a point-prevalence survey, using rectal, nasal, gastrostomy-tube site, wound, and axillary cultures, June 1-3, 1998; 117 (98%) had at least one swab collected and 114 (95%) had a rectal swab collected. Demographic and clinical characteristics were evaluated as risk factors for colonization. All isolates were strain typed by pulsed-field gel electrophoresis of total genomic deoxyribonucleic acid.

RESULTS

Of 117 participants, 50 (43%) were culture positive for > or =1 antimicrobial-resistant pathogen: MRSA (24%), ESBL-producing K. pneumoniae (18%) or E. coli (15%), and VRE (3.5%). Of 50 residents culture positive for any of these four antimicrobial-resistant species, 13 (26%) were colonized by more than one resistant species; only three (6%) were on contact-isolation precautions at the time of the prevalence survey. Risk factors for colonization varied by pathogen: total dependence on healthcare workers (HCWs) for activities of daily living (ADLs) and antimicrobial receipt for MRSA, total dependence on HCWs for ADLs for ESBL-producing K. pneumoniae, and antimicrobial receipt for VRE. No significant risk factors were identified for colonization by ESBL-producing E. coli. Among colonized patients, there was a limited number of strain types for MRSA (24 patients, 4 strain types) and ESBL-producing K. pneumoniae (21 patients, 3 strain types), and a high proportion of unique strain types for VRE (4 patients, 4 strain types) and FSBL-producing E. coli (17 patients, 10 strain types).

CONCLUSION

A large unrecognized reservoir of skilled-care-unit residents was colonized by antimicrobial-resistant pathogens, and co-colonization by more than one target species was common. To prevent transmission of antimicrobial-resistant pathogens in long-term care facilities in which residents have high rates of colonization, infection-control strategies may need to be modified. Potential modifications include enhanced infection-control strategies, such as universal gloving for all or high-risk residents, or screening of high-risk residents, such as those with total dependence on HCWs for ADLs or recent antimicrobial receipt, and initiation of contact-isolation precautions for colonized residents.

The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans' Affairs hospital

OBJECTIVE

To describe the clinical and molecular epidemiology of mupirocin-resistant (MR) and mupirocin-susceptible (MS) methicillin-resistant Staphylococcus aureus (MRSA) at a Veterans' Affairs hospital and to assess risk factors associated with the acquisition of MR MRSA.

DESIGN

All clinical MRSA isolates for the period October 1990 through March 1995 underwent susceptibility testing to mupirocin. Mupirocin resistance trends were measured, and MS MRSA and MR MRSA isolates underwent typing by pulsed-field gel electrophoresis (PFGE). A retrospective case-control study was conducted to evaluate risk factors for having MR versus MS MRSA.

SETTING

The James H. Quillen Veterans' Affairs Medical Center in Mountain Home, Tennessee, included a 324-bed acute-care hospital, a 120-bed nursing home, and a 525-bed domiciliary. Colonizations and infections with MRSA were endemic, and mupirocin ointment was commonly used.

PATIENTS

Inpatients and outpatients at the facility.

RESULTS

MS MRSA was recovered from 506 patients and MR MRSA from 126. Among MR MRSA isolates, 58% showed low-level mupirocin resistance (minimum inhibitory concentration [MIC] > or = 4 to 256 microg/mL), and 42% showed high-level mupirocin resistance (MIC > or = 512 microg/mL). A significant increase (P=.002) in the number of high-level MR isolates occurred during the 1993 to 1995 period. A case-control study showed that presence of a decubitus ulcer correlated with high-level resistant isolates (P<.05). The distribution of PFGE patterns did not differ for MR and MS MRSA CONCLUSIONS: Use of mupirocin ointment in a program aimed at managing endemic MRSA infection or colonization resulted in a significant increase in the recovery of high-level MR MRSA isolates. These isolates appeared to emerge from our existing MRSA pool. A case-control study provided few clues concerning patients likely to harbor MR MRSA. We confirmed the position that the extended use of mupirocin ointment should be avoided in settings where MRSA is endemic.

Methicillin-resistant Staphylococcus aureus colonization in nursing home residents: a prevalence study in Northamptonshire

A prevalence study of methicillin-resistant Staphylococcus aureus (MRSA) colonization was carried out in 17 nursing homes in Northamptonshire over a 20-month period. Thirteen of 275 residents swabbed (4.7%) were found to be colonized and six of the 17 homes (35%) had colonized residents. Only two homes had more than one colonized resident. Individual risk factors for colonization were gender (male) and the presence of skin ulcers and sores. There were no significant risk factors identified for homes. Spread may have occurred in the two homes which had more than one colonized resident. Both these homes had the epidemic strain EMRSA-15 whereas three of the four homes with a single colonized resident had EMRSA-16. It is suggested that homes with residents colonized with EMRSA-16 may be able to prevent spread by adherence to good infection control procedures but that this may not be adequate to prevent spread of EMRSA-15.

Methicillin-resistant Staphylococcus aureus: long-term care concerns

Colonization of residents of long-term care facilities with methicillin-resistant Staphylococcus aureus (MRSA) is an important healthcare concern. MRSA colonization is prevalent; in two of the most common sites of colonization, nares and wounds, colonization rates range from 8% to 53%, and 30% to 82%, respectively. With such a large number of patients harboring the organism, it is imperative that long-term care facilities are knowledgeable regarding the overall significance of MRSA, are aware of MRSA infection rates at their facilities, and have established a threshold above which outbreak precautions will be instituted. More importantly, facilities must ensure that appropriate precautions (e.g., hand washing, glove changes, gowns) are utilized to prevent transmission of MRSA to noncolonized residents. If these basic measures are taken, MRSA-colonized residents of long-term facilities should be able to be fully integrated into the everyday activities within the long-term care environment. In the event of an outbreak of MRSA infection, stricter isolation of colonized and infected residents is warranted, and such isolation should be discontinued as soon as the chain of transmission has been disrupted. Systemic antibiotics should be avoided in asymptomatic colonized patients; topical antibiotics like mupirocin should be reserved for short-term administration in outbreak situations.

Issues in the management of resistant bacteria in long-term-care facilities

The prevalence of antibiotic-resistant bacteria in the long-term-care setting and the risk to nursing home residents is still unknown. Few studies have been done in community-based nursing homes, and most have focused on colonization rather than infection rates. Concerns about methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci have been expressed most often, while relatively scant attention has been paid to the problem of antibiotic resistance in gram-negative bacilli. Antibiotic resistance precautions need to be developed for nursing homes that are simple, effective, inexpensive, and recognize the unique rehabilitative and long-term custodial missions of chronic-care facilities.