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Methicillin-Resistant Staph in the Community

MRSA infections, once exclusively nosocomial, now are occurring in healthy outpatients, including professional football players.

Methicillin-resistant Staphylococcus aureus (MRSA) infections once were exclusively nosocomial, but now they occur in healthy outpatients. Three reports illustrate the spectrum of disease associated with this organism.

Four previously healthy adults with community-acquired pneumonia that was caused by MRSA were admitted to Johns Hopkins Hospital during the winter of 2003-2004. All presented with severe necrotizing pneumonia, leukopenia, respiratory failure, and shock. One (a smoker, age 52) died on hospital day 2. The others (ages 20, 31, and 33) required prolonged intensive care unit stays, but they survived. Influenza A serology was positive in the two patients in whom it was ordered. All bacterial isolates were susceptible to clindamycin and trimethoprim-sulfamethoxazole as well as to vancomycin, and all isolates possessed genes for a staphylococcal virulence factor (Panton-Valentine leukocidin [PVL]).

Outbreaks of MRSA skin infections also were reported on two football teams in 2003. On a Connecticut college team, 10 of 100 players developed 13 episodes of cellulitis or skin abscesses caused by MRSA. Wide receivers and cornerbacks had the highest risk; independent behavioral risks included body shaving and whirlpool use. In an outbreak of 8 MRSA-infected turf burns among 5 of 58 members of the St. Louis Rams, linemen and linebackers had the highest risk; case numbers were too small to identify behavioral risks. In both outbreaks, nasal cultures failed to identify MRSA carriers on the team, and environmental sources of MRSA were not identified. The PVL gene was present in all isolates tested, but serious morbidity did not occur.

Comment: Community-acquired MRSA is becoming one of the biggest infectious mysteries of the decade; investigators are not sure where it came from, where it lives, or how it spreads. The athletic team outbreaks imply person-to-person transmission, but whether this applies to cases of pneumonia is unclear. Primary care providers should keep an eye out for these infections and should remember to culture outpatient staph infections that fail to respond to standard empirical anti-staphylococcal penicillins or cephalosporins. When patients are seriously ill, vancomycin should be the empirical anti-staph drug of choice.

— Abigail Zuger, MD

Published in Journal Watch General Medicine February 18, 2005

Citation(s):

Francis JS et al. Severe community-onset pneumonia in healthy adults caused by methicillin-resistant Staphylococcus aureus carrying the Panton-Valentine leukocidin genes. Clin Infect Dis 2005 Jan 1; 40:100-7.

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Begier EM et al. A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players on a college football team, facilitated by cosmetic body shaving and turf burns. Clin Infect Dis 2004 Nov 15; 39:1446-53.

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Kazakova SV et al. A clone of methicillin-resistant Staphylococcus aureus among professional football players. N Engl J Med 2005 Feb 3; 352:468-75.

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• Medline abstract (Free)