Methicillin-resistant Staphylococcus aureus septic arthritis: an emerging clinical syndrome (2022)

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Volume 44 Issue 9

September 2005

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J. J. Ross,

J. J. Ross

Correspondence to: J. J. Ross, Division of Infectious Diseases, Caritas Saint Elizabeth's Medical Center, 736 Cambridge Street, Boston, MA 02135, USA. E-mail: jrossmd@cchcs.org

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L. Davidson

L. Davidson

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Rheumatology, Volume 44, Issue 9, September 2005, Pages 1197–1198, https://doi.org/10.1093/rheumatology/kei035

Published:

27 July 2005

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Accepted:

24 June 2005

Published:

27 July 2005

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    J. J. Ross, L. Davidson, Methicillin-resistant Staphylococcus aureus septic arthritis: an emerging clinical syndrome, Rheumatology, Volume 44, Issue 9, September 2005, Pages 1197–1198, https://doi.org/10.1093/rheumatology/kei035

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Sir, Despite the increasing importance of methicillin-resistant Staphylococcus aureus (MRSA) as a nosocomial and community pathogen, little is known about the clinical characteristics of MRSA septic arthritis. Prior descriptions of native joint MRSA septic arthritis in adults are confined to case reports [1–4]. In recent European studies, 6–8% cases of septic arthritis were due to MRSA [5, 6], although these patients were not described in detail. We reviewed cases of native joint septic arthritis from the past 5 yr from our institutions to assess the prevalence and characteristics of MRSA septic arthritis, and the relative contributions of the health-care setting and the community to its epidemiology. Dichotomous variables were analysed using Fisher's exact test and continuous variables were analysed using Student's t-test.

Demographic and clinical information are summarized in Table 1. Fifteen of 59 septic arthritis cases (25%) involved MRSA. Patients with MRSA septic arthritis were significantly older than patients with non-MRSA septic arthritis (69 vs 54 yr; P = 0.003). MRSA septic arthritis patients also had a significantly greater mean number of comorbid medical conditions compared with non-MRSA septic arthritis patients (5.8 vs 2.6; P<0.0001). All 15 patients with MRSA septic arthritis had significant exposure to the health-care system. Hospitalization within the preceding 6 months was observed in 80% (12 of 15 patients) of the MRSA group compared with 34% (15 of 44 patients) of the non-MRSA septic arthritis group (P = 0.002). Of the other three MRSA patients, one had a history of MRSA bacteraemia 3 yr previously and the other two were HIV-positive intravenous drug users.

Table 1.

Characteristics of patients with septic arthritis due to MRSA vs those with non-MRSA septic arthritis

MRSA septic arthritisNon-MRSA septic arthritis
Characteristic(n = 15)(n = 44)P
Demographics and risk factors
    Male9/15 (60)31/44 (70)0.13
    Age (yr), mean69540.003
    Hospitalization in past 6 months12/15 (80)15/44 (34)0.002
    No. of comorbid medical conditions, mean5.82.6<0.0001
    Pre-existing rheumatic disease3/15 (20)11/44 (25)>0.2
    Previously healthy0/15 (0)7/44 (16)0.11
Clinical presentation and outcome
    Fever7/15 (47)16/39 (41)>0.2
    Leucocytosis10/15 (67)14/37 (38)0.04
    Bacteraemia9/15 (60)16/44 (36)0.07
    Polyarticular involvement4/15 (27)4/44 (9)0.08
    Arthroscopic or open surgical drainage9/15 (60)26/44 (59)>0.2
    Mortality3/15 (20)3/44 (7)0.13
MRSA septic arthritisNon-MRSA septic arthritis
Characteristic(n = 15)(n = 44)P
Demographics and risk factors
    Male9/15 (60)31/44 (70)0.13
    Age (yr), mean69540.003
    Hospitalization in past 6 months12/15 (80)15/44 (34)0.002
    No. of comorbid medical conditions, mean5.82.6<0.0001
    Pre-existing rheumatic disease3/15 (20)11/44 (25)>0.2
    Previously healthy0/15 (0)7/44 (16)0.11
Clinical presentation and outcome
    Fever7/15 (47)16/39 (41)>0.2
    Leucocytosis10/15 (67)14/37 (38)0.04
    Bacteraemia9/15 (60)16/44 (36)0.07
    Polyarticular involvement4/15 (27)4/44 (9)0.08
    Arthroscopic or open surgical drainage9/15 (60)26/44 (59)>0.2
    Mortality3/15 (20)3/44 (7)0.13

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Table 1.

Characteristics of patients with septic arthritis due to MRSA vs those with non-MRSA septic arthritis

MRSA septic arthritisNon-MRSA septic arthritis
Characteristic(n = 15)(n = 44)P
Demographics and risk factors
    Male9/15 (60)31/44 (70)0.13
    Age (yr), mean69540.003
    Hospitalization in past 6 months12/15 (80)15/44 (34)0.002
    No. of comorbid medical conditions, mean5.82.6<0.0001
    Pre-existing rheumatic disease3/15 (20)11/44 (25)>0.2
    Previously healthy0/15 (0)7/44 (16)0.11
Clinical presentation and outcome
    Fever7/15 (47)16/39 (41)>0.2
    Leucocytosis10/15 (67)14/37 (38)0.04
    Bacteraemia9/15 (60)16/44 (36)0.07
    Polyarticular involvement4/15 (27)4/44 (9)0.08
    Arthroscopic or open surgical drainage9/15 (60)26/44 (59)>0.2
    Mortality3/15 (20)3/44 (7)0.13
MRSA septic arthritisNon-MRSA septic arthritis
Characteristic(n = 15)(n = 44)P
Demographics and risk factors
    Male9/15 (60)31/44 (70)0.13
    Age (yr), mean69540.003
    Hospitalization in past 6 months12/15 (80)15/44 (34)0.002
    No. of comorbid medical conditions, mean5.82.6<0.0001
    Pre-existing rheumatic disease3/15 (20)11/44 (25)>0.2
    Previously healthy0/15 (0)7/44 (16)0.11
Clinical presentation and outcome
    Fever7/15 (47)16/39 (41)>0.2
    Leucocytosis10/15 (67)14/37 (38)0.04
    Bacteraemia9/15 (60)16/44 (36)0.07
    Polyarticular involvement4/15 (27)4/44 (9)0.08
    Arthroscopic or open surgical drainage9/15 (60)26/44 (59)>0.2
    Mortality3/15 (20)3/44 (7)0.13

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Joint involvement was similar between the two groups, except that shoulder involvement was significantly more common in MRSA cases: 6 of 15 MRSA cases (40%) vs 6 of 44 non-MRSA cases (14%), P = 0.03. This probably relates to the predisposing role of recent falls, upper extremity trauma and orthopaedic procedures among the older patient population with MRSA infection, rather than a particular tropism for the shoulder joint.

Mortality during the initial hospitalization was 3 of 15 patients (20%) in the MRSA group vs 3 of 44 patients (7%) in the non-MRSA group (P = 0.13). Six of the 12 MRSA patients who survived developed osteomyelitis in the bone adjacent to the joint. Five of the 15 patients had extra-articular foci of MRSA infection: two patients had central line sepsis, one patient had endocarditis, one patient had an epidural abscess, and one patient had infection of an abdominal aortic graft. All 12 survivors were clinically cured of septic arthritis after an average of 6 weeks of antibiotic therapy. Eleven patients received vancomycin and one patient received linezolid. Limited information was available regarding functional outcome.

Colonization or infection with MRSA during hospitalization establishes a durable risk of subsequent MRSA infection. In one study, 29% of hospitalized patients who acquired MRSA developed new or recurrent MRSA infection in the 18 months after discharge [7]. Of the 12 patients with a history of hospitalization in the preceding 6 months, seven developed symptoms of septic arthritis in patients (58%) while out in the community. Although these patients all received empirical treatment with vancomycin, failure to take into account the history of hospitalization could have resulted in inappropriately narrow empirical antibiotic coverage.

MRSA may be more virulent than methicillin-sensitive Staphylococcus aureus (MSSA). Approximately 1.6% of episodes of MRSA bacteraemia result in septic arthritis, a rate higher than observed for MSSA bacteraemia [8]. One meta-analysis showed a higher mortality for MRSA bacteraemia than MSSA bacteraemia, a finding that might be explained by bacterial virulence, patient factors, or the lack of rapidly bactericidal antibiotics for MRSA treatment [9]. Our experience is inadequate to determine whether MRSA septic arthritis is more aggressive than MSSA septic arthritis, particularly as the affected older population with chronic illness would be expected to have worse clinical outcomes.

Ten of 12 (83%) MRSA isolates were resistant to clindamycin. As 79% of health-care-associated MRSA strains in the USA are resistant to clindamycin, compared with only 17% of community isolates of MRSA, this suggests a predominance of MRSA septic arthritis from strains originating in the health-care system [10].

Recommendations for the treatment of septic arthritis place insufficient emphasis on the possibility of MRSA infection in individuals with health-care system exposure. As septic arthritis may cause rapid joint destruction, and delayed initiation of appropriate therapy is associated with poor outcomes, the correct choice of empirical antibiotic therapy is crucial. Patients with suspected septic arthritis who have a history of recent hospitalization, previous MRSA infection or colonization, multiple comorbid medical conditions, other risk factors for MRSA infection, such as intravenous drug use, or who live in locales with a high prevalence of community-acquired MRSA, should receive an antibiotic regimen containing vancomycin.

The authors have declared no conflict of interest.

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Author notes

Division of Infectious Diseases, Caritas Saint Elizabeth's Medical Center and 1Division of Geographic Medicine and Infectious Diseases, New England Medical Center, Boston, MA, USA

© The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org

© The Author 2005. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oupjournals.org

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RESEARCH ARTICLEHigh Prevalence of Methicillin-Resistant Staphylococcus aureus among Patients with Septic Arthritis Caused by Staphylococcus aureus Wei-Ting Lin1,2, Chung-Da Wu1, Shun-Chien Cheng1, Chong-Chi Chiu3,4, ChiChou Tseng5, Huan-Tee Chan5, Po-Yih Chen5, Chien-Ming Chao6,7* 1 Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan, 2 Department of Physical Therapy, Shu Zen Junior College of Medicine and Management, Tainan, Taiwan, 3 Department of General Surgery, Chi Mei Medical Center, Liouying, Tainan, Taiwan, 4 Department of Electrical Engineering, Southern Taiwan University of Science and Technology, Tainan, Taiwan, 5 Department of Orthopaedics, Chi Mei Medical Center, Liouying, Tainan, Taiwan, 6 Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan, 7 Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan * [email protected]. Background This study investigated the clinical characteristics of patients with septic arthritis caused by Staphylococcus aureus and tried to identify the risk factors for methicillin-resistant S. aureus (MRSA) arthritis.. Results A total of 93 patients with S. aureus arthritis were identified, and MRSA arthritis was found in 38 (40.9%) cases.. Patients with MRSA arthritis were more frequently elderly and found in the setting of healthcare-associated infection than patients with methicillin-susceptible S. aureus (MSSA) infections.. Additionally, we wanted to identify risk factors for MRSA arthritis and analyze the prognostic factors of mortality among patients with S. aureus arthritis.. Comparison between patients with MSSA arthritis and MRSA arthritis We compared the clinical manifestations between 55 patients with MSSA arthritis and 38 patients with MRSA arthritis (Table 2).. Comparison of 55 and 38 patients with septic arthritis caused by methicillin-susceptible Staphylococcus aureus and methicillin-resistant Staphylococcus aureus.. Most important, about 40% of cases of S. aureus arthritis were caused by MRSA, and more than 80% of MRSA arthritis cases were classified as community-acquired infections.. This is consistent with previous findings about different types of S. aureus infection in Taiwan, in which MRSA infection accounted for more than half of nosocomial S. aureus infections [9] and was an emerging pathogen causing community-acquired infections [10].. We further tried to find the risk factors for MRSA arthritis among patients with S. aureus arthritis.. Ross found that patients with MRSA arthritis were significantly older than patients with non-MRSA arthritis (69 vs. 54, p = 0.003) [12].. In conclusion, this study in Taiwan showed a high prevalence of MRSA in patients with septic arthritis, even in community-acquired infections.

Methods: We report a case of community-acquired fatal MRSA septic arthritis of the hip and analyze the clinical features of 56 additional adult patients with native-joint MRSA septic arthritis identified through a systematic literature review.. A preexisting rheumatic disease is the most common predisposition.. A preexisting rheumatic disease is the most common predisposition.. A preexisting rheumatic disease is the most common predisposition.. A preexisting rheumatic disease is the most common predisposition.

Pneumonia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus Positive for Exfoliative Toxin A and Secondary to Allergic Bronchopulmonary Aspergillosis. Case report Published: May 25, 2022. Cite this article as: Itano J, Tanimoto Y, Nishimura T, et al. (May 25, 2022) Pneumonia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus Positive for Exfoliative Toxin A and Secondary to Allergic Bronchopulmonary Aspergillosis.. Draft WGS led to identifying the genotype and virulence factors and showed that the strain was a rare sequence-type of MRSA with the following characteristics: staphylococcal cassette chromosome mec (SCC mec ) type IV, sequence type 121, exfoliative toxin A-positive, and specific staphylococcal protein A type t5110.. To shed light on the clinical course, toxin, and genotypes of the strains responsible for CA-MRSA in Japan, we reviewed previous reports that included chest radiographs, CT findings, and data on toxin production and genetic analysis using SCC mec typing, MLST, and spa typing.. Although CA-MRSA pneumonia caused by a strain belonging to ST121 and not producing PVL, TSST-1, or ETA was reported, the clinical background of the case was different than that of ours, as the patient in the former was 92 years old, had a history of cerebral infarction, and died of aspiration pneumonia [12] .. While the relationship between ETA and CA-MRSA pneumonia remains unclear, our data indicate that our patient was infected with a rare subclone of MRSA belonging to ST121 and producing ETA.. In summary, we reported a case of CA-MRSA pneumonia caused by a rare MRSA subclone in a patient with ABPA.. 10.1016/j.jmii.2012.09.004 Wan TW, Tomita Y, Saita N, et al.: Emerging ST121/agr4 community-associated methicillin-resistant Staphylococcus aureus (MRSA) with strong adhesin and cytolytic activities: trigger for MRSA pneumonia and fatal aspiration pneumonia in an influenza-infected elderly .. 10.1016/j.rmcr.2020.101316 Defres S, Marwick C, Nathwani D: MRSA as a cause of lung infection including airway infection, community-acquired pneumonia and hospital-acquired pneumonia .. Case report Pneumonia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus Positive for Exfoliative Toxin A and Secondary to Allergic Bronchopulmonary Aspergillosis Junko Itano Department of Allergy and Respiratory Medicine, National Hospital Organization Minami-Okayama Medical Center, Okayama, JPN. DOICite this article as: Itano J, Tanimoto Y, Nishimura T, et al. (May 25, 2022) Pneumonia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus Positive for Exfoliative Toxin A and Secondary to Allergic Bronchopulmonary Aspergillosis.. Case report Pneumonia Caused by Community-Acquired Methicillin-Resistant Staphylococcus aureus Positive for Exfoliative Toxin A and Secondary to Allergic Bronchopulmonary Aspergillosis

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