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Epidemiology of Necrotizing Infection Caused by Staphylococcus Aureus and Streptococcus Pyogenes at an Iowa Hospital

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Epidemiology of Necrotizing Infection Caused by Staphylococcus Aureus and Streptococcus Pyogenes at an Iowa Hospital Journal of Infection and Public Health (2015) 8, 634—641 View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector SHORT COMMUNICATION Epidemiology of necrotizing infection caused by Staphylococcus aureus and Streptococcus pyogenes at an Iowa hospital a,b,1 a,b Dipendra Thapaliya , Ashley M. O’Brien , a,b a,b,∗,1 Shylo E. Wardyn , Tara C. Smith a Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA b Center for Emerging Infectious Diseases, University of Iowa College of Public Health, Iowa City, IA, USA Received 2 February 2015; received in revised form 28 May 2015; accepted 12 June 2015 KEYWORDS Summary The present study was performed to characterize the epidemiology Staphylococcus aureus; of necrotizing soft tissue infection caused by Streptococcus pyogenes (n = 14) and Streptococcus Staphylococcus aureus (n = 14) isolates collected at the University of Iowa Hospitals pyogenes; and Clinics. An additional 9 S. pyogenes isolates were collected from patients being treated for mild respiratory infections and served as a comparison sample in the anal- Necrotizing fasciitis; ysis. Patient data corresponding to the isolates (n = 37) were also collected in order Epidemiology; to identify risk factors or comorbid conditions possibly correlated with necrotizing Infection fasciitis (NF). The prevalence of methicillin-resistant S. aureus among the study isolates was 35.7% (5/14), and the prevalence of the Panton—Valentine leukocidin (PVL) gene was 57% (8/14). The S. pyogenes NF (wound) isolates (n = 14) belonged to 10 different emm types, none of which appeared to be associated with more severe disease when compared to the milder infection (throat) samples (n = 9). Comorbid conditions such as diabetes and cardiovascular disease were significantly associated with NF. The results indicate that there may be a high prevalence of the PVL vir- ulence factor in NF infections and that spa type t008 may be responsible for the increasing incidence of S. aureus NF infections in Iowa. © 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved. ∗ Corresponding author at: 750 Hilltop Drive, Lowry Hall, Kent, OH 44242, USA. Tel.: +1 330 672 3946. E-mail address: [email protected] (T.C. Smith). 1 Present address: Department of Biostatistics, Environmental Health Sciences, & Epidemiology, College of Public Health, Kent State University, Kent, OH, USA. http://dx.doi.org/10.1016/j.jiph.2015.06.003 1876-0341/© 2015 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved. Necrotizing fasciitis in Iowa 635 Introduction Materials and methods In the United States, the incidence of necrotiz- Study isolates (n = 38) were collected and stored ing infections is approximately 0.04 cases per 1000 at the University of Iowa Hospitals and Clinics persons-years [1]; nevertheless, the disease is often Pathology Department between January 2011 and characterized by its rapid progression and high mor- September 2012. Fourteen S. aureus and 14 S. tality rate, which is estimated to range from 25% pyogenes samples were collected from cases of to 35% [1,2], though some studies have reported necrotizing infection; the remaining 10 S. pyo- a mortality rate as high as 50% [3]. Most necro- genes isolates were obtained from throat cultures tizing infection cases are caused by Streptococcus collected from patients being treated for mild pyogenes; however, the incidence of necrotizing respiratory infections and served as a comparison fasciitis (NF) with Staphylococcus aureus identified in the analysis. Isolates were attained from the as the primary pathogen is on the rise [4,5]. Pathology Department in October 2012 following To date, little is known about the pathogeni- IRB approval, and were analyzed at the Center city of necrotizing infections, primarily regarding for Emerging Infectious Diseases with molecular molecular characterization and virulence factors, typing. as well as host factors that may be correlated Genomic DNA extraction was performed using with severe necrotizing infections. Three notable the Wizard Genomic DNA preparation kit (Promega, virulence factors associated with S. pyogenes infec- WI). Polymerase chain reaction (PCR) was per- tion include emm type, mutations in the covR/covS formed to detect mecA and PVL genes (lukS, lukF) system, and the presence of superantigens. Previ- present in the S. aureus isolates [13,14]. The ous research has indicated that certain emm types staphylococcus protein A (spa) gene was amplified may be responsible for necrotizing S. pyogenes using SpaF (5 -GAACAA-CGTAACGGCTTCATCC-3 ) infections, particularly emm types 1, 3, and 12 and 1514R (5 -CAGCAGTAGTGCCGTTTGCCT-3 ), as [6—8]. previously described [15,16]; emm typing was car- A key virulence factor of interest for S. aureus ried out for all S. pyogenes isolates [17], and 16s infections is the presence of the Panton—Valentine rRNA PCR was performed with all isolates to confirm leukocidin (PVL) gene. Of particular interest, two the species [18]. Upon completion of 16s rRNA PCR, previous studies performed molecular typing on 1 isolate among the S. pyogenes throat samples was subsets of methicillin-resistant S. aureus (MRSA) found to belong to the Streptococcus parasangui- isolates causing NF and reported the presence of nis species, and was subsequently excluded from the PVL gene in 100% of the samples (5/5) [4,9]. further analysis, leaving 9 throat infection isolates. Along with molecular characterization, numer- Multilocus sequence typing was completed on all ous studies have investigated the association but 1 study isolate [19]. between certain host factors and an increased All S. aureus and 23 S. pyogenes isolates were risk of NF. Studies examining patient medical tested for antibiotic susceptibility by using the histories have identified a multitude of factors, VITEK 2 System (bioMérieux). We used the AST- including prior trauma, surgery, nonsteroidal anti- GP71 and AST-ST01 cards of the VITEK 2 System inflammatory drug use, burns, chronic alcohol for the antibiotic susceptibility testing of S. aureus consumption, immunosuppressive drug use, cancer, and S. pyogenes, respectively. S. aureus isolates diabetes, obesity, and renal disease, among others, were tested for susceptibility to benzylpeni- that may be correlated with NF [10—12]. However, cillin, oxacillin, tetracycline, erythromycin, cipro- studies also have reported the occurrence of necro- floxacin, moxifloxacin, minocycline, clindamycin, tizing infections in patients with no known risk trimethoprim—sulfamethoxazole, quinupristin/ factors or comorbid conditions [4,11]. dalfopristin, gentamicin, levofloxacin, line- The previously described findings demonstrate zolid, daptomycin, vancomycin, rifampicin, the need for further research regarding the etiol- minocycline, tigecycline, and nitrofurantoin. S. ogy of NF. The goals of our study were to determine pyogenes isolates were tested for susceptibility the molecular characterization of NF caused by to benzylpenicillin, ampicillin, cefotaxime, cef- S. pyogenes and S. aureus, including emm type triaxone, tetracycline, erythromycin, clindamycin, (S. pyogenes), spa type, and the presence of the trimethoprim—sulfamethoxazole, levofloxacin, PVL and mecA genes (S. aureus), and to identify linezolid, and vancomycin. Isolates showing inter- whether specific host factors are correlated with mediate levels of susceptibility were classified as severe necrotizing infections among patients at the resistant. S. aureus isolates that were resistant to University of Iowa Hospitals and Clinics. 3 or more classes of antimicrobials or that were 636 D. Thapaliya et al. resistant to oxacillin were considered multidrug were detected among the 14 necrotizing infec- resistant [20]. tion and 9 throat infection S. pyogenes isolates. We retrieved patient data from the medical ST36 was the most common sequence type iden- records of the University of Iowa Hospitals and tified (17%; 4/23), followed by ST678 (13%; 3/23), Clinics and linked patients’ medical record num- ST101 (13%; 3/23), and ST63 (9%; 2/23). No other bers to the bacterial specimens for the purposes sequence types (48%; 11/23) were found to be of investigating host factors that may be associated repeated. with necrotizing infection. Patients’ demographics, Among 14 S. aureus isolates, oxacillin resis- clinical data, comorbid conditions, outcome vari- tance was observed in 35.7% (5/14). Four isolates ables, and specimen-specific data were extracted (28.6%) were resistant to ciprofloxacin; 7 (50%) and entered into the database. Analysis of patient were resistant to erythromycin; 2 (14.3%) were data was conducted using SAS statistical software resistant to clindamycin; 3 (21.4%) were resistant (version 9.3, SAS Institute Inc., Cary, NC). to levofloxacin; and all 14 (100%) were resistant to benzylpenicillin. Eight isolates (57%) were mul- tidrug resistant S. aureus. Among 23 S. pyogenes Results isolates, 7 isolates (30.4%) were resistant to eryth- romycin; 1 (4.3%) was resistant to ciprofloxacin; 8 (34.8%) were resistant to clindamycin; 1 (4.3%) Molecular typing revealed 9 different spa types was resistant to ceftriaxone; 7 (30.4%) were resis- among the S. aureus study isolates, with the only tant to tetracycline; and 1 (4.3%) was resistant to repeat type being t008 (43%; n = 6). The prevalence cefotaxime. of MRSA in the study sample was 35.7% (5/14). All of Sixty-nine percent (9/13) and 31% (4/13) of the MRSA isolates were spa type t008. Fifty-seven the NF patients were male and female, respec- percent (8/14) of the S. aureus isolates harbored tively. Sixty-nine percent of the patients (9/13) the PVL gene, while all MRSA isolates harbored the were white, and 31% (4/13) were African Ameri- PVL genes. Most of the S. aureus isolates (86%; can. The median age of the patients was 48 years 12/14) contained a functional agr. (n = 13; mean, 42.69; standard deviation, 12.65; A total of 7 different sequence types were range, 21—61) (Table 2). detected among 14 necrotizing infection S. aureus The median length of hospitalization was 10 isolates.
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