University of Edinburgh



The prevalence of methicillin-resistant Staphylococcus aureus among diabetic patients: a meta-analysisHelen J. Stacey1^, Caitlin S. Clements2^, Susan C. Welburn2,3 and Joshua D. Jones2,3*1Edinburgh Medical School, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK2Division of Infection and Pathway Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK3ZJU-UoE Institute, Zhejiang University School of Medicine, International Campus, Zhejiang University, 718 East Haizhou Road, Haining, Zhejiang 314400, P.R. China^These authors contributed equally to this work.*E-mail: josh.jones@ed.ac.ukRunning title: The prevalence of MRSA in diabetic patientsAbstract: 268Article (excl. refs.): 3,522Abstract BackgroundDiabetic patients have multiple risk factors for colonisation with methicillin-resistant Staphylococcus aureus (MRSA), a nosocomial pathogen associated with significant morbidity and mortality. This meta-analysis was conducted to estimate the prevalence of MRSA among diabetic patients.Methods The MEDLINE, Embase, BIOSIS and Web of Science databases were searched for studies published up to May 2018 that reported primary data on the prevalence of MRSA in 10 or more diabetic patients. Two authors independently assessed study eligibility and extracted the data. The main outcomes were the pooled prevalence rates of MRSA colonisation and infection among diabetic populations.ResultsEligible datasets were divided into three groups containing data about the prevalence of MRSA colonisation or in diabetic foot or other infections. From 23 datasets, the prevalence of MRSA colonisation among 11577 diabetics was 9.20% (95% CI, 6.26-12.63%). Comparison of data from 14 studies that examined diabetic and non-diabetic patients found that diabetics had a 4.75% greater colonisation rate (P < 0.0001). From 41 datasets, the prevalence of MRSA in 10994 diabetic foot infection patients was 16.78% (95% CI, 13.21-20.68%). Among 2147 non-foot skin and soft tissue infections the MRSA prevalence rate was 18.03% (95% CI, 6.64-33.41). ConclusionsThe prevalence of MRSA colonisation among diabetic patients is often higher than among non-diabetics, this may make targeted screening attractive. In the UK many diabetic patients may already be covered by current screening policies. The prevalence and impact of MRSA among diabetic healthcare workers requires further research. The high prevalence of MRSA among diabetic foot infections may have implications for antimicrobial resistance and should encourage strategies aimed at infection prevention or alternative therapies.KeywordsDiabetes; diabetic patients; meta-analysis; methicillin-resistant Staphylococcus aureus; MRSA; prevalence; resistanceAbbreviationsCIs, 95% confidence intervals; HIV-1, human immunodeficiency virus type one; MRSA, methicillin-resistant Staphylococcus aureus; NF, necrotizing fasciitis; PCR, polymerase chain reaction; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; SSTI, skin and soft tissue infection. IntroductionStaphylococcus aureus infections can be classified as methicillin-resistant Staphylococcus aureus (MRSA) or methicillin-sensitive Staphylococcus aureus (MSSA). Individuals colonised with MRSA are typically asymptomatic, however if the bacterium breaches the patient’s physical defences infection can occur. The economic and clinical burden of MRSA is significant, with high rates of morbidity and mortality and increased hospital costs associated with MRSA compared to MSSA ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"W4a9D1Km","properties":{"formattedCitation":"(1,2)","plainCitation":"(1,2)","noteIndex":0},"citationItems":[{"id":16772,"uris":[""],"uri":[""],"itemData":{"id":16772,"type":"article-journal","title":"Comparison of Mortality Associated with Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus Bacteremia: A Meta-analysis","container-title":"Clinical Infectious Diseases","page":"53-59","volume":"36","issue":"1","source":"academic.","abstract":"Abstract. A meta-analysis was performed to summarize the impact of methicillin-resistance on mortality in Staphylococcus aureus bacteremia. A search of the MED","DOI":"10.1086/345476","ISSN":"1058-4838","shortTitle":"Comparison of Mortality Associated with Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus Bacteremia","journalAbbreviation":"Clin Infect Dis","language":"en","author":[{"family":"Cosgrove","given":"Sara E."},{"family":"Sakoulas","given":"George"},{"family":"Perencevich","given":"Eli N."},{"family":"Schwaber","given":"Mitchell J."},{"family":"Karchmer","given":"Adolf W."},{"family":"Carmeli","given":"Yehuda"}],"issued":{"date-parts":[["2003",1,1]]}}},{"id":16776,"uris":[""],"uri":[""],"itemData":{"id":16776,"type":"article-journal","title":"Excess Costs and Utilization Associated with Methicillin Resistance for Patients with Staphylococcus aureus Infection","container-title":"Infection Control & Hospital Epidemiology","page":"365-373","volume":"31","issue":"04","source":"Crossref","DOI":"10.1086/651094","ISSN":"0899-823X, 1559-6834","language":"en","author":[{"family":"Filice","given":"Gregory A."},{"family":"Nyman","given":"John A."},{"family":"Lexau","given":"Catherine"},{"family":"Lees","given":"Christine H."},{"family":"Bockstedt","given":"Lindsay A."},{"family":"Como-Sabetti","given":"Kathryn"},{"family":"Lesher","given":"Lindsey J."},{"family":"Lynfield","given":"Ruth"}],"issued":{"date-parts":[["2010"]]}}}],"schema":""} (1,2). Risk factors which increase susceptibility to MRSA colonisation include recent exposure to antimicrobial agents, sustained hyperglycaemia associated with diabetes mellitus (diabetes), hospitalisation within the past year, skin and skin structure infections (SSTIs) and human immunodeficiency virus type one (HIV) infection ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nwxfEU2G","properties":{"formattedCitation":"(3)","plainCitation":"(3)","noteIndex":0},"citationItems":[{"id":16777,"uris":[""],"uri":[""],"itemData":{"id":16777,"type":"article-journal","title":"Risk Factors for Colonization with Methicillin-Resistant Staphylococcus aureus (MRSA) in Patients Admitted to an Urban Hospital: Emergence of Community-Associated MRSA Nasal Carriage","container-title":"Clinical Infectious Diseases","page":"159-166","volume":"41","issue":"2","source":"academic.","abstract":"Abstract. Background. Surveillance cultures performed at hospital admission have been recommended to identify patients colonized with methicillin-resistant Sta","DOI":"10.1086/430910","ISSN":"1058-4838","shortTitle":"Risk Factors for Colonization with Methicillin-Resistant Staphylococcus aureus (MRSA) in Patients Admitted to an Urban Hospital","journalAbbreviation":"Clin Infect Dis","language":"en","author":[{"family":"Hidron","given":"Alicia I."},{"family":"Kourbatova","given":"Ekaterina V."},{"family":"Halvosa","given":"J. Sue"},{"family":"Terrell","given":"Bianca J."},{"family":"McDougal","given":"Linda K."},{"family":"Tenover","given":"Fred C."},{"family":"Blumberg","given":"Henry M."},{"family":"King","given":"Mark D."}],"issued":{"date-parts":[["2005",7,15]]}}}],"schema":""} (3). Independently, MRSA colonisation has been associated with an increased risk of MRSA infection ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"9F6Lkpvy","properties":{"formattedCitation":"(4)","plainCitation":"(4)","noteIndex":0},"citationItems":[{"id":16780,"uris":[""],"uri":[""],"itemData":{"id":16780,"type":"article-journal","title":"Methicillin-Resistant Staphylococcus aureus (MRSA) Nares Colonization at Hospital Admission and Its Effect on Subsequent MRSA Infection","container-title":"Clinical Infectious Diseases","page":"776-782","volume":"39","issue":"6","source":"academic.","abstract":"Abstract. Background. Asymptomatic colonization with methicillin-resistant Staphylococcus aureus (MRSA) has been described as a risk factor for subsequent MRSA","DOI":"10.1086/422997","ISSN":"1058-4838","journalAbbreviation":"Clin Infect Dis","language":"en","author":[{"family":"Davis","given":"Kepler A."},{"family":"Stewart","given":"Justin J."},{"family":"Crouch","given":"Helen K."},{"family":"Florez","given":"Christopher E."},{"family":"Hospenthal","given":"Duane R."}],"issued":{"date-parts":[["2004",9,15]]}}}],"schema":""} (4). Certain patient groups therefore have multiple risk factors and a significantly increased susceptibility to MRSA colonisation and infection. These include, but are not limited to, patients with diabetes mellitus (diabetics), HIV-positive individuals and haemodialysis patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"wq6ABlK8","properties":{"formattedCitation":"(5,6)","plainCitation":"(5,6)","noteIndex":0},"citationItems":[{"id":16677,"uris":[""],"uri":[""],"itemData":{"id":16677,"type":"article-journal","title":"Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients","container-title":"Journal of the American Society of Nephrology: JASN","page":"2131-2141","volume":"25","issue":"9","abstract":"Patients undergoing dialysis are particularly vulnerable to methicillin-resistant Staphylococcus aureus (MRSA) infections. We performed a meta-analysis of published studies to estimate the prevalence of MRSA colonization in dialysis patients, time trends, and long-term risk of subsequent MRSA infections. Our search of the PubMed and Embase databases returned 5743 nonduplicate citations, from which we identified 38 relevant studies that included data on 5596 dialysis patients. The estimated prevalence of MRSA colonization was 6.2% (95% confidence interval [95% CI], 4.2% to 8.5%). The prevalence increased over time but remained stable after 2000. Stratification of patients according to dialysis modality and setting revealed that 7.2% (95% CI, 4.9% to 9.9%) of patients on hemodialysis were colonized with MRSA compared with 1.3% (95% CI, 0.5% to 2.4%) of patients on peritoneal dialysis (P=0.01), and that a statistically significant difference existed in the percentage of colonized inpatients and outpatients (14.2% [95% CI, 8.0% to 21.8%] versus 5.4% [95% CI, 3.5% to 7.7%], respectively; P=0.04). Notably, the risk of developing MRSA infections increased among colonized hemodialysis patients compared with noncolonized patients (relative risk, 11.5 [95% CI, 4.7 to 28.0]). The long-term (6-20 months) probability of developing a MRSA infection was 19% among colonized hemodialysis patients compared with only 2% among noncolonized patients. In summary, 6.2% of dialysis patients are MRSA colonized, and the average prevalence of colonization has remained stable since 2000. Colonization in hemodialysis patients is associated with increased risk of MRSA infection.","DOI":"10.1681/ASN.2013091028","ISSN":"1533-3450","note":"PMID: 24652802\nPMCID: PMC4147983","journalAbbreviation":"J. Am. Soc. Nephrol.","language":"eng","author":[{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Zervou","given":"Fainareti N."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",9]]}}},{"id":16675,"uris":[""],"uri":[""],"itemData":{"id":16675,"type":"article-journal","title":"Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV infection: a meta-analysis","container-title":"Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America","page":"1302-1311","volume":"59","issue":"9","abstract":"BACKGROUND: Human immunodeficiency virus (HIV)-infected individuals who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) have increased risk for MRSA infection. We conducted a meta-analysis of published studies to estimate the prevalence of MRSA colonization in this population.\nMETHODS: We performed a systematic literature review and meta-analysis. The PubMed and Embase databases were searched and studies reporting prevalence of MRSA colonization among HIV-infected individuals were included.\nRESULTS: Among 7940 citations, 32 studies reporting data on 6558 HIV-infected individuals were considered eligible for our meta-analysis. We found that 6.9% (95% confidence interval [CI], 4.8-9.3) of individuals with HIV infection are MRSA carriers, with the corresponding figure across North American studies being 8.8% (95% CI, 6.0-12.2). History of hospitalization during the previous 12 months was associated with a 3.1 times higher risk of MRSA colonization (risk ratio [RR], 3.11 [95% CI, 1.62-5.98]). Previous or current incarceration was also associated with a higher risk for carriage (RR, 1.77 [95% CI, 1.26-2.48]). Current antiretroviral therapy or use of trimethoprim-sulfamethoxazole did not impact the risk of MRSA carriage (RR, 1.02 [95% CI, .64-1.63] and 1.45 [95% CI, .69-3.03], respectively). Extranasal screening increased the detection of MRSA colonization by at least 31.6% (95% CI, 15.8-50.0). The added yield from groin screening was 19.3% (95% CI, 11.5-28.5), from perirectal screening 18.5% (95% CI, 7.4-33.2), and from throat cultures 17.5% (95% CI, 12.0-24).\nCONCLUSIONS: Individuals with HIV infection constitute a highly vulnerable population for MRSA colonization, and prior exposure to hospital or incarceration are significant factors. Nasal screening alone will underestimate the rate of colonization by at least one-third.","DOI":"10.1093/cid/ciu559","ISSN":"1537-6591","note":"PMID: 25031291\nPMCID: PMC4271036","journalAbbreviation":"Clin. Infect. Dis.","language":"eng","author":[{"family":"Zervou","given":"Fainareti N."},{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Rich","given":"Josiah D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",11,1]]}}}],"schema":""} (5,6). Diabetes is the most common metabolic disease in the world, and the global number of diabetics is predicted to rise from 382 million in 2013, to 592 million in 2035 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ReMLUiZo","properties":{"formattedCitation":"(7)","plainCitation":"(7)","noteIndex":0},"citationItems":[{"id":16783,"uris":[""],"uri":[""],"itemData":{"id":16783,"type":"article-journal","title":"Global estimates of diabetes prevalence for 2013 and projections for 2035","container-title":"Diabetes Research and Clinical Practice","page":"137-149","volume":"103","issue":"2","source":"ScienceDirect","abstract":"Introduction\nDiabetes is a serious and increasing global health burden and estimates of prevalence are essential for appropriate allocation of resources and monitoring of trends.\nMethods\nWe conducted a literature search of studies reporting the age-specific prevalence for diabetes and used the Analytic Hierarchy Process to systematically select studies to generate estimates for 219 countries and territories. Estimates for countries without available source data were modelled from pooled estimates of countries that were similar in regard to geography, ethnicity, and economic development. Logistic regression was applied to generate smoothed age-specific prevalence estimates for adults 20–79 years which were then applied to population estimates for 2013 and 2035.\nResults\nA total of 744 data sources were considered and 174 included, representing 130 countries. In 2013, 382 million people had diabetes; this number is expected to rise to 592 million by 2035. Most people with diabetes live in low- and middle-income countries and these will experience the greatest increase in cases of diabetes over the next 22 years.\nConclusion\nThe new estimates of diabetes in adults confirm the large burden of diabetes, especially in developing countries. Estimates will be updated annually including the most recent, high-quality data available.","DOI":"10.1016/j.diabres.2013.11.002","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Guariguata","given":"L."},{"family":"Whiting","given":"D. R."},{"family":"Hambleton","given":"I."},{"family":"Beagley","given":"J."},{"family":"Linnenkamp","given":"U."},{"family":"Shaw","given":"J. E."}],"issued":{"date-parts":[["2014",2,1]]}}}],"schema":""} (7). Diabetes may be complicated by foot disease. In Scotland 4.7% of diabetics are recorded as having had a foot ulcer and 0.7% as having had a lower limb amputation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2nrOPvrC","properties":{"formattedCitation":"(8)","plainCitation":"(8)","noteIndex":0},"citationItems":[{"id":16982,"uris":[""],"uri":[""],"itemData":{"id":16982,"type":"report","title":"Scottish Diabetes Survey 2016","URL":"","author":[{"family":"Scottish Diabetes Survey Monitoring Group","given":""}],"issued":{"date-parts":[["2016"]]},"accessed":{"date-parts":[["2018",11,9]]}}}],"schema":""} (8). It’s been estimated that in England approximately ?1 of every ?140 spent by the NHS goes towards the cost of caring for ulceration or amputation, and that the cost of treating diabetic foot is greater than that of the four most common cancers combined ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kh0dm31F","properties":{"formattedCitation":"(9)","plainCitation":"(9)","noteIndex":0},"citationItems":[{"id":17064,"uris":[""],"uri":[""],"itemData":{"id":17064,"type":"webpage","title":"Foot Care in Diabetes: The Human and Financial Cost","URL":"","author":[{"family":"Insight Health Economics","given":""}],"issued":{"date-parts":[["2017"]]}}}],"schema":""} (9). Gram positive organisms are commonly identified from diabetic foot infections (DFIs), with S. aureus among those most commonly isolated. A 2010 systematic review of the prevalence of MRSA in diabetic foot infections estimated the prevalence to be 15-30% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"gIqysduv","properties":{"formattedCitation":"(10)","plainCitation":"(10)","noteIndex":0},"citationItems":[{"id":17084,"uris":[""],"uri":[""],"itemData":{"id":17084,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus in diabetic foot infections","container-title":"Drugs","page":"1785-1797","volume":"70","issue":"14","source":"PubMed","abstract":"Diabetic foot ulcers are often complicated by infection. Among pathogens, Staphylococcus aureus predominates. The prevalence of methicillin-resistant S. aureus (MRSA) in infected foot ulcers is 15-30% and there is an alarming trend for increase in many countries. There are also data that recognize new strains of MRSA that are resistant to vancomycin. The risk for MRSA isolation increases in the presence of osteomyelitis, nasal carriage of MRSA, prior use of antibacterials or hospitalization, larger ulcer size and longer duration of the ulcer. The need for amputation and surgical debridement increases in patients infected with MRSA. Infections of mild or moderate severity caused by community-acquired MRSA can be treated with cotrimoxazole (trimethoprim/sulfamethoxazole), doxycycline or clindamycin when susceptibility results are available, while severe community-acquired or hospital-acquired MRSA infections should be managed with glycopeptides, linezolide or daptomycin. Dalbavancin, tigecycline and ceftobiprole are newer promising antimicrobial agents active against MRSA that may also have a role in the treatment of foot infections if more data on their efficacy and safety become available.","DOI":"10.2165/11538070-000000000-00000","ISSN":"1179-1950","note":"PMID: 20836573","journalAbbreviation":"Drugs","language":"eng","author":[{"family":"Eleftheriadou","given":"Ioanna"},{"family":"Tentolouris","given":"Nicholas"},{"family":"Argiana","given":"Vasiliki"},{"family":"Jude","given":"Edward"},{"family":"Boulton","given":"Andrew J."}],"issued":{"date-parts":[["2010",10,1]]}}}],"schema":""} (10).The rising prevalence of diabetes, predominantly in low and middle-income countries, is occurring against the backdrop of globally increasing rates of antimicrobial resistance. Knowledge of the prevalence of colonisation or infection of diabetic patients by resistant pathogens, including MRSA, will therefore be important in assessing the extent to which interventions targeted towards diabetic patients may mitigate the spread of resistant pathogens.Several meta-analyses have examined the prevalence of MRSA in high-risk populations, such as haemodialysis patients, HIV-positive patients and general, neonatal or paediatric intensive care patients and ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"z2vLVeoL","properties":{"formattedCitation":"(5,6,11,12)","plainCitation":"(5,6,11,12)","noteIndex":0},"citationItems":[{"id":16678,"uris":[""],"uri":[""],"itemData":{"id":16678,"type":"article-journal","title":"MRSA colonization and risk of infection in the neonatal and pediatric ICU: a meta-analysis","container-title":"Pediatrics","page":"e1015-1023","volume":"133","issue":"4","abstract":"BACKGROUND AND OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) is a significant cause of morbidity and mortality in NICUs and PICUs. Our objective was to assess the burden of MRSA colonization on admission, study the time trends, and examine the significance of MRSA colonization in this population.\nMETHODS: PubMed and Embase databases were consulted. Studies that reported prevalence of MRSA colonization on ICU admission were selected. Two authors independently extracted data on MRSA colonization and infection.\nRESULTS: We identified 18 suitable articles and found an overall prevalence of MRSA colonization of 1.9% (95% confidence interval [CI] 1.3%-2.6%) on admission to the NICU or PICU, with a stable trend over the past 12 years. Interestingly, 5.8% (95% CI 1.9%-11.4%) of outborn neonates were colonized with MRSA on admission to NICU, compared with just 0.2% (95% CI 0.0%-0.9%) of inborn neonates (P = .01). The pooled acquisition rate of MRSA colonization was 4.1% (95% CI 1.2%-8.6%) during the NICU and PICU stay and was as high as 6.1% (95% CI 2.8%-10.6%) when the NICU population was studied alone. There was a relative risk of 24.2 (95% CI 8.9-66.0) for colonized patients to develop a MRSA infection during hospitalization.\nCONCLUSIONS: In the NICU and PICU, there are carriers of MRSA on admission, and MRSA colonization in the NICU is almost exclusively associated with outborn neonates. Importantly, despite infection control measures, the acquisition rate is high, and patients colonized with MRSA on admission are more likely to suffer a MRSA infection during hospitalization.","DOI":"10.1542/peds.2013-3413","ISSN":"1098-4275","note":"PMID: 24616358","journalAbbreviation":"Pediatrics","language":"eng","author":[{"family":"Zervou","given":"Fainareti N."},{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",4]]}}},{"id":16677,"uris":[""],"uri":[""],"itemData":{"id":16677,"type":"article-journal","title":"Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients","container-title":"Journal of the American Society of Nephrology: JASN","page":"2131-2141","volume":"25","issue":"9","abstract":"Patients undergoing dialysis are particularly vulnerable to methicillin-resistant Staphylococcus aureus (MRSA) infections. We performed a meta-analysis of published studies to estimate the prevalence of MRSA colonization in dialysis patients, time trends, and long-term risk of subsequent MRSA infections. Our search of the PubMed and Embase databases returned 5743 nonduplicate citations, from which we identified 38 relevant studies that included data on 5596 dialysis patients. The estimated prevalence of MRSA colonization was 6.2% (95% confidence interval [95% CI], 4.2% to 8.5%). The prevalence increased over time but remained stable after 2000. Stratification of patients according to dialysis modality and setting revealed that 7.2% (95% CI, 4.9% to 9.9%) of patients on hemodialysis were colonized with MRSA compared with 1.3% (95% CI, 0.5% to 2.4%) of patients on peritoneal dialysis (P=0.01), and that a statistically significant difference existed in the percentage of colonized inpatients and outpatients (14.2% [95% CI, 8.0% to 21.8%] versus 5.4% [95% CI, 3.5% to 7.7%], respectively; P=0.04). Notably, the risk of developing MRSA infections increased among colonized hemodialysis patients compared with noncolonized patients (relative risk, 11.5 [95% CI, 4.7 to 28.0]). The long-term (6-20 months) probability of developing a MRSA infection was 19% among colonized hemodialysis patients compared with only 2% among noncolonized patients. In summary, 6.2% of dialysis patients are MRSA colonized, and the average prevalence of colonization has remained stable since 2000. Colonization in hemodialysis patients is associated with increased risk of MRSA infection.","DOI":"10.1681/ASN.2013091028","ISSN":"1533-3450","note":"PMID: 24652802\nPMCID: PMC4147983","journalAbbreviation":"J. Am. Soc. Nephrol.","language":"eng","author":[{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Zervou","given":"Fainareti N."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",9]]}}},{"id":16675,"uris":[""],"uri":[""],"itemData":{"id":16675,"type":"article-journal","title":"Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV infection: a meta-analysis","container-title":"Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America","page":"1302-1311","volume":"59","issue":"9","abstract":"BACKGROUND: Human immunodeficiency virus (HIV)-infected individuals who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) have increased risk for MRSA infection. We conducted a meta-analysis of published studies to estimate the prevalence of MRSA colonization in this population.\nMETHODS: We performed a systematic literature review and meta-analysis. The PubMed and Embase databases were searched and studies reporting prevalence of MRSA colonization among HIV-infected individuals were included.\nRESULTS: Among 7940 citations, 32 studies reporting data on 6558 HIV-infected individuals were considered eligible for our meta-analysis. We found that 6.9% (95% confidence interval [CI], 4.8-9.3) of individuals with HIV infection are MRSA carriers, with the corresponding figure across North American studies being 8.8% (95% CI, 6.0-12.2). History of hospitalization during the previous 12 months was associated with a 3.1 times higher risk of MRSA colonization (risk ratio [RR], 3.11 [95% CI, 1.62-5.98]). Previous or current incarceration was also associated with a higher risk for carriage (RR, 1.77 [95% CI, 1.26-2.48]). Current antiretroviral therapy or use of trimethoprim-sulfamethoxazole did not impact the risk of MRSA carriage (RR, 1.02 [95% CI, .64-1.63] and 1.45 [95% CI, .69-3.03], respectively). Extranasal screening increased the detection of MRSA colonization by at least 31.6% (95% CI, 15.8-50.0). The added yield from groin screening was 19.3% (95% CI, 11.5-28.5), from perirectal screening 18.5% (95% CI, 7.4-33.2), and from throat cultures 17.5% (95% CI, 12.0-24).\nCONCLUSIONS: Individuals with HIV infection constitute a highly vulnerable population for MRSA colonization, and prior exposure to hospital or incarceration are significant factors. Nasal screening alone will underestimate the rate of colonization by at least one-third.","DOI":"10.1093/cid/ciu559","ISSN":"1537-6591","note":"PMID: 25031291\nPMCID: PMC4271036","journalAbbreviation":"Clin. Infect. Dis.","language":"eng","author":[{"family":"Zervou","given":"Fainareti N."},{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Rich","given":"Josiah D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",11,1]]}}},{"id":16682,"uris":[""],"uri":[""],"itemData":{"id":16682,"type":"article-journal","title":"The prevalence and significance of methicillin-resistant Staphylococcus aureus colonization at admission in the general ICU Setting: a meta-analysis of published studies","container-title":"Critical Care Medicine","page":"433-444","volume":"42","issue":"2","abstract":"OBJECTIVE: To estimate the prevalence and significance of nasal methicillin-resistant Staphylococcus aureus colonization in the ICU and its predictive value for development of methicillin-resistant S. aureus infection.\nDATA SOURCES: MEDLINE and EMBASE and reference lists of all eligible articles.\nSTUDY SELECTION: Studies providing raw data on nasal methicillin-resistant S. aureus colonization at ICU admission, published up to February 2013. Analyses were restricted in the general ICU setting. Medical, surgical, and interdisciplinary ICUs were eligible. ICU studies referring solely on highly specialized ICUs populations and reports on methicillin-resistant S. aureus outbreaks were excluded.\nDATA EXTRACTION: Two authors independently assessed study eligibility and extrapolated data in a blinded fashion. The two outcomes of interest were the prevalence estimate of methicillin-resistant S. aureus nasal colonization at admission in the ICU and the sensitivity/specificity of colonization in predicting methicillin-resistant S. aureus-associated infections.\nDATA SYNTHESIS: Meta-analysis, using a random-effect model, and meta-regression were performed. Pooled data extracted from 63,740 evaluable ICU patients provided an estimated prevalence of methicillin-resistant S. aureus nasal colonization at admission of 7.0% (95% CI, 5.8-8.3). Prevalence was higher for North American studies (8.9%; 95% CI, 7.1-10.7) and for patients screened using polymerase chain reaction (14.0%; 95% CI, 9.6-19). A significant per year increase in methicillin-resistant S. aureus colonization was also noted. In 17,738 evaluable patients, methicillin-resistant S. aureus infections (4.1%; 95% CI, 2.0-6.8) developed in 589 patients. The relative risk for colonized patients was 8.33 (95% CI, 3.61-19.20). Methicillin-resistant S. aureus nasal carriage had a high specificity (0.96; 95% CI, 0.90-0.98) but low sensitivity (0.32; 95% CI, 0.20-0.48) to predict methicillin-resistant S. aureus-associated infections, with corresponding positive and negative predictive values at 0.25 (95% CI, 0.11-0.39) and 0.97 (95% CI, 0.83-1.00), respectively.\nCONCLUSIONS: Among ICU patients, 5.8-8.3% of patients are colonized by methicillin-resistant S. aureus at admission, with a significant upward trend. Methicillin-resistant S. aureus colonization is associated with a more than eight-fold increase in the risk of associated infections during ICU stay, and methicillin-resistant S. aureus infection develops in one fourth of patients who are colonized with methicillin-resistant S. aureus at admission to the ICU.","DOI":"10.1097/CCM.0b013e3182a66bb8","ISSN":"1530-0293","note":"PMID: 24145849","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Ziakas","given":"Panayiotis D."},{"family":"Anagnostou","given":"Theodora"},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",2]]}}}],"schema":""} (5,6,11,12). However, to date no meta-analysis has examined the prevalence of MRSA in diabetic patients. Therefore, the aim of this meta-analysis was to use studies of any design which reported data for 10 or more patients to estimate the prevalence of MRSA in diabetic patients.MethodsSearch strategyFour electronic databases were searched for articles published up to 16 May 2018: EMBASE (1980-2018), Ovid MEDLINE? Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE? Daily, Ovid MEDLINE and Versions? (1946-2018), Web of Science and BIOSIS Citation Index (1926-2018). The Web of Science Core Collection Citation Indexes searched were: Science Citation Index Expanded (1900-2018), Conference Proceedings Citation Index- Science (1990-2018), Book Citation Index– Science (2005-2018) and the Emerging Sources Citation Index (2015-2018). The search was performed using the following terms: (“me??icillin-resistant Staphylococcus aureus” OR “MRSA” OR “?A-MRSA”) AND (“diabetes” OR “DFI” OR “diabetic foot” OR “diabetes mellitus type” OR “non?insulin dependent diabetes” OR “insulin?dependent diabetes” OR “?IDDM”) AND (“prevalence” OR “incidence” OR “epidemiology” OR “frequency” OR “occurrence” OR “rate” OR “predict*”). In Ovid these terms were followed by the suffix ‘.mp.’ and they were searched as topics in Web of Science. Further articles were obtained using reference lists from a review article ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"On4dPfqw","properties":{"formattedCitation":"(10)","plainCitation":"(10)","noteIndex":0},"citationItems":[{"id":17084,"uris":[""],"uri":[""],"itemData":{"id":17084,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus in diabetic foot infections","container-title":"Drugs","page":"1785-1797","volume":"70","issue":"14","source":"PubMed","abstract":"Diabetic foot ulcers are often complicated by infection. Among pathogens, Staphylococcus aureus predominates. The prevalence of methicillin-resistant S. aureus (MRSA) in infected foot ulcers is 15-30% and there is an alarming trend for increase in many countries. There are also data that recognize new strains of MRSA that are resistant to vancomycin. The risk for MRSA isolation increases in the presence of osteomyelitis, nasal carriage of MRSA, prior use of antibacterials or hospitalization, larger ulcer size and longer duration of the ulcer. The need for amputation and surgical debridement increases in patients infected with MRSA. Infections of mild or moderate severity caused by community-acquired MRSA can be treated with cotrimoxazole (trimethoprim/sulfamethoxazole), doxycycline or clindamycin when susceptibility results are available, while severe community-acquired or hospital-acquired MRSA infections should be managed with glycopeptides, linezolide or daptomycin. Dalbavancin, tigecycline and ceftobiprole are newer promising antimicrobial agents active against MRSA that may also have a role in the treatment of foot infections if more data on their efficacy and safety become available.","DOI":"10.2165/11538070-000000000-00000","ISSN":"1179-1950","note":"PMID: 20836573","journalAbbreviation":"Drugs","language":"eng","author":[{"family":"Eleftheriadou","given":"Ioanna"},{"family":"Tentolouris","given":"Nicholas"},{"family":"Argiana","given":"Vasiliki"},{"family":"Jude","given":"Edward"},{"family":"Boulton","given":"Andrew J."}],"issued":{"date-parts":[["2010",10,1]]}}}],"schema":""} (10) and manual searching ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"yZ163w2g","properties":{"formattedCitation":"(13,14)","plainCitation":"(13,14)","noteIndex":0},"citationItems":[{"id":16919,"uris":[""],"uri":[""],"itemData":{"id":16919,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus: Prevalence, incidence, risk factors, and effects on survival of patients in a specialist palliative care unit: A prospective observational study","container-title":"Palliative Medicine","page":"374-381","volume":"30","issue":"4","source":"SAGE Journals","abstract":"Background:Little is known about the impact of methicillin-resistant Staphylococcus aureus in palliative care settings. To date, the clinical impact of methicillin-resistant Staphylococcus aureus in palliative care is unknown.Aim:To determine prevalence and incidence of methicillin-resistant Staphylococcus aureus colonisation in a specialist palliative care setting, to identify risk factors for methicillin-resistant Staphylococcus aureus colonisation, to determine the eradication success rate and to determine the impact of methicillin-resistant Staphylococcus aureus on survival.Design:Prospective cohort study.Setting/participants:Data were collected for consecutive admissions to an inpatient palliative care service. Patients were screened for methicillin-resistant Staphylococcus aureus colonisation on admission and 1?week post admission. Methicillin-resistant Staphylococcus aureus eradication was attempted in methicillin-resistant Staphylococcus aureus positive patients.Results:Data were collected from 609 admissions for 466 individual patients. Admission screening data were available in 95.5%. Prevalence of methicillin-resistant Staphylococcus aureus colonisation was 11.59% (54 patients). One week incidence of methicillin-resistant Staphylococcus aureus colonisation was 1.2%. Risk factors for methicillin-resistant Staphylococcus aureus colonisation were determined using Chi-Squared test and included high Waterlow score (p?","DOI":"10.1177/0269216315595158","ISSN":"0269-2163","shortTitle":"Methicillin-resistant Staphylococcus aureus","journalAbbreviation":"Palliat Med","language":"en","author":[{"family":"Gleeson","given":"Aoife"},{"family":"Larkin","given":"Philip"},{"family":"Walsh","given":"Cathal"},{"family":"O’Sullivan","given":"Niamh"}],"issued":{"date-parts":[["2016",4,1]]}}},{"id":16904,"uris":[""],"uri":[""],"itemData":{"id":16904,"type":"article-journal","title":"Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality","container-title":"BMC Infectious Diseases","volume":"15","issue":"417","abstract":"Background\nNecrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection. This study aimed to investigate the clinical characteristics and mortality- associated factors in diabetic patients.\n\nMethods\nDetailed clinical information of 165 NF cases was retrospectively collected and analyzed in National Taiwan University Hospital between January 1997 and February 2013. We documented and compared the clinical features according to the presence of underlying diabetes mellitus, and we identified risk factors associated with mortality.\n\nResults\nThere were 84 patients (51?%) with diabetes. The overall case fatality rate was 29.7?%, and we found no significant difference between the patients with or without diabetes. Compared with the nondiabetic patients, diabetic patients were older and exhibited higher serum levels of glucose and potassium on admission. Polymicrobial infection and monomicrobial NF caused by Klebsiella pneumoniae were also more frequently associated with diabetic patients. Moreover, diabetic NF patients exhibit a significantly higher chance of limb loss during hospitalization. In the combined diabetic and nondiabetic cohort, a high serum level of potassium (odds ratio, 2.2; 95?% confidence interval, 1.2 to 4.02; P?=?0.011) on admission was independently associated with mortality, whereas positive blood culture on admission was associated with mortality in the diabetic cohort (odds ratio, 7.36; 95?% confidence interval, 1.66 to 32.54; P?=?0.009).\n\nConclusions\nDiabetic patients are more susceptible to NF caused by polymicrobial infection or K. pneumoniae, and they are more likely to receive limb amputation for infection control. Bacteraemia on admission is a significant risk factor for mortality in diabetic NF patients.","DOI":"10.1186/s12879-015-1144-0","ISSN":"1471-2334","note":"PMID: 26463900\nPMCID: PMC4604726","journalAbbreviation":"BMC Infect Dis","author":[{"family":"Cheng","given":"Nai-Chen"},{"family":"Tai","given":"Hao-Chih"},{"family":"Chang","given":"Shan-Chwen"},{"family":"Chang","given":"Chin-Hao"},{"family":"Lai","given":"Hong-Shiee"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} (13,14). A study protocol was not published prior to this study.Study selection criteriaAll studies underwent title and abstract screening, eligible studies met the following criteria: (1) the patients had been diagnosed with diabetes mellitus and were colonised or infected with MRSA; (2) the study reported primary patient data on the prevalence of MRSA in 10 or more patients; (3) the study was published in the English language. There were no limitations on study date or type. Eligible studies were accessed in full-text to ensure they fulfilled the inclusion criteria and provided sufficient data for the meta-analysis. Studies which could not be accessed in full-text, including presentation abstracts, were excluded; their authors were not contacted. MRSA prevalence data can be reported in terms of positive isolates or ulcers (potentially multiple per patient) and/or patients. For clarity, only studies which reported the prevalence of MRSA in terms of patient numbers were included. Title and abstract and full-text screening were performed independently by two authors (HJS, JDJ), with discrepancies resolved by consensus. Deduplication was performed using Endnote (version X8.0.1) and Zotero (version 5.0.47). This review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cjbaqf1E","properties":{"formattedCitation":"(15)","plainCitation":"(15)","noteIndex":0},"citationItems":[{"id":17063,"uris":[""],"uri":[""],"itemData":{"id":17063,"type":"article-journal","title":"Meta-analysis of Observational Studies in Epidemiology: A Proposal for Reporting","container-title":"JAMA","page":"2008-2012","volume":"283","issue":"15","source":"","abstract":"ObjectiveBecause of the pressure for timely, informed decisions in public health and clinical practice and the explosion of information in the scientific literature, research results must be synthesized. Meta-analyses are increasingly used to address this problem, and they often evaluate observational studies. A workshop was held in Atlanta, Ga, in April 1997, to examine the reporting of meta-analyses of observational studies and to make recommendations to aid authors, reviewers, editors, and readers.ParticipantsTwenty-seven participants were selected by a steering committee, based on expertise in clinical practice, trials, statistics, epidemiology, social sciences, and biomedical editing. Deliberations of the workshop were open to other interested scientists. Funding for this activity was provided by the Centers for Disease Control and Prevention.EvidenceWe conducted a systematic review of the published literature on the conduct and reporting of meta-analyses in observational studies using MEDLINE, Educational Research Information Center (ERIC), PsycLIT, and the Current Index to Statistics. We also examined reference lists of the 32 studies retrieved and contacted experts in the field. Participants were assigned to small-group discussions on the subjects of bias, searching and abstracting, heterogeneity, study categorization, and statistical methods.Consensus ProcessFrom the material presented at the workshop, the authors developed a checklist summarizing recommendations for reporting meta-analyses of observational studies. The checklist and supporting evidence were circulated to all conference attendees and additional experts. All suggestions for revisions were addressed.ConclusionsThe proposed checklist contains specifications for reporting of meta-analyses of observational studies in epidemiology, including background, search strategy, methods, results, discussion, and conclusion. Use of the checklist should improve the usefulness of meta-analyses for authors, reviewers, editors, readers, and decision makers. An evaluation plan is suggested and research areas are explored.","DOI":"10.1001/jama.283.15.2008","ISSN":"0098-7484","shortTitle":"Meta-analysis of Observational Studies in Epidemiology","journalAbbreviation":"JAMA","language":"en","author":[{"family":"Stroup","given":"Donna F."},{"family":"Berlin","given":"Jesse A."},{"family":"Morton","given":"Sally C."},{"family":"Olkin","given":"Ingram"},{"family":"Williamson","given":"G. David"},{"family":"Rennie","given":"Drummond"},{"family":"Moher","given":"David"},{"family":"Becker","given":"Betsy J."},{"family":"Sipe","given":"Theresa Ann"},{"family":"Thacker","given":"Stephen B."},{"family":"Epidemiology (MOOSE)\nGroup","given":"for the Meta-analysis Of Observational Studies","dropping-particle":"in"}],"issued":{"date-parts":[["2000",4,19]]}}}],"schema":""} (15), and a PRISMA checklist completed (see additional file one).Data extraction & critical appraisalThe following information was extracted from each study into a spreadsheet: author(s), year of publication, country, study design, study setting, study population size, number of MRSA positive patients, whether the study reported on MRSA colonisation or infection and type of infection.All eligible studies were critically assessed using a modified Joanna Briggs Institute checklist for prevalence studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"NLvMRLAp","properties":{"formattedCitation":"(16)","plainCitation":"(16)","noteIndex":0},"citationItems":[{"id":16962,"uris":[""],"uri":[""],"itemData":{"id":16962,"type":"webpage","title":"Critical appraisal tools - JBI","URL":"","author":[{"family":"The Joanna Briggs Institute","given":""}],"accessed":{"date-parts":[["2018",8,17]]}}}],"schema":""} (16). Publication bias was assessed using funnel plots. Funnel plots of subgroup analyses were not used to assess for publication bias, as funnel plot reliability decreases when the number of studies decreases, particularly below 10 studies ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"r5uVHBYl","properties":{"formattedCitation":"(17)","plainCitation":"(17)","noteIndex":0},"citationItems":[{"id":16793,"uris":[""],"uri":[""],"itemData":{"id":16793,"type":"article-journal","title":"Meta-analyses: how to read a funnel plot","container-title":"BMJ","page":"f1342","volume":"346","source":"","abstract":"Researchers undertook a meta-analysis to evaluate the relative short term safety of carotid endarterectomy compared with carotid artery stenting.1 Randomised controlled trials were included if they compared carotid endarterectomy with carotid artery stenting in patients with carotid artery stenosis (with or without symptoms). In total, 10 trials were identified that reported short term outcomes. The primary endpoint was mortality or stroke within 30 days of the procedure.\n\nThe total overall periprocedural risk of mortality or stroke was lower for carotid endarterectomy than for carotid artery stenting (odds ratio 0.67, 95% confidence interval 0.47 to 0.95; P=0.025). A funnel plot was presented (figure?). Egger’s test gave a P value equal to 0.932.\n\n\n\nFunnel plot for the meta-analysis of the short term safety (periprocedural mortality or stroke) of carotid endarterectomy compared with carotid artery stenting\n\n\n\nWhich of the following statements, if any, are true?\n\nStatements a and b are true, whereas c is false.\n\nThe meta-analysis investigated the relative short term safety of carotid endarterectomy compared with carotid artery stenting. Ten trials were identified …","DOI":"10.1136/bmj.f1342","ISSN":"1756-1833","shortTitle":"Meta-analyses","journalAbbreviation":"BMJ","language":"en","author":[{"family":"Sedgwick","given":"Philip"}],"issued":{"date-parts":[["2013",3,1]]}}}],"schema":""} (17). Statistical analysisRandom-effects meta-analyses were used throughout to calculate the pooled prevalence of MRSA in a given population with 95% confidence intervals (95% CIs). Study heterogeneity was assessed by the I2 statistic, reported with 95% CIs, and interpreted as low (≤25%), moderate (25-50%) or high (≥75%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"W7ObUi7z","properties":{"formattedCitation":"(18)","plainCitation":"(18)","noteIndex":0},"citationItems":[{"id":16796,"uris":[""],"uri":[""],"itemData":{"id":16796,"type":"article-journal","title":"Measuring inconsistency in meta-analyses","container-title":"BMJ","page":"557-560","volume":"327","issue":"7414","source":"","abstract":"Cochrane Reviews have recently started including the quantity I 2 to help readers assess the consistency of the results of studies in meta-analyses. What does this new quantity mean, and why is assessment of heterogeneity so important to clinical practice? \n\nSystematic reviews and meta-analyses can provide convincing and reliable evidence relevant to many aspects of medicine and health care.1 Their value is especially clear when the results of the studies they include show clinically important effects of similar magnitude. However, the conclusions are less clear when the included studies have differing results. In an attempt to establish whether studies are consistent, reports of meta-analyses commonly present a statistical test of heterogeneity. The test seeks to determine whether there are genuine differences underlying the results of the studies (heterogeneity), or whether the variation in findings is compatible with chance alone (homogeneity). However, the test is susceptible to the number of trials included in the meta-analysis. We have developed a new quantity, I 2, which we believe gives a better measure of the consistency between trials in a meta-analysis.\n\nAssessment of the consistency of effects across studies is an essential part of meta-analysis. Unless we know how consistent the results of studies are, we cannot determine the generalisability of the findings of the meta-analysis. Indeed, several hierarchical systems for grading evidence state that the results of studies must be consistent or homogeneous to obtain the highest grading.2–4\n\nTests for heterogeneity are commonly used to decide on methods for combining studies and for concluding consistency or inconsistency of findings.5 6 But what does the test achieve in practice, and how should the resulting P values be interpreted?\n\nA test for heterogeneity examines the null hypothesis that all studies are evaluating the same effect. The usual test statistic …","DOI":"10.1136/bmj.327.7414.557","ISSN":"0959-8138, 1468-5833","note":"PMID: 12958120","journalAbbreviation":"BMJ","language":"en","author":[{"family":"Higgins","given":"Julian P. T."},{"family":"Thompson","given":"Simon G."},{"family":"Deeks","given":"Jonathan J."},{"family":"Altman","given":"Douglas G."}],"issued":{"date-parts":[["2003",9,4]]}}}],"schema":""} (18). All meta-analyses were carried out using MedCalc statistical software, version 18.0 (MedCalc Software, Ostend, Belgium). The significance of proportions was compared using the MedCalc N-1 Chi-squared calculator ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tjEpG5Ck","properties":{"formattedCitation":"(19)","plainCitation":"(19)","noteIndex":0},"citationItems":[{"id":16800,"uris":[""],"uri":[""],"itemData":{"id":16800,"type":"webpage","title":"Comparison of proportions calculator","URL":"","author":[{"family":"MedCalc","given":""}],"accessed":{"date-parts":[["2018",7,8]]}}}],"schema":""} (19). Results After deduplication, systematic searching yielded 1056 articles published between March 1985 and May 2018. An additional 14 manuscripts were identified from a review article (n = 12) and manual searching ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"poEQhbfj","properties":{"formattedCitation":"(10,13,14)","plainCitation":"(10,13,14)","noteIndex":0},"citationItems":[{"id":17084,"uris":[""],"uri":[""],"itemData":{"id":17084,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus in diabetic foot infections","container-title":"Drugs","page":"1785-1797","volume":"70","issue":"14","source":"PubMed","abstract":"Diabetic foot ulcers are often complicated by infection. Among pathogens, Staphylococcus aureus predominates. The prevalence of methicillin-resistant S. aureus (MRSA) in infected foot ulcers is 15-30% and there is an alarming trend for increase in many countries. There are also data that recognize new strains of MRSA that are resistant to vancomycin. The risk for MRSA isolation increases in the presence of osteomyelitis, nasal carriage of MRSA, prior use of antibacterials or hospitalization, larger ulcer size and longer duration of the ulcer. The need for amputation and surgical debridement increases in patients infected with MRSA. Infections of mild or moderate severity caused by community-acquired MRSA can be treated with cotrimoxazole (trimethoprim/sulfamethoxazole), doxycycline or clindamycin when susceptibility results are available, while severe community-acquired or hospital-acquired MRSA infections should be managed with glycopeptides, linezolide or daptomycin. Dalbavancin, tigecycline and ceftobiprole are newer promising antimicrobial agents active against MRSA that may also have a role in the treatment of foot infections if more data on their efficacy and safety become available.","DOI":"10.2165/11538070-000000000-00000","ISSN":"1179-1950","note":"PMID: 20836573","journalAbbreviation":"Drugs","language":"eng","author":[{"family":"Eleftheriadou","given":"Ioanna"},{"family":"Tentolouris","given":"Nicholas"},{"family":"Argiana","given":"Vasiliki"},{"family":"Jude","given":"Edward"},{"family":"Boulton","given":"Andrew J."}],"issued":{"date-parts":[["2010",10,1]]}}},{"id":16919,"uris":[""],"uri":[""],"itemData":{"id":16919,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus: Prevalence, incidence, risk factors, and effects on survival of patients in a specialist palliative care unit: A prospective observational study","container-title":"Palliative Medicine","page":"374-381","volume":"30","issue":"4","source":"SAGE Journals","abstract":"Background:Little is known about the impact of methicillin-resistant Staphylococcus aureus in palliative care settings. To date, the clinical impact of methicillin-resistant Staphylococcus aureus in palliative care is unknown.Aim:To determine prevalence and incidence of methicillin-resistant Staphylococcus aureus colonisation in a specialist palliative care setting, to identify risk factors for methicillin-resistant Staphylococcus aureus colonisation, to determine the eradication success rate and to determine the impact of methicillin-resistant Staphylococcus aureus on survival.Design:Prospective cohort study.Setting/participants:Data were collected for consecutive admissions to an inpatient palliative care service. Patients were screened for methicillin-resistant Staphylococcus aureus colonisation on admission and 1?week post admission. Methicillin-resistant Staphylococcus aureus eradication was attempted in methicillin-resistant Staphylococcus aureus positive patients.Results:Data were collected from 609 admissions for 466 individual patients. Admission screening data were available in 95.5%. Prevalence of methicillin-resistant Staphylococcus aureus colonisation was 11.59% (54 patients). One week incidence of methicillin-resistant Staphylococcus aureus colonisation was 1.2%. Risk factors for methicillin-resistant Staphylococcus aureus colonisation were determined using Chi-Squared test and included high Waterlow score (p?","DOI":"10.1177/0269216315595158","ISSN":"0269-2163","shortTitle":"Methicillin-resistant Staphylococcus aureus","journalAbbreviation":"Palliat Med","language":"en","author":[{"family":"Gleeson","given":"Aoife"},{"family":"Larkin","given":"Philip"},{"family":"Walsh","given":"Cathal"},{"family":"O’Sullivan","given":"Niamh"}],"issued":{"date-parts":[["2016",4,1]]}}},{"id":16904,"uris":[""],"uri":[""],"itemData":{"id":16904,"type":"article-journal","title":"Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality","container-title":"BMC Infectious Diseases","volume":"15","issue":"417","abstract":"Background\nNecrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection. This study aimed to investigate the clinical characteristics and mortality- associated factors in diabetic patients.\n\nMethods\nDetailed clinical information of 165 NF cases was retrospectively collected and analyzed in National Taiwan University Hospital between January 1997 and February 2013. We documented and compared the clinical features according to the presence of underlying diabetes mellitus, and we identified risk factors associated with mortality.\n\nResults\nThere were 84 patients (51?%) with diabetes. The overall case fatality rate was 29.7?%, and we found no significant difference between the patients with or without diabetes. Compared with the nondiabetic patients, diabetic patients were older and exhibited higher serum levels of glucose and potassium on admission. Polymicrobial infection and monomicrobial NF caused by Klebsiella pneumoniae were also more frequently associated with diabetic patients. Moreover, diabetic NF patients exhibit a significantly higher chance of limb loss during hospitalization. In the combined diabetic and nondiabetic cohort, a high serum level of potassium (odds ratio, 2.2; 95?% confidence interval, 1.2 to 4.02; P?=?0.011) on admission was independently associated with mortality, whereas positive blood culture on admission was associated with mortality in the diabetic cohort (odds ratio, 7.36; 95?% confidence interval, 1.66 to 32.54; P?=?0.009).\n\nConclusions\nDiabetic patients are more susceptible to NF caused by polymicrobial infection or K. pneumoniae, and they are more likely to receive limb amputation for infection control. Bacteraemia on admission is a significant risk factor for mortality in diabetic NF patients.","DOI":"10.1186/s12879-015-1144-0","ISSN":"1471-2334","note":"PMID: 26463900\nPMCID: PMC4604726","journalAbbreviation":"BMC Infect Dis","author":[{"family":"Cheng","given":"Nai-Chen"},{"family":"Tai","given":"Hao-Chih"},{"family":"Chang","given":"Shan-Chwen"},{"family":"Chang","given":"Chin-Hao"},{"family":"Lai","given":"Hong-Shiee"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} (10,13,14). Title and abstract screening identified 216 eligible articles, 148 of which were subsequently excluded after full-text screening. Articles were excluded because they: did not contain appropriate data (n = 66), were only available as an abstract (e.g. poster, presentation; n = 24), could not be accessed in full (n = 24), were not primary literature (n = 11), were not available in English (n = 11), had insufficient clarity for data extraction (n = 10) or duplicated analysis of another dataset (n = 2). The study selection process is shown in (figure 1).A total of 68 studies were eligible for inclusion. Six studies contained two prevalence datasets; four contained data regarding the prevalence of MRSA in the nares and ulcers of diabetic foot infection (DFI) patients, another contained MRSA prevalence data for DFI and other SSTI patients and another data regarding nasal colonization or unspecified infection with MRSA among diabetic patients. There was therefore a total of 74 eligible datasets (table 1). The datasets were categorised for subsequent meta-analysis: those with data about the prevalence of MRSA among DFI (41/74), necrotizing fasciitis (NF) and other skin and soft tissue infections (SSTIs; 7/74), infections of unspecified source (3/74) and those with colonisation prevalence data (23/74). While critical appraisal of eligible studies highlighted shortcomings in reporting it did not reveal further grounds to exclude any studies (see additional file two). StudyStudy designStudy date(s)CountrySettingMean age% MaleStudy populationMRSA +%95% CIsCol/InfGoldstein et al. 1996P cohort1993-94USAIpatNR6825520.06.83-40.70DFITentolouris et al. 1999RetroNRUKOpat61.5NR751216.08.55-26.28DFIEl-Tahawy 2000Retro1997-99Saudi ArabiaIpatNR5711198.123.78-14.83DFISaxena et al. 2002P cohort1996-99Saudi ArabiaIpat (HD)47.5*45.7*581220.6911.17-33.35Col (N)Ge et al. 2002RCTNRUSAOpatNRNR812374.563.23-6.23DFIVon Baum et al. 2002P cohort1999-02GermanyCom (NH)81.2*29.5*32851.520.50-3.52Col (N)Dang et al. 2003Retro2000-01UKOpatNRNR631930.1619.23-43.03DFIHartemann-Heurtier et al. 2004P cohortNRFranceIpat65751802916.1111.06-22.31DFILipsky et al. 2005P cohort1999-01IntIpat61.55410354.851.60-10.97DFIShankar et al. 2005P cohort2003-04IndiaIpat6359.777810.394.59-19.45DFIDaeschlein et al. 2006P cohort2003GermanyCom (NH)77.6*16.2*17500.000.00-2.09Col (N)Gadepalli et al. 2006P cohortNRIndiaIpat53.985801417.509.91-27.62DFISharma et al. 2006Retro2004-05NepalIpat6155.84300.00.00-8.22DFICitron et al. 2007Retro2001-04USAIpatNRNR4334811.098.29-14.43DFIStanaway et al. 2007P cohortNRUKOpat6161651218.469.92-30.03DFIStanaway et al. 2007 continued1116.928.76-28.27Col (N)Gorwitz et al. 2008P cohort2003-04USAComNR491125181.600.95-2.52Col (N)Nather et al. 2008P cohort2005-06SingaporeIpat605012275.742.34-11.47DFIRichard et al. 2008P cohort2003-04FranceIpat6869.71883719.6814.25-26.09DFIAragon-Sanchez et al. 2008Retro2002-07SpainI, O64.762.71853519.8914.26-26.56DFIMaghsoudi et al. 2008P cohort2000-06IranIpat53.440.49400.000.00-3.85Inf (Burns)Sotto et al. 2008P cohort2004-07FranceIpat6861513489.366.98-12.21DFIGarazi et al. 2009Cross-sectionalNRUSACom (NH)83.4*26.7*511835.2922.43-49.93Col (N)Galkowska et al. 2009P cohort2006-07PolandI, O5875.75501326.0014.63-40.35DFILipsky et al. 2010Retro2003-07USAIpat60 (med)6422201657.436.38-8.60DFILipsky et al. 2010 continued61 (med)54.6810789.637.69-11.87nfSSTIRaju et al. 2010P cohort2004IndiaI, ONRNR1101412.737.14-20.43Inf (NS)Wang et al. 2010Retro2004-06ChinaIpat60.857.61182117.8011.37-25.91DFIChangchien et al. 2011Retro2004-08TaiwanIpat57.9641553522.5816.26-29.98NFLipsky et al. 2011RetroMixedIntIpatNRNR868349$40.2136.93-43.56nfSSTILu et al. 2011P cohort2009TaiwanEDNR53.4*12497.263.37-13.33Col (N)Schechter-Perkins et al. 2011P cohort2009-10USAED41*47*51611.774.44-23.87Col (N, Ph, H, G, P, W, C)Tascini et al. 2011P cohort2006-08ItalyOpatNRNR1295765.874.65-7.29DFIKutlu et al. 2012P cohort2006-09TurkeyOpat56.2846.4304309.876.76-13.79Col (N)Mendes et al. 2012P cohort2010PortugalI, O62.742.9492551.0236.34-65.58DFIAcharya et al. 2013Retro2003-08UKOpat66.266.91302015.399.66-22.76DFIDjahmi et al. 2013P cohort2011-12AlgeriaIpat64*62.3*1287357.0347.99-65.74DFIFowler and Ilyas 2013Retro2005-10USAIpatNRNR823239.0228.44-50.43nfSSTIGupta et al. 2013Retro2008-10USAIpatNR95.7*5019554*11.0410.18-11.94Col (N)Haleem et al. 2013Cross-sectionalNRUSAI, O55647978.863.64-17.41Col (N)Haleem et al. 2013 continued78.863.64-17.41DFIParriott and Arah 2013RetroNRUSAIpatNR028949170.060.03-0.09Inf (NS)Torres and Sampathkumar 2013Mixed2008USAIpatNrNR336339.826.86-13.52Col (N)Ahmed et al. 2014P cohort2007-10EgyptIpat44.4*N/A52917.318.23-30.33DFIHennessey et al. 2014P cohort2000-11USAIpat55* (med)50.5*541527.7816.46-41.64Inf (Abdo)Lavery et al. 2014RetroNRUSAIpat59.55NR571729.8318.43-43.40DFIYeoh et al. 2014Retro2010-11SingaporeIpat (HD)59.1*54.51392517.9911.99-25.40Col (N, A, G)Cervantes-Garcia et al. 2015P cohort2012-13MexicoI, O52.5551003434.0024.82-44.15DFICheng et al. 2015Retro1997-13TaiwanIpat58.8*67*8467.142.67-14.90NFCommons et al. 2015P cohort2012-13AustraliaIpat54.4601777743.5036.08-51.15DFIDaeschlein et al. 2015Retro2006-10GermanyIpat59*NR1138302.641.79-3.74Col (N)Hart et al. 2015P cohort2008-11AustraliaCom65.153.166081.210.53-2.37Col (N, A)Jayarani and Sundarji 2015Retro2014-15Sri LankaIpatNR701004040.0030.33-50.28Col (N)Kao et al. 2015P cohort2008-10TaiwanIpat69.4*62.7*3767820.7516.76-25.20Inf (NS)Kao et al. 2015 continued6617.5513.84-21.78Col (N)Karadag-Oncel et al. 2015P cohort2005 and 2013TurkeyOpat12.161.523520.850.10-3.04Col (N)Lipsky et al. 2015Retro2011-13IntI, O61.757.22018341.2934.41-48.44DFISaltoglu et al. 2015Retro2011-13TurkeyI, O61 (med)6845571.540.62-3.14DFIBravo-Molina et al. 2016P cohort2009-13SpainIpat66801312015.279.58-22.59DFIGleeson et al. 2016P cohortNRIrelandIpat69*55*451022.2211.21-37.09Col (N, P, W, C)Reveles et al. 2016Retro2010-14USAIpat52 (med)693184714.7811.07-19.17DFIShettigar et al. 2016P cohort2011-12IndiaIpat60.572.52005226.0020.07-32.66DFIAshong et al. 2017Retro2011-15USAIpat65 (med)NR1583119.6213.74-26.68DFIDunyach-Remy et al. 2017P cohort2010-12FranceIpat68.572.5276176.163.63-9.68DFIDunyach-Remy et al. 2017 continued186.523.91-10.11Col (N)Lin et al. 2017Cross-sectional2014-15ChinaCom66.1330.43529224.162.62-6.23Col (N)Shah et al. 2017Cross-sectional2014-15PakistanIpat42.251.41403323.5716.82-31.48DFIWu et al. 2017P cohort2009-14ChinaIpatNRNR312216.734.21-10.11DFILegese et al. 2018P cohort2016EthiopiaHCW31.78*41.3*10330.006.67-65.25Col (N)Henig et al. 2018Retro2012-15USAIpat58.464.364822434.5730.91-38.37DFILin et al. 2018P cohort2015TaiwanI, ONRNR354102.831.36-5.13Col (N)Lin et al. 2018 continuedIpatNRNR1122724.1116.53-33.10DFIvan Asten et al. 2018Retro2010-14USAIpat53.876.9143117.693.90-13.35DFIViquez-Molina et al. 2018P cohort2014-16Costa RicaIpatNRNR379359.246.52-10.81DFITable 1. Eligible datasets. P’ cohort, prospective cohort. Retro, retrospective analysis. Int, international. (HD), inpatient (haemodialysis). Opat, outpatient. Com (NH), community (nursing home). I, O, mixed in- and out- patient population. NR, not recorded. *age or gender data were not available for the diabetic portion of the study population and are instead representative of a larger portion of or the whole study population. $combined data from three clinical trials. CIs, 95% confidence intervals. Col, colonisation. (med), median value. Inf, infection. Abdo, abdominal. NS, not specified. DFI, diabetic foot infection. Col (N, A, G, W, C, Ph, H), colonisation (nasal, axilla, groin, surface wound, catheter, pharynx, hand). nfSSTI, non-foot skin and soft tissue infection. NF, necrotizing fasciitis. The prevalence of MRSA colonisation among diabetic patients 23 datasets investigated the prevalence of MRSA colonisation among diabetic patients, published from 2002 to 2018 ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZmLh5R39","properties":{"formattedCitation":"(13,20\\uc0\\u8211{}41)","plainCitation":"(13,20–41)","noteIndex":0},"citationItems":[{"id":16919,"uris":[""],"uri":[""],"itemData":{"id":16919,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus: Prevalence, incidence, risk factors, and effects on survival of patients in a specialist palliative care unit: A prospective observational study","container-title":"Palliative Medicine","page":"374-381","volume":"30","issue":"4","source":"SAGE Journals","abstract":"Background:Little is known about the impact of methicillin-resistant Staphylococcus aureus in palliative care settings. To date, the clinical impact of methicillin-resistant Staphylococcus aureus in palliative care is unknown.Aim:To determine prevalence and incidence of methicillin-resistant Staphylococcus aureus colonisation in a specialist palliative care setting, to identify risk factors for methicillin-resistant Staphylococcus aureus colonisation, to determine the eradication success rate and to determine the impact of methicillin-resistant Staphylococcus aureus on survival.Design:Prospective cohort study.Setting/participants:Data were collected for consecutive admissions to an inpatient palliative care service. Patients were screened for methicillin-resistant Staphylococcus aureus colonisation on admission and 1?week post admission. Methicillin-resistant Staphylococcus aureus eradication was attempted in methicillin-resistant Staphylococcus aureus positive patients.Results:Data were collected from 609 admissions for 466 individual patients. Admission screening data were available in 95.5%. Prevalence of methicillin-resistant Staphylococcus aureus colonisation was 11.59% (54 patients). One week incidence of methicillin-resistant Staphylococcus aureus colonisation was 1.2%. Risk factors for methicillin-resistant Staphylococcus aureus colonisation were determined using Chi-Squared test and included high Waterlow score (p?","DOI":"10.1177/0269216315595158","ISSN":"0269-2163","shortTitle":"Methicillin-resistant Staphylococcus aureus","journalAbbreviation":"Palliat Med","language":"en","author":[{"family":"Gleeson","given":"Aoife"},{"family":"Larkin","given":"Philip"},{"family":"Walsh","given":"Cathal"},{"family":"O’Sullivan","given":"Niamh"}],"issued":{"date-parts":[["2016",4,1]]}}},{"id":16739,"uris":[""],"uri":[""],"itemData":{"id":16739,"type":"article-journal","title":"Nasal carriage, risk factors and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus among healthcare workers in Adigrat and Wukro hospitals, Tigray, Northern Ethiopia","container-title":"BMC Research Notes","page":"250","volume":"11","issue":"1","source":"BioMed Central","abstract":"The aim of this study was to determine nasal carriage, risk factors and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus among health care-workers of Adigrat and Wukro hospitals Northern Ethiopia.","DOI":"10.1186/s13104-018-3353-2","ISSN":"1756-0500","journalAbbreviation":"BMC Research Notes","author":[{"family":"Legese","given":"Haftom"},{"family":"Kahsay","given":"Atsebaha Gebrekidan"},{"family":"Kahsay","given":"Amlisha"},{"family":"Araya","given":"Tadele"},{"family":"Adhanom","given":"Gebre"},{"family":"Muthupandian","given":"Saravanan"},{"family":"Gebreyesus","given":"Araya"}],"issued":{"date-parts":[["2018",4,23]]}}},{"id":16721,"uris":[""],"uri":[""],"itemData":{"id":16721,"type":"article-journal","title":"Changes in the Prevalence of Nasal Colonization with Staphylococcus aureus in the United States, 2001–2004","container-title":"The Journal of Infectious Diseases","page":"1226-1234","volume":"197","issue":"9","source":"academic.","abstract":"Abstract. BackgroundStaphylococcus aureus is a common cause of infection, particularly in persons colonized by this organism. Virulent strains of methicillin-r","DOI":"10.1086/533494","ISSN":"0022-1899","journalAbbreviation":"J Infect Dis","language":"en","author":[{"family":"Gorwitz","given":"Rachel J."},{"family":"Kruszon-Moran","given":"Deanna"},{"family":"McAllister","given":"Sigrid K."},{"family":"McQuillan","given":"Geraldine"},{"family":"McDougal","given":"Linda K."},{"family":"Fosheim","given":"Gregory E."},{"family":"Jensen","given":"Bette J."},{"family":"Killgore","given":"George"},{"family":"Tenover","given":"Fred C."},{"family":"Kuehnert","given":"Matthew J."}],"issued":{"date-parts":[["2008",5,1]]}}},{"id":16907,"uris":[""],"uri":[""],"itemData":{"id":16907,"type":"article-journal","title":"Risk factors for Staphylococcus aureus nasal carriage in residents of three nursing homes in Germany","container-title":"Journal of Hospital Infection","page":"216-220","volume":"63","issue":"2","source":"ScienceDirect","abstract":"Summary\nThe prevalence of Staphylococcus aureus nasal carriage in three nursing homes (N=500) was 36.6%. No meticillin-resistant S. aureus (MRSA) was detected. The following significant risk factors for S. aureus nasal carriage were identified: vascular cognitive impairment [odds ratio (OR)=0.31]; diabetes mellitus (OR=1.82); hypertension (OR=0.30); chronic obstructive pulmonary disease (OR=1.86); stroke (OR=3.31); antibiotic therapy within the previous three months (OR=2.10); and level 2 care (defined as highly dependent, needing help in activities of daily living for up to 4h/day) (OR=1.97). Compared with other countries, the prevalence of MRSA nasal carriage in residents of German nursing homes is low.","DOI":"10.1016/j.jhin.2005.12.014","ISSN":"0195-6701","journalAbbreviation":"Journal of Hospital Infection","author":[{"family":"Daeschlein","given":"G."},{"family":"Assadian","given":"O."},{"family":"Rangous","given":"I."},{"family":"Kramer","given":"A."}],"issued":{"date-parts":[["2006",6,1]]}}},{"id":16910,"uris":[""],"uri":[""],"itemData":{"id":16910,"type":"article-journal","title":"Risk factors for MRSA colonization in dermatologic patients in Germany","container-title":"JDDG: Journal der Deutschen Dermatologischen Gesellschaft","page":"1015-1022","volume":"13","issue":"10","source":"Wiley Online Library","abstract":"Background and objectives Detection of methicillin-resistant Staphylococcus aureus (MRSA) carriage requires well-defined risk factors (RFs). Except for “chronic wounds”, RFs are mostly specified in national recommendations. To avoid ineffective and expensive screening, we divided the entity “wounds” into different categories and calculated further RFs in dermatologic patients. Patients and Methods After a surveillance period with general MRSA screening, we correlated MRSA results with wound categories and dermatologically relevant diagnoses. We analyzed the screening efficacy by adding potential new RFs. Results Ulcers (pressure, arterial, combined pressure/arterial ulcers, ulcers otherwise unclassified), type 2 diabetes mellitus (DM), and atopic dermatitis (AD) were significantly associated with MRSA carriage. Tumors (subgroup basal and squamous cell carcinoma) were also significantly associated with MRSA carriage but had a protective odds ratio. Differentiation of wound types did not provide added benefit. In all MRSA-positive patients with chronic wounds, other RKI-listed RFs or type 2 DM were found. Screening sensitivity was increased combining classic RFs (except wounds) with type 2 DM and AD. Conclusions In dermatologic patients, AD and type 2 DM were identified as new RFs. Distinct wound types were also found to be significant RFs, but differentiated screening offers no benefit. When screening patients according to national recommendations, excluding wounds but including type 2 DM and AD, there is no loss of sensitivity.","DOI":"10.1111/ddg.12705","ISSN":"1610-0387","language":"en","author":[{"family":"Daeschlein","given":"Georg"},{"family":"Podewils","given":"Sebastian","dropping-particle":"von"},{"family":"Bloom","given":"Tina"},{"family":"Assadian","given":"Ojan"},{"family":"Napp","given":"Matthias"},{"family":"Haase","given":"Hermann"},{"family":"Jünger","given":"Michael"}],"issued":{"date-parts":[["2015",10,1]]}}},{"id":16923,"uris":[""],"uri":[""],"itemData":{"id":16923,"type":"article-journal","title":"MRSA Nasal Carriage Patterns and the Subsequent Risk of Conversion between Patterns, Infection, and Death","container-title":"PLOS ONE","page":"e53674","volume":"8","issue":"1","source":"PLoS Journals","abstract":"Background Patterns of methicillin-resistant S. aureus (MRSA) nasal carriage over time and across the continuum of care settings are poorly characterized. Knowledge of prevalence rates and outcomes associated with MRSA nasal carriage patterns could help direct infection prevention strategies. The VA integrated health-care system and active surveillance program provides an opportunity to delineate nasal carriage patterns and associated outcomes of death, infection, and conversion in carriage. Methods/Findings We conducted a retrospective cohort study including all patients admitted to 5 acute care VA hospitals between 2008–2010 who had nasal MRSA PCR testing within 48 hours of admission and repeat testing within 30 days. The PCR results were used to define a baseline nasal carriage pattern of never, intermittently, or always colonized at 30 days from admission. Follow-up was up to two years and included acute, long-term, and outpatient care visits. Among 18,038 patients, 91.1%, 4.4%, and 4.6% were never, intermittently, or always colonized at the 30-day baseline. Compared to non-colonized patients, those who were persistently colonized had an increased risk of death (HR 2.58; 95% CI 2.18;3.05) and MRSA infection (HR 10.89; 95% CI 8.6;13.7). Being in the non-colonized group at 30 days had a predictive value of 87% for being non-colonized at 1 year. Conversion to MRSA colonized at 6 months occurred in 11.8% of initially non-colonized patients. Age >70 years, long-term care, antibiotic exposure, and diabetes identified >95% of converters. Conclusions The vast majority of patients are not nasally colonized with MRSA at 30 days from acute hospital admission. Conversion from non-carriage is infrequent and can be risk-stratified. A positive carriage pattern is strongly associated with infection and death. Active surveillance programs in the year following carriage pattern designation could be tailored to focus on non-colonized patients who are at high risk for conversion, reducing universal screening burden.","DOI":"10.1371/journal.pone.0053674","ISSN":"1932-6203","journalAbbreviation":"PLOS ONE","language":"en","author":[{"family":"Gupta","given":"Kalpana"},{"family":"Martinello","given":"Richard A."},{"family":"Young","given":"Melissa"},{"family":"Strymish","given":"Judith"},{"family":"Cho","given":"Kelly"},{"family":"Lawler","given":"Elizabeth"}],"issued":{"date-parts":[["2013",1,10]]}}},{"id":16926,"uris":[""],"uri":[""],"itemData":{"id":16926,"type":"article-journal","title":"Concordance of nasal and diabetic foot ulcer staphylococcal colonization","container-title":"Diagnostic microbiology and infectious disease","page":"85-89","volume":"79","issue":"1","source":"PubMed Central","abstract":"Background\nNasal carriage of Staphylococcus aureus (SA) is an important risk factor for surgical site infections. The goal of this study was to investigate the concordance between nasal and diabetic foot ulcer (DFU) SA carriage.\n\nMethods\n79 subjects with DFUs were assessed for nasal and DFU colonization with SA, including Methicillin-resistant-SA (MRSA).\n\nResults\nTwenty-five (31.6%) subjects had nares colonization with SA; 29 (36.7%) had DFU colonization with SA. Seven (8.8%) subjects had nares colonization with MRSA and 7 (8.8%) had DFU colonization with MRSA. Ulcer duration was associated with MRSA presence (p=0.01). Sensitivity and specificity of positive nasal SA colonization with positive DFU colonization were 41 and 74%.\n\nConclusions\nWe found substantial discordance between SA strains colonizing DFU and the nasal cavity. The poor positive predictive values for SA isolation in a DFU based on nasal carriage suggests SA colonization of a DFU by endogenous SA strains cannot be assumed.","DOI":"10.1016/j.diagmicrobio.2014.01.014","ISSN":"0732-8893","note":"PMID: 24560808\nPMCID: PMC3989386","journalAbbreviation":"Diagn Microbiol Infect Dis","author":[{"family":"Haleem","given":"Ambar"},{"family":"Schultz","given":"Jonathan S."},{"family":"Heilmann","given":"Kristopher P."},{"family":"Dohrn","given":"Cassie L."},{"family":"Diekema","given":"Daniel J."},{"family":"Gardner","given":"Sue E."}],"issued":{"date-parts":[["2014",5]]}}},{"id":16929,"uris":[""],"uri":[""],"itemData":{"id":16929,"type":"article-journal","title":"Prevalence, risk factors and sequelae of Staphylococcus aureus carriage in diabetes: the Fremantle Diabetes Study Phase II","container-title":"Journal of Diabetes and its Complications","page":"1092-1097","volume":"29","issue":"8","source":"ScienceDirect","abstract":"Aims\nTo determine the prevalence and associates of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) carriage in community-based diabetes, and their relationship to hospitalization with S. aureus infection.\nMethods\nA cross-sectional subset of 660 Fremantle Diabetes Study Phase II patients (mean±SD age 65.1±11.5years, 53.1% males) had nasal/axillary swabs as part of biennial review. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were measured in 358 patients. Those with positive swabs were invited back for a repeat swab. Hospitalizations with S. aureus infections were ascertained from validated data linkage. Multiple logistic regression was used to identify associates of carriage, and Cox proportional hazards modelling was used to determine predictors of subsequent hospitalization.\nResults\n258 patients (39.1%) were positive for S. aureus and eight (3.1%) carried MRSA. S. aureus carriage was independently associated with being married/in a de facto relationship and inversely with older age and being born overseas (P≤0.043). Repeat swabs in 137 patients (53.1% of those with an initially positive swab) grew S. aureus in 113 (82.5%). Five of eight MRSA-positive patients were re-swabbed, and four were MRSA-positive. Independent predictors of hospitalization with staphylococcal infection after the initial swab were S. aureus carriage (hazard ratio (95% CI) 5.42 (1.49–19.79)), prior hospitalization with S. aureus (4.84 (1.19–19.63)) and Aboriginality (7.20 (1.91–27.17) (P≤0.027). Serum 25(OH)D was not associated with S. aureus carriage or subsequent hospitalization.\nConclusions\nS. aureus and MRSA carriage in our patients was consistent with previous general population studies. There were no diabetes-specific risk factors. Persistent colonization may underlie the increased risk of hospitalization with S. aureus.","DOI":"10.1016/j.jdiacomp.2015.06.005","ISSN":"1056-8727","shortTitle":"Prevalence, risk factors and sequelae of Staphylococcus aureus carriage in diabetes","journalAbbreviation":"Journal of Diabetes and its Complications","author":[{"family":"Hart","given":"Julie"},{"family":"Hamilton","given":"Emma J."},{"family":"Makepeace","given":"Ashley"},{"family":"Davis","given":"Wendy A."},{"family":"Latkovic","given":"Erin"},{"family":"Lim","given":"Ee Mun"},{"family":"Dyer","given":"John R."},{"family":"Davis","given":"Timothy M. E."}],"issued":{"date-parts":[["2015",11,1]]}}},{"id":16932,"uris":[""],"uri":[""],"itemData":{"id":16932,"type":"article-journal","title":"Detection of MRSA from nasal carrier among diabetic foot ulcer patients in Tertiary Care Hospital Puducherry","container-title":"International Journal of Pharma and Bio Sciences","page":"B618-B623","volume":"6","issue":"3","source":"ResearchGate","abstract":"The purpose of this study was to evaluate risk factors for Methicillin-resistant Staphylococcus aureus (MRSA) from nasal carriers in patients hospitalized for diabetic foot ulcer infections. The study material consisted of nasal swabs collected from diabetic foot ulcer patients admitted at Sri Lakshmi Narayana Institute of medical sciences during the period of 3 months from November 2014 to January 2015. All the samples were subjected to gram staining and bacterial culture and S. aureus isolates were screened for MRSA prevalence using microbiological methods. All the clinical isolates are subjected to antimicrobial susceptibility testing on Mueller Hinton agar using the Kirby-Bauer disc diffusion method. S. aureus was the most common pathogen among the Gram-positive bacteria isolated from nasal carriers of diabetic foot ulcer patients. Out of 100samples, 65 Staphylococcus aureus was isolated, 40 (40%) were found to be Methicillin-resistant Staphylococcus aureus (MRSA) (MRSA) and 25 (25%) were found to be Methicillin sensitive Staphylococcus aureus (MSSA).Patients with diabetes with high blood sugar level (350-450mg/dl) were predominantly affected and the foot ulcers were significantly higher in males (70%). Identifying risk factors for MRSA infections could improve prevention and treatment in diabetic foot infections, reduce resistance patterns and reduce health care costs.","author":[{"family":"Jayarani","given":"K"},{"family":"Sundarji","given":"S.S."}],"issued":{"date-parts":[["2015"]]}}},{"id":16934,"uris":[""],"uri":[""],"itemData":{"id":16934,"type":"article-journal","title":"Prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus in children with diabetes mellitus: Trends between 2005 and 2013","container-title":"American Journal of Infection Control","page":"1015-1017","volume":"43","issue":"9","source":"PubMed","abstract":"The aim of this prospective study was to establish the methicillin-resistant Staphylococcus aureus (MRSA) colonization rates in pediatric outpatients with type 1 diabetes mellitus, while also evaluating changes in colonization rates over time. There was no significant difference between 2005 and 2013 patients in terms of demographic and clinical findings. MRSA colonization rates were 0.7% (in 101 patients) and 0.9% (in 134 patients) (P?=?.84). Although increased MRSA colonization has become a significant problem worldwide, it does not seem to be a major issue in our diabetic outpatient population.","DOI":"10.1016/j.ajic.2015.04.206","ISSN":"1527-3296","note":"PMID: 26050099","shortTitle":"Prevalence of nasal carriage of methicillin-resistant Staphylococcus aureus in children with diabetes mellitus","journalAbbreviation":"Am J Infect Control","language":"eng","author":[{"family":"Karadag-Oncel","given":"Eda"},{"family":"Gonc","given":"Nazli"},{"family":"Altay","given":"Ozlem"},{"family":"Cengiz","given":"Ali Bulent"},{"family":"Ozon","given":"Alev"},{"family":"Pinar","given":"Ahmet"},{"family":"Ceyhan","given":"Mehmet"},{"family":"Alikasifoglu","given":"Ayfer"},{"family":"Akyon","given":"Yakut"},{"family":"Kandemir","given":"Nurgun"},{"family":"Ozsurekci","given":"Yasemin"},{"family":"Kara","given":"Ates"}],"issued":{"date-parts":[["2015",9,1]]}}},{"id":16936,"uris":[""],"uri":[""],"itemData":{"id":16936,"type":"article-journal","title":"Prevalence and risk factors for methicillin-resistant Staphylococcus aureus colonization in a diabetic outpatient population: a prospective cohort study","container-title":"American Journal of Infection Control","page":"365-368","volume":"40","issue":"4","source":"PubMed","abstract":"BACKGROUND: Diabetes mellitus is a risk factor for methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection. We attempted to determine the prevalence and risk factors for MRSA colonization in a population of outpatients with diabetes.\nMETHODS: This prospective cohort study enrolled patients with diabetes. Anterior nares cultures were obtained from patients with diabetes admitted to outpatient endocrinology and metabolism clinics, and risk factors for MRSA colonization were analyzed.\nRESULTS: Out of the 304 patients evaluated, 127 (41.9%) were colonized with S aureus and 30 (9.9%) were colonized with MRSA. Overall, 23.6% of all S aureus isolates were MRSA. In multivariate analysis, factors independently associated with an increased risk of MRSA colonization included the presence of connective tissue disease (odds ratio, 7.075; 95% confidence interval, 2.157-23.209; P = .001) and insulin therapy (odds ratio, 3.910; 95% confidence interval, 1.652-9.251; P = .002).\nCONCLUSIONS: The prevalence of MRSA colonization in our sample of diabetic outpatients was 9.9%. Independent risk factors for MRSA colonization were the presence of connective tissue disease and insulin use. A better understanding of the epidemiology and risk factors for nasal MRSA colonization in the persons with diabetes may have significant implications for the treatment and prevention of MRSA infections.","DOI":"10.1016/j.ajic.2011.05.009","ISSN":"1527-3296","note":"PMID: 21864943","shortTitle":"Prevalence and risk factors for methicillin-resistant Staphylococcus aureus colonization in a diabetic outpatient population","journalAbbreviation":"Am J Infect Control","language":"eng","author":[{"family":"Kutlu","given":"Selda Sayin"},{"family":"Cevahir","given":"Nural"},{"family":"Akalin","given":"Serife"},{"family":"Akin","given":"Fulya"},{"family":"Dirgen Caylak","given":"Selmin"},{"family":"Bastemir","given":"Mehmet"},{"family":"Tekin","given":"Koray"}],"issued":{"date-parts":[["2012",5]]}}},{"id":16938,"uris":[""],"uri":[""],"itemData":{"id":16938,"type":"article-journal","title":"Prevalence and characteristics of Staphylococcus aureus and methicillin‐resistant Staphylococcus aureus nasal colonization among a community‐based diabetes population in Foshan, China","container-title":"Journal of Diabetes Investigation","page":"383-391","volume":"8","issue":"3","source":"PubMed Central","abstract":"Aims/Introduction\nEvidence suggests that diabetes might cause an increase in colonization of Staphylococcus aureus (S. aureus) and methicillin‐resistant S. aureus (MRSA) in community settings. We carried out a cross‐sectional study to determine the prevalence and influencing factors of S. aureus and MRSA nasal colonization among a community‐based diabetes population, and to identify the characteristics of the isolated strains.\n\nMaterials and Methods\nA total of 956 participants from 11 community settings were included in the study.\n\nResults\nOf the 529 diabetes participants, 46 were colonized with S. aureus and 22 were colonized with MRSA. Of the 427 non‐diabetes participants, 25 were colonized with S. aureus and 12 were colonized with MRSA. Men (odds ratio 0.45, 95% confidence interval 0.20–0.99, P = 0.047) were less likely to have S. aureus nasal colonization, and those with well‐controlled blood glucose (odds ratio 2.04, 95% confidence interval 1.01–4.13, P = 0.047) among the diabetes population were more likely to have S. aureus nasal colonization. The proportion of multidrug‐resistant S. aureus strains in the diabetes population (52.17%) was higher than that in the non‐diabetes population (28.00%; χ2 = 3.848, P = 0.050). The most common clonal complex type and Staphylococcal chromosome cassette mec type of MRSA in diabetes population was clonal complex 5 (40.91%) and type IV (27.27%), respectively. The proportion of Panton–Valentine leukocidin gene in MRSA strains was 17.65%. There was great sequence type diversity in MRSA strains.\n\nConclusions\nThe prevalence of MRSA in the community‐based diabetes population was moderate, and the high proportions of multidrug‐resistant S. aureus strains and diverse molecular characteristics in the diabetes population should be noticed.","DOI":"10.1111/jdi.12591","ISSN":"2040-1116","note":"PMID: 27808480\nPMCID: PMC5415482","journalAbbreviation":"J Diabetes Investig","author":[{"family":"Lin","given":"Jialing"},{"family":"Xu","given":"Ping"},{"family":"Peng","given":"Yang"},{"family":"Lin","given":"Dongxin"},{"family":"Ou","given":"Qianting"},{"family":"Zhang","given":"Ting"},{"family":"Bai","given":"Chan"},{"family":"Ye","given":"Xiaohua"},{"family":"Zhou","given":"Junli"},{"family":"Yao","given":"Zhenjiang"}],"issued":{"date-parts":[["2017",5]]}}},{"id":16943,"uris":[""],"uri":[""],"itemData":{"id":16943,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus nasal colonization among adult patients visiting emergency department in a medical center in Taiwan","container-title":"PloS One","page":"e18620","volume":"6","issue":"6","source":"PubMed","abstract":"BACKGROUND: Within the past 10 years, methicillin-resistant Staphylococcus aureus (MRSA) has not only been a hospital pathogen but also a community pathogen. To understand the carriage rate of methicillin-resistant Staphylococcus aureus (MRSA) among the adult patients visiting emergency department (ED), we conducted this study.\nMETHODOLOGY/PRINCIPAL FINDINGS: From May 21 to August 12, 2009, a total of 502 adult patients visiting emergency department (ED) of a tertiary care hospital in northern Taiwan were recruited in this study and surveyed for nasal carriage of MRSA. A questionnaire regarding the risk factors for MRSA acquisition was also obtained. The overall prevalence of MRSA nasal carriage among the patients was 3.8%. The carriage rate was significantly higher in patients with risk factors for MRSA acquisition (5.94%) than those without risk factors (2.12%). Patients with urinary complaints, diabetes mellitus, chronic kidney disease and current percutaneous tube usage were significantly associated with MRSA colonization. By multiple logistic regression analysis, only current usage of catheters or tubes was the independent predictor for MRSA nasal colonization. Of the 19 MRSA, most isolates belonged to one of two linages, characterized as sequence type (ST) 239 (32%) and ST 59 (58%). The latter linage, accounting for 83% of 6 isolates from patients without risk factors, is a community-associated (CA) clone in Taiwan, while the former linage is among healthcare-associated clones.\nCONCLUSION/SIGNIFICANCE: A substantial proportion of patients visiting ED, particularly with current usage of percutaneous catheter or tubes, in northern Taiwan carried MRSA, mostly community strains, in nares.","DOI":"10.1371/journal.pone.0018620","ISSN":"1932-6203","note":"PMID: 21695178\nPMCID: PMC3113794","journalAbbreviation":"PLoS ONE","language":"eng","author":[{"family":"Lu","given":"Sheng-Yun"},{"family":"Chang","given":"Fang-Yu"},{"family":"Cheng","given":"Ching-Chung"},{"family":"Lee","given":"Keong-Diong"},{"family":"Huang","given":"Yhu-Chering"}],"issued":{"date-parts":[["2011"]]}}},{"id":16947,"uris":[""],"uri":[""],"itemData":{"id":16947,"type":"article-journal","title":"The impact of nasal carriage of methicillin-resistant and methicillin-susceptible Staphylococcus a ureus (MRSA & MSSA) on vascular access-related septicemia among patients with type-II diabetes on dialysis","container-title":"Renal Failure","page":"763-777","volume":"24","issue":"6","source":"PubMed","abstract":"BACKGROUND: Fairly higher nasal carriage rates among type-II diabetics place them at a greater risk of endogenous Staphylococcus aureus linked vascular access-related septicemia (VRS) that is also dependent on the type of vascular access used for hemodialysis (HD). The prevalence of nasal carriage of methicillin susceptible and methicillin-resistant S. aureus (MSSA and MRSA) and its impact on VRS was determined in order to identify most vulnerable group and plan potential prophylactic strategies, accordingly.\nMETHODS: Five standardized nasal swab cultures were performed in 208 patients enrolled for long-term HD through July 1996 to July 1999. Persistent nasal carriage was defined by two or more positive cultures for MSSA or MRSA. Peripheral blood cultures were collected on clinical suspicion of septicemia.\nRESULTS: The prevalence of type-II diabetes of 28.0% with 72.4% of nasal carriage rate and three folds higher S. aureus related VRS (RR-3.19, p<0.0001) than diabetic non-carriers on HD, was observed. Type-II diabetics also had higher MSSA and MRSA nasal carriage rates (53.4% and 19.0%) than non-diabetic nasal carriers (18.6 and 6.0%) yet, carried a comparable (RR-4.0 vs. 4.5) risk of VRS between MSSA and MRSA nasal carriers. Among diabetic type-II S. aureus nasal carriers, central venous catheters (CVCs) carried 35 and 38 times higher collective risk of developing MSSA and MRSA nasal carriage-related VRS respectively than Arterio-venous fistula (AVF). The AVF recorded the lowest risk of developing MSSA and MRSA nasal carriage-related VRS (0.013 and 0.010 episodes/patient-year) in both diabetic type-II MSSA and MRSA nasal carrier groups.\nCONCLUSIONS: Diabetic type-II S. aureus nasal carriers on HD through CVCs make an extremely high-risk group for MSSA and MRSA nasal carriage-related VRS. The incidence of S. aureus nasal carriage-related VRS could reasonably be reduced through a challenging obligation of optimizing AVF prevalence in this high-risk group, while limiting the use of CVCs, at the same time.","ISSN":"0886-022X","note":"PMID: 12472199","journalAbbreviation":"Ren Fail","language":"eng","author":[{"family":"Saxena","given":"Anil K."},{"family":"Panhotra","given":"B. R."},{"family":"Venkateshappa","given":"C. K."},{"family":"Sundaram","given":"D. S."},{"family":"Naguib","given":"Mohammed"},{"family":"Uzzaman","given":"Wahid"},{"family":"Al Mulhim","given":"Khalifa"}],"issued":{"date-parts":[["2002",11]]}}},{"id":16949,"uris":[""],"uri":[""],"itemData":{"id":16949,"type":"article-journal","title":"Prevalence and Predictors of Nasal and Extranasal Staphylococcal Colonization in Patients Presenting to the Emergency Department","container-title":"Annals of Emergency Medicine","page":"492-499","volume":"57","issue":"5","source":"ScienceDirect","abstract":"Study objective\nMethicillin-resistant Staphylococcus aureus (MRSA) is one of the most common causes of skin and soft tissue infections in patients presenting to the emergency department (ED). The prevalence of asymptomatic MRSA colonization in ED patients is less well described, particularly in the absence of a skin and soft tissue infection–related complaint. The goals of this study are to assess the prevalence of nasal and extranasal staphylococcal colonization in ED patients, evaluate risk factors, and molecularly characterize the strains.\nMethods\nWe performed active surveillance for methicillin-susceptible S aureus (MSSA) and MRSA colonization in 400 subjects presenting to an urban ED. Risk factor assessment was performed and culture testing was conducted on anterior nares, oropharynx, palms, groin, perirectal area, wounds, and catheter insertion sites. Multiplex polymerase chain reaction was used to identify the USA300/400 clonal types.\nResults\nThe prevalence of colonization with MSSA was 39% (95% confidence interval 34.2% to 44.0%), and prevalence of colonization with MRSA was 5% (95% confidence interval 3.1% to 7.6%). Among MRSA-colonized subjects, an extranasal site tested positive in 80% of subjects, and 45% had exclusive extranasal colonization. USA300 was identified in 55% of MRSA-colonized subjects. The main risk factors for MRSA colonization included HIV infection, diabetes, and participation in contact sports.\nConclusion\nThe overall prevalence of MRSA colonization in this ED population was lower than that reported in other high-risk ambulatory care settings. However, extranasal colonization was present in more than half of MRSA-colonized subjects, and USA300 was the predominant clonal type.","DOI":"10.1016/j.annemergmed.2010.11.024","ISSN":"0196-0644","journalAbbreviation":"Annals of Emergency Medicine","author":[{"family":"Schechter-Perkins","given":"Elissa M."},{"family":"Mitchell","given":"Patricia M."},{"family":"Murray","given":"Kate A."},{"family":"Rubin-Smith","given":"Julia E."},{"family":"Weir","given":"Susan"},{"family":"Gupta","given":"Kalpana"}],"issued":{"date-parts":[["2011",5,1]]}}},{"id":16952,"uris":[""],"uri":[""],"itemData":{"id":16952,"type":"article-journal","title":"Predictors of methicillin-resistant Staphylococcus aureus colonization at hospital admission","container-title":"American Journal of Infection Control","page":"1043-1047","volume":"41","issue":"11","source":"PubMed","abstract":"BACKGROUND: The best strategy for active surveillance for methicillin-resistant Staphylococcus aureus (MRSA) remains unclear. We attempted to identify a risk factor score to predict MRSA colonization at hospital admission.\nMETHODS: Data on 9 variables reported as risk factors for MRSA colonization were analyzed, and a risk factor score to predict MRSA colonization was generated using multivariable logistic regression and receiver operating characteristic curve analyses. This risk score was then prospectively validated.\nRESULTS: Four risk factors (nursing home residence, diabetes, hospitalization in the past year, and chronic skin condition/infection) were significantly associated with MRSA colonization (c-statistic = 0.846). A cut-off score of 8 or greater would result in screening 20% of admissions and would detect 71% of MRSA-colonized patients. In the prospective validation study, a cut-off score of 8 or greater required screening 21% of admissions and detected 54% of MRSA. Nursing home residence was the best predictor of MRSA colonization.\nCONCLUSION: A similar risk factor-based screening strategy could be used to predict MRSA colonization in other institutions. Our data support routine screening of nursing home patients at hospital admission.","DOI":"10.1016/j.ajic.2013.02.013","ISSN":"1527-3296","note":"PMID: 23706830","journalAbbreviation":"Am J Infect Control","language":"eng","author":[{"family":"Torres","given":"Katherine"},{"family":"Sampathkumar","given":"Priya"}],"issued":{"date-parts":[["2013",11]]}}},{"id":16954,"uris":[""],"uri":[""],"itemData":{"id":16954,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus carriage in hospitalized chronic hemodialysis patients and its predisposing factors","container-title":"Hemodialysis International. International Symposium on Home Hemodialysis","page":"142-147","volume":"18","issue":"1","source":"PubMed","abstract":"There has been a paucity of literature on methicillin-resistant Staphylococcus aureus (MRSA) colonization in chronic hemodialysis patients who required admission. The purpose of this study is to determine the MRSA carriage rate in hospitalized chronic hemodialysis patients, to identify the risk factors, and assess the consequences of MRSA colonization. This was a retrospective study of hospitalized chronic hemodialysis patients at Khoo Teck Puat Hospital from July 1, 2010 to June 30, 2011. MRSA screening was done on the day of admission using culture method with MRSA select (Bio-Rad)?. The patients were divided into two groups: MRSA carriers and noncarriers. Demographic data, medical, and laboratory information was obtained via electronic medical record system. Outcome measures were infection rates during current hospitalization episode, frequency of hospitalization, and cumulative hospitalization days per year. Prevalence rate of MRSA colonization in hospitalized chronic hemodialysis patients was 15.1%, compared to all admitted patients (5.8%). Diabetes mellitus, Malay ethnicity, shorter hemodialysis duration and use of tunneled hemodialysis catheters were associated with MRSA colonization (P?<?0.05). Relative risk of infection during the episode of admission among MRSA carriers was 3.2-fold compared to noncarriers. MRSA colonization rates tend to be higher in patients on hemodialysis for less than 3 years and it correlates with longer hospitalization after adjustment for other variables (P?<?0.05). Patients on chronic hemodialysis requiring admission have higher rates of MRSA colonization. The risk factors of MRSA carriers and the correlation of MRSA rates to longer hospitalization suggest its nosocomial origin in this group of patients.","DOI":"10.1111/hdi.12061","ISSN":"1542-4758","note":"PMID: 23763574","journalAbbreviation":"Hemodial Int","language":"eng","author":[{"family":"Yeoh","given":"Lee Ying"},{"family":"Tan","given":"Feng Ling Grace"},{"family":"Willis","given":"George Christopher"},{"family":"Ooi","given":"Say Tat"}],"issued":{"date-parts":[["2014",1]]}}},{"id":17114,"uris":[""],"uri":[""],"itemData":{"id":17114,"type":"article-journal","title":"Risk Factors for Methicillin-Resistant Staphylococcus Aureus Carriage in Residents of German Nursing Homes","container-title":"Infection Control & Hospital Epidemiology","page":"511-515","volume":"23","issue":"9","source":"Cambridge Core","abstract":"Objectives:To determine the prevalence of and the risk factors for methicillin-resistant Staphylococcus aureus (MRSA) carriage in nursing home residents in the Rhine-Neckar region of southern Germany.Design:Point-prevalence survey.Setting:Forty-seven nursing homes in the region.Participants:All residents of the approached nursing homes who agreed to participate.Methods:After informed consent was obtained, all participants had their nares swabbed, some personal data collected, or both. All swabs were examined for growth of MRSA All S. aureus isolates underwent oxacillin susceptibility testing and polymerase chain reaction for demonstration of the meek gene. All MRSA isolates were typed using pulsed-field gel electrophoresis after digestion with SmaI.Results:Swabs from 3,236 nursing home residents yielded 36 MRSA strains, contributing to a prevalence rate of 1.1%. Significant risk factors for MRSA carriage in the multivariate analysis were the presence of wounds or urinary catheters, limited mobility, admission to a hospital during the preceding 3 months, or stay in a medium-size nursing home. One predominant MRSA strain could be detected in 30 of the 36 MRSA carriers.Conclusions:The prevalence of MRSA in German nursing homes is still low. These residents seemed to acquire their MRSA in the hospital and transfer it to their nursing home. Apart from well-known risk factors for the acquisition of MRSA we identified the size of the nursing home as an independent risk factor. This might be due to an increased use of antimicrobials in nursing homes of a certain size.","DOI":"10.1086/502098","ISSN":"0899-823X, 1559-6834","language":"en","author":[{"family":"Baum","given":"H.","dropping-particle":"von"},{"family":"Schmidt","given":"C."},{"family":"Svoboda","given":"D."},{"family":"Bock-Hensley","given":"O."},{"family":"Wendt","given":"Constanze"}],"issued":{"date-parts":[["2002",9]]}}},{"id":17109,"uris":[""],"uri":[""],"itemData":{"id":17109,"type":"article-journal","title":"Risk Factors of Methicillin-Resistant Staphylococcus aureus Infection and Correlation With Nasal Colonization Based on Molecular Genotyping in Medical Intensive Care Units: A Prospective Observational Study","container-title":"Medicine","page":"e1100","volume":"94","issue":"28","source":"journals.","abstract":"Methicillin-resistant Staphylococcus aureus (MRSA) is a common and important cause of colonization and infection in medical intensive care units (ICU). The aim of this study was to assess association factors between MRSA nasal colonization and subsequent infections in medical ICU patients by clinical investigation and molecular genotyping.\n A prospective cohort observational analysis of consecutive patients admitted to medical ICUs between November 2008 and May 2010 at a tertiary teaching hospital were included. To detect MRSA colonization, the specimens from the nares were obtained within 3 days of admission to the ICU and again 1 week following admission to the ICU. Genetic relatedness for colonized and clinical isolates from each study patient with MRSA infection were analyzed and compared.\n A total of 1266 patients were enrolled after excluding 195 patients with already present MRSA infections. Subsequent MRSA infection rates were higher in patients with nasal colonization than in those without (39.1% versus 14.7%, respectively). Multivariate Poisson regression analysis demonstrated that nasal MRSA colonization (relative risk [RR]: 2.50; 95% confidence interval [CI]: 1.90–3.27; P < 0.001) was independent predictors for subsequent MRSA infections. History of tracheostomy, however, was a protective predictor in all patients (RR: 0.38; 95% CI: 0.18–0.79; P = 0.010) and in patients with MRSA nasal colonization (RR: 0.22; 95% CI: 0.55–0.91; P = 0.037). Molecular genetics studies revealed that most MRSA isolates were healthcare-associated clones and that nasal and clinical isolates exhibited up to 75% shared identity.\n Methicillin-resistant S. aureus nasal colonization was significantly associated with subsequent MRSA infection among medical ICU patients. Previous MRSA infection was associated with subsequent MRSA infections, and history of tracheostomy associated with reducing this risk. Most MRSA isolates were healthcare-associated strains that were significantly correlated between nasal and clinical isolates.","DOI":"10.1097/MD.0000000000001100","ISSN":"0025-7974","shortTitle":"Risk Factors of Methicillin-Resistant Staphylococcus aureus Infection and Correlation With Nasal Colonization Based on Molecular Genotyping in Medical Intensive Care Units","language":"en-US","author":[{"family":"Kao","given":"Kuo-Chin"},{"family":"Chen","given":"Chun-Bing"},{"family":"Hu","given":"Han-Chung"},{"family":"Chang","given":"Hui-Ching"},{"family":"Huang","given":"Chung-Chi"},{"family":"Huang","given":"Yhu-Chering"}],"issued":{"date-parts":[["2015",7]]}}},{"id":17117,"uris":[""],"uri":[""],"itemData":{"id":17117,"type":"article-journal","title":"Nursing Homes as Reservoirs of MRSA: Myth or Reality?","container-title":"Journal of the American Medical Directors Association","page":"414-418","volume":"10","issue":"6","source":"Crossref","DOI":"10.1016/j.jamda.2009.02.014","ISSN":"15258610","shortTitle":"Nursing Homes as Reservoirs of MRSA","language":"en","author":[{"family":"Garazi","given":"Michele"},{"family":"Edwards","given":"Barbara"},{"family":"Caccavale","given":"Donna"},{"family":"Auerbach","given":"Charles"},{"family":"Wolf-Klein","given":"Gisele"}],"issued":{"date-parts":[["2009",7]]}}},{"id":17119,"uris":[""],"uri":[""],"itemData":{"id":17119,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus nasal carriage and infection among patients with diabetic foot ulcer","container-title":"Journal of Microbiology, Immunology and Infection","source":"Crossref","abstract":"Purpose: To evaluate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage in patients with diabetic foot ulcer (DFU) in Taiwan, and to assess the concordance between colonizing and clinical MRSA isolates from the patients.","URL":"","DOI":"10.1016/j.jmii.2018.03.005","ISSN":"16841182","language":"en","author":[{"family":"Lin","given":"Shin-Yi"},{"family":"Lin","given":"Nai-Yu"},{"family":"Huang","given":"Yu-Yao"},{"family":"Hsieh","given":"Chi-Chun"},{"family":"Huang","given":"Yhu-Chering"}],"issued":{"date-parts":[["2018"]]}}},{"id":16827,"uris":[""],"uri":[""],"itemData":{"id":16827,"type":"article-journal","title":"Link between nasal carriage of Staphylococcus?aureus and infected diabetic foot ulcers","container-title":"Diabetes & Metabolism","page":"167-171","volume":"43","issue":"2","source":"ScienceDirect","abstract":"Aims\nNasal carriage of Staphylococcus?aureus in diabetic patients may be a risk factor for diabetic foot lesion infections. The aims of this study were to compare the genotypic profiles of S.?aureus strains isolated from nares and diabetic foot ulcers (DFUs) using microarray technology.\nMethods\nPatients were included if they were admitted for diabetic foot infection (DFI) at any of three diabetology departments of Montpellier and N?mes University Hospitals between 1 September 2010 to 30 June 2012. All S.?aureus isolates were analyzed using oligonucleotides arrays; S.?aureus resistance and virulence genes were determined and each isolate was affiliated to a clonal complex.\nResults\nThe prevalence of S.?aureus nasal carriage among the 276 included patients was 39.5% (n=109), while 36.6% (n=101) had S.?aureus at both sites (nares and foot wounds) and, of these patients, 65.3% of patients harboured the same strain at both sites. In addition, the spread of the methicillin-resistant S.?aureus (MRSA) ST398 clone in DFI and its tropism for bone were also further confirmed.\nConclusion\nThese findings appear to provide new arguments in favour of the systematic detection of nasal S.?aureus carriage to anticipate the management of DFI.","DOI":"10.1016/j.diabet.2016.09.003","ISSN":"1262-3636","journalAbbreviation":"Diabetes & Metabolism","author":[{"family":"Dunyach-Remy","given":"C."},{"family":"Courtais-Coulon","given":"C."},{"family":"DeMattei","given":"C."},{"family":"Jourdan","given":"N."},{"family":"Schuldiner","given":"S."},{"family":"Sultan","given":"A."},{"family":"Carrière","given":"C."},{"family":"Alonso","given":"S."},{"family":"Sotto","given":"A."},{"family":"Lavigne","given":"J. -P."}],"issued":{"date-parts":[["2017",4,1]]}}},{"id":16880,"uris":[""],"uri":[""],"itemData":{"id":16880,"type":"article-journal","title":"Methicillin-resistant Staphyloccocus aureus (MRSA) isolation from diabetic foot ulcers correlates with nasal MRSA carriage","container-title":"Diabetes Research and Clinical Practice","page":"47-50","volume":"75","issue":"1","source":"ScienceDirect","abstract":"Methicillin-resistant Staphylococcus aureus is increasingly isolated from diabetic foot ulcers, and may be associated with an adverse prognosis. We have explored the relationship between MRSA isolation from foot ulcers and nasal MRSA carriage. Over a 12 month period, 65 consecutively attending patients with diabetic foot ulceration were recruited. Demographic information was collected, and the ulcer and nose swabbed bacteriologically using standard techniques. The patients were mean age 61year, diabetes duration 14 year, and HbA1c 8.5%. There were 61% male and 85% with type 2 diabetes. Ulcers were neuropathic in 55%, ischaemic in 14% and neuroischaemic in 31%. MRSA was isolated from 12 (19%) ulcers, and 11 (17%) had nasal carriage. Of the MRSA positive ulcer patients 7/12 (58%) had nasal MRSA carriage, compared with 4/53 (8%) with MRSA negative ulcers (p<0.0003). We conclude that nasal MRSA carriage in diabetic patients is a significant risk factor for foot ulcer MRSA infection.","DOI":"10.1016/j.diabres.2006.05.021","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Stanaway","given":"Stephen"},{"family":"Johnson","given":"Deborah"},{"family":"Moulik","given":"Probal"},{"family":"Gill","given":"Geoffrey"}],"issued":{"date-parts":[["2007",1,1]]}}}],"schema":""} (13,20–41). The majority (19/23) examined MRSA carriage in the nares, one study examined the nares and axilla, another supplemented this with groin swabs, another with perineum and sites of wounds or catheters and another used multiple sites. Together the 23 datasets represented a pooled population of 11577 diabetic patients with an MRSA colonisation rate of 9.20% (95% CI, 6.26-12.63%; figure 2A); heterogeneity among the studies was high (I2 = 96.38% [95% CI, 95.45-97.12%]). All forest plots are presented in the same way, the boxes show effect estimates for each study, weighted according to a random-effects model; the horizontal lines indicate 95% CIs; the centre of the diamond shows the pooled proportion and the horizontal tips represent 95% CIs. A funnel plot - on which the vertical line represents the summary estimate derived by meta-analysis and the diagonals represent 95% CIs around the summary effect - did not indicate publication bias (figure 2B). Inspection of the colonisation rates across the available 16 years did not reveal any correlation (R2 = 0.0052). Sub-analyses of the data were conducted by patient setting and region or, where possible, nation (table 2). Among patient settings for which meta-analysis was possible, haemodialysis (HD) patients were found to have the highest colonisation rate (19.08%), followed by inpatients (13.46%), out- or emergency patients (8.33%), diabetics in nursing homes (6.61%) and diabetics in the community (2.19%). Only one study of 10 patients examined the prevalence of MRSA among diabetic healthcare workers (HCWs), of which 3/10 were MRSA positive ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QfWTnLnn","properties":{"formattedCitation":"(20)","plainCitation":"(20)","noteIndex":0},"citationItems":[{"id":16739,"uris":[""],"uri":[""],"itemData":{"id":16739,"type":"article-journal","title":"Nasal carriage, risk factors and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus among healthcare workers in Adigrat and Wukro hospitals, Tigray, Northern Ethiopia","container-title":"BMC Research Notes","page":"250","volume":"11","issue":"1","source":"BioMed Central","abstract":"The aim of this study was to determine nasal carriage, risk factors and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus among health care-workers of Adigrat and Wukro hospitals Northern Ethiopia.","DOI":"10.1186/s13104-018-3353-2","ISSN":"1756-0500","journalAbbreviation":"BMC Research Notes","author":[{"family":"Legese","given":"Haftom"},{"family":"Kahsay","given":"Atsebaha Gebrekidan"},{"family":"Kahsay","given":"Amlisha"},{"family":"Araya","given":"Tadele"},{"family":"Adhanom","given":"Gebre"},{"family":"Muthupandian","given":"Saravanan"},{"family":"Gebreyesus","given":"Araya"}],"issued":{"date-parts":[["2018",4,23]]}}}],"schema":""} (20). There was enough data to conduct regional and national analyses including all patient settings for East Asia, the Middle East, Germany, Taiwan and the USA. The greatest colonisation prevalence was found in East Asia (12.85%) and the lowest in Germany (1.38%). Nation(s)No. of datasetsNo. of patientsPooled prevalence of MRSA %95% CII2 (%)95% CIDiabetic patients-23115779.206.26-12.6396.3895.45-97.12Healthcare workers-11030^N/AN/AN/AHaemodialysis patients-219719.0813.93-24.810.000.00-0.00Inpatients*-7729013.467.94-20.1697.0195.48-98.02Out- or emergency patients-57798.333.10-15.7789.4878.25-94.91Nursing homes only-35546.610.01-23.9996.6298.36Community (excl. nursing homes)-323142.190.94-3.9583.4049.74-94.52East AsiaChina, Taiwan, Singapore, Sri Lanka6162212.855.34-23.0096.4094.21-97.77Middle EastSaudi Arabia, Turkey35978.431.05-21.8694.8888.39-97.75USA-6666111.085.14-18.9297.3395.88-98.27Taiwan-38548.481.44-20.5696.0091.42-98.14Germany-316411.380.27-3.3380.2337.66-93.73Table 2. Subgroup analyses of the prevalence of MRSA colonisation among diabetic patients. *Inpatients excludes haemodialysis patients, which were analysed separately. ^Only one dataset available. CI, confidence interval.Many of the studies which contained colonisation data did so for diabetic patients as a sub-group of a wider cohort. Next, we therefore selected the 14 studies that contained colonisation data for diabetic and non-diabetic patients for comparison. Meta-analyses revealed that among a pooled population of diabetic patients (n = 8975) there was an MRSA colonisation rate of 10.27% (95% CI, 6.27-15.12%; I2 = 96.80% [95.74-97.60%]). Among the comparative non-diabetic population (n = 38976) the colonisation rate was 5.52% (95% CI, 2.93-8.88%; I2 = 99.18% [99.01-99.32%]). The 4.75% difference between these colonisation rates was significant (P < 0.0001). There was sufficient data among the 14 studies to perform sub-analyses for American (5/14), German (3/14) and East Asian (3/14) diabetics, as well as for nursing home residents (3/14) and inpatients (5/14). Across five studies, American diabetics (n = 6582) had a pooled MRSA carriage rate of 11.46% (95% CI, 4.84-20.42%; I2 = 97.87% [95% CI, 96.65-98.64%]) compared to 8.08% (95% CI, 2.82-15.72%; I2 = 99.66% [95% CI, 99.56-99.73%]) among 31005 non-diabetic Americans (P < 0.0001). Analysis of the three German studies revealed that 1641 diabetics had an MRSA carriage rate of 1.38% (95% CI, 0.27-3.33%; I2 = 80.23% [95% CI, 37.66-93.73%]), this was greater than the comparative rate of 0.84% (95% CI, 0.40-1.45%; I2 = 73.57% [95% CI, 11.49-92.11%]) for 5883 non-diabetics in these studies (P = 0.047). Comparison across the three East Asian studies revealed that 639 diabetics had a carriage rate of 14.34% (95% CI, 8.46-21.46%; I2 = 79.70% [95% CI, 35.60-93.60%]), compared to 7.65% (95% CI, 0.84-20.40%; I2 = 96.74% [95% CI, 93.33-98.41%]) in the comparative population of 1296 non-diabetics (P < 0.0001). Among the five studies that contained data on 6914 inpatient diabetics (excluding HD patients) there was a colonisation rate of 11.17% (95% CI, 5.78-18.04%; I2 = 97.18% [95% CI, 95.39-98.28%]), compared to 7.43% (95% CI, 3.02-13.59%; I2 = 99.08% [95% CI, 98.70-99.34%]) among 17072 non-diabetic inpatients (P < 0.0001). Three studies contained data regarding 554 nursing home residents, with a pooled MRSA prevalence rate of 6.61% (95% CI, 0.01-23.99%; I2 = 96.62% [95% CI, 93.01-98.36%]). This was similar to the 6.62% (95% CI, 0.23-20.71%; I2 = 97.93% [95% CI, 96.15-98.89%]) carriage rate among the comparative population of 3298 non-diabetic residents examined by these studies (P = 0.993).The prevalence of MRSA among patients with DFIData about the prevalence of MRSA among DFI patients was contained in 41 datasets ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a2kG2Q3P","properties":{"unsorted":true,"formattedCitation":"(42\\uc0\\u8211{}50,40,51\\uc0\\u8211{}68,41,69\\uc0\\u8211{}75,39,76,77,25,78)","plainCitation":"(42–50,40,51–68,41,69–75,39,76,77,25,78)","noteIndex":0},"citationItems":[{"id":16802,"uris":[""],"uri":[""],"itemData":{"id":16802,"type":"article-journal","title":"Conservative management of diabetic foot osteomyelitis","container-title":"Diabetes Research and Clinical Practice","page":"e18-e20","volume":"101","issue":"3","source":"ScienceDirect","abstract":"In this retrospective study, 130 patients with diabetic foot osteomyelitis were analysed. 66.9% of these healed with antibiotic treatment alone and 13.9% needed amputation, of which 1.5% were major. Presence of MRSA was associated with adverse outcome (53.3% vs 21.1%, p=0.04) which was defined as death, amputation and failure to heal.","DOI":"10.1016/j.diabres.2013.06.010","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Acharya","given":"S."},{"family":"Soliman","given":"M."},{"family":"Egun","given":"A."},{"family":"Rajbhandari","given":"S. M."}],"issued":{"date-parts":[["2013",9,1]]}}},{"id":16805,"uris":[""],"uri":[""],"itemData":{"id":16805,"type":"article-journal","title":"Prevalence of Methicillin Resistant Staphylococcus aureus among Egyptian Patients after Surgical Interventions","container-title":"Surgical Infections","page":"404-411","volume":"15","issue":"4","source":" (Atypon)","abstract":"Background:Staphylococcus aureus (S. aureus) is isolated frequently from surgical site infections and other soft tissue infections. There are limited data examining the prevalence of methicillin resistant S. aureus (MRSA) among Egyptian patients after surgery. The current study determined the prevalence of MRSA isolated from surgical site and soft tissue infections at Minia University Hospital (MUH), determined their susceptibility to β-lactams and other antimicrobials, and examined their mecA gene expression.Methods: A total of 208 hospitalized patients attending the General Surgery Department at MUH were enrolled and all had skin and soft tissue infections (SSTIs) of different causes. These 208 patients (143 males and 65 females) were suffering from surgical site infection (SSI; n=82), diabetic foot (n=52), abscess (n=45), or burn (n=29) infections. Samples were cultured on different media for isolation and identification of S. aureus and the isolates were screened for antibiotic susceptibility. All MRSA isolates were tested by polymerase chain reaction to detect the mecA gene responsible for methicllin resistance.Results: 241 Staphylococcal species represented the most common isolates (64.8%) among 371 collected isolates from the 208 patients. Out of the 241 staphylococcal isolates, 127 were S. aureus (61% of the total patients). The prevalence of S. aureus among SSI, diabetic foot, abscess, and burn patients were 59%, 75%, 56%, and 52%, whereas that of MRSA was 16%, 17%, 13%, and 10%, respectively. MRSA isolates (n=31; 15% of patients) showed multiple resistance to at least one member of the antimicrobial groups tested with an average resistance to 6.6±1.9 antimicrobial groups. Polymerase chain reaction data showed that only 29 isolates of the MRSA isolates (94%) were positive for mecA gene.Conclusions:Staphylococcus aureus isolates are the major pathogens responsible for wound and surgical site infections at MUH and MRSA are a potential threat for wound patients in Egypt.","DOI":"10.1089/sur.2013.212","ISSN":"1096-2964","journalAbbreviation":"Surgical Infections","author":[{"family":"Ahmed","given":"Eman F."},{"family":"Gad","given":"Gamal F.M."},{"family":"Abdalla","given":"Ahlam M."},{"family":"Hasaneen","given":"Ayman M."},{"family":"Abdelwahab","given":"Sayed F."}],"issued":{"date-parts":[["2014",5,9]]}}},{"id":16807,"uris":[""],"uri":[""],"itemData":{"id":16807,"type":"article-journal","title":"Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement","container-title":"Diabetologia","page":"1962","volume":"51","issue":"11","source":"link.","abstract":"Aims/hypothesisWe analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation.MethodsA consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death.ResultsProbing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as ‘other’. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection.Conclusions/interpretationConservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.","DOI":"10.1007/s00125-008-1131-8","ISSN":"0012-186X, 1432-0428","shortTitle":"Outcomes of surgical treatment of diabetic foot osteomyelitis","journalAbbreviation":"Diabetologia","language":"en","author":[{"family":"Aragón-Sánchez","given":"F. J."},{"family":"Cabrera-Galván","given":"J. J."},{"family":"Quintana-Marrero","given":"Y."},{"family":"Hernández-Herrero","given":"M. J."},{"family":"Lázaro-Martínez","given":"J. L."},{"family":"García-Morales","given":"E."},{"family":"Beneit-Montesinos","given":"J. V."},{"family":"Armstrong","given":"D. G."}],"issued":{"date-parts":[["2008",11,1]]}}},{"id":16810,"uris":[""],"uri":[""],"itemData":{"id":16810,"type":"article-journal","title":"Influence of wound scores and microbiology on the outcome of the diabetic foot syndrome","container-title":"Journal of Diabetes and its Complications","page":"329-334","volume":"30","issue":"2","source":"ScienceDirect","abstract":"Aims\nTo establish if the microbiology and the TEXAS, PEDIS and Wagner wound classifications of the diabetic foot syndrome (DFS) predict amputation.\nMethods\nProspective cohort study of 250 patients with DFS from 2009 to 2013. Tissue samples for culture were obtained and wound classification scores were recorded at admission.\nResults\nInfection was monomicrobial in 131 patients (52%). Staphylococcus aureus was the most frequent pathogen (76 patients, 30%); being methicillin-resistant S. aureus in 26% (20/76) Escherichia coli and Enterobacter faecalis were 2nd and 3rd most frequent pathogens. Two hundred nine patients (85%) needed amputation being major in 25 patients (10%). The three wound scales associated minor amputation but did not predict this outcome. Predictors of minor amputation in the multivariate analysis were the presence of osteomyelitis, the location of the wound in the forefoot and of major amputation elevated C reactive proteine (CRP) levels. A low ankle-brachial index (ABI) predicted major amputation in the follow-up. Overall, 74% of gram-positives were sensitive to quinolones and 98% to vancomycin and 90% of gram-negatives to cefotaxime and 95% to carbapenems.\nConclusions\nThe presence of osteomyelitis and the location of the wound in the forefoot predict minor amputation and elevated CRP levels predict major amputation. In the follow-up a low ABI predicts major amputation.","DOI":"10.1016/j.jdiacomp.2015.11.001","ISSN":"1056-8727","journalAbbreviation":"Journal of Diabetes and its Complications","author":[{"family":"Bravo-Molina","given":"Alejandra"},{"family":"Linares-Palomino","given":"José Patricio"},{"family":"Lozano-Alonso","given":"Silvia"},{"family":"Asensio-García","given":"Ricardo"},{"family":"Ros-Díe","given":"Eduardo"},{"family":"Hernández-Quero","given":"José"}],"issued":{"date-parts":[["2016",3,1]]}}},{"id":16813,"uris":[""],"uri":[""],"itemData":{"id":16813,"type":"article-journal","title":"Infections of Diabetic Foot Ulcers With Methicillin-Resistant Staphylococcus aureus","container-title":"The International Journal of Lower Extremity Wounds","page":"44-49","volume":"14","issue":"1","source":"SAGE Journals","abstract":"Infected diabetic foot is the most common reason for hospitalization and complications in patients with type 2 diabetes mellitus (DM2). Methicillin-resistant Staphylococcus aureus (MRSA) is frequently isolated from such lesions, and its presence is growing, seriously deteriorating the infected patient’s quality of life. The aim of this study was to assess the prevalence of MRSA as well as other microbiota in 100 patients diagnosed with (DM2) and with infected foot ulcers at the Hospital General de Mexico. The main results obtained show a prevalence of Staphylococcus aureus (42%), followed by Escherichia coli (36%) and, in lower percentages, other bacteria. MRSA was predominant (34%), and we conclude that the use of cefoxitin instead of oxacillin as the first-choice antibiotic has an advantage because it is a better inducer of methicillin-resistance expression.","DOI":"10.1177/1534734614564053","ISSN":"1534-7346","journalAbbreviation":"The International Journal of Lower Extremity Wounds","language":"en","author":[{"family":"Cervantes-García","given":"Estrella"},{"family":"García-González","given":"Rafael"},{"family":"Reséndiz-Albor","given":"Aldo"},{"family":"Salazar-Schettino","given":"Paz Maria"}],"issued":{"date-parts":[["2015",3,1]]}}},{"id":16815,"uris":[""],"uri":[""],"itemData":{"id":16815,"type":"article-journal","title":"Bacteriology of Moderate-to-Severe Diabetic Foot Infections and In Vitro Activity of Antimicrobial Agents","container-title":"Journal of Clinical Microbiology","page":"2819-2828","volume":"45","issue":"9","source":"PubMed Central","abstract":"As part of a United States-based multicenter clinical trial, conducted from 2001 to 2004, that compared ertapenem to piperacillin-tazobactam for the treatment of moderate-to-severe diabetic foot infections (DFIs), we obtained 454 pretreatment specimens from 433 patients. After debridement, the investigators collected wound specimens, mostly by curettage or biopsy, and sent them to the R. M. Alden Research Laboratory for aerobic and anaerobic culture. Among the 427 positive cultures, 83.8% were polymicrobial, 48% grew only aerobes, 43.7% had both aerobes and anaerobes, and 1.3% had only anaerobes. Cultures yielded a total of 1,145 aerobic strains and 462 anaerobic strains, with an average of 2.7 organisms per culture (range, 1 to 8) for aerobes and 2.3 organisms per culture (range, 1 to 9) for anaerobes. The predominant aerobic organisms were oxacillin-susceptible Staphylococcus aureus (14.3%), oxacillin-resistant Staphylococcus aureus (4.4%), coagulase-negative Staphylococcus species (15.3%), Streptococcus species (15.5%), Enterococcus species (13.5%), Corynebacterium species (10.1%), members of the family Enterobacteriaceae (12.8%), and Pseudomonas aeruginosa (3.5%). The predominant anaerobes were gram-positive cocci (45.2%), Prevotella species (13.6%), Porphyromonas species (11.3%), and the Bacteroides fragilis group (10.2%). Pure cultures were noted for 20% of oxacillin-resistant Staphylococcus aureus cultures, 9.2% of Staphylococcus epidermidis cultures, and 2.5% of P. aeruginosa cultures. Two or more species of Staphylococcus were present in 13.1% of the patients. Ertapenem and piperacillin-tazobactam were each active against >98% of the enteric gram-negative rods, methicillin-sensitive S. aureus, and anaerobes. Among the fluoroquinolones, 24% of anaerobes, especially the gram-positive cocci, were resistant to moxifloxacin; 27% of the gram-positive aerobes but only 6% of the members of the family Enterobacteriaceae were resistant to levofloxacin. Moderate-to-severe DFIs are typically polymicrobial, and almost half include anaerobes. Our antibiotic susceptibility results can help to inform therapeutic choices.","DOI":"10.1128/JCM.00551-07","ISSN":"0095-1137","note":"PMID: 17609322\nPMCID: PMC2045270","journalAbbreviation":"J Clin Microbiol","author":[{"family":"Citron","given":"Diane M."},{"family":"Goldstein","given":"Ellie J. C."},{"family":"Merriam","given":"C. Vreni"},{"family":"Lipsky","given":"Benjamin A."},{"family":"Abramson","given":"Murray A."}],"issued":{"date-parts":[["2007",9]]}}},{"id":16818,"uris":[""],"uri":[""],"itemData":{"id":16818,"type":"article-journal","title":"High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study)","container-title":"Diabetes research and clinical practice","page":"147-157","volume":"110","issue":"2","source":"PubMed Central","abstract":"Introduction\nThe risk of diabetes mellitus is increasing worldwide, and is particularly high in Indigenous Australians. Complicated foot infection is one of the most common sequelae of diabetes. We describe the incidence and associations of Indigenous and non-Indigenous inpatients with diabetic foot infections at Royal Darwin Hospital.\n\nMethods\nAll adult Royal Darwin Hospital inpatients with diabetic foot infections were enrolled prospectively from September 2012 to November 2013. Incidence, demographics, microbiology, management and clinical outcomes were analysed by Indigenous status, and association with methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa.\n\nResults\nThere were 245 separate hospital admissions in 177 patients with an incidence of 79 admissions per 100,000 person years. Patients occupied a mean of 19.4 hospital beds each day. Compared to the non-Indigenous population, Indigenous patients had a greater incidence of admission (Rate Ratio (RR) = 5.1, [95%CI = 3.8, 7.0]), were younger (mean difference of 11.1 years; p < 0.001), and more likely to undergo major and minor amputations (RR = 4.1 [95%CI = 1.6, 10.7], and 6.2 [95%CI = 3.5, 11.1] respectively). Non-multiresistant methicillin resistant S. aureus was present in 44.7% of wounds from Indigenous patients versus 20.6% of non-Indigenous patients (Odds Ratio (OR) = 3.1, [95%CI = 1.5, 6.4]), whereas P. aeruginosa presence was significantly lower (15.8% versus 46.0%; OR = 0.22; [95%CI = 0.11, 0.45]). Methicillin resistant S. aureus or P. aeruginosa infections were associated with longer antibiotic courses and durations of stay.\n\nConclusions\nThis study highlights a rising burden of diabetic foot infections in the Top End of Australia, with a four-fold increase in bed days since 2002 and an overrepresentation in the Indigenous population.","DOI":"10.1016/j.diabres.2015.09.016","ISSN":"0168-8227","note":"PMID: 26453263\nPMCID: PMC4684095","shortTitle":"High burden of diabetic foot infections in the top end of Australia","journalAbbreviation":"Diabetes Res Clin Pract","author":[{"family":"Commons","given":"Robert J."},{"family":"Robinson","given":"Claire H."},{"family":"Gawler","given":"David"},{"family":"Davis","given":"Joshua S."},{"family":"Price","given":"Ric N."}],"issued":{"date-parts":[["2015",11]]}}},{"id":16821,"uris":[""],"uri":[""],"itemData":{"id":16821,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem","container-title":"Diabetic Medicine","page":"159-161","volume":"20","issue":"2","source":"Wiley Online Library","abstract":"Aims To determine if there has been a change in the prevalence of pathogenic organisms in foot ulcers in diabetic patients in 2001 compared with our previous study in 1998. Methods A retrospective analysis of wound swabs taken from infected foot ulcers in diabetic patients attending the outpatient clinic in the Manchester Foot Hospital over a twelve-month period. A total of 63 patients with positive wound swabs were identified. Results Gram-positive aerobic bacteria still predominate (84.2%) and the commonest single isolate remains Staphylococcus aureus (79.0%) which is higher than we previously reported. MRSA was isolated in 30.2% of the patients which is almost double the proportion of MRSA-affected patients three years ago. This did not appear to be related to prior antibiotic usage. There was no increase in hospitalisation because of MRSA infection. Conclusions The problem of MRSA continues to increase despite the precautions taken to prevent MRSA spread. There is a need for a multi-centre study looking into the prevalence of MRSA in diabetic foot ulcer and how this can be reduced in the diabetic foot clinic.","DOI":"10.1046/j.1464-5491.2003.00860.x","ISSN":"1464-5491","shortTitle":"Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic","language":"en","author":[{"family":"Dang","given":"C. N."},{"family":"Prasad","given":"Y. D. M."},{"family":"Boulton","given":"A. J. M."},{"family":"Jude","given":"E. B."}],"issued":{"date-parts":[["2003",2,1]]}}},{"id":16824,"uris":[""],"uri":[""],"itemData":{"id":16824,"type":"article-journal","title":"Molecular epidemiology of Staphylococcus aureus strains isolated from inpatients with infected diabetic foot ulcers in an Algerian University Hospital","container-title":"Clinical Microbiology and Infection","page":"E398-E404","volume":"19","issue":"9","source":"ScienceDirect","abstract":"Staphylococcus aureus is the most common pathogen cultured from diabetic foot infection (DFI). The consequence of its spread to soft tissue and bony structures is a major causal factor for lower-limb amputation. The objective of the study was to explore ecological data and epidemiological characteristics of S. aureus strains isolated from DFI in an Algerian hospital setting. Patients were included if they were admitted for DFI in the Department of Diabetology at the Annaba University Hospital from April 2011 to March 2012. Ulcers were classified according to the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification system. All S. aureus isolates were analysed. Using oligonucleotide arrays, S. aureus resistance and virulence genes were determined and each isolate was affiliated to a clonal complex. Among the 128 patients, 277 strains were isolated from 183 samples (1.51 isolate per sample). Aerobic Gram-negative bacilli were the most common isolated organisms (54.9% of all isolates). The study of ecological data highlighted the extremely high rate of multidrug-resistant organisms (MDROs) (58.5% of all isolates). The situation was especially striking for S. aureus [(85.9% were methicillin-resistant S. aureus (MRSA)], Klebsiella pneumonia (83.8%) and Escherichia coli (60%). Among the S. aureus isolates, 82.2% of MRSA belonged to ST239, one of the most worldwide disseminated clones. Ten strains (13.7%) belonged to the European clone PVL+ ST80. ermA, aacA-aphD, aphA, tetM, fosB, sek, seq, lukDE, fnbB, cap8 and agr group 1 genes were significantly associated with MRSA strains (p <0.01). The study shows for the first time the alarming prevalence of MDROs in DFI in Algeria.","DOI":"10.1111/1469-0691.12199","ISSN":"1198-743X","journalAbbreviation":"Clinical Microbiology and Infection","author":[{"family":"Djahmi","given":"N."},{"family":"Messad","given":"N."},{"family":"Nedjai","given":"S."},{"family":"Moussaoui","given":"A."},{"family":"Mazouz","given":"D."},{"family":"Richard","given":"J. -L."},{"family":"Sotto","given":"A."},{"family":"Lavigne","given":"J. -P."}],"issued":{"date-parts":[["2013",9,1]]}}},{"id":16827,"uris":[""],"uri":[""],"itemData":{"id":16827,"type":"article-journal","title":"Link between nasal carriage of Staphylococcus?aureus and infected diabetic foot ulcers","container-title":"Diabetes & Metabolism","page":"167-171","volume":"43","issue":"2","source":"ScienceDirect","abstract":"Aims\nNasal carriage of Staphylococcus?aureus in diabetic patients may be a risk factor for diabetic foot lesion infections. The aims of this study were to compare the genotypic profiles of S.?aureus strains isolated from nares and diabetic foot ulcers (DFUs) using microarray technology.\nMethods\nPatients were included if they were admitted for diabetic foot infection (DFI) at any of three diabetology departments of Montpellier and N?mes University Hospitals between 1 September 2010 to 30 June 2012. All S.?aureus isolates were analyzed using oligonucleotides arrays; S.?aureus resistance and virulence genes were determined and each isolate was affiliated to a clonal complex.\nResults\nThe prevalence of S.?aureus nasal carriage among the 276 included patients was 39.5% (n=109), while 36.6% (n=101) had S.?aureus at both sites (nares and foot wounds) and, of these patients, 65.3% of patients harboured the same strain at both sites. In addition, the spread of the methicillin-resistant S.?aureus (MRSA) ST398 clone in DFI and its tropism for bone were also further confirmed.\nConclusion\nThese findings appear to provide new arguments in favour of the systematic detection of nasal S.?aureus carriage to anticipate the management of DFI.","DOI":"10.1016/j.diabet.2016.09.003","ISSN":"1262-3636","journalAbbreviation":"Diabetes & Metabolism","author":[{"family":"Dunyach-Remy","given":"C."},{"family":"Courtais-Coulon","given":"C."},{"family":"DeMattei","given":"C."},{"family":"Jourdan","given":"N."},{"family":"Schuldiner","given":"S."},{"family":"Sultan","given":"A."},{"family":"Carrière","given":"C."},{"family":"Alonso","given":"S."},{"family":"Sotto","given":"A."},{"family":"Lavigne","given":"J. -P."}],"issued":{"date-parts":[["2017",4,1]]}}},{"id":16894,"uris":[""],"uri":[""],"itemData":{"id":16894,"type":"article-journal","title":"Bacteriology of diabetic foot infections","container-title":"Saudi Medical Journal","page":"344-347","volume":"21","issue":"4","author":[{"family":"El-Tahawy","given":"A. T."}],"issued":{"date-parts":[["2000"]]}}},{"id":16830,"uris":[""],"uri":[""],"itemData":{"id":16830,"type":"article-journal","title":"A Clinico-microbiological Study of Diabetic Foot Ulcers in an Indian Tertiary Care Hospital","container-title":"Diabetes Care","page":"1727-1732","volume":"29","issue":"8","source":"care.","abstract":"OBJECTIVE—To determine the microbiological profile and antibiotic susceptibility patterns of organisms isolated from diabetic foot ulcers. Also, to assess potential risk factors for infection of ulcers with multidrug-resistant organisms (MDROs) and the outcome of these infections.\nRESEARCH DESIGN AND METHODS—Pus samples for bacterial culture were collected from 80 patients admitted with diabetic foot infections. All patients had ulcers with Wagner’s grade 3–5. Fifty patients (62.5%) had coexisting osteomyelitis. Gram-negative bacilli were tested for extended spectrum β-lactamase (ESBL) production by double disc diffusion method. Staphylococcal isolates were tested for susceptibility to oxacillin by screen agar method, disc diffusion, and mec A–based PCR. Potential risk factors for MDRO-positive samples were explored.\nRESULTS—Gram-negative aerobes were most frequently isolated (51.4%), followed by gram-positive aerobes and anaerobes (33.3 and 15.3%, respectively). Seventy-two percent of patients were positive for MDROs. ESBL production and methicillin resistance was noted in 44.7 and 56.0% of bacterial isolates, respectively. MDRO-positive status was associated with presence of neuropathy (P = 0.03), osteomyelitis (P = 0.01), and ulcer size >4 cm2 (P < 0.001) but not with patient characteristics, ulcer type and duration, or duration of hospital stay. MDRO-infected patients had poor glycemic control (P = 0.01) and had to be surgically treated more often (P < 0.01).\nCONCLUSIONS—Infection with MDROs is common in diabetic foot ulcers and is associated with inadequate glycemic control and increased requirement for surgical treatment. There is a need for continuous surveillance of resistant bacteria to provide the basis for empirical therapy and reduce the risk of complications.","DOI":"10.2337/dc06-0116","ISSN":"0149-5992, 1935-5548","note":"PMID: 16873771","language":"en","author":[{"family":"Gadepalli","given":"Ravisekhar"},{"family":"Dhawan","given":"Benu"},{"family":"Sreenivas","given":"Vishnubhatla"},{"family":"Kapil","given":"Arti"},{"family":"Ammini","given":"A. C."},{"family":"Chaudhry","given":"Rama"}],"issued":{"date-parts":[["2006",8,1]]}}},{"id":16834,"uris":[""],"uri":[""],"itemData":{"id":16834,"type":"article-journal","title":"Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers: Focus on the differences between species isolated from individuals with ischemic vs. neuropathic foot ulcers","container-title":"Diabetes Research and Clinical Practice","page":"187-193","volume":"84","issue":"2","source":"ScienceDirect","abstract":"We examined whether foot ischemia or neuropathy with diabetic foot ulcer (DFU) promote selection of staphylococci species, evaluated frequency of MRSA and MRSE among strains yielded from patients with DFU and assessed multidrug resistance of isolates. Patients with DFU and foot osteomyelitis were divided into ischemic foot ulcer (IFU, n=21) and neuropathic foot ulcer (NFU, n=29) groups. Frequency of Staphylococcus epidermidis yielded from curettage of IFU was higher compared with NFU (P<0.05). S. epidermidis was also more frequently isolated from the toe web surface of patients with IFU compared with NFU (55% vs. 17.9%, respectively) and healthy volunteers (HV, n=20) (17.6%, P<0.05). These mostly MRSE strains (83.3–100%) originating from DFU patients were multidrug resistant (88.8%). Also, most of MRSA isolates were multidrug resistant (70.3%). Higher rates of MSSA from DFU patients than HV showed resistance to antimicrobials. This is the first report indicating that diabetic patients with IFU differ with NFU patients in higher frequency of S. epidermidis skin colonization and ulcer infection. We suggest that IFU should be defined as separate disease state of DFU and S. epidermidis should be appreciated as a nosocomial pathogen.","DOI":"10.1016/j.diabres.2009.02.008","ISSN":"0168-8227","shortTitle":"Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Galkowska","given":"Hanna"},{"family":"Podbielska","given":"Adrianna"},{"family":"Olszewski","given":"Waldemar L."},{"family":"Stelmach","given":"Ewa"},{"family":"Luczak","given":"Miroslaw"},{"family":"Rosinski","given":"Grzegorz"},{"family":"Karnafel","given":"Waldemar"}],"issued":{"date-parts":[["2009",5,1]]}}},{"id":16837,"uris":[""],"uri":[""],"itemData":{"id":16837,"type":"article-journal","title":"Microbiological profile of infected diabetic foot ulcers","container-title":"Diabetic Medicine","page":"1032-1034","volume":"19","issue":"12","source":"Wiley Online Library","DOI":"10.1046/j.1464-5491.2002.00696_1.x","ISSN":"1464-5491","language":"en","author":[{"family":"Ge","given":"Y."},{"family":"MacDonald","given":"H."},{"family":"Hait","given":"H."},{"family":"Lipsky","given":"B."},{"family":"Zasloff","given":"M."},{"family":"Holroyd","given":"K."}],"issued":{"date-parts":[["2002",12,1]]}}},{"id":16840,"uris":[""],"uri":[""],"itemData":{"id":16840,"type":"article-journal","title":"Diabetic Foot Infections: Bacteriology and activity of 10 oral antimicrobial agents against bacteria isolated from consecutive cases","container-title":"Diabetes Care","page":"638-641","volume":"19","issue":"6","source":"care.","abstract":"OBJECTIVE To study the relative frequency of bacterial isolates cultured from community-acquired foot infections and assess their comparative in vitro susceptibility to sparfloxacin, levofloxacin, and eight other commonly used oral antimicrobial agents.\nRESEARCH DESIGN AND METHODS This is a prospective study in which the infected wounds of 25 consecutive diabetic patients seen by one of the authors were cultured as they entered the hospital. Isolates were stored and tested for susceptibility to 10 oral antimicrobial agents using the agar dilution method.\nRESULTS Staphylococcus aurcus was the most common isolate (76% of patients), including methicillin-resistant S. aurcus (MRSA) in 5 of 25 (20%) patient wounds. Streptococci, enterococci, Enterobacteriaceae, and anaerobes were also present in ≥40% of patient wounds. Sparfloxacin and levofloxacin were the most active agents tested with activity against ≥88% of isolates. Isolates resistant to sparfloxacin and levofloxacin included MRSA, enterococci, and some anaerobes. When analyzed by prior exposure to antibiotics, patients who had previously received oral antibiotics were more likely to have MRSA, enterococci, and Pseudomonas aeruginosa isolated and less likely to have Enterobacteriaceae and anaerobes isolated from their wounds.\nCONCLUSIONS MRSA and enterococci are now a common cause of diabetic foot infections, and the increased prevalence may be due to antimicrobial use. These wounds may require use of combined antimicrobial therapy for initial outpatient management. The new fluoroquinolones, sparfloxacin and levofloxacin, were the most active oral agents tested.","DOI":"10.2337/diacare.19.6.638","ISSN":"0149-5992, 1935-5548","note":"PMID: 8725864","shortTitle":"Diabetic Foot Infections","language":"en","author":[{"family":"Goldstein","given":"Ellie J. C."},{"family":"Citron","given":"Diane M."},{"family":"Nesbit","given":"Catherine A."}],"issued":{"date-parts":[["1996",6,1]]}}},{"id":16844,"uris":[""],"uri":[""],"itemData":{"id":16844,"type":"article-journal","title":"Diabetic foot ulcer and multidrug-resistant organisms: risk factors and impact","container-title":"Diabetic Medicine","page":"710-715","volume":"21","issue":"7","source":"Wiley Online Library","abstract":"Aims The primary objective was to characterize factors allowing the colonization of diabetic foot wounds by multidrug-resistant organisms (MDRO), and the secondary objective was to evaluate the influence of MDRO colonization/infection on wound healing. Methods In 180 patients admitted to a specialized diabetic foot unit, microbiological specimens were taken on admission. Potential risk factors for MDRO-positive specimens were examined using univariate and multivariate analyses. Prospective follow-up data from 75 patients were used to evaluate the influence of MDRO colonization/infection on time to healing. Results Eighteen per cent of admission specimens were positive for MDRO. MDRO-positive status was not associated with patient characteristics (age, sex, type of diabetes, complications of diabetes), wound duration, or wound type (neuropathic or ischaemic). In the multivariate analysis, the only factors significantly associated with positive MDRO status on admission were a history of previous hospitalization for the same wound (21/32 compared with 48/148; P = 0.0008) or the presence of osteomyelitis (22/32 compared with 71/148; P = 0.025). In the longitudinal study of 75 wounds, MDRO-positive status on admission or during follow-up (6 months at least or until healing, mean 9 ± 7 months) was not associated with time to healing (P = 0.71). Conclusion MDROs are often present in severe diabetic foot wounds. About one-third of patients with a history of previous hospitalization for the same wound, and 25% of patients with osteomyelitis, had MDRO-positive specimens. This suggests that hygiene measures, or isolation precautions in the case of admission of patients presenting with these characteristics, should be aggressively implemented to prevent cross-transmission. Positive MDRO status is not associated with a longer time to healing.","DOI":"10.1111/j.1464-5491.2004.01237.x","ISSN":"1464-5491","shortTitle":"Diabetic foot ulcer and multidrug-resistant organisms","language":"en","author":[{"family":"Hartemann‐Heurtier","given":"A."},{"family":"Robert","given":"J."},{"family":"Jacqueminet","given":"S."},{"family":"Van","given":"G. Ha"},{"family":"Golmard","given":"J. L."},{"family":"Jarlier","given":"V."},{"family":"Grimaldi","given":"A."}],"issued":{"date-parts":[["2004",7,1]]}}},{"id":16850,"uris":[""],"uri":[""],"itemData":{"id":16850,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus: an increasing problem in a diabetic foot clinic","container-title":"Diabetic Medicine","page":"767-771","volume":"16","issue":"9","source":"Wiley Online Library","abstract":"Aim To study the prevalence of pathogenic organisms and the prevalence and outcome of methicillin-resistant Staphylococcus aureus (MRSA) infection in foot ulcers in diabetic patients. Methods A retrospective analysis of wound swabs taken from infected foot ulcers in diabetic patients, selected from an outpatient diabetic foot clinic. Seventy-five patients (79 ulcers) with positive wound swabs were included. Size of ulcer and time to healing, in particular for MRSA-infected ulcers, were measured in all patients. Results Gram-positive aerobic bacteria were the commonest micro-organism isolated (56.7%) followed by Gram-negative aerobic bacteria and anaerobes (29.8% and 13.5%, respectively). Of the Gram-positive aerobes, S. aureus was found most frequently and 40% were MRSA. MRSA was isolated more commonly in patients treated with antibiotics prior to the swab compared to those who had not received antibiotics (P = 0.01). Patients whose foot ulcers were infected by MRSA had longer healing time than patients whose ulcers were infected by methicillin-sensitive S. aureus (mean (range) 35.4 (19–64) and 17.8 (8–24) weeks, respectively, P = 0.03). Conclusion MRSA infection is common in diabetic foot ulcers and is associated with previous antibiotic treatment and prolonged time to healing. Further studies are required to assess the need for antibiotics in treating foot ulcers in diabetes and to assess the optimum therapeutic approach to this problem.","DOI":"10.1046/j.1464-5491.1999.00132.x","ISSN":"1464-5491","shortTitle":"Methicillin-resistant Staphylococcus aureus","language":"en","author":[{"family":"Tentolouris","given":"N."},{"family":"Jude","given":"E. B."},{"family":"Smirnof","given":"I."},{"family":"Knowles","given":"E. A."},{"family":"Boulton","given":"A. J. M."}],"issued":{"date-parts":[["1999",9,1]]}}},{"id":16847,"uris":[""],"uri":[""],"itemData":{"id":16847,"type":"article-journal","title":"Risk factors for methicillin-resistant Staphylococcus aureus in diabetic foot infections","container-title":"Diabetic Foot & Ankle","volume":"5","issue":"10.3402","abstract":"Objective\nThe purpose of this study was to evaluate risk factors for methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized for diabetic foot infections.\n\nMethods\nWe reviewed hospital admissions for foot infections in patients with diabetes which had nasal swabs, and anaerobic and aerobic tissue cultures at the time of admission. Data collected included patient characteristics and medical history to determine risk factors for developing an MRSA infection in the foot.\n\nResults\nThe prevalence of MRSA in these infections was 29.8%. Risk factors for MRSA diabetic foot infections were history of MRSA foot infection, MRSA nasal colonization, and multidrug-resistant organisms (p<0.05). Positive predictive value (PPV) and negative predictive value (NPV) of nasal colonization with MRSA to identify MRSA diabetic foot infections were 66.7% and 80.0% (sensitivity 41%, specificity 90%). Admission from a nursing home was not a significant risk factor.\n\nConclusion\nPositive nasal swabs are not predictive of the infecting agent; however, a negative nasal swab rules out MRSA as the infecting agent in foot wounds with 90% accuracy.","DOI":"10.3402/dfa.v5.23575","ISSN":"2000-625X","note":"PMID: 24765246\nPMCID: PMC3984406","journalAbbreviation":"Diabet Foot Ankle","author":[{"family":"Lavery","given":"Lawrence A."},{"family":"Fontaine","given":"Javier La"},{"family":"Bhavan","given":"Kavita"},{"family":"Kim","given":"Paul J."},{"family":"Williams","given":"Jayme R."},{"family":"Hunt","given":"Nathan A."}],"issued":{"date-parts":[["2014"]]}}},{"id":16853,"uris":[""],"uri":[""],"itemData":{"id":16853,"type":"article-journal","title":"Daptomycin for treating infected diabetic foot ulcers: evidence from a randomized, controlled trial comparing daptomycin with vancomycin or semi-synthetic penicillins for complicated skin and skin-structure infections","container-title":"Journal of Antimicrobial Chemotherapy","page":"240-245","volume":"55","issue":"2","source":"academic.","abstract":"Abstract. Objectives:The predominant pathogens causing diabetic foot infections are Gram-positive cocci, many of which are now resistant to commonly prescribed","DOI":"10.1093/jac/dkh531","ISSN":"0305-7453","shortTitle":"Daptomycin for treating infected diabetic foot ulcers","journalAbbreviation":"J Antimicrob Chemother","language":"en","author":[{"family":"Lipsky","given":"Benjamin A."},{"family":"Stoutenburgh","given":"Uschi"}],"issued":{"date-parts":[["2005",2,1]]}}},{"id":16855,"uris":[""],"uri":[""],"itemData":{"id":16855,"type":"article-journal","title":"Skin and soft tissue infections in hospitalised patients with diabetes: culture isolates and risk factors associated with mortality, length of stay and cost","container-title":"Diabetologia","page":"914-923","volume":"53","issue":"5","source":"link.","abstract":"Aims/hypothesisSkin and soft tissue infections (SSTIs) cause substantial morbidity in persons with diabetes. There are few data on pathogens or risk factors associated with important outcomes in diabetic patients hospitalised with SSTIs.MethodsUsing a clinical research database from CareFusion, we identified 3,030 hospitalised diabetic patients with positive culture isolates and a diagnosis of SSTI in 97 US hospitals between 2003 and 2007. We classified the culture isolates and analysed their association with the anatomic location of infection, mortality, length of stay and hospital costs.ResultsThe only culture isolate with a significantly increased prevalence was methicillin-resistant Staphylococcus aureus (MRSA); prevalence for infection of the foot was increased from 11.6 to 21.9% (p < 0.0001) and for non-foot locations from 14.0% to 24.6% (p = 0.006). Patients with non-foot (vs foot) infections were more severely ill at presentation and had higher mortality rates (2.2% vs 1.0%, p < 0.05). Significant independent risk factors associated with higher mortality rates included having a polymicrobial culture with Pseudomonas aeruginosa (OR 3.1), a monomicrobial culture with other gram-negatives (OR 8.9), greater illness severity (OR 1.9) and being transferred from another hospital (OR 5.1). These factors and need for major surgery were also independently associated with longer length of stay and higher costs.Conclusions/interpretationAmong diabetic patients hospitalised with SSTI from 2003 to 2007, only MRSA increased in prevalence. Patients with non-foot (vs foot) infections were more severely ill. Independent risk factors for increased mortality rates, length of stay and costs included more severe illness, transfer from another hospital and wound cultures with Pseudomonas or other gram-negatives.","DOI":"10.1007/s00125-010-1672-5","ISSN":"0012-186X, 1432-0428","shortTitle":"Skin and soft tissue infections in hospitalised patients with diabetes","journalAbbreviation":"Diabetologia","language":"en","author":[{"family":"Lipsky","given":"B. A."},{"family":"Tabak","given":"Y. P."},{"family":"Johannes","given":"R. S."},{"family":"Vo","given":"L."},{"family":"Hyde","given":"L."},{"family":"Weigelt","given":"J. A."}],"issued":{"date-parts":[["2010",5,1]]}}},{"id":16859,"uris":[""],"uri":[""],"itemData":{"id":16859,"type":"article-journal","title":"Clinical and bacteriological survey of diabetic foot infections in Lisbon","container-title":"Diabetes Research and Clinical Practice","page":"153-161","volume":"95","issue":"1","source":"ScienceDirect","abstract":"Aims\nAn epidemiological survey of diabetic foot infections (DFIs) in Lisbon, stratifying the bacterial profile based on patient demographical data, diabetic foot characteristics (PEDIS classification), ulcer duration and antibiotic therapy.\nMethods\nA transversal observational multicenter study, with clinical data collection using a structured questionnaire and microbiological products (aspirates, biopsies or swabs collected using the Levine method) of clinically infected foot ulcers of patients with diabetes mellitus (DM).\nResults\nForty-nine hospitalized and ambulatory patients were enrolled in this study, and 147 microbial isolates were cultured. Staphylococcus was the main genus identified, and methicillin-resistant Staphylococcus aureus (MRSA) was present in 24.5% of total cases. In the clinical samples collected from patients undergoing antibiotic therapy, 93% of the antibiotic regimens were considered inadequate based on the antibiotic susceptibility test results. The average duration of an ulcer with any isolated multi-drug resistant (MDR) organism was 29 days, and previous treatment with fluoroquinolones was statistically associated with multi-drug resistance.\nConclusions\nStaphylococcus aureus was the most common cause of DFIs in our area. Prevalence and precocity of MDR organisms, namely MRSA, were high and were probably related to previous indiscriminate antibiotic use. Clinicians should avoid fluoroquinolones and more frequently consider the use of empirical anti-MRSA therapy.","DOI":"10.1016/j.diabres.2011.10.001","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Mendes","given":"J. J."},{"family":"Marques-Costa","given":"A."},{"family":"Vilela","given":"C."},{"family":"Neves","given":"J."},{"family":"Candeias","given":"N."},{"family":"Cavaco-Silva","given":"P."},{"family":"Melo-Cristino","given":"J."}],"issued":{"date-parts":[["2012",1,1]]}}},{"id":16862,"uris":[""],"uri":[""],"itemData":{"id":16862,"type":"article-journal","title":"Epidemiology of diabetic foot problems and predictive factors for limb loss","container-title":"Journal of Diabetes and its Complications","page":"77-82","volume":"22","issue":"2","source":"ScienceDirect","abstract":"Objectives\nThe aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major amputations (below- and above-knee).\nMethods\nThis is a prospective study of 202 patients treated in National University Hospital (NUH) during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for limb loss were determined using univariate and stepwise logistic regression analysis.\nResults\nOne hundred ninety-two patients had Type 2 diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays (P=.0015) and Indians (P=.036) and significantly lower in Chinese (P<.05). Of patients, 72.8% had poor endocrine control (GHb level >7%), and 42.1% of patients had sensory neuropathy based on 5.07 Semmes–Weinstein Monofilament test. Common DFP included gangrene (31.7%), infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcot's osteoarthropathy (2.0%). Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in 6.9%).\nConclusions\nThis is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP. Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) <0.8, gangrene, infection, and pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression analysis, only PVD and infection were significant.","DOI":"10.1016/j.jdiacomp.2007.04.004","ISSN":"1056-8727","journalAbbreviation":"Journal of Diabetes and its Complications","author":[{"family":"Nather","given":"Aziz"},{"family":"Bee","given":"Chionh Siok"},{"family":"Huak","given":"Chan Yiong"},{"family":"Chew","given":"Jocelyn L. L."},{"family":"Lin","given":"Clarabelle B."},{"family":"Neo","given":"Shuhui"},{"family":"Sim","given":"Eileen Y."}],"issued":{"date-parts":[["2008",3,1]]}}},{"id":16865,"uris":[""],"uri":[""],"itemData":{"id":16865,"type":"article-journal","title":"Epidemiology of Methicillin-Resistant Staphylococcus aureus Diabetic Foot Infections in a Large Academic Hospital: Implications for Antimicrobial Stewardship","container-title":"PLOS ONE","page":"e0161658","volume":"11","issue":"8","source":"PLoS Journals","abstract":"Introduction Diabetic foot infections (DFIs) are the leading cause of non-traumatic lower extremity amputations in the United States. Antimicrobials active against methicillin-resistant Staphylococcus aureus (MRSA) are recommended in patients with associated risk factors; however, limited data exist to support these recommendations. Due to the changing epidemiology of MRSA, and the consequences of unnecessary antibiotic therapy, guidance regarding the necessity of empirical MRSA coverage in DFIs is needed. We sought to 1) describe the prevalence of MRSA DFIs at our institution and compare to the proportion of patients who receive MRSA antibiotic coverage and 2) identify risk factors for MRSA DFI. Methods This was a retrospective cohort study of all adult, culture-positive DFI patients managed at University Hospital, San Antonio, TX between January 1, 2010 and September 1, 2014. Patient eligibility included a principal ICD-9-CM discharge diagnosis code for foot infection and a secondary diagnosis of diabetes. The primary outcome was MRSA identified in the wound culture. Independent variables assessed included patient demographics, comorbidities, prior hospitalization, DFI therapies, prior antibiotics, prior MRSA infection, and laboratory values. Multivariable logistic regression was used to identify risk factors for MRSA DFI. Results Overall, 318 patients met inclusion criteria. Patients were predominantly Hispanic (79%) and male (69%). Common comorbidities included hypertension (76%), dyslipidemia (52%), and obesity (49%). S. aureus was present in 46% of culture-positive DFIs (MRSA, 15%). A total of 273 patients (86%) received MRSA antibiotic coverage, resulting in 71% unnecessary use. Male gender (OR 3.09, 95% CI 1.37–7.99) and bone involvement (OR 1.93, 1.00–3.78) were found to be independent risk factors for MRSA DFI. Conclusions Although MRSA was the causative pathogen in a small number of DFI, antibiotic coverage targeted against MRSA was unnecessarily high.","DOI":"10.1371/journal.pone.0161658","ISSN":"1932-6203","shortTitle":"Epidemiology of Methicillin-Resistant Staphylococcus aureus Diabetic Foot Infections in a Large Academic Hospital","journalAbbreviation":"PLOS ONE","language":"en","author":[{"family":"Reveles","given":"Kelly R."},{"family":"Duhon","given":"Bryson M."},{"family":"Moore","given":"Robert J."},{"family":"Hand","given":"Elizabeth O."},{"family":"Howell","given":"Crystal K."}],"issued":{"date-parts":[["2016",8,24]]}}},{"id":16871,"uris":[""],"uri":[""],"itemData":{"id":16871,"type":"article-journal","title":"Predictors for limb loss among patient with diabetic foot infections: an observational retrospective multicentric study in Turkey","container-title":"Clinical Microbiology and Infection","page":"659-664","volume":"21","issue":"7","source":"ScienceDirect","abstract":"We aimed to investigate the predictors for limb loss among patients with diabetes who have complicated skin/soft-tissue infections. In this observational study, consecutive patients with diabetic foot infection (DFI) from 17 centres in Turkey, between May 2011 and May 2013 were included. The Turkish DFI Working Group performed the study. Predictors of limb loss were investigated by multivariate analysis. In total, 455 patients with DFI were included. Median age was 61 years, 68% were male, 65% of the patients were hospitalized, 52% of the patients had used antibiotics within the last month, and 121 (27%) had osteomyelitis. Of the 208 microorganisms isolated, 92 (44.2%) were Gram-positive cocci and 114 (54.8%) were Gram-negative rods (GNR). The most common GNR was Pseudomonas; the second was Escherichia coli, with extended spectrum β-lactamase positivity of 33%. Methicillin-resistant Staphylococcus species were found in 14% (29/208). Amputations were performed in 126/455 (28%) patients, 44/126 (34%) of these were major amputations. In multivariate analysis, significant predictors for limb loss were, male gender (OR 1.75, 95% CI 1.04–2.96, p 0.034), duration of diabetes >20 years (OR 1.9, 95% CI 1.18–3.11, p 0.008), infected ulcer versus cellulitis (OR 1.9, 95% CI 1.11–3.18, p 0.019), history of peripheral vascular disease (OR 2, 95% CI 1.26–3.27, p 0.004), retinopathy (OR 2.25, 95% CI 1.19–4.25, p 0.012), erythrocyte sedimentation rate >70 mm/hr (OR 1.6, 95% CI 1.01–2.68, p 0.05), and infection with GNR (OR 1.8, 95% CI 1.08–3.02, p 0.02). Multivariate analysis revealed that, besides the known risk factors such as male gender, duration of diabetes >20 years, infected ulcers, history of peripheral vascular disease and retinopathy, detection of GNR was a significant predictor of limb loss.","DOI":"10.1016/j.cmi.2015.03.018","ISSN":"1198-743X","shortTitle":"Predictors for limb loss among patient with diabetic foot infections","journalAbbreviation":"Clinical Microbiology and Infection","author":[{"family":"Saltoglu","given":"N."},{"family":"Yemisen","given":"M."},{"family":"Ergonul","given":"O."},{"family":"Kadanali","given":"A."},{"family":"Karagoz","given":"G."},{"family":"Batirel","given":"A."},{"family":"Ak","given":"O."},{"family":"Eraksoy","given":"H."},{"family":"Cagatay","given":"A."},{"family":"Vatan","given":"A."},{"family":"Sengoz","given":"G."},{"family":"Pehlivanoglu","given":"F."},{"family":"Aslan","given":"T."},{"family":"Akkoyunlu","given":"Y."},{"family":"Engin","given":"D."},{"family":"Ceran","given":"N."},{"family":"Erturk","given":"B."},{"family":"Mulazimoglu","given":"L."},{"family":"Oncul","given":"O."},{"family":"Ay","given":"H."},{"family":"Sargin","given":"F."},{"family":"Ozgunes","given":"N."},{"family":"Simsek","given":"F."},{"family":"Yildirmak","given":"T."},{"family":"Tuna","given":"N."},{"family":"Karabay","given":"O."},{"family":"Yasar","given":"K."},{"family":"Uzun","given":"N."},{"family":"Kucukardali","given":"Y."},{"family":"Sonmezoglu","given":"M."},{"family":"Yilmaz","given":"F."},{"family":"Tozalgan","given":"U."},{"family":"Ozer","given":"S."},{"family":"Ozyazar","given":"M."}],"issued":{"date-parts":[["2015",7,1]]}}},{"id":16896,"uris":[""],"uri":[""],"itemData":{"id":16896,"type":"article-journal","title":"Frequency of Methicillin Resistant Staphylococcus Aureus in Diabetic Foot Infections","container-title":"Medical Forum Monthly","page":"17-21","volume":"28","issue":"9","author":[{"family":"Shah","given":"M."},{"family":"Shoaib","given":"M."},{"family":"Razaq","given":"A."},{"family":"Ashraf","given":"M."},{"family":"Ahmad","given":"W."}],"issued":{"date-parts":[["2017"]]}}},{"id":16876,"uris":[""],"uri":[""],"itemData":{"id":16876,"type":"article-journal","title":"Bacterial etiology of diabetic foot infections in South India","container-title":"European Journal of Internal Medicine","page":"567-570","volume":"16","issue":"8","source":"ScienceDirect","abstract":"Background\nFoot infections are a frequent complication of patients with diabetes mellitus, accounting for up to 20% of diabetes-related hospital admissions. Infectious agents are associated with the worst outcomes, which may ultimately lead to amputation of the infected foot unless prompt treatment strategies are ensued. The present study sought to reveal the bacterial etiology of diabetic foot ulcers in South India, the diabetic capital of India.\nMethods\nA 10-month-long descriptive study was carried out to analyse the aerobic and anaerobic bacterial isolates of all patients admitted with diabetic foot infections presenting with Wagner grade 2–5 ulcers. Bacteriological diagnosis and antibiotic sensitivity profiles were carried out and analysed using standard procedures.\nResults\nDiabetic polyneuropathy was found to be common (56.8%) and gram-negative bacteria (57.6%) were isolated more often than gram-positive ones (42.3%) in the patients screened. The most frequent bacterial isolates were Pseudomonas aeruginosa, Staphylococcus aureus, coagulase-negative staphylococci (CONS), and Enterobacteriaceaes. Forty-nine cultures (68%) showed polymicrobial involvement. About 44% of P. aeruginosa were multi-drug-resistant, and MRSA was recovered on eight occasions (10.3%). Bacteroides spp. and Peptostreptococcus spp. were the major anaerobic isolates.\nConclusions\nOur study supports the viewpoint put forth by previous South Indian authors that the distribution of gram-negative bacteria (57.6%) is more common than that of gram-positive ones (42.3%) and it is contrary to the viewpoint that diabetic foot infections are frequently monomicrobial. Furthermore, recovery of multi-drug-resistant P. aeruginosa isolates is of serious concern, as almost no one has reported the same from the South Indian milieu.","DOI":"10.1016/j.ejim.2005.06.016","ISSN":"0953-6205","journalAbbreviation":"European Journal of Internal Medicine","author":[{"family":"Shankar","given":"E. M."},{"family":"Mohan","given":"V."},{"family":"Premalatha","given":"G."},{"family":"Srinivasan","given":"R. S."},{"family":"Usha","given":"A. R."}],"issued":{"date-parts":[["2005",12,1]]}}},{"id":16895,"uris":[""],"uri":[""],"itemData":{"id":16895,"type":"article-journal","title":"Common pathogens isolated in diabetic foot infection in Bir Hospital","container-title":"Kathmandu University Medical Journal","page":"295-301","volume":"4","issue":"15","author":[{"family":"Sharma","given":"V. K."},{"family":"Khadka","given":"P. B"},{"family":"Joshi","given":"A."},{"family":"Sharma","given":"R."}],"issued":{"date-parts":[["2006"]]}}},{"id":16874,"uris":[""],"uri":[""],"itemData":{"id":16874,"type":"article-journal","title":"Virulence determinants in clinical Staphylococcus aureus from monomicrobial and polymicrobial infections of diabetic foot ulcers","container-title":"Journal of Medical Microbiology","page":"1392-1404","volume":"65","issue":"12","source":"Microbiology Society Journals","abstract":"Antibiotic resistance in Staphylococcus aureus is a major public health concern, and methicillin-resistant S. aureus has emerged as an important pathogen. We characterized S. aureus isolates from monomicrobial and polymicrobial wound infections from 200 diabetic individuals with foot ulcers to understand their underlying diversity and pathogenicity. Staphylococcal cassette chromosome mec typing was performed, and genes coding for production of biofilm, Panton–Valentine leukocidin, toxic shock syndrome toxin and leukotoxins DE and M were screened. Biofilm production was also quantified by the tissue culture plate method. Strains were genotyped using multilocus sequence typing, multiple-locus variable number tandem repeat analysis and repetitive sequence PCR methods. Polymicrobial infections were present in 115 samples, 61 samples showed monomicrobial infection and 24 samples were culture negative. Polymicrobial infections were significantly higher in patients with previous amputation history. Of the 86 samples infected with S. aureus, virulence genes were found in 81 isolates, and 41 isolates possessed more than one virulence gene. Strains which contained pvl gene alone or luk-DE alone were significantly higher in polymicrobial wounds. Based on biofilm production, 18.6?% of isolates were classified as high, 24.4?% as moderate and 57?% as low biofilm producers. Genotyping of 30 strains revealed 10 different sequence types with a strong association among sequence types, specific virulence markers and antibiotic resistance profiles. Moreover, isolates from monomicrobial and polymicrobial wounds differed significantly in their virulence potential and the sequence types to which they belonged, and these are helpful in mapping the evolution of the identified strains of S. aureus.","DOI":"10.1099/jmm.0.000370","author":[{"family":"Shettigar","given":"Kavitha"},{"family":"Jain","given":"Spoorthi"},{"family":"Bhat","given":"Deepika V."},{"family":"Acharya","given":"Raviraj"},{"family":"Ramachandra","given":"Lingadakai"},{"family":"Satyamoorthy","given":"Kapaettu"},{"family":"Murali","given":"Thokur Sreepathy"}],"issued":{"date-parts":[["2016"]]}}},{"id":16880,"uris":[""],"uri":[""],"itemData":{"id":16880,"type":"article-journal","title":"Methicillin-resistant Staphyloccocus aureus (MRSA) isolation from diabetic foot ulcers correlates with nasal MRSA carriage","container-title":"Diabetes Research and Clinical Practice","page":"47-50","volume":"75","issue":"1","source":"ScienceDirect","abstract":"Methicillin-resistant Staphylococcus aureus is increasingly isolated from diabetic foot ulcers, and may be associated with an adverse prognosis. We have explored the relationship between MRSA isolation from foot ulcers and nasal MRSA carriage. Over a 12 month period, 65 consecutively attending patients with diabetic foot ulceration were recruited. Demographic information was collected, and the ulcer and nose swabbed bacteriologically using standard techniques. The patients were mean age 61year, diabetes duration 14 year, and HbA1c 8.5%. There were 61% male and 85% with type 2 diabetes. Ulcers were neuropathic in 55%, ischaemic in 14% and neuroischaemic in 31%. MRSA was isolated from 12 (19%) ulcers, and 11 (17%) had nasal carriage. Of the MRSA positive ulcer patients 7/12 (58%) had nasal MRSA carriage, compared with 4/53 (8%) with MRSA negative ulcers (p<0.0003). We conclude that nasal MRSA carriage in diabetic patients is a significant risk factor for foot ulcer MRSA infection.","DOI":"10.1016/j.diabres.2006.05.021","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Stanaway","given":"Stephen"},{"family":"Johnson","given":"Deborah"},{"family":"Moulik","given":"Probal"},{"family":"Gill","given":"Geoffrey"}],"issued":{"date-parts":[["2007",1,1]]}}},{"id":16879,"uris":[""],"uri":[""],"itemData":{"id":16879,"type":"article-journal","title":"Microbiology at first visit of moderate-to-severe diabetic foot infection with antimicrobial activity and a survey of quinolone monotherapy","container-title":"Diabetes Research and Clinical Practice","page":"133-139","volume":"94","issue":"1","source":"ScienceDirect","abstract":"Samples from 1295 patients with diabetic foot infection were evaluated; 4332 samples were collected with an average of 3.3 samples per patient. Fifty-seven percent of patients had a 2B ulcer and 23% had a 3B ulcer according to Texas University Classification. In 64.2% of samples collected at first visit an etiologic agent was identified. About 40% of the positive samples were polymicrobial. Gram positive bacteria were more frequently isolated (52.6%), Staphylococcus aureus was the most frequently isolated single agent (29.9%) and MRSA was 22% of S. aureus. Enterococcus spp., mainly Enterococcus faecalis, were 9.9%, all vancomycin susceptible except 2 isolates. Streptococci were 4.6%, more than 60% Streptococcus agalactiae. Gram negative rods were 40.6%, with enterobacteria 23.5% and Pseudomonas aeruginosa 10.3%. Anaerobes were only 0.3%, probably due to culture methods applied in our laboratory. Cotrimoxazole, rifampin and doxycycline were still active against S. aureus. ESBL producers, among enterobacteria, were 10%, mainly Escherichia coli and Proteus spp. Only colistin had a rate of susceptibility against P. aeruginosa above 90%. Levofloxacin had the best clinical activity with respect to the other quinolones, but when it failed, selected more resistant strains with respect to moxifloxacin among S. aureus and with respect to ciprofloxacin among P. aeruginosa.","DOI":"10.1016/j.diabres.2011.07.017","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Tascini","given":"Carlo"},{"family":"Piaggesi","given":"Alberto"},{"family":"Tagliaferri","given":"Enrico"},{"family":"Iacopi","given":"Elisabetta"},{"family":"Fondelli","given":"Serena"},{"family":"Tedeschi","given":"Anna"},{"family":"Rizzo","given":"Loredana"},{"family":"Leonildi","given":"Alessandro"},{"family":"Menichetti","given":"Francesco"}],"issued":{"date-parts":[["2011",10,1]]}}},{"id":16885,"uris":[""],"uri":[""],"itemData":{"id":16885,"type":"article-journal","title":"Complications during the treatment of diabetic foot osteomyelitis","container-title":"Diabetes Research and Clinical Practice","page":"58-64","volume":"135","source":"ScienceDirect","abstract":"Aim\nTo identify complications of medical treatment in patients with diabetic foot osteomyelitis (DFO).\nMethods\nWe reviewed 143 records of consecutive patients admitted with DFO, confirmed by bone histopathology or culture. Complications monitored included acute kidney injuries (AKI), development of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), gastrointestinal complications, and venous catheter related complications during a 12months follow-up period.\nResults\nForty-seven AKI episodes were reported during follow-up; half occurred during the first hospitalization with involvement of antimicrobial therapy in 14 events (29.8%). Patients with AKI were more likely to have recurrent ulcerations (69.2% vs. 45.2%, p=0.02), recurrent infections (38.5% vs. 17.3%, p=0.01), and recurrent hospitalizations (43.6% vs. 28.8%, p=0.02) during follow-up. Only 14 MRSA isolates were found in bone samples at baseline (9.8%). Resistant strains of MRSA and VRE were identified in twenty-one patients (14.7%) during follow-up. Patients re-hospitalized for infection were more likely to have resistant bacterial strains (52.6% vs. 25.8%, p=0.02).\nConclusions\nIn this study, the rates of VRE and MRSA in bone biopsies of patients with DFO were lower than in previous reports. Acute kidney injury occurred frequently in our patient population but might not be associated with antibiotic exposure.","DOI":"10.1016/j.diabres.2017.06.002","ISSN":"0168-8227","journalAbbreviation":"Diabetes Research and Clinical Practice","author":[{"family":"Asten","given":"Suzanne A. V.","non-dropping-particle":"van"},{"family":"Mithani","given":"Moez"},{"family":"Peters","given":"Edgar J. G."},{"family":"La Fontaine","given":"Javier"},{"family":"Kim","given":"Paul J."},{"family":"Lavery","given":"Lawrence A."}],"issued":{"date-parts":[["2018",1,1]]}}},{"id":16888,"uris":[""],"uri":[""],"itemData":{"id":16888,"type":"article-journal","title":"Virulence Factor Genes in Staphylococcus aureus Isolated From Diabetic Foot Soft Tissue and Bone Infections","container-title":"The International Journal of Lower Extremity Wounds","page":"36-41","volume":"17","issue":"1","source":"SAGE Journals","abstract":"The aim of this study is to describe the presence of genes encoding for 4 virulence factors (pvl, eta, etb, and tsst), as well as the mecA gene conferring resistance to beta-lactam antibiotics, in patients with diabetes and a staphylococcal foot infection. We have also analyzed whether isolates of Staphylococcus aureus from bone infections have a different profile for these genes compared with those from exclusively soft tissue infections. In this cross-sectional study of a prospectively recruited series of patients admitted to the Diabetic Foot Unit, San Juan de Dios Hospital, San José, Costa Rica with a moderate or severe diabetic foot infection (DFI), we collected samples from infected soft tissue and from bone during debridement. During the study period (June 1, 2014 to May 31, 2016), we treated 379 patients for a DFI. S aureus was isolated from 101 wound samples, of which 43 were polymicrobial infections; we only included the 58 infections that were monomicrobial S aureus for this study. Infections were exclusively soft tissue in 17 patients (29.3%) while 41 (70.7%) had bone involvement (osteomyelitis). The mecA gene was detected in 35 cases (60.3%), pvl gene in 4 cases (6.9%), and tsst gene in 3 (5.2%). We did not detect etA and etB in any of the cases. There were no differences in the profile of S aureus genes encoding for virulence factors (pvl, etA, etB, and tsst) recovered from DFIs between those with just soft tissue compared to those with osteomyelitis. However, we found a significantly higher prevalence of pvl+ strains of S aureus associated with soft tissue compared with bone infections. Furthermore, we observed a significantly longer time to healing among patients infected with mecA+ (methicillin-resistant) S aureus (MRSA).","DOI":"10.1177/1534734618764237","ISSN":"1534-7346","journalAbbreviation":"The International Journal of Lower Extremity Wounds","language":"en","author":[{"family":"Víquez-Molina","given":"Gerardo"},{"family":"Aragón-Sánchez","given":"Javier"},{"family":"Pérez-Corrales","given":"Cristian"},{"family":"Murillo-Vargas","given":"Christian"},{"family":"López-Valverde","given":"María Eugenia"},{"family":"Lipsky","given":"Benjamin A."}],"issued":{"date-parts":[["2018",3,1]]}}},{"id":16890,"uris":[""],"uri":[""],"itemData":{"id":16890,"type":"article-journal","title":"Meticillin-resistant Staphylococcus aureus isolated from foot ulcers in diabetic patients in a Chinese care hospital: risk factors for infection and prevalence","container-title":"Journal of Medical Microbiology","page":"1219-1224","volume":"59","issue":"10","source":"Microbiology Society Journals","abstract":"A retrospective case–control study of 118 (male?:?female, 68?:?50) Chinese type 2 diabetic patients with foot ulcers (Wagner's grade 3–5) was conducted to determine the prevalence and risk factors for meticillin-resistant Staphylococcus aureus (MRSA) infection in relation to the original community or hospital parameters. Ulcer specimens were processed for Gram staining, aerobic culture and antimicrobial susceptibility testing. Staphylococcus species were tested for meticillin resistance using oxacillin. S. aureus was the most frequent pathogen (25.6?%) in diabetic patient specimens (160 isolates), and a high proportion of S. aureus isolates were MRSA (63.4?%). A high percentage of S. aureus isolates (65.4?%) satisfied the definition for hospital-associated MRSA (HA-MRSA) infection. The size of ulcers [adjusted odds ratio (OR) 1.61; 95?% confidence interval (CI) 1.22–2.12] and osteomyelitis (adjusted OR 18.51, 95?% CI 2.50–137.21) were independent predictors of MRSA infection. The HA-MRSA group had a significantly different distribution from the community-associated MRSA group with respect to age, history of diabetes and length of hospital stay (all P<0.001). Neuropathy, vascular disease (all P=0.049) and osteomyelitis (P=0.026) were the most common underlying conditions observed in the HA-MRSA group. This study contributes to the establishment of precautions against the emergence of MRSA including MRSA acquired from different sources among the Chinese population with diabetic foot ulcers based on their original or clinical parameters.","DOI":"10.1099/jmm.0.020537-0","shortTitle":"Meticillin-resistant Staphylococcus aureus isolated from foot ulcers in diabetic patients in a Chinese care hospital","author":[{"family":"Wang","given":"Shao-Hua"},{"family":"Sun","given":"Zi-Lin"},{"family":"Guo","given":"Yi-Jing"},{"family":"Yang","given":"Bing-Quan"},{"family":"Yuan","given":"Yang"},{"family":"Wei","given":"Qiong"},{"family":"Ye","given":"Kuan-Ping"}],"issued":{"date-parts":[["2010"]]}}},{"id":16892,"uris":[""],"uri":[""],"itemData":{"id":16892,"type":"article-journal","title":"Empirical Antibiotic Treatment in Diabetic Foot Infection: A Study Focusing on the Culture and Antibiotic Sensitivity in a Population From Southern China","container-title":"The International Journal of Lower Extremity Wounds","page":"173-182","volume":"16","issue":"3","source":"SAGE Journals","abstract":"Diabetic foot and subsequent diabetic ulcer infections are the most devastating complication of diabetes. This study was conducted to explore the bacterial spectrum, sensitivity of microbials, and analysis of the empirical antibiotic regimens in our health center. The study included patients with diabetic foot ulcer infection (DFI) seen from 2009 to 2014. The patients included had all information covering the physical examination, laboratory tests, and image examinations. We sent appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all participants. A total of 312 patients were included: 52, 112, 95 and 53 patients within uninfected, mild, moderate, and severe infection groups. The total percentages of Gram-positive cocci (GPCs) and Gram-negative rods (GNRs) were 54% and 48.8% (P = 0.63). The most common GPC was Staphylococcus aureus (22.4%) and GNR was Pseudomonas aeruginosa (11.9%). Methicillin-resistant Staphylococcus aureus was isolated from 21 patients (6.7%). Even in the mild infection group, there was no significant difference between GPC and GNR infection, irrespective of recent antibiotic use (P = 0.053). The most frequently used empirical antibiotics in our center were second-/third-generation cephalosporin ± clindamycin, both in the mild and moderate/severe infection groups. In our center, the amoxicillin/clavulanate or ampicillin/sulbactam (β-L-ase 1) and second-/third-generation cephalosporins were highly resistant to the common GNR (30%-60%). The ticarcillin/clavulanate, piperacillin/tazuobactam (β-L-ase 2), fluoroquinolone, and group 2 carbapenem had good sensitivity. This study presents a comprehensive microbiological survey of diabetic foot ulcers in inpatients and provides reliable evidence of the local microbial epidemiology and sensitivity of antibiotics, which may help us improve clinical outcomes in DFI patients.","DOI":"10.1177/1534734617725410","ISSN":"1534-7346","shortTitle":"Empirical Antibiotic Treatment in Diabetic Foot Infection","journalAbbreviation":"The International Journal of Lower Extremity Wounds","language":"en","author":[{"family":"Wu","given":"Wen-xia"},{"family":"Liu","given":"Dan"},{"family":"Wang","given":"Yi-wen"},{"family":"Wang","given":"Chuan"},{"family":"Yang","given":"Chuan"},{"family":"Liu","given":"Xing-zhou"},{"family":"Mai","given":"Li-fang"},{"family":"Ren","given":"Meng"},{"family":"Yan","given":"Li"}],"issued":{"date-parts":[["2017",9,1]]}}},{"id":17120,"uris":[""],"uri":[""],"itemData":{"id":17120,"type":"article-journal","title":"Methicillin-Resistant Staphylococcus aureus in Foot Osteomyelitis","container-title":"Surgical Infections","page":"143-148","volume":"18","issue":"2","source":" (Atypon)","abstract":"Background: Conflicting studies exist regarding the impact of methicillin-resistant Staphylococcus aureus (MRSA) on increased time to wound healing, future need for surgical procedures, and likelihood of treatment failure in patients with diabetic foot osteomyelitis. The purpose of this study is to determine the overall significance of MRSA in predicting treatment failure in bone infections of the foot and to determine an appropriate pre-operative and empiric post-operative antibiotic regimen.Patients and Methods: Patients presenting with an initial episode of “probable” or “definite” foot osteomyelitis were included for review and analysis if the following criteria were met: (1) Osteomyelitis occurred in the foot (i.e., distal to the malleoli of the ankle); episodes occurring above the ankle were excluded. (2) Patients received either no antibiotics or only oral antibiotics for long-term treatment; episodes managed with long-term parenteral antibiotics were excluded. (3) The infection was managed initially with medical therapy or conservative surgical therapy; episodes managed with major (above-ankle) amputation as the initial treatment were excluded. The primary objective of this study was to assess whether episodes of foot osteomyelitis associated with MRSA resulted in treatment failure more frequently than not.Results: Of 178 episodes included in the study, 50 (28.1%) episodes had treatment failure. Median time-to-treatment failure was 60 days (range 7–598 days). In 28.1% (9/32 episodes) in which treatment failure occurred and 39.0% (41/105) episodes in which no treatment failure occurred, MRSA was present. The presence of MRSA was not significantly associated with treatment failure (p?=?0.99).Conclusions: The presence of MRSA in bone culture and whether antibiotic use had anti-MRSA activity was not associated with increased treatment failure of diabetic foot osteomyelitis in our institution. Empiric antibiotic coverage of MRSA may not be necessary for many patients presenting with foot osteomyelitis.","DOI":"10.1089/sur.2016.165","ISSN":"1096-2964","journalAbbreviation":"Surgical Infections","author":[{"family":"Ashong","given":"Chester N."},{"family":"Raheem","given":"Shazia A."},{"family":"Hunter","given":"Andrew S."},{"family":"Mindru","given":"Cezarina"},{"family":"Barshes","given":"Neal R."}],"issued":{"date-parts":[["2016",11,29]]}}},{"id":17122,"uris":[""],"uri":[""],"itemData":{"id":17122,"type":"article-journal","title":"Epidemiology of Diabetic Foot Infection in the Metro-Detroit Area With a Focus on Independent Predictors for Pathogens Resistant to Recommended Empiric Antimicrobial Therapy","container-title":"Open Forum Infectious Diseases","volume":"5","issue":"11","source":"PubMed Central","abstract":"Background\nThe polymicrobial nature of diabetic foot infection (DFI) and the emergence of antimicrobial resistance have complicated DFI treatment. Current treatment guidelines for deep DFI recommend coverage of methicillin-resistant Staphylococcus aureus (MRSA) and susceptible Enterobacteriaceae. This study aimed to describe the epidemiology of DFI and to identify predictors for DFI associated with multidrug-resistant organisms (MDROs) and pathogens resistant to recommended treatment (PRRT).\n\nMethods\nAdult patients admitted to Detroit Medical Center from January 2012 to December 2015 with DFI and positive cultures were included. Demographics, comorbidities, microbiological history, sepsis severity, and antimicrobial use within 3 months before DFI were obtained retrospectively. DFI-PRRT was defined as a DFI associated with a pathogen resistant to both vancomycin and ceftriaxone. DFI-MDRO pathogens included MRSA in addition to PRRT.\n\nResults\nSix-hundred forty-eight unique patients were included, with a mean age of 58.4 ± 13.7 years. DFI-MDRO accounted for 364 (56%) of the cohort, and 194 (30%) patients had DFI-PRRT. Independent predictors for DFI-PRRT included history of PRRT in a diabetic foot ulcer, antimicrobial exposure in the prior 90 days, peripheral vascular disease, and chronic kidney disease. Long-term care facility residence was independently associated with DFI due to ceftriaxone-resistant Enterobacteriaceae, and recent hospitalization was an independent predictor of DFI due to vancomycin-resistant Enterococcus.\n\nConclusions\nAn unexpectedly high prevalence of DFI-PRRT pathogens was identified. History of the same pathogen in a prior diabetic foot ulcer and recent antimicrobial exposure were independent predictors of DFI-PRRT and should be considered when selecting empiric DFI therapy.","DOI":"10.1093/ofid/ofy245","ISSN":"2328-8957","note":"PMID: 30402532\nPMCID: PMC6215454","journalAbbreviation":"Open Forum Infect Dis","author":[{"family":"Henig","given":"Oryan"},{"family":"Pogue","given":"Jason M"},{"family":"Cha","given":"Raymond"},{"family":"Kilgore","given":"Paul E"},{"family":"Hayat","given":"Umar"},{"family":"Ja’ara","given":"Mahmoud"},{"family":"Ali","given":"Raza Muhamad"},{"family":"Mahboob","given":"Salman"},{"family":"Pansare","given":"Rahul"},{"family":"Deeds","given":"Kathryn"},{"family":"Joarder","given":"Bushra"},{"family":"Kandala","given":"Hyndavi"},{"family":"Dhar","given":"Sorabh"},{"family":"Kaye","given":"Keith S"}],"issued":{"date-parts":[["2018",9,27]]}}},{"id":17119,"uris":[""],"uri":[""],"itemData":{"id":17119,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus nasal carriage and infection among patients with diabetic foot ulcer","container-title":"Journal of Microbiology, Immunology and Infection","source":"Crossref","abstract":"Purpose: To evaluate the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) nasal carriage in patients with diabetic foot ulcer (DFU) in Taiwan, and to assess the concordance between colonizing and clinical MRSA isolates from the patients.","URL":"","DOI":"10.1016/j.jmii.2018.03.005","ISSN":"16841182","language":"en","author":[{"family":"Lin","given":"Shin-Yi"},{"family":"Lin","given":"Nai-Yu"},{"family":"Huang","given":"Yu-Yao"},{"family":"Hsieh","given":"Chi-Chun"},{"family":"Huang","given":"Yhu-Chering"}],"issued":{"date-parts":[["2018"]]}}},{"id":17125,"uris":[""],"uri":[""],"itemData":{"id":17125,"type":"article-journal","title":"Virulence Potential of Staphylococcus aureus Strains Isolated From Diabetic Foot Ulcers","container-title":"Diabetes Care","page":"2318-2324","volume":"31","issue":"12","source":"PubMed Central","abstract":"OBJECTIVE—The purpose of this study was to assess the virulence potential of Staphylococcus aureus strains isolated from diabetic foot ulcers and to discriminate noninfected from infected ulcers., RESEARCH DESIGN AND METHODS—Diabetic patients hospitalized in a diabetic foot department with a foot ulcer were prospectively enrolled if they had been free of antibiotic treatment over the previous 6 months. At admission, ulcers were classified as infected or noninfected on the basis of clinical examination, according to the International Working Group on the Diabetic Foot system. Only patients carrying S. aureus as the sole pathogen were included. In individuals with a grade 1 ulcer, a second bacterial specimen was obtained 1 month later. Using virulence genotyping markers, clonality tools, and an in vivo Caenorhabditis elegans model, we correlated the virulence of 132 S. aureus strains with grade, time of collection, and ulcer outcome., RESULTS—Among virulence genes, the most relevant combination derived from the logistic regression was the association of cap8, sea, sei, lukE, and hlgv (area under the curve 0.958). These markers were useful to distinguish noninfected (grade 1) from infected (grades 2–4) ulcers and to predict wound status at the follow-up. With use of the nematode model, S. aureus strains isolated from grade 1 ulcers were found to be significantly less virulent than strains from ulcers at or above grade 2 (P < 0.001)., CONCLUSIONS—This study highlights the coexistence of two S. aureus populations on diabetic foot ulcers. A combination of five genes that may help distinguish colonized grade 1 from infected grade ≥2 wounds, predict ulcer outcome, and contribute to more appropriate use of antibiotics was discovered.","DOI":"10.2337/dc08-1010","ISSN":"0149-5992","note":"PMID: 18809632\nPMCID: PMC2584189","journalAbbreviation":"Diabetes Care","author":[{"family":"Sotto","given":"Albert"},{"family":"Lina","given":"Gérard"},{"family":"Richard","given":"Jean-Louis"},{"family":"Combescure","given":"Christophe"},{"family":"Bourg","given":"Gisèle"},{"family":"Vidal","given":"Laure"},{"family":"Jourdan","given":"Nathalie"},{"family":"Etienne","given":"Jér?me"},{"family":"Lavigne","given":"Jean-Philippe"}],"issued":{"date-parts":[["2008",12]]}}},{"id":17128,"uris":[""],"uri":[""],"itemData":{"id":17128,"type":"article-journal","title":"Ceftaroline fosamil for treatment of diabetic foot infections: the CAPTURE study experience","container-title":"Diabetes/Metabolism Research and Reviews","page":"395-401","volume":"31","issue":"4","source":"Wiley Online Library","abstract":"Background To ascertain which demographic, clinical, and microbiological factors might affect clinical outcomes of patients with diabetic foot infections, excluding known osteomyelitis, by analysing Clinical Assessment Program and Teflaro? Utilization Registry study data of patients treated with ceftaroline fosamil. Methods At participating study centres, we collected data by randomized selection and chart review, including patient demographics, co-morbidities, infecting pathogens, antibiotic use, surgical interventions, and clinical response. Evaluable patients were those with data sufficient to determine clinical outcome. Clinical success was defined as clinical cure with no use of other antibiotics or clinical improvement with a switch to oral antibiotic therapy at the end of intravenous ceftaroline fosamil treatment. Results Among 201 patients (mean age 61.7 years, mean body mass index 33.2 and 57% male patients), 40% had peripheral vascular disease. Prior antibiotic therapy had been given to 161 (80%) of the patients, most commonly with vancomycin and/or piperacillin–tazobactam. Patients received ceftaroline fosamil for mean duration of 6.1 days (range 1–30), as monotherapy in 130 (65%) patients and concurrently with other antibiotics in 71 (35%). Bacterial pathogens were identified in 114 (57%) of the patients; methicillin-resistant Staphylococcus aureus and methicillin-sensitive S. aureus were isolated from 56 (49%) and 28 (25%) of culture-positive patients respectively. Clinical success was noted in 81% of patients and was not significantly associated with co-morbidities, pathogen type, or need for surgical intervention. Conclusions Ceftaroline fosamil treatment of diabetic foot infections was associated with high clinical success, including inpatients with obesity, co-morbidities, or methicillin-resistant Staphylococcus aureus or mixed infections or requiring surgical intervention. Copyright ? 2014 John Wiley & Sons, Ltd.","DOI":"10.1002/dmrr.2624","ISSN":"1520-7560","shortTitle":"Ceftaroline fosamil for treatment of diabetic foot infections","language":"en","author":[{"family":"Lipsky","given":"Benjamin A."},{"family":"Cannon","given":"Chad M."},{"family":"Ramani","given":"Ananthakrishnan"},{"family":"Jandourek","given":"Alena"},{"family":"Calmaggi","given":"Anibal"},{"family":"Friedland","given":"H. D."},{"family":"Goldstein","given":"Ellie J. C."}],"issued":{"date-parts":[["2015"]]}}},{"id":16926,"uris":[""],"uri":[""],"itemData":{"id":16926,"type":"article-journal","title":"Concordance of nasal and diabetic foot ulcer staphylococcal colonization","container-title":"Diagnostic microbiology and infectious disease","page":"85-89","volume":"79","issue":"1","source":"PubMed Central","abstract":"Background\nNasal carriage of Staphylococcus aureus (SA) is an important risk factor for surgical site infections. The goal of this study was to investigate the concordance between nasal and diabetic foot ulcer (DFU) SA carriage.\n\nMethods\n79 subjects with DFUs were assessed for nasal and DFU colonization with SA, including Methicillin-resistant-SA (MRSA).\n\nResults\nTwenty-five (31.6%) subjects had nares colonization with SA; 29 (36.7%) had DFU colonization with SA. Seven (8.8%) subjects had nares colonization with MRSA and 7 (8.8%) had DFU colonization with MRSA. Ulcer duration was associated with MRSA presence (p=0.01). Sensitivity and specificity of positive nasal SA colonization with positive DFU colonization were 41 and 74%.\n\nConclusions\nWe found substantial discordance between SA strains colonizing DFU and the nasal cavity. The poor positive predictive values for SA isolation in a DFU based on nasal carriage suggests SA colonization of a DFU by endogenous SA strains cannot be assumed.","DOI":"10.1016/j.diagmicrobio.2014.01.014","ISSN":"0732-8893","note":"PMID: 24560808\nPMCID: PMC3989386","journalAbbreviation":"Diagn Microbiol Infect Dis","author":[{"family":"Haleem","given":"Ambar"},{"family":"Schultz","given":"Jonathan S."},{"family":"Heilmann","given":"Kristopher P."},{"family":"Dohrn","given":"Cassie L."},{"family":"Diekema","given":"Daniel J."},{"family":"Gardner","given":"Sue E."}],"issued":{"date-parts":[["2014",5]]}}},{"id":16868,"uris":[""],"uri":[""],"itemData":{"id":16868,"type":"article-journal","title":"Risk factors and healing impact of multidrug-resistant bacteria in diabetic foot ulcers","container-title":"Diabetes & Metabolism","page":"363-369","volume":"34","issue":"4, Part 1","source":"ScienceDirect","abstract":"Aim\nTo determine the risk factors for acquiring multidrug-resistant organisms (MDRO) and their impact on outcome in infected diabetic foot ulcers.\nMethods\nPatients hospitalized in our diabetic foot unit for an episode of infected foot ulcer were prospectively included. Diagnosis of infection was based on clinical findings using the International Working Group on the Diabetic Foot–Infectious Diseases Society of America (IWGDF–ISDA) system, and wound specimens were obtained for bacterial cultures. Each patient was followed-up for 1?year. Univariate analysis was performed to compare infected ulcers according to the presence or absence of MDRO; logistic regression was used to identify explanatory variables for MDRO presence. Factors related to healing time were evaluated by univariate and multivariate survival analyses.\nResults\nMDRO were isolated in 45 (23.9%) of the 188 patients studied. Deep and recurrent ulcer, previous hospitalization, HbA1c level, nephropathy and retinopathy were significantly associated with MDRO-infected ulceration. By multivariate analysis, previous hospitalization (OR=99.6, 95%?CI=[19.9–499.0]) and proliferative retinopathy (OR=7.4, 95%?CI=[1.6–33.7]) significantly increased the risk of MDRO infection. Superficial ulcers were associated with a significant decrease in healing time, whereas neuroischaemic ulcer, proliferative retinopathy and high HbA1c level were associated with an increased healing time. In the multivariate analysis, presence of MDRO had no significant influence on healing time.\nConclusion\nMDRO are pathogens frequently isolated from diabetic foot infection in our foot clinic. Nevertheless, their presence appears to have no significant impact on healing time if early aggressive treatment, as in the present study, is given, including empirical broad-spectrum antibiotic treatment, later adjusted according to microbiological findings.\nRésumé\nObjectif\nDéterminer les facteurs de risque d’acquisition des bactéries multirésistantes (BMR) et leur impact sur le devenir des plaies du pied chez le diabétique.\nMéthodes\nTous les patients diabétiques hospitalisés pour une infection de plaies du pied ont été inclus prospectivement au CHU de N?mes. Le diagnostic d’infection a été effectué en utilisant la classification proposée par l’International Working Group on the Diabetic Foot–Infectious Diseases Society of America (IWGDF–ISDA) et les plaies ont été prélevées afin d’obtenir des données microbiologiques. Chaque patient a été suivi durant un an. L’analyse univariée a comparé les plaies infectées en fonction de la présence/absence de BMR?; un modèle de régression logistique a été utilisé pour identifier les variables explicatives associées à la présence de BMR. Les facteurs influen?ant le temps de cicatrisation ont été évalués par des analyses de survie uni- et multivariée.\nRésultats\nLes BMR ont été isolées chez 45 (23,9?%) des 188 patients inclus. Les plaies profondes et récidivantes, les antécédents d’hospitalisation, le taux d’HbA1c, la néphropathie et la rétinopathie ont été significativement associés aux plaies infectées par une BMR. Lors de l’analyse multivariée, les antécédents d’hospitalisation (OR=99,6?; 95?% IC=[19,9–499,0]) et l’existence d’une rétinopathie proliférante (OR=7,4?; 95?% IC=[1,6–33,7]) étaient associés significativement au risque d’infection par une BMR. Les plaies superficielles étaient associées à une diminution du temps de cicatrisation alors que les ulcères neuro-ischémiques, la rétinopathie proliférante et un niveau élevé d’HbA1c étaient associés à une augmentation de ce temps. L’analyse multivariée a démontré que la présence de BMR n’influen?ait pas significativement le délai de cicatrisation.\nConclusion\nLes BMR sont des pathogènes fréquemment isolés lors d’infections de plaies du pied chez le diabétique. Néanmoins, leur isolement ne semble avoir aucun impact significatif sur le temps de la guérison, sous réserve qu’un traitement agressif par antibiotiques à large spectre avec une documentation microbiologique soit mis précocement en place, comme dans cette étude.","DOI":"10.1016/j.diabet.2008.02.005","ISSN":"1262-3636","journalAbbreviation":"Diabetes & Metabolism","author":[{"family":"Richard","given":"J. -L."},{"family":"Sotto","given":"A."},{"family":"Jourdan","given":"N."},{"family":"Combescure","given":"C."},{"family":"Vannereau","given":"D."},{"family":"Rodier","given":"M."},{"family":"Lavigne","given":"J. -P."}],"issued":{"date-parts":[["2008",9,1]]}}}],"schema":""} (42–50,40,51–68,41,69–75,39,76,77,25,78), representing 10994 patients, with an MRSA prevalence rate of 16.78% (95% CI, 13.21-20.68%; figure 3A). Inter-study variability was high (I2 = 96.16% [95% CI, 95.43-96.77%]). A funnel plot of these studies was weakly asymmetrical (figure 3B). Analysis of the prevalence by publication year did not reveal any trend (R2 = 0.0487). Sub-analyses by patient setting, region or nation were conducted (table 3). These revealed that the 2.82% difference in the proportion of DFI out- and in- patients that were MRSA positive was significantly different (P = 0.0008). There was sufficient data to perform sub-analyses of all patient settings for five broad regions, of which Central America had the highest (20.07%) and East Asia the lowest (12.73%) prevalence of MRSA. Among the five nations for which there was sufficient data to perform national sub-analyses, the UK had the highest prevalence (19.59%), while China had the lowest (11.65%). The prevalence of MRSA among patients with NF or SSTIs and unspecified infections Seven datasets examined the prevalence of MRSA in NF (n = 2), burns (n = 1) and non-foot SSTI (n = 4), and three further studies did not specify the type of infection in question ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"CxXu6asi","properties":{"formattedCitation":"(14,37,60,79\\uc0\\u8211{}85)","plainCitation":"(14,37,60,79–85)","noteIndex":0},"citationItems":[{"id":16904,"uris":[""],"uri":[""],"itemData":{"id":16904,"type":"article-journal","title":"Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality","container-title":"BMC Infectious Diseases","volume":"15","issue":"417","abstract":"Background\nNecrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection. This study aimed to investigate the clinical characteristics and mortality- associated factors in diabetic patients.\n\nMethods\nDetailed clinical information of 165 NF cases was retrospectively collected and analyzed in National Taiwan University Hospital between January 1997 and February 2013. We documented and compared the clinical features according to the presence of underlying diabetes mellitus, and we identified risk factors associated with mortality.\n\nResults\nThere were 84 patients (51?%) with diabetes. The overall case fatality rate was 29.7?%, and we found no significant difference between the patients with or without diabetes. Compared with the nondiabetic patients, diabetic patients were older and exhibited higher serum levels of glucose and potassium on admission. Polymicrobial infection and monomicrobial NF caused by Klebsiella pneumoniae were also more frequently associated with diabetic patients. Moreover, diabetic NF patients exhibit a significantly higher chance of limb loss during hospitalization. In the combined diabetic and nondiabetic cohort, a high serum level of potassium (odds ratio, 2.2; 95?% confidence interval, 1.2 to 4.02; P?=?0.011) on admission was independently associated with mortality, whereas positive blood culture on admission was associated with mortality in the diabetic cohort (odds ratio, 7.36; 95?% confidence interval, 1.66 to 32.54; P?=?0.009).\n\nConclusions\nDiabetic patients are more susceptible to NF caused by polymicrobial infection or K. pneumoniae, and they are more likely to receive limb amputation for infection control. Bacteraemia on admission is a significant risk factor for mortality in diabetic NF patients.","DOI":"10.1186/s12879-015-1144-0","ISSN":"1471-2334","note":"PMID: 26463900\nPMCID: PMC4604726","journalAbbreviation":"BMC Infect Dis","author":[{"family":"Cheng","given":"Nai-Chen"},{"family":"Tai","given":"Hao-Chih"},{"family":"Chang","given":"Shan-Chwen"},{"family":"Chang","given":"Chin-Hao"},{"family":"Lai","given":"Hong-Shiee"}],"issued":{"date-parts":[["2015"]]}}},{"id":17109,"uris":[""],"uri":[""],"itemData":{"id":17109,"type":"article-journal","title":"Risk Factors of Methicillin-Resistant Staphylococcus aureus Infection and Correlation With Nasal Colonization Based on Molecular Genotyping in Medical Intensive Care Units: A Prospective Observational Study","container-title":"Medicine","page":"e1100","volume":"94","issue":"28","source":"journals.","abstract":"Methicillin-resistant Staphylococcus aureus (MRSA) is a common and important cause of colonization and infection in medical intensive care units (ICU). The aim of this study was to assess association factors between MRSA nasal colonization and subsequent infections in medical ICU patients by clinical investigation and molecular genotyping.\n A prospective cohort observational analysis of consecutive patients admitted to medical ICUs between November 2008 and May 2010 at a tertiary teaching hospital were included. To detect MRSA colonization, the specimens from the nares were obtained within 3 days of admission to the ICU and again 1 week following admission to the ICU. Genetic relatedness for colonized and clinical isolates from each study patient with MRSA infection were analyzed and compared.\n A total of 1266 patients were enrolled after excluding 195 patients with already present MRSA infections. Subsequent MRSA infection rates were higher in patients with nasal colonization than in those without (39.1% versus 14.7%, respectively). Multivariate Poisson regression analysis demonstrated that nasal MRSA colonization (relative risk [RR]: 2.50; 95% confidence interval [CI]: 1.90–3.27; P < 0.001) was independent predictors for subsequent MRSA infections. History of tracheostomy, however, was a protective predictor in all patients (RR: 0.38; 95% CI: 0.18–0.79; P = 0.010) and in patients with MRSA nasal colonization (RR: 0.22; 95% CI: 0.55–0.91; P = 0.037). Molecular genetics studies revealed that most MRSA isolates were healthcare-associated clones and that nasal and clinical isolates exhibited up to 75% shared identity.\n Methicillin-resistant S. aureus nasal colonization was significantly associated with subsequent MRSA infection among medical ICU patients. Previous MRSA infection was associated with subsequent MRSA infections, and history of tracheostomy associated with reducing this risk. Most MRSA isolates were healthcare-associated strains that were significantly correlated between nasal and clinical isolates.","DOI":"10.1097/MD.0000000000001100","ISSN":"0025-7974","shortTitle":"Risk Factors of Methicillin-Resistant Staphylococcus aureus Infection and Correlation With Nasal Colonization Based on Molecular Genotyping in Medical Intensive Care Units","language":"en-US","author":[{"family":"Kao","given":"Kuo-Chin"},{"family":"Chen","given":"Chun-Bing"},{"family":"Hu","given":"Han-Chung"},{"family":"Chang","given":"Hui-Ching"},{"family":"Huang","given":"Chung-Chi"},{"family":"Huang","given":"Yhu-Chering"}],"issued":{"date-parts":[["2015",7]]}}},{"id":16855,"uris":[""],"uri":[""],"itemData":{"id":16855,"type":"article-journal","title":"Skin and soft tissue infections in hospitalised patients with diabetes: culture isolates and risk factors associated with mortality, length of stay and cost","container-title":"Diabetologia","page":"914-923","volume":"53","issue":"5","source":"link.","abstract":"Aims/hypothesisSkin and soft tissue infections (SSTIs) cause substantial morbidity in persons with diabetes. There are few data on pathogens or risk factors associated with important outcomes in diabetic patients hospitalised with SSTIs.MethodsUsing a clinical research database from CareFusion, we identified 3,030 hospitalised diabetic patients with positive culture isolates and a diagnosis of SSTI in 97 US hospitals between 2003 and 2007. We classified the culture isolates and analysed their association with the anatomic location of infection, mortality, length of stay and hospital costs.ResultsThe only culture isolate with a significantly increased prevalence was methicillin-resistant Staphylococcus aureus (MRSA); prevalence for infection of the foot was increased from 11.6 to 21.9% (p < 0.0001) and for non-foot locations from 14.0% to 24.6% (p = 0.006). Patients with non-foot (vs foot) infections were more severely ill at presentation and had higher mortality rates (2.2% vs 1.0%, p < 0.05). Significant independent risk factors associated with higher mortality rates included having a polymicrobial culture with Pseudomonas aeruginosa (OR 3.1), a monomicrobial culture with other gram-negatives (OR 8.9), greater illness severity (OR 1.9) and being transferred from another hospital (OR 5.1). These factors and need for major surgery were also independently associated with longer length of stay and higher costs.Conclusions/interpretationAmong diabetic patients hospitalised with SSTI from 2003 to 2007, only MRSA increased in prevalence. Patients with non-foot (vs foot) infections were more severely ill. Independent risk factors for increased mortality rates, length of stay and costs included more severe illness, transfer from another hospital and wound cultures with Pseudomonas or other gram-negatives.","DOI":"10.1007/s00125-010-1672-5","ISSN":"0012-186X, 1432-0428","shortTitle":"Skin and soft tissue infections in hospitalised patients with diabetes","journalAbbreviation":"Diabetologia","language":"en","author":[{"family":"Lipsky","given":"B. A."},{"family":"Tabak","given":"Y. P."},{"family":"Johannes","given":"R. S."},{"family":"Vo","given":"L."},{"family":"Hyde","given":"L."},{"family":"Weigelt","given":"J. A."}],"issued":{"date-parts":[["2010",5,1]]}}},{"id":16901,"uris":[""],"uri":[""],"itemData":{"id":16901,"type":"article-journal","title":"Retrospective study of necrotizing fasciitis and characterization of its associated Methicillin-resistant Staphylococcus aureus in Taiwan","container-title":"BMC Infectious Diseases","page":"297","volume":"11","source":"PubMed Central","abstract":"Background\nMethicillin-resistant Staphylococcus aureus (MRSA) has emerged as a prevalent pathogen of necrotizing fasciitis (NF) in Taiwan. A four-year NF cases and clinical and genetic differences between hospital acquired (HA)- and community-acquired (CA)-MRSA infection and isolates were investigated.\n\nMethods\nA retrospective study of 247 NF cases in 2004-2008 and antimicrobial susceptibilities, staphylococcal chromosomal cassette mec (SCCmec) types, pulsed field gel electrophoresis (PFGE) patterns, virulence factors, and multilocus sequence typing (MLST) of 16 NF-associated MRSA in 2008 were also evaluated.\n\nResults\nIn 247 cases, 42 microbial species were identified. S. aureus was the major prevalent pathogen and MRSA accounted for 19.8% of NF cases. Most patients had many coexisting medical conditions, including diabetes mellitus, followed by hypertension, chronic azotemia and chronic hepatic disease in order of decreasing prevalence. Patients with MRSA infection tended to have more severe clinical outcomes in terms of amputation rate (p < 0.05) and reconstruction rate (p = 0.001) than those with methicillin-sensitive S. aureus or non-S. aureus infection. NF patients infected by HA-MRSA had a significantly higher amputation rate, comorbidity, C-reactive protein level, and involvement of lower extremity than those infected by CA-MRSA. In addition to over 90% of MRSA resistant to erythromycin and clindamycin, HA-MRSA was more resistant than CA-MRSA to trimethoprim-sulfamethoxazole (45.8% vs. 4%). ST59/pulsotype C/SCCmec IV and ST239/pulsotype A/SCCmec III isolates were the most prevalent CA- and HA-MRSA, respectively in 16 isolates obtained in 2008. In contrast to the gene for γ-hemolysin found in all MRSA, the gene for Panton-Valentine leukocidin was only identified in ST59 MRSA isolates. Other three virulence factors TSST-1, ETA, and ETB were occasionally identified in MRSA isolates tested.\n\nConclusion\nNF patients with MRSA infection, especially HA-MRSA infection, had more severe clinical outcomes than those infected by other microbial. The prevalent NF-associated MRSA clones in Taiwan differed distinctly from the most predominant NF-associated USA300 CA-MRSA clone in the USA. Initial empiric antimicrobials with a broad coverage for MRSA should be considered in the treatment of NF patients in an endemic area.","DOI":"10.1186/1471-2334-11-297","ISSN":"1471-2334","note":"PMID: 22040231\nPMCID: PMC3221646","journalAbbreviation":"BMC Infect Dis","author":[{"family":"Changchien","given":"Chih-Hsuan"},{"family":"Chen","given":"Ying-Ying"},{"family":"Chen","given":"Shu-Wun"},{"family":"Chen","given":"Wan-Lin"},{"family":"Tsay","given":"Jwu-Guh"},{"family":"Chu","given":"Chishih"}],"issued":{"date-parts":[["2011",10,31]]}}},{"id":16913,"uris":[""],"uri":[""],"itemData":{"id":16913,"type":"article-journal","title":"Epidemiology of Adult Acute Hand Infections at an Urban Medical Center","container-title":"The Journal of Hand Surgery","page":"1189-1193","volume":"38","issue":"6","source":"ScienceDirect","abstract":"Purpose\nTo define the current epidemiology of adult acute hand infections in an urban setting, with the aim of helping to improve empiric treatment, as hand infections represent a major source of morbidity and can result in stiffness and, possibly, amputation.\nMethods\nWe performed an electronic medical record search to identify all patients admitted to our urban academic medical center with diagnoses related to open wounds and infections in the hand and fingers over a 6-year period (2005–2010). We recorded demographic data, location of infection, medical comorbidities, and culture data.\nResults\nOf the 2,287 patients admitted with diagnoses related to open wounds and infections in the hand and fingers, 1,507 incision and drainage procedures were performed, which resulted in 458 patients (30%) with culture-positive infections. Wound cultures identified 39 different species of bacteria. Most of these were methicillin-resistant Staphylococcus aureus, which compromised 53% of positive cultures, followed by methicillin-sensitive S aureus in 23% of positive cultures. The cultures were polymicrobial in 19%. History of intravenous drug use or diabetes mellitus was a strong predictor of polymicrobial infection.\nConclusions\nMethicillin-resistant Staphylococcus aureus was the most common bacteria cultured from these infections. Empiric antibiotic coverage should routinely cover methicillin-resistant S aureus. We noted a higher incidence of polymicrobial infections than previously reported, particularly with intravenous drug use, diabetes, and human bites. Volar hand infections had the highest percentage of positive cultures, whereas paronychia had the lowest percentage.\nType of study/level of evidence\nPrognostic IV.","DOI":"10.1016/j.jhsa.2013.03.013","ISSN":"0363-5023","journalAbbreviation":"The Journal of Hand Surgery","author":[{"family":"Fowler","given":"John R."},{"family":"Ilyas","given":"Asif M."}],"issued":{"date-parts":[["2013",6,1]]}}},{"id":16941,"uris":[""],"uri":[""],"itemData":{"id":16941,"type":"article-journal","title":"The role of diabetes mellitus in the treatment of skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus: results from three randomized controlled trials","container-title":"International journal of infectious diseases: IJID: official publication of the International Society for Infectious Diseases","page":"e140-146","volume":"15","issue":"2","source":"PubMed","abstract":"OBJECTIVE: To compare outcomes of treating complicated skin and skin structure infections (cSSSI) caused by methicillin-resistant Staphylococcus aureus (MRSA) with linezolid versus vancomycin in diabetic and non-diabetic patients.\nMETHODS: We pooled data from three prospective clinical trials in which 1056 patients were randomized to receive either linezolid (intravenous (IV) or oral) or vancomycin (IV) every 12h, for 7-28 days.\nRESULTS: Diabetic (n=349) and non-diabetic patients (n=707) had comparable demographics and co-morbidities. Clinical success rates were lower in diabetic than in non-diabetic patients (72.3% and 85.8%, respectively). Overall, non-diabetic patients had a shorter adjusted mean length of stay (LOS) compared with diabetic patients (8.2 and 10.7 days, respectively; p<0.0001). Among diabetic patients, rates were comparable with linezolid and vancomycin treatment for clinical success (74% and 71%, respectively) and microbiological success (60% and 54%, respectively). Among non-diabetic patients, clinical and microbiological success rates were higher in linezolid- than in vancomycin-treated patients (90% and 81%, respectively, and 78% and 65%, respectively). Rates of drug-related adverse events were comparable in diabetic and non-diabetic patients and with linezolid and vancomycin treatment. Adjusted mean LOS was shorter with linezolid than with vancomycin treatment in diabetic patients (9.5 and 11.7 days, respectively; p=0.03) and non-diabetic patients (7.6 and 8.9 days, respectively; p=0.02).\nCONCLUSIONS: Clinical success rates were lower in diabetic than non-diabetic patients with cSSSI caused by MRSA. Comparing linezolid and vancomycin, clinical and microbiological success rates were comparable in diabetic patients, but were better for linezolid than for vancomycin in non-diabetic patients.","DOI":"10.1016/j.ijid.2010.10.003","ISSN":"1878-3511","note":"PMID: 21134775","shortTitle":"The role of diabetes mellitus in the treatment of skin and skin structure infections caused by methicillin-resistant Staphylococcus aureus","journalAbbreviation":"Int. J. Infect. Dis.","language":"eng","author":[{"family":"Lipsky","given":"Benjamin A."},{"family":"Itani","given":"Kamal M. F."},{"family":"Weigelt","given":"John A."},{"family":"Joseph","given":"Warren"},{"family":"Paap","given":"Christopher M."},{"family":"Reisman","given":"Arlene"},{"family":"Myers","given":"Daniela E."},{"family":"Huang","given":"David B."}],"issued":{"date-parts":[["2011",2]]}}},{"id":16956,"uris":[""],"uri":[""],"itemData":{"id":16956,"type":"article-journal","title":"Diabetes and early postpartum methicillin-resistant Staphylococcus aureus infection in US hospitals","container-title":"American Journal of Infection Control","page":"576-580","volume":"41","issue":"7","source":"PubMed","abstract":"BACKGROUND: The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) infection in postpartum women is not well characterized. Because diabetes is a risk factor for some infections, we sought to characterize the relationship between diabetes and invasive MRSA infections in women admitted to US hospitals for delivery of an infant.\nMETHODS: We used data from the Nationwide Inpatient Sample, a representative sample of US community hospitals. Multivariate hierarchical logistic regression was used to estimate odds ratios (OR), adjusting for age, race, selected comorbidities, and expected payer, and hospital teaching status, urbanicity, bed size, geographic region, and ownership.\nRESULTS: The odds ratio for prepregnancy diabetes was 3.4 (95% confidence interval: 1.9-6.0). The relationship remained strong after external adjustment for obesity (OR, 2.5; 95% CI: 1.3-4.8). The OR comparing women with complicated versus uncomplicated diabetes was 1.5 (95% CI: 0.3-6.0). We did not find an association with gestational diabetes (OR, 1.1; 95% CI: 0.7-1.7).\nCONCLUSION: Prepregnancy diabetes, but not gestational diabetes, appears to be a risk factor for invasive MRSA infection in the early postpartum period. Women with diabetic complications may be at additional risk, but estimates were imprecise.","DOI":"10.1016/j.ajic.2012.10.011","ISSN":"1527-3296","note":"PMID: 23809689","journalAbbreviation":"Am J Infect Control","language":"eng","author":[{"family":"Parriott","given":"Andrea M."},{"family":"Arah","given":"Onyebuchi A."}],"issued":{"date-parts":[["2013",7]]}}},{"id":16958,"uris":[""],"uri":[""],"itemData":{"id":16958,"type":"article-journal","title":"Prevalence of multidrug-resistant Staphylococcus aureus in diabetics clinical samples","container-title":"World Journal of Microbiology and Biotechnology","page":"171","volume":"26","issue":"1","source":"link.","abstract":"Antibiotic resistance in 40 Staphylococcus aureus clinical isolates from 110 diabetic patients (36%) was evaluated. Of these, 32 (80%) of the isolates showed multidrug-resistance to more than eight antibiotics and 35% isolates were found to be methicillin resistant S. aureus (MRSA). All 40 S. aureus strains (100%) screened from diabetic clinical specimens were resistant to penicillin, 63% to ampicillin, 55% to streptomycin, 50% to tetracycline and 50% to gentamicin. Where as low resistance rate was observed to ciprofloxacin (20%) and rifampicin (8%). In contrast, all (100%) S. aureus strains recorded susceptibility to teicoplanin, which was followed by vancomycin (95%). Genotypical examination revealed that 80% of the aminoglycoside resistant S. aureus (ARSA) have aminoglycoside modifying enzyme (AME) coding genes; however, 20% of ARSA which showed non-AME mediated (adaptive) aminoglycoside resistance lacked these genes in their genome. In contrast all MRSA isolates possessed mecA, femA genetic determinants in their genome.","DOI":"10.1007/s11274-009-0157-5","ISSN":"0959-3993, 1573-0972","journalAbbreviation":"World J Microbiol Biotechnol","language":"en","author":[{"family":"Raju","given":"S."},{"family":"Oli","given":"Ajay Kumar"},{"family":"Patil","given":"S. A."},{"family":"Chandrakanth","given":"R. Kelmani"}],"issued":{"date-parts":[["2010",1,1]]}}},{"id":17131,"uris":[""],"uri":[""],"itemData":{"id":17131,"type":"article-journal","title":"Burns in diabetic patients","container-title":"International Journal of Diabetes in Developing Countries","page":"19-25","volume":"28","issue":"1","source":"PubMed Central","abstract":"CONTEXT AND AIMS:\nDiabetic burn patients comprise a significant population in burn centers. The purpose of this study was to determine the demographic characteristics of diabetic burn patients.\n\nMATERIALS AND METHODS:\nProspective data were collected on 94 diabetic burn patients between March 20, 2000 and March 20, 2006. Of 3062 burns patients, 94 (3.1%) had diabetes; these patients were compared with 2968 nondiabetic patients with burns. Statistical analysis was performed using the statistical analysis software SPSS 10.05. Differences between the two groups were evaluated using Student's t-test and the chi square test. P < 0.05 was considered as significant.\n\nRESULTS:\nThe major mechanism of injury for the diabetic patients was scalding and flame burns, as was also the case in the nondiabetic burn patients. The diabetic burn patients were significantly older, with a lower percentage of total burn surface area (TBSA) than the nondiabetic burn population. There was significant difference between the diabetic and nondiabetic patients in terms of frequency of infection. No difference in mortality rate between diabetic and nondiabetic burn patients was observed. The most common organism in diabetic and nondiabetic burn patients was methicillin-resistant staphylococcus. Increasing %TBSA burn and the presence of inhalation injury are significantly associated with increased mortality following burn injury.\n\nCONCLUSIONS:\nDiabetics have a higher propensity for infection. Education for diabetic patients must include caution about potential burn mishaps and the complications that may ensue from burns.","DOI":"10.4103/0973-3930.41982","ISSN":"0973-3930","note":"PMID: 19902035\nPMCID: PMC2772003","journalAbbreviation":"Int J Diabetes Dev Ctries","author":[{"family":"Maghsoudi","given":"Hemmat"},{"family":"Aghamohammadzadeh","given":"Naser"},{"family":"Khalili","given":"Nasim"}],"issued":{"date-parts":[["2008"]]}}},{"id":17133,"uris":[""],"uri":[""],"itemData":{"id":17133,"type":"article-journal","title":"Can Nasal Methicillin-Resistant Staphylococcus aureus Screening Be Used to Avoid Empiric Vancomycin Use in Intra-Abdominal Infection?","container-title":"Surgical Infections","page":"396-400","volume":"16","issue":"4","source":"PubMed Central","abstract":"Background: Vancomycin is used widely as empiric therapy for gram-positive organisms in patients with an intra-abdominal infection (IAI), even in those with no history of methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization. Potential adverse effects of vancomycin include nephrotoxicity, increased cost, and bacterial resistance. We hypothesized that MRSA nasal screening could be used to predict patients with a MRSA IAI and used to avoid unnecessary empiric vancomycin use., Methods: A surgical infections database collected prospectively from a single institution was reviewed for all IAIs between January 1, 2000–December 31, 2011. Patients with and without MRSA obtained from abdominal cultures as either a monomicrobial or polymicrobial isolate were compared by univariate analysis. A multivariable logistic regression was performed to identify independent predictors of MRSA IAI., Results: Of 2,591 patients with an IAI, 240 patients had a nasal MRSA screen within 30?d prior to infection and abdominal culture data, with an incidence of 23% for MRSA IAI. Patients with MRSA IAI (n=45) had more healthcare associated infections, lower white blood cell counts and greater rates of positive nasal MRSA screenings compared with those with non-MRSA IAI. By multivariable analysis (C statistic=0.908), the strongest independent predictor of an MRSA IAI was a positive MRSA screen (odds ratio [OR] 40.9, confidence interval [CI] 14.2–118.1). The positive predictive value for a MRSA screen was 53% whereas the negative predictive value of a MRSA screen was 97%., Conclusion: A negative MRSA nasal screen indicates with near certainty the absence of MRSA as part of an IAI. In the setting of a recent screen, empiric vancomycin can be withheld. Further, rapid MRSA nasal screening could be used to forego or to discontinue vancomycin therapy rapidly in the setting of IAI. This change in empiric antibiotic management of IAI may lead to decreased morbidity, reduction in cost, and a decrease in bacterial resistance.","DOI":"10.1089/sur.2014.211","ISSN":"1096-2964","note":"PMID: 26069990\nPMCID: PMC4702425","journalAbbreviation":"Surg Infect (Larchmt)","author":[{"family":"Hennessy","given":"Sara A."},{"family":"Shah","given":"Puja M."},{"family":"Guidry","given":"Christopher A."},{"family":"Davies","given":"Stephen W."},{"family":"Hranjec","given":"Tjasa"},{"family":"Sawyer","given":"Robert G."}],"issued":{"date-parts":[["2015",8,1]]}}}],"schema":""} (14,37,60,79–85). The NF and non-foot SSTI studies were grouped together for analysis and represented a population of 2147 patients with an MRSA prevalence rate of 18.03% (95% CI, 6.64-33.41%; I2 = 98.20% [95% CI, 97.44-98.73%]). The three studies that did not specify the nature of the MRSA infection studied represented 29435 patients with a prevalence rate of 8.08% (95% CI, 0.30-34.80%; I2 = 99.43% [95% CI, 99.14-99.62%]). Table 3. Subgroup analyses of the prevalence of MRSA amongst DFI patients. CI, confidence interval.Nation(s)No. of datasetsNo. of patientsPooled prevalence %95% CII2 (%)95% CIDFI patients-411099416.7813.21-20.6896.1695.43-96.77Outpatients-6244013.167.88-19.5591.9985.34-95.63Inpatients-28744415.9811.99-20.4295.5994.51-96.47Central AmericaCosta Rica, Mexico247920.072.45-48.6496.8191.55-98.80North Africa & The Middle EastAlgeria, Egypt, Saudi Arabia, Turkey474617.250.63-49.1698.6297.83-99.12Western EuropeFrance, Italy, Portugal, Spain7229516.969.77-25.6394.9691.83-96.89Indian SubcontinentIndia, Nepal, Pakistan554014.406.43-24.8789.1177.32-94.77East AsiaChina, Singapore, Taiwan466412.735.64-22.1589.8876.99-95.55UK-433319.5913.88-26.0149.560.00-83.31India-335718.3410.06-28.4478.9132.51-93.41USA-10489314.708.54-22.1897.2996.25-98.05France-4115712.287.18-18.5188.0471.78-94.93China-243011.653.14-24.5690.4065.19-97.35DiscussionDiabetes mellitus is the most prevalent metabolic disease worldwide and has been reported to be a risk factor for MRSA colonisation at the time of admission to hospital ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FrlStvho","properties":{"formattedCitation":"(86)","plainCitation":"(86)","noteIndex":0},"citationItems":[{"id":16681,"uris":[""],"uri":[""],"itemData":{"id":16681,"type":"article-journal","title":"A systematic literature review and meta-analysis of factors associated with methicillin-resistant Staphylococcus aureus colonization at time of hospital or intensive care unit admission","container-title":"Infection Control and Hospital Epidemiology","page":"1077-1086","volume":"34","issue":"10","abstract":"OBJECTIVE: Screening for methicillin-resistant Staphylococcus aureus (MRSA) in high-risk patients is a legislative mandate in 9 US states and has been adopted by many hospitals. Definitions of high risk differ among hospitals and state laws. A systematic evaluation of factors associated with colonization is lacking. We performed a systematic review of the literature to assess factors associated with MRSA colonization at hospital admission.\nDESIGN: We searched MEDLINE from 1966 to 2012 for articles comparing MRSA colonized and noncolonized patients on hospital or intensive care unit (ICU) admission. Data were extracted using a standardized instrument. Meta-analyses were performed to identify factors associated with MRSA colonization.\nRESULTS: We reviewed 4,381 abstracts; 29 articles met inclusion criteria (n = 76,913 patients). MRSA colonization at hospital admission was associated with recent prior hospitalization (odds ratio [OR], 2.4 [95% confidence interval (CI), 1.3-4.7]; P < .01), nursing home exposure (OR, 3.8 [95% CI, 2.3-6.3]; P < .01), and history of exposure to healthcare-associated pathogens (MRSA carriage: OR, 8.0 [95% CI, 4.2-15.1]; Clostridium difficile infection: OR, 3.4 [95% CI, 2.2-5.3]; vancomycin-resistant Enterococci carriage: OR, 3.1 [95% CI, 2.5-4.0]; P < .01 for all). Select comorbidities were associated with MRSA colonization (congestive heart failure, diabetes, pulmonary disease, immunosuppression, and renal failure; P < .01 for all), while others were not (human immunodeficiency virus, cirrhosis, and malignancy). ICU admission was not associated with an increased risk of MRSA colonization (OR, 1.1 [95% CI, 0.6-1.8]; P = .87).\nCONCLUSIONS: MRSA colonization on hospital admission was associated with healthcare contact, previous healthcare-associated pathogens, and select comorbid conditions. ICU admission was not associated with MRSA colonization, although this is commonly used in state mandates for MRSA screening. Infection prevention programs utilizing targeted MRSA screening may consider our results to define patients likely to have MRSA colonization.","DOI":"10.1086/673157","ISSN":"1559-6834","note":"PMID: 24018925\nPMCID: PMC3883507","journalAbbreviation":"Infect Control Hosp Epidemiol","language":"eng","author":[{"family":"McKinnell","given":"James A."},{"family":"Miller","given":"Loren G."},{"family":"Eells","given":"Samantha J."},{"family":"Cui","given":"Eric"},{"family":"Huang","given":"Susan S."}],"issued":{"date-parts":[["2013",10]]}}}],"schema":""} (86). The MRSA colonisation rates of diabetic in- and out- patients in this study were 13.46% and 8.33% respectively. These are higher than many national estimations, for example the nasal MRSA colonisation rate has been estimated at 2.6% in Japan ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pr9iKQIk","properties":{"formattedCitation":"(87)","plainCitation":"(87)","noteIndex":0},"citationItems":[{"id":16715,"uris":[""],"uri":[""],"itemData":{"id":16715,"type":"article-journal","title":"Prevalence and characteristics of methicillin‐resistant Staphylococcus aureus in community residents of Japan","container-title":"Journal of General and Family Medicine","page":"77-81","volume":"19","issue":"3","source":"PubMed Central","abstract":"Background\nTo implement effective precautions to avoid methicillin‐resistant Staphylococcus aureus (MRSA) nosocomial infections, it is important to clarify when, how, and from whom MRSA was transmitted to the patients. However, MRSA strains obtained from outpatient population were not analyzed, and the transmission routes of MRSA in the community are not completely understood. The purpose of this study was to clarify whether MRSA is spreading in community settings or whether MRSA transmission still occurs only in healthcare institutions.\n\nMethods\nSurveillance cultures of 1274 residents living in a community were performed in two different areas, Kochi and Osaka prefectures of Japan. All isolated MRSA strains were evaluated using multilocus sequence typing (MLST) to clarify the transmission routes of MRSA. The results were compared with those of inpatients. Moreover, written questionnaires and medical records were analyzed.\n\nResults\nAnalysis of surveillance cultures from residents living in the community in Japan revealed an MRSA colonization rate of 0.94%. The proportion of MRSA to?S.?aureus colonization was 2.6% in the 310 residents, which was significantly lower than in the 393 hospitalized patients (63.1%; P?<?.0001). MRSA strains in residents are different from the endemic strains in the hospitalized patients. Previous hospital admission is a risk factor for MRSA infection of the endemic strain in hospital.\n\nConclusions\nMethicillin‐resistant Staphylococcus aureus colonization in community setting is rare in Japan. MLST results suggest that some MRSA strains are moving to the community through previous hospital admissions; however, MRSA is not spreading in community settings.","DOI":"10.1002/jgf2.160","ISSN":"2189-6577","note":"PMID: 29744260\nPMCID: PMC5931346","journalAbbreviation":"J Gen Fam Med","author":[{"family":"Yamasaki","given":"Fumi"},{"family":"Takeuchi","given":"Seisho"},{"family":"Uehara","given":"Yoshio"},{"family":"Matsushita","given":"Masahide"},{"family":"Arise","given":"Kazumi"},{"family":"Morimoto","given":"Norihito"},{"family":"Seo","given":"Hiromi"}],"issued":{"date-parts":[["2018",3,9]]}}}],"schema":""} (87), 3.9% among healthy Chinese children ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2DmfS6n1","properties":{"formattedCitation":"(88)","plainCitation":"(88)","noteIndex":0},"citationItems":[{"id":16668,"uris":[""],"uri":[""],"itemData":{"id":16668,"type":"article-journal","title":"Methicillin-Resistant Staphylococcus aureus Nasal Colonization in Chinese Children: A Prevalence Meta-Analysis and Review of Influencing Factors","container-title":"PloS One","page":"e0159728","volume":"11","issue":"7","abstract":"OBJECTIVE: To determine the pooled prevalence and review the influencing factors of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization in Chinese children.\nMETHODS: Articles published between January 2005 and October 2015 that studied prevalence or influencing factors of MRSA nasal colonization in Chinese children were retrieved from Chinese Biomedical Literature database (CBM), China National Knowledge Infrastructure (CNKI) database, Chinese VIP database, Chinese Wanfang database, Medline database and Ovid database. Prevalence and influencing factors were analyzed by STATA 13.1.\nRESULTS: Thirteen articles were included. The overall prevalence of MRSA nasal colonization was 4.4% (95% confidence interval [CI]: 0.027-0.062). With an MRSA prevalence of 3.9% (95% CI: 0.018-0.061) in healthy children and 5.8% (95% CI: 0.025-0.092) in children with underlying medical conditions. Children recruited in the hospitals presented MRSA prevalence of 6.4% (95% CI: 0.037-0.091), which was higher than those recruited in the communities [2.7% (95% CI: 0.012-0.043)]. A number of influencing factors for MRSA nasal colonization were noted in three eligible studies: gender (male vs female; OR: 0.67; 95% CI: 0.55-0.82), younger age (OR: 2.98; 95% CI: 1.31-6.96 and OR: 1.56; 95% CI: 1.21-2.00), attending day care centers (OR: 2.97; 95% CI: 1.28-6.76), having infectious diseases (OR: 2.31; 95% CI: 1.10-4.52), using antibiotics (OR: 2.77; 95% CI: 1.45-5.05), residing in northern Taiwan (OR: 1.41; 95% CI: 1.15-1.71), passive smoking (OR: 1.30; 95% CI: 1.02-1.63), and pneumococcal vaccination (OR: 1.22; 95% CI: 1.01-1.48).\nCONCLUSIONS: Children could act as reservoirs of MRSA transmissions. Hospitals remained the most frequent microorganism-circulated settings. More MRSA infection control strategies are required to prevent the dissemination among children.","DOI":"10.1371/journal.pone.0159728","ISSN":"1932-6203","note":"PMID: 27442424\nPMCID: PMC4956239","journalAbbreviation":"PLoS ONE","language":"eng","author":[{"family":"Lin","given":"Jialing"},{"family":"Peng","given":"Yang"},{"family":"Xu","given":"Ping"},{"family":"Zhang","given":"Ting"},{"family":"Bai","given":"Chan"},{"family":"Lin","given":"Dongxin"},{"family":"Ou","given":"Qianting"},{"family":"Yao","given":"Zhenjiang"}],"issued":{"date-parts":[["2016"]]}}}],"schema":""} (88) and up to 2.1% across nine European countries ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"H7xpO1Z6","properties":{"formattedCitation":"(89)","plainCitation":"(89)","noteIndex":0},"citationItems":[{"id":16718,"uris":[""],"uri":[""],"itemData":{"id":16718,"type":"article-journal","title":"Prevalence and resistance of commensal Staphylococcus aureus, including meticillin-resistant S aureus, in nine European countries: a cross-sectional study","container-title":"The Lancet Infectious Diseases","page":"409-415","volume":"13","issue":"5","source":"ScienceDirect","abstract":"Summary\nBackground\nInformation about the prevalence of Staphylococcus aureus resistance to antimicrobial drugs has mainly been obtained from invasive strains, although the commensal microbiota is thought to be an important reservoir of resistance. We aimed to compare the prevalence of nasal S aureus carriage and antibiotic resistance, including meticillin-resistant S aureus (MRSA), in healthy patients across nine European countries.\nMethods\nIn this cross-sectional study, nasal swabs were obtained from 32?206 patients recruited by family doctors participating in existing nationwide family doctor networks in Austria, Belgium, Croatia, France, Hungary, Spain, Sweden, the Netherlands, and the UK. Eligible patients were aged 4 years or older (≥18 years in the UK) and presented with a non-infectious disorder. Swabs were sent to national microbiological laboratories for identification and isolation of S aureus. Antibiotic resistance testing was done at one central microbiological laboratory. We established the genotypic structure of the isolated MRSA strains with the spa typing method.\nFindings\nS aureus was isolated from 6956 (21·6%) of 32?206 patients swabbed. The adjusted S aureus prevalence for patients older than 18 years ranged from 12·1% (Hungary) to 29·4% (Sweden). Except for penicillin, the highest recorded resistance rate was to azithromycin (from 1·6% in Sweden to 16·9% in France). In total, 91 MRSA strains were isolated, and the highest MRSA prevalence was reported in Belgium (2·1%). 53 different spa types were detected—the most prevalent were t002 (n=9) and t008 (n=8).\nInterpretation\nThe prevalence of S aureus nasal carriage differed across the nine European countries assessed, even after correction for age, sex, and family doctor. Generally, the prevalence of resistance, including that of MRSA, was low. The MRSA strains recorded showed genotypic heterogeneity, both within and between countries.\nFunding\nEuropean Commission, 7th Framework Programme(grant agreement 223083).","DOI":"10.1016/S1473-3099(13)70036-7","ISSN":"1473-3099","shortTitle":"Prevalence and resistance of commensal Staphylococcus aureus, including meticillin-resistant S aureus, in nine European countries","journalAbbreviation":"The Lancet Infectious Diseases","author":[{"family":"Heijer","given":"Casper DJ","non-dropping-particle":"den"},{"family":"Bijnen","given":"Evelien ME","non-dropping-particle":"van"},{"family":"Paget","given":"W John"},{"family":"Pringle","given":"Mike"},{"family":"Goossens","given":"Herman"},{"family":"Bruggeman","given":"Cathrien A"},{"family":"Schellevis","given":"Fran?ois G"},{"family":"Stobberingh","given":"Ellen E"}],"issued":{"date-parts":[["2013",5,1]]}}}],"schema":""} (89). In Scotland, a colonisation rate of 3.8% on admission has been observed, rising to 20% among patients admitted to nephrology, care of the elderly, dermatology and vascular surgery – specialties likely to see high numbers of diabetic patients ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"AqqaZcfh","properties":{"formattedCitation":"(90)","plainCitation":"(90)","noteIndex":0},"citationItems":[{"id":16752,"uris":[""],"uri":[""],"itemData":{"id":16752,"type":"webpage","title":"MRSA Screening Programme National Targeted Rollout: MRSA Screening","URL":"","author":[{"family":"Health Protection Scotland","given":""}],"issued":{"date-parts":[["2010"]]},"accessed":{"date-parts":[["2018",7,8]]}}}],"schema":""} (90). The MRSA colonisation rate identified by this study among diabetics in the community was generally comparable with values for broader populations (2.19%). National sub-analyses showed that in America diabetics had a carriage rate 7.4 times higher than previously estimated national prevalence rate of 1.5% ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"oVDQwjwh","properties":{"formattedCitation":"(21)","plainCitation":"(21)","noteIndex":0},"citationItems":[{"id":16721,"uris":[""],"uri":[""],"itemData":{"id":16721,"type":"article-journal","title":"Changes in the Prevalence of Nasal Colonization with Staphylococcus aureus in the United States, 2001–2004","container-title":"The Journal of Infectious Diseases","page":"1226-1234","volume":"197","issue":"9","source":"academic.","abstract":"Abstract. BackgroundStaphylococcus aureus is a common cause of infection, particularly in persons colonized by this organism. Virulent strains of methicillin-r","DOI":"10.1086/533494","ISSN":"0022-1899","journalAbbreviation":"J Infect Dis","language":"en","author":[{"family":"Gorwitz","given":"Rachel J."},{"family":"Kruszon-Moran","given":"Deanna"},{"family":"McAllister","given":"Sigrid K."},{"family":"McQuillan","given":"Geraldine"},{"family":"McDougal","given":"Linda K."},{"family":"Fosheim","given":"Gregory E."},{"family":"Jensen","given":"Bette J."},{"family":"Killgore","given":"George"},{"family":"Tenover","given":"Fred C."},{"family":"Kuehnert","given":"Matthew J."}],"issued":{"date-parts":[["2008",5,1]]}}}],"schema":""} (21). While in Germany, diabetics had an MRSA colonisation rate 1.5 times higher than has recently been estimated for the wider German population ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VAaui5Ob","properties":{"formattedCitation":"(91)","plainCitation":"(91)","noteIndex":0},"citationItems":[{"id":16724,"uris":[""],"uri":[""],"itemData":{"id":16724,"type":"article-journal","title":"Molecular Epidemiology of Staphylococcus aureus in the General Population in Northeast Germany: Results of the Study of Health in Pomerania (SHIP-TREND-0)","container-title":"Journal of Clinical Microbiology","page":"2774-2785","volume":"54","issue":"11","source":"jcm.","abstract":"Population-based studies on Staphylococcus aureus nasal colonization are scarce. We examined the prevalence, resistance, and molecular diversity of S. aureus in the general population in Northeast Germany. Nasal swabs were obtained from 3,891 adults in the large-scale population-based Study of Health in Pomerania (SHIP-TREND). Isolates were characterized using spa genotyping, as well as antibiotic resistance and virulence gene profiling. We observed an S. aureus prevalence of 27.2%. Nasal S. aureus carriage was associated with male sex and inversely correlated with age. Methicillin-resistant S. aureus (MRSA) accounted for 0.95% of the colonizing S. aureus strains. MRSA carriage was associated with frequent visits to hospitals, nursing homes, or retirement homes within the previous 24 months. All MRSA strains were resistant to multiple antibiotics. Most MRSA isolates belonged to the pandemic European hospital-acquired MRSA sequence type 22 (HA-MRSA-ST22) lineage. We also detected one livestock-associated MRSA ST398 (LA-MRSA-ST398) isolate, as well as six livestock-associated methicillin-susceptible S. aureus (LA-MSSA) isolates (clonal complex 1 [CC1], CC97, and CC398). spa typing revealed a diverse but also highly clonal S. aureus population structure. We identified a total of 357 spa types, which were grouped into 30 CCs or sequence types. The major seven CCs (CC30, CC45, CC15, CC8, CC7, CC22, and CC25) included 75% of all isolates. Virulence gene patterns were strongly linked to the clonal background. In conclusion, MSSA and MRSA prevalences and the molecular diversity of S. aureus in Northeast Germany are consistent with those of other European countries. The detection of HA-MRSA and LA-MRSA within the general population indicates possible transmission from hospitals and livestock, respectively, and should be closely monitored.","DOI":"10.1128/JCM.00312-16","ISSN":"0095-1137, 1098-660X","note":"PMID: 27605711","shortTitle":"Molecular Epidemiology of Staphylococcus aureus in the General Population in Northeast Germany","journalAbbreviation":"J. Clin. Microbiol.","language":"en","author":[{"family":"Holtfreter","given":"Silva"},{"family":"Grumann","given":"Dorothee"},{"family":"Balau","given":"Veronika"},{"family":"Barwich","given":"Annette"},{"family":"Kolata","given":"Julia"},{"family":"Goehler","given":"André"},{"family":"Weiss","given":"Stefan"},{"family":"Holtfreter","given":"Birte"},{"family":"Bauerfeind","given":"Stephanie S."},{"family":"D?ring","given":"Paula"},{"family":"Friebe","given":"Erika"},{"family":"Haasler","given":"Nicole"},{"family":"Henselin","given":"Kristin"},{"family":"Kühn","given":"Katrin"},{"family":"Nowotny","given":"Sophie"},{"family":"Radke","given":"D?rte"},{"family":"Schulz","given":"Katrin"},{"family":"Schulz","given":"Sebastian R."},{"family":"Trübe","given":"Patricia"},{"family":"Vu","given":"Chi Hai"},{"family":"Walther","given":"Birgit"},{"family":"Westphal","given":"Susanne"},{"family":"Cuny","given":"Christiane"},{"family":"Witte","given":"Wolfgang"},{"family":"V?lzke","given":"Henry"},{"family":"Grabe","given":"Hans J?rgen"},{"family":"Kocher","given":"Thomas"},{"family":"Steinmetz","given":"Ivo"},{"family":"Br?ker","given":"Barbara M."}],"issued":{"date-parts":[["2016",11,1]]}}}],"schema":""} (91), although more studies of MRSA carriage among German diabetics are needed to confirm this as only three were available. The levels of MRSA colonisation among diabetics in nursing homes or the wider community, inpatients and outpatients suggests MRSA carriage reflects the extent of interaction with the healthcare system. It is difficult to compare the values obtained here for in- and out- patients to data regarding the prevalence of MRSA colonisation among general hospital populations as such studies offer a variety of results that typically reflect different patient populations and contexts ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kQQ4S2E7","properties":{"unsorted":true,"formattedCitation":"(92\\uc0\\u8211{}95)","plainCitation":"(92–95)","noteIndex":0},"citationItems":[{"id":16734,"uris":[""],"uri":[""],"itemData":{"id":16734,"type":"article-journal","title":"Random meticillin-resistant Staphylococcus aureus carrier surveillance at a district hospital and the impact of interventions to reduce endemic carriage","container-title":"Journal of Hospital Infection","page":"327-332","volume":"71","issue":"4","source":"ScienceDirect","abstract":"Summary\nColonisation with meticillin-resistant Staphylococcus aureus (MRSA) has previously been described as a risk factor for subsequent infection. MRSA colonisation reached endemic proportions in most healthcare institutions in the UK during the 1990s. Bacteraemia due to MRSA is associated with increased mortality and morbidity compared with meticillin-susceptible S. aureus and national targets have been set for reduction. We present our findings of regular random colonisation surveillance and systematic decolonisation of MRSA carriers over a five-year period with the aim of reducing the pool of carriers and number of MRSA bacteraemia cases. Interventions to reduce the rate of colonisation included assurance of decolonisation and follow up, targeting wards with the highest carriage rates using enhanced screening and education, and screening all admissions aged >65 years. There was a statistically significant reduction in the proportion of patients colonised from 14.6% to 7.0% (P<0.001) and the total number of bacteraemia cases from 42 to 22 (P=0.012) in the initial 24 months of surveillance compared to the most recent 24 months. Regular surveillance of MRSA carriage is useful for monitoring the effects of control measures on MRSA carriage among inpatients. Interventions to reduce carriage are able to reduce the pool of MRSA carriers, thereby reducing cases of bacteraemia.","DOI":"10.1016/j.jhin.2008.12.002","ISSN":"0195-6701","journalAbbreviation":"Journal of Hospital Infection","author":[{"family":"Karas","given":"J. A."},{"family":"Enoch","given":"D. A."},{"family":"Eagle","given":"H. J."},{"family":"Emery","given":"M. M."}],"issued":{"date-parts":[["2009",4,1]]}}},{"id":16732,"uris":[""],"uri":[""],"itemData":{"id":16732,"type":"article-journal","title":"Universal screening for meticillin-resistant Staphylococcus aureus: interim results from the NHS Scotland pathfinder project","container-title":"Journal of Hospital Infection","page":"35-41","volume":"74","issue":"1","source":"ScienceDirect","abstract":"Summary\nFollowing recommendations from a Health Technology Assessment (HTA), a prospective cohort study of meticillin-resistant Staphylococcus aureus (MRSA) screening of all admissions (N=29 690) to six acute hospitals in three regions in Scotland indicated that 7.5% of patients were colonised on admission to hospital. Factors associated with colonisation included re-admission, specialty of admission (highest in nephrology, care of the elderly, dermatology and vascular surgery), increasing age, and the source of admission (care home or other hospital). Three percent of all those who were identified as colonised developed hospital-associated MRSA infection, compared with only 0.1% of those not colonised. Specialties with a high rate of colonisation on admission also had higher rates of MRSA infection. Very few patients refused screening (11 patients, 0.03%) or had treatment deferred (14 patients, 0.05%). Several organisational issues were identified, including difficulties in achieving complete uptake of screening (88%) or decolonisation (41%); the latter was largely due to short duration of stay and turnaround time for test results. Patient movement resulted in a decision to decolonise all positive patients rather than just those in high risk specialties as proposed by the HTA. Issues also included a lack of isolation facilities to manage patients with MRSA. The study raises significant concerns about the contribution of decolonisation to reducing risks in hospital due to short duration of stay, and reinforces the central role of infection control precautions. Further study is required before the HTA model can be re-run and conclusions redrawn on the cost and clinical effectiveness of universal MRSA screening.","DOI":"10.1016/j.jhin.2009.08.013","ISSN":"0195-6701","shortTitle":"Universal screening for meticillin-resistant Staphylococcus aureus","journalAbbreviation":"Journal of Hospital Infection","author":[{"family":"Reilly","given":"J. S."},{"family":"Stewart","given":"S."},{"family":"Christie","given":"P."},{"family":"Allardice","given":"G."},{"family":"Smith","given":"A."},{"family":"Masterton","given":"R."},{"family":"Gould","given":"I. M."},{"family":"Williams","given":"C."}],"issued":{"date-parts":[["2010",1,1]]}}},{"id":16729,"uris":[""],"uri":[""],"itemData":{"id":16729,"type":"article-journal","title":"MRSA screening in orthopaedic surgery?: Clinically valuable and cost effective?","container-title":"Acta Orthop. Belg.","page":"463-469","volume":"79","issue":"4","source":"Zotero","language":"en","author":[{"family":"Barkatali","given":"M"},{"family":"Heywood","given":"N"},{"family":"White","given":"R"},{"family":"Paton","given":"R"}],"issued":{"date-parts":[["2013"]]}}},{"id":16730,"uris":[""],"uri":[""],"itemData":{"id":16730,"type":"article-journal","title":"A selected screening programme was less effective in the detection of methicillin-resistant Staphylococcus aureus colonisation in an orthopaedic unit","container-title":"International Orthopaedics","page":"163-167","volume":"38","issue":"1","source":"link.","abstract":"PurposeOur unit has used a selective screening policy for methicillin-resistant Staphylococcus aureus (MRSA) colonisation using standard chromogenic growth media, based upon risk stratification. The aim of this study was to examine the effectiveness of this selective screening policy.MethodsA cohort of 429 patients was assessed for their risk status for MRSA colonisation using both rapid polymerase chain reaction (PCR) swabs and traditional culture and sensitivity analysis. The sensitivity, specificity, positive predictive values and negative predictive values of the traditional selective approach were calculated compared to universal rapid screening.ResultsOne hundred eighteen patients were considered high risk and would traditionally be further screened with standard culture of swabs. The prevalence of MRSA was 15/429 (3.5 %). The sensitivity of selective screening was 53 % identifying eight of 15 cases. The false-negative rate was therefore 47 % and seven would have been missed. PCR results were available within four to six hours, whereas culture results were only available at 24 hours for the media showing no growth and not until 72 hours for positive MRSA cases.ConclusionsWe now advocate universal screening prior to, or on admission, using this rapid PCR test, as we consider this identifies MRSA colonisation more effectively and facilitates “ring-fencing” of orthopaedic beds.","DOI":"10.1007/s00264-013-2079-y","ISSN":"0341-2695, 1432-5195","journalAbbreviation":"International Orthopaedics (SICOT)","language":"en","author":[{"family":"Dave","given":"Jayshree"},{"family":"Jenkins","given":"Paul J."},{"family":"Hardie","given":"Alison"},{"family":"Smith","given":"Melvyn"},{"family":"Gaston","given":"Paul"},{"family":"Gibb","given":"Alan P."},{"family":"Templeton","given":"Kate"},{"family":"Simpson","given":"Alastair H."}],"issued":{"date-parts":[["2014",1,1]]}}}],"schema":""} (92–95). However, this study compared the MRSA colonisation rates for diabetic and non-diabetic patients across the 14 studies that contained data for both and showed that diabetics had a significantly higher colonisation rate than non-diabetics, a finding which held for sub-analysis of inpatient, American, German or East Asian populations. Notably, the rates of MRSA carriage among diabetic and non-diabetic nursing home residents were very similar, supporting the above suggestion that MRSA carriage rates reflect the extent of interaction with a healthcare environment.Further sub-analyses showed that diabetic HD patients had the greatest colonisation rate (19.08%; n = 197). The colonisation rate of non-diabetic HD patients has been previously estimated by meta-analysis to be 6.2% (n = 5,596; ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"EYm5C56S","properties":{"formattedCitation":"(11)","plainCitation":"(11)","dontUpdate":true,"noteIndex":0},"citationItems":[{"id":16677,"uris":[""],"uri":[""],"itemData":{"id":16677,"type":"article-journal","title":"Meta-analysis of methicillin-resistant Staphylococcus aureus colonization and risk of infection in dialysis patients","container-title":"Journal of the American Society of Nephrology: JASN","page":"2131-2141","volume":"25","issue":"9","abstract":"Patients undergoing dialysis are particularly vulnerable to methicillin-resistant Staphylococcus aureus (MRSA) infections. We performed a meta-analysis of published studies to estimate the prevalence of MRSA colonization in dialysis patients, time trends, and long-term risk of subsequent MRSA infections. Our search of the PubMed and Embase databases returned 5743 nonduplicate citations, from which we identified 38 relevant studies that included data on 5596 dialysis patients. The estimated prevalence of MRSA colonization was 6.2% (95% confidence interval [95% CI], 4.2% to 8.5%). The prevalence increased over time but remained stable after 2000. Stratification of patients according to dialysis modality and setting revealed that 7.2% (95% CI, 4.9% to 9.9%) of patients on hemodialysis were colonized with MRSA compared with 1.3% (95% CI, 0.5% to 2.4%) of patients on peritoneal dialysis (P=0.01), and that a statistically significant difference existed in the percentage of colonized inpatients and outpatients (14.2% [95% CI, 8.0% to 21.8%] versus 5.4% [95% CI, 3.5% to 7.7%], respectively; P=0.04). Notably, the risk of developing MRSA infections increased among colonized hemodialysis patients compared with noncolonized patients (relative risk, 11.5 [95% CI, 4.7 to 28.0]). The long-term (6-20 months) probability of developing a MRSA infection was 19% among colonized hemodialysis patients compared with only 2% among noncolonized patients. In summary, 6.2% of dialysis patients are MRSA colonized, and the average prevalence of colonization has remained stable since 2000. Colonization in hemodialysis patients is associated with increased risk of MRSA infection.","DOI":"10.1681/ASN.2013091028","ISSN":"1533-3450","note":"PMID: 24652802\nPMCID: PMC4147983","journalAbbreviation":"J. Am. Soc. Nephrol.","language":"eng","author":[{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Zervou","given":"Fainareti N."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",9]]}}}],"schema":""} [11]). The higher finding here likely reflects the synergy of two high-risk states and differences in study population size. However, the MRSA colonisation rate among diabetic patients in this study (9.20%) exceeded previous meta-analytic estimates of the colonisation rate among other high-risk groups, e.g. 6.9% among 6,558 HIV-1 patients and 7% and 1.9% among 63,740 general and 19,722 neonatal or paediatric intensive care patients respectively ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aT0nkf2g","properties":{"formattedCitation":"(6,11,12)","plainCitation":"(6,11,12)","noteIndex":0},"citationItems":[{"id":16675,"uris":[""],"uri":[""],"itemData":{"id":16675,"type":"article-journal","title":"Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization in HIV infection: a meta-analysis","container-title":"Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America","page":"1302-1311","volume":"59","issue":"9","abstract":"BACKGROUND: Human immunodeficiency virus (HIV)-infected individuals who are colonized with methicillin-resistant Staphylococcus aureus (MRSA) have increased risk for MRSA infection. We conducted a meta-analysis of published studies to estimate the prevalence of MRSA colonization in this population.\nMETHODS: We performed a systematic literature review and meta-analysis. The PubMed and Embase databases were searched and studies reporting prevalence of MRSA colonization among HIV-infected individuals were included.\nRESULTS: Among 7940 citations, 32 studies reporting data on 6558 HIV-infected individuals were considered eligible for our meta-analysis. We found that 6.9% (95% confidence interval [CI], 4.8-9.3) of individuals with HIV infection are MRSA carriers, with the corresponding figure across North American studies being 8.8% (95% CI, 6.0-12.2). History of hospitalization during the previous 12 months was associated with a 3.1 times higher risk of MRSA colonization (risk ratio [RR], 3.11 [95% CI, 1.62-5.98]). Previous or current incarceration was also associated with a higher risk for carriage (RR, 1.77 [95% CI, 1.26-2.48]). Current antiretroviral therapy or use of trimethoprim-sulfamethoxazole did not impact the risk of MRSA carriage (RR, 1.02 [95% CI, .64-1.63] and 1.45 [95% CI, .69-3.03], respectively). Extranasal screening increased the detection of MRSA colonization by at least 31.6% (95% CI, 15.8-50.0). The added yield from groin screening was 19.3% (95% CI, 11.5-28.5), from perirectal screening 18.5% (95% CI, 7.4-33.2), and from throat cultures 17.5% (95% CI, 12.0-24).\nCONCLUSIONS: Individuals with HIV infection constitute a highly vulnerable population for MRSA colonization, and prior exposure to hospital or incarceration are significant factors. Nasal screening alone will underestimate the rate of colonization by at least one-third.","DOI":"10.1093/cid/ciu559","ISSN":"1537-6591","note":"PMID: 25031291\nPMCID: PMC4271036","journalAbbreviation":"Clin. Infect. Dis.","language":"eng","author":[{"family":"Zervou","given":"Fainareti N."},{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Rich","given":"Josiah D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",11,1]]}}},{"id":16682,"uris":[""],"uri":[""],"itemData":{"id":16682,"type":"article-journal","title":"The prevalence and significance of methicillin-resistant Staphylococcus aureus colonization at admission in the general ICU Setting: a meta-analysis of published studies","container-title":"Critical Care Medicine","page":"433-444","volume":"42","issue":"2","abstract":"OBJECTIVE: To estimate the prevalence and significance of nasal methicillin-resistant Staphylococcus aureus colonization in the ICU and its predictive value for development of methicillin-resistant S. aureus infection.\nDATA SOURCES: MEDLINE and EMBASE and reference lists of all eligible articles.\nSTUDY SELECTION: Studies providing raw data on nasal methicillin-resistant S. aureus colonization at ICU admission, published up to February 2013. Analyses were restricted in the general ICU setting. Medical, surgical, and interdisciplinary ICUs were eligible. ICU studies referring solely on highly specialized ICUs populations and reports on methicillin-resistant S. aureus outbreaks were excluded.\nDATA EXTRACTION: Two authors independently assessed study eligibility and extrapolated data in a blinded fashion. The two outcomes of interest were the prevalence estimate of methicillin-resistant S. aureus nasal colonization at admission in the ICU and the sensitivity/specificity of colonization in predicting methicillin-resistant S. aureus-associated infections.\nDATA SYNTHESIS: Meta-analysis, using a random-effect model, and meta-regression were performed. Pooled data extracted from 63,740 evaluable ICU patients provided an estimated prevalence of methicillin-resistant S. aureus nasal colonization at admission of 7.0% (95% CI, 5.8-8.3). Prevalence was higher for North American studies (8.9%; 95% CI, 7.1-10.7) and for patients screened using polymerase chain reaction (14.0%; 95% CI, 9.6-19). A significant per year increase in methicillin-resistant S. aureus colonization was also noted. In 17,738 evaluable patients, methicillin-resistant S. aureus infections (4.1%; 95% CI, 2.0-6.8) developed in 589 patients. The relative risk for colonized patients was 8.33 (95% CI, 3.61-19.20). Methicillin-resistant S. aureus nasal carriage had a high specificity (0.96; 95% CI, 0.90-0.98) but low sensitivity (0.32; 95% CI, 0.20-0.48) to predict methicillin-resistant S. aureus-associated infections, with corresponding positive and negative predictive values at 0.25 (95% CI, 0.11-0.39) and 0.97 (95% CI, 0.83-1.00), respectively.\nCONCLUSIONS: Among ICU patients, 5.8-8.3% of patients are colonized by methicillin-resistant S. aureus at admission, with a significant upward trend. Methicillin-resistant S. aureus colonization is associated with a more than eight-fold increase in the risk of associated infections during ICU stay, and methicillin-resistant S. aureus infection develops in one fourth of patients who are colonized with methicillin-resistant S. aureus at admission to the ICU.","DOI":"10.1097/CCM.0b013e3182a66bb8","ISSN":"1530-0293","note":"PMID: 24145849","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Ziakas","given":"Panayiotis D."},{"family":"Anagnostou","given":"Theodora"},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",2]]}}},{"id":16678,"uris":[""],"uri":[""],"itemData":{"id":16678,"type":"article-journal","title":"MRSA colonization and risk of infection in the neonatal and pediatric ICU: a meta-analysis","container-title":"Pediatrics","page":"e1015-1023","volume":"133","issue":"4","abstract":"BACKGROUND AND OBJECTIVE: Methicillin-resistant Staphylococcus aureus (MRSA) is a significant cause of morbidity and mortality in NICUs and PICUs. Our objective was to assess the burden of MRSA colonization on admission, study the time trends, and examine the significance of MRSA colonization in this population.\nMETHODS: PubMed and Embase databases were consulted. Studies that reported prevalence of MRSA colonization on ICU admission were selected. Two authors independently extracted data on MRSA colonization and infection.\nRESULTS: We identified 18 suitable articles and found an overall prevalence of MRSA colonization of 1.9% (95% confidence interval [CI] 1.3%-2.6%) on admission to the NICU or PICU, with a stable trend over the past 12 years. Interestingly, 5.8% (95% CI 1.9%-11.4%) of outborn neonates were colonized with MRSA on admission to NICU, compared with just 0.2% (95% CI 0.0%-0.9%) of inborn neonates (P = .01). The pooled acquisition rate of MRSA colonization was 4.1% (95% CI 1.2%-8.6%) during the NICU and PICU stay and was as high as 6.1% (95% CI 2.8%-10.6%) when the NICU population was studied alone. There was a relative risk of 24.2 (95% CI 8.9-66.0) for colonized patients to develop a MRSA infection during hospitalization.\nCONCLUSIONS: In the NICU and PICU, there are carriers of MRSA on admission, and MRSA colonization in the NICU is almost exclusively associated with outborn neonates. Importantly, despite infection control measures, the acquisition rate is high, and patients colonized with MRSA on admission are more likely to suffer a MRSA infection during hospitalization.","DOI":"10.1542/peds.2013-3413","ISSN":"1098-4275","note":"PMID: 24616358","journalAbbreviation":"Pediatrics","language":"eng","author":[{"family":"Zervou","given":"Fainareti N."},{"family":"Zacharioudakis","given":"Ioannis M."},{"family":"Ziakas","given":"Panayiotis D."},{"family":"Mylonakis","given":"Eleftherios"}],"issued":{"date-parts":[["2014",4]]}}}],"schema":""} (6,11,12).Only one study investigated the MRSA colonisation rate among diabetic HCWs, showing that it exceeded that of non-diabetic HCWs (30% [n = 10] vs. 5.8% [n = 242]; ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"klwsxo9L","properties":{"formattedCitation":"(20)","plainCitation":"(20)","noteIndex":0},"citationItems":[{"id":16739,"uris":[""],"uri":[""],"itemData":{"id":16739,"type":"article-journal","title":"Nasal carriage, risk factors and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus among healthcare workers in Adigrat and Wukro hospitals, Tigray, Northern Ethiopia","container-title":"BMC Research Notes","page":"250","volume":"11","issue":"1","source":"BioMed Central","abstract":"The aim of this study was to determine nasal carriage, risk factors and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus among health care-workers of Adigrat and Wukro hospitals Northern Ethiopia.","DOI":"10.1186/s13104-018-3353-2","ISSN":"1756-0500","journalAbbreviation":"BMC Research Notes","author":[{"family":"Legese","given":"Haftom"},{"family":"Kahsay","given":"Atsebaha Gebrekidan"},{"family":"Kahsay","given":"Amlisha"},{"family":"Araya","given":"Tadele"},{"family":"Adhanom","given":"Gebre"},{"family":"Muthupandian","given":"Saravanan"},{"family":"Gebreyesus","given":"Araya"}],"issued":{"date-parts":[["2018",4,23]]}}}],"schema":""} (20)]). Previous meta-analysis of MRSA colonisation among HCW in Europe and the USA has estimated carriage at 1.8-4.4%, with nurses reported have a carriage rate of 6.9% with an odds ratio of 2.58 compared to other HCWs ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"zkCcz6Tt","properties":{"formattedCitation":"(96)","plainCitation":"(96)","noteIndex":0},"citationItems":[{"id":16676,"uris":[""],"uri":[""],"itemData":{"id":16676,"type":"article-journal","title":"MRSA carriage among healthcare workers in non-outbreak settings in Europe and the United States: a systematic review","container-title":"BMC infectious diseases","page":"363","volume":"14","abstract":"ABSTARCT BACKGROUND: A recent review estimated prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare workers (HCWs) to be 4.6%. However, MRSA carriage in HCWs in non-outbreak settings is thought to be higher than in an outbreak situation, due to increased hygiene awareness in outbreaks, but valid data are missing. The goals of this paper are to summarise the prevalence of MRSA carriage amongst HCWs in non-outbreak situations and to identify occupational groups in healthcare services associated with a higher risk of MRSA colonisation.\nMETHODS: A systematic search for literature was conducted in the MEDLINE and EMBASE databases. The methodological quality of the studies was assessed using seven criteria. Pooled prevalence rates were calculated. Pooled effect estimates were identified in a meta-analysis.\nRESULTS: 31 studies were included in this review. The pooled MRSA colonisation rate was 1.8% (95% confidence interval [CI], 1.34%-2.50%). The rate increased to 4.4% (95% CI, 3.98%-4.88%) when one study from the Netherlands was excluded. The pooled MRSA rate was highest in nursing staff (6.9%). Nursing staff had an odds ratio of 1.72 (95% CI, 1.07-2.77) when compared with medical staff and an odds ratio of 2.58 (95%, 1.83-3.66) when compared with other healthcare staff. Seven studies were assessed as being of high quality. The pooled MRSA prevalence in high quality studies was 1.1% or 5.4% if the one large study from the Netherlands is not considered. The pooled prevalence in studies of moderate quality was 4.0%.\nCONCLUSIONS: MRSA prevalence among HCWs in non-outbreak settings was no higher than carriage rates estimated for outbreaks. Our estimate is in the lower half of the range of the published MRSA rates in the endemic setting. Our findings demonstrate that nursing staff have an increased risk for MRSA colonisation. In order to confirm this finding, more studies are needed, including healthcare professionals with varying degrees of exposure to MRSA. In order to reduce misclassification bias, standardisation of HCWs screening is warranted.","DOI":"10.1186/1471-2334-14-363","ISSN":"1471-2334","note":"PMID: 24996225\nPMCID: PMC4094410","journalAbbreviation":"BMC Infect. Dis.","language":"eng","author":[{"family":"Dulon","given":"Madeleine"},{"family":"Peters","given":"Claudia"},{"family":"Schablon","given":"Anja"},{"family":"Nienhaus","given":"Albert"}],"issued":{"date-parts":[["2014",7,3]]}}}],"schema":""} (96). The increased carriage risk for nurses has been recorded elsewhere, and intensive patient contact is thought to be a risk factor ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qIT20xqk","properties":{"formattedCitation":"(97,98)","plainCitation":"(97,98)","noteIndex":0},"citationItems":[{"id":16745,"uris":[""],"uri":[""],"itemData":{"id":16745,"type":"article-journal","title":"MRSA Prevalence and Associated Risk Factors among Health-Care Workers in Non-outbreak Situations in the Dutch-German EUREGIO","container-title":"Frontiers in Microbiology","volume":"7","abstract":"Preventing the spread of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare facilities is a major infection control target. However, only a few studies have assessed the potential role of healthcare workers (HCWs) for MRSA dissemination. To investigate the MRSA prevalence and the risk factors for MRSA colonization among HCWs, nasopharyngeal swabs were taken between June 2010 and January 2011 from 726 employees from nine acute care hospitals with different care levels within the German part of a Dutch-German border region (EUREGIO). The isolated MRSA strains were investigated using spa typing. The overall MRSA prevalence among HCWs in a non-outbreak situation was 4.6% (33 of 726), and was higher in nurses (5.6%, 29 of 514) than in physicians (1.2%, 1 of 83). Possible risk factors associated with MRSA colonization were a known history of MRSA carriage and the presence of acne. Intensive contact with patients may facilitate MRSA transmission between patients and HCWs. Furthermore, an accumulation of risk factors was accompanied by an increased MRSA prevalence in HCW.","ISSN":"1664-302X","note":"PMID: 27597843\nPMCID: PMC4993013","journalAbbreviation":"Front Microbiol","author":[{"family":"Sassmannshausen","given":"Ricarda"},{"family":"Deurenberg","given":"Ruud H."},{"family":"K?ck","given":"Robin"},{"family":"Hendrix","given":"Ron"},{"family":"Jurke","given":"Annette"},{"family":"Rossen","given":"John W. A."},{"family":"Friedrich","given":"Alexander W."}],"issued":{"date-parts":[["2016",8,22]]}}},{"id":16687,"uris":[""],"uri":[""],"itemData":{"id":16687,"type":"article-journal","title":"Prevalence and risk factors of MRSA colonisations: a cross-sectional study among personnel in outpatient care settings in Hamburg, Germany","container-title":"BMJ open","page":"e021204","volume":"8","issue":"7","abstract":"OBJECTIVES: Healthcare workers frequently come into contact with infected individuals and are at a greater risk of infection than the general population due to their occupation. Multidrug-resistant organisms (MDROs) also pose a significant challenge for personnel and medical facilities. Currently, little is known about the occupational risk of methicillin-resistant Staphylococcus aureus (MRSA) in outpatient care settings. Therefore, a cross-sectional study was conducted in Hamburg to investigate MRSA colonisation among outpatient nursing staff.\nMETHODS: MRSA screening with nasal swabs was carried out, the known risk factors for colonisation were determined and information on infection control was inquired. Where tests were positive, a control swab was taken; if this confirmed a positive result, decolonisation was offered. A molecular biological examination of the MRSA samples was performed. The occupational MRSA exposure and risk factors were compared with the situation for personnel in inpatient geriatric care.\nRESULTS: A total of 39 outpatient services participated in the study and 579 employees were tested. The MRSA prevalence was 1.2% in all and 1.7% in nursing staff. Most of the employees that tested positive had close or known contact with MRSA patients. Health personnel frequently reported personal protective measures and their application. Compared with inpatient care staff, outpatient staff were older and had worked in their profession for a longer time.\nCONCLUSION: This study marks the first time that data has been made available on the occupational MRSA risk of outpatient care personnel in Hamburg. The MRSA prevalence is low and provides a good basis for describing the MRSA risk of occupational exposure by health personnel in outpatient care.","DOI":"10.1136/bmjopen-2017-021204","ISSN":"2044-6055","note":"PMID: 30012786","journalAbbreviation":"BMJ Open","language":"eng","author":[{"family":"Peters","given":"Claudia"},{"family":"Kleinmüller","given":"Olaf"},{"family":"Nienhaus","given":"Albert"},{"family":"Schablon","given":"Anja"}],"issued":{"date-parts":[["2018",7,16]]}}}],"schema":""} (97,98). The significance of potentially greater rates of MRSA colonisation of diabetic HCWs requires further investigation, especially given the high prevalence of obesity among some sectors of the healthcare workforce ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tNYn2spj","properties":{"formattedCitation":"(99)","plainCitation":"(99)","noteIndex":0},"citationItems":[{"id":16748,"uris":[""],"uri":[""],"itemData":{"id":16748,"type":"article-journal","title":"Obesity prevalence among healthcare professionals in England: a cross-sectional study using the Health Survey for England","container-title":"BMJ Open","page":"e018498","volume":"7","issue":"12","source":"bmjopen.","abstract":"Objective To estimate obesity prevalence among healthcare professionals in England and compare prevalence with those working outside of the health services.\nDesign Cross-sectional study based on data from 5 years (2008–2012) of the nationally representative Health Survey for England.\nSetting England.\nParticipants 20 103 adults aged 17–65 years indicating they were economically active at the time of survey classified into four occupational groups: nurses (n=422), other healthcare professionals (n=412), unregistered care workers (n=736) and individuals employed in non-health-related occupations (n=18 533).\nOutcome measure Prevalence of obesity defined as body mass index ≥30.0 with 95% CIs and weighted to reflect the population.\nResults Obesity prevalence was high across all occupational groups including: among nurses (25.1%, 95% CI 20.9% to 29.4%); other healthcare professionals (14.4%, 95% CI 11.0% to 17.8%); non-health-related occupations (23.5%, 95% CI 22.9% to 24.1%); and unregistered care workers who had the highest prevalence of obesity (31.9%, 95% CI 28.4% to 35.3%). A logistic regression model adjusted for sociodemographic composition and survey year indicated that, compared with nurses, the odds of being obese were significantly lower for other healthcare professionals (adjusted OR (aOR) 0.52, 95% CI 0.37 to 0.75) and higher for unregistered care workers (aOR 1.46, 95% CI 1.11 to 1.93). There was no significant difference in obesity prevalence between nurses and people working in non-health-related occupations (aOR 0.94, 95% CI 0.74 to 1.18).\nConclusions High obesity prevalence among nurses and unregistered care workers is concerning as it increases the risks of musculoskeletal conditions and mental health conditions that are the main causes of sickness absence in health services. Further research is required to better understand the reasons for high obesity prevalence among healthcare professionals in England to inform interventions to support individuals to achieve and maintain a healthy weight.","DOI":"10.1136/bmjopen-2017-018498","ISSN":"2044-6055, 2044-6055","note":"PMID: 29203505","shortTitle":"Obesity prevalence among healthcare professionals in England","language":"en","author":[{"family":"Kyle","given":"Richard G."},{"family":"Wills","given":"Jane"},{"family":"Mahoney","given":"Catherine"},{"family":"Hoyle","given":"Louise"},{"family":"Kelly","given":"Muireann"},{"family":"Atherton","given":"Iain M."}],"issued":{"date-parts":[["2017",12,1]]}}}],"schema":""} (99).Diabetic foot infections can be mono- or poly- microbial and may be caused by a wide range of pathogens, including MRSA. This study found that the prevalence of MRSA among 10994 DFI patients was 16.78%. This is comparable to the prevalence estimated by a 2010 systematic review ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"l3z0sQwR","properties":{"formattedCitation":"(10)","plainCitation":"(10)","noteIndex":0},"citationItems":[{"id":17084,"uris":[""],"uri":[""],"itemData":{"id":17084,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus in diabetic foot infections","container-title":"Drugs","page":"1785-1797","volume":"70","issue":"14","source":"PubMed","abstract":"Diabetic foot ulcers are often complicated by infection. Among pathogens, Staphylococcus aureus predominates. The prevalence of methicillin-resistant S. aureus (MRSA) in infected foot ulcers is 15-30% and there is an alarming trend for increase in many countries. There are also data that recognize new strains of MRSA that are resistant to vancomycin. The risk for MRSA isolation increases in the presence of osteomyelitis, nasal carriage of MRSA, prior use of antibacterials or hospitalization, larger ulcer size and longer duration of the ulcer. The need for amputation and surgical debridement increases in patients infected with MRSA. Infections of mild or moderate severity caused by community-acquired MRSA can be treated with cotrimoxazole (trimethoprim/sulfamethoxazole), doxycycline or clindamycin when susceptibility results are available, while severe community-acquired or hospital-acquired MRSA infections should be managed with glycopeptides, linezolide or daptomycin. Dalbavancin, tigecycline and ceftobiprole are newer promising antimicrobial agents active against MRSA that may also have a role in the treatment of foot infections if more data on their efficacy and safety become available.","DOI":"10.2165/11538070-000000000-00000","ISSN":"1179-1950","note":"PMID: 20836573","journalAbbreviation":"Drugs","language":"eng","author":[{"family":"Eleftheriadou","given":"Ioanna"},{"family":"Tentolouris","given":"Nicholas"},{"family":"Argiana","given":"Vasiliki"},{"family":"Jude","given":"Edward"},{"family":"Boulton","given":"Andrew J."}],"issued":{"date-parts":[["2010",10,1]]}}}],"schema":""} (10). A higher prevalence was identified for inpatients compared to outpatients, likely reflecting the difference in extent of interaction with the healthcare system. In the UK, one eligible study reported MRSA colonisation data among diabetics at a value lower than the proportion of MRSA positive UK DFI patients (16.9% vs. 19.59%). Further work is needed in the UK to clarify the extent to which diabetic patients are colonised with MRSA. This study was limited by the small number of eligible studies, such that only sub-analyses based on patient setting or geographic region could be conducted. Much of the often-high level of heterogeneity observed in individual sub-analyses therefore likely reflects variation in other factors not simultaneously subject to sub-analysis. Sub-analyses by geographic region, although useful for appraising broad trends, are low resolution given the complexity of factors that underlie MRSA prevalence. While there were enough studies to conduct some national sub-analyses, many included low numbers of studies and were also subject to influence by local inter-study variation. More studies, in particular of the prevalence of MRSA colonisation among diabetic patients, are needed to provide a greater evidence base and permit finer stratification of data in future analyses. The variety of detection techniques used by eligible studies may have led to a slight underestimation, with PCR and chromogenic culture media being more sensitive than nonchromogenic media ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"t17Xoo5M","properties":{"formattedCitation":"(100)","plainCitation":"(100)","noteIndex":0},"citationItems":[{"id":16769,"uris":[""],"uri":[""],"itemData":{"id":16769,"type":"article-journal","title":"Diagnostic accuracy of culture-based and PCR-based detection tests for methicillin-resistant Staphylococcus aureus: a meta-analysis","container-title":"Clinical Microbiology and Infection","page":"146-154","volume":"17","issue":"2","source":"ScienceDirect","abstract":"A systematic review and meta-analysis were performed to determine and compare the sensitivity and specificity of PCR-based and culture-based diagnostic tests for methicillin-resistant Staphylococcus aureus (MRSA). Our analysis included 74 accuracy measurements from 29 publications. Nine tests were evaluated: the PCR-based Genotype MRSA Direct and IDI-MRSA, the chromogenic media CHROMagar, Chromogenic MRSA Medium, MRSA ID, MRSA Select and ORSAB, and the nonchromogenic culture media MSA-Cefoxitin and MSA-Oxacillin. For four chromogenic media, incubation periods of 18–24 and 48 h were evaluated. Considerable heterogeneity was detected in most analyses. A significantly higher sensitivity was found for the overall PCR pooled estimate (92.5; 95% CI 87.4–95.9) and the chromogenic media after 48 h of incubation (87.6; 95% CI 82.1–91.6) compared to the overall sensitivity of chromogenic media after 18–24 h (78.3; 95% CI 71.0–84.1). The specificity of chromogenic media after 18–24 h (98.6; 95% CI 97.7–99.1) was higher than the specificity of PCR (97.0; 95% CI 94.5–98.4) but declined after 48 h of incubation (94.7; 95% CI 91.6–96.8). The most sensitive chromogenic medium after 18–24 h of incubation was Chromogenic MRSA Medium (sensitivity: 89.3; 95% CI 72.8–96.3), whereas the most specific chromogenic medium after 18–24 h of incubation was MRSA Select (specificity: 99.4; 95% CI 98.6–99.7). After 48 h of incubation, MRSA Select had the highest sensitivity (93.2; 95% CI 83.5–97.0), whereas CHROMagar had the highest specificity (96.4; 95% CI 91.3–98.5). This meta-analysis showed statistically significant differences in diagnostic accuracy between several of the tests and the test methods evaluated. A reduction of the incubation time of chromogenic media (from 48 to 18–24 h) increases specificity but reduces sensitivity.","DOI":"10.1111/j.1469-0691.2010.03202.x","ISSN":"1198-743X","shortTitle":"Diagnostic accuracy of culture-based and PCR-based detection tests for methicillin-resistant Staphylococcus aureus","journalAbbreviation":"Clinical Microbiology and Infection","author":[{"family":"Luteijn","given":"J. M."},{"family":"Hubben","given":"G. A. A."},{"family":"Pechlivanoglou","given":"P."},{"family":"Bonten","given":"M. J."},{"family":"Postma","given":"M. J."}],"issued":{"date-parts":[["2011",2,1]]}}}],"schema":""} (100).Meta-analyses are designed to be reproducible and identify as many eligible manuscripts as possible. However, this may be limited by the omission of some relevant manuscripts because they don’t contain the appropriate terms in the fields searched or were incorrectly indexed ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"WwhMzKBO","properties":{"formattedCitation":"(101)","plainCitation":"(101)","noteIndex":0},"citationItems":[{"id":17092,"uris":[""],"uri":[""],"itemData":{"id":17092,"type":"article-journal","title":"Systematic review and meta-analysis: tools for the information age","container-title":"Postgraduate Medical Journal","page":"696-703","volume":"93","issue":"1105","source":"Crossref","abstract":"The amount of available biomedical information is vast and growing. Natural limitations of the way clinicians and researchers approach this treasure trove of information comprise difficulties locating the information, and once located, cognitive biases may lead to inappropriate use of the information. Systematic reviews and meta-analyses represent important tools in the information age to improve knowledge and action. Systematic reviews represent a census approach to identifying literature to avoid non-response bias. They are a necessary prelude to producing combined quantitative summaries of associations or treatment effects. Meta-analysis comprises the arithmetical techniques for producing combined summaries from individual study reports. Careful, thoughtful and rigorous use of these tools is likely to enhance knowledge and action. Use of standard guidelines, such as the Preferred Reporting Items for Systematic Reviews and MetaAnalyses guidelines, or embedding these activities within collaborative groups such as the Cochrane Collaboration, are likely to lead to more useful systematic review and meta-analysis reporting.","DOI":"10.1136/postgradmedj-2017-135034","ISSN":"0032-5473, 1469-0756","shortTitle":"Systematic review and meta-analysis","language":"en","author":[{"family":"Weatherall","given":"Mark"}],"issued":{"date-parts":[["2017",11]]}}}],"schema":""} (101). During this study we became aware of two manuscripts that contained pertinent data but weren’t detected by our systematic search as they lacked terms related to diabetes ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5QHnNTOI","properties":{"formattedCitation":"(13)","plainCitation":"(13)","noteIndex":0},"citationItems":[{"id":16919,"uris":[""],"uri":[""],"itemData":{"id":16919,"type":"article-journal","title":"Methicillin-resistant Staphylococcus aureus: Prevalence, incidence, risk factors, and effects on survival of patients in a specialist palliative care unit: A prospective observational study","container-title":"Palliative Medicine","page":"374-381","volume":"30","issue":"4","source":"SAGE Journals","abstract":"Background:Little is known about the impact of methicillin-resistant Staphylococcus aureus in palliative care settings. To date, the clinical impact of methicillin-resistant Staphylococcus aureus in palliative care is unknown.Aim:To determine prevalence and incidence of methicillin-resistant Staphylococcus aureus colonisation in a specialist palliative care setting, to identify risk factors for methicillin-resistant Staphylococcus aureus colonisation, to determine the eradication success rate and to determine the impact of methicillin-resistant Staphylococcus aureus on survival.Design:Prospective cohort study.Setting/participants:Data were collected for consecutive admissions to an inpatient palliative care service. Patients were screened for methicillin-resistant Staphylococcus aureus colonisation on admission and 1?week post admission. Methicillin-resistant Staphylococcus aureus eradication was attempted in methicillin-resistant Staphylococcus aureus positive patients.Results:Data were collected from 609 admissions for 466 individual patients. Admission screening data were available in 95.5%. Prevalence of methicillin-resistant Staphylococcus aureus colonisation was 11.59% (54 patients). One week incidence of methicillin-resistant Staphylococcus aureus colonisation was 1.2%. Risk factors for methicillin-resistant Staphylococcus aureus colonisation were determined using Chi-Squared test and included high Waterlow score (p?","DOI":"10.1177/0269216315595158","ISSN":"0269-2163","shortTitle":"Methicillin-resistant Staphylococcus aureus","journalAbbreviation":"Palliat Med","language":"en","author":[{"family":"Gleeson","given":"Aoife"},{"family":"Larkin","given":"Philip"},{"family":"Walsh","given":"Cathal"},{"family":"O’Sullivan","given":"Niamh"}],"issued":{"date-parts":[["2016",4,1]]}}}],"schema":""} (13) or MRSA ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"8SpfOzNu","properties":{"formattedCitation":"(14)","plainCitation":"(14)","noteIndex":0},"citationItems":[{"id":16904,"uris":[""],"uri":[""],"itemData":{"id":16904,"type":"article-journal","title":"Necrotizing fasciitis in patients with diabetes mellitus: clinical characteristics and risk factors for mortality","container-title":"BMC Infectious Diseases","volume":"15","issue":"417","abstract":"Background\nNecrotizing fasciitis (NF) is a rapidly progressive and life-threatening infection. This study aimed to investigate the clinical characteristics and mortality- associated factors in diabetic patients.\n\nMethods\nDetailed clinical information of 165 NF cases was retrospectively collected and analyzed in National Taiwan University Hospital between January 1997 and February 2013. We documented and compared the clinical features according to the presence of underlying diabetes mellitus, and we identified risk factors associated with mortality.\n\nResults\nThere were 84 patients (51?%) with diabetes. The overall case fatality rate was 29.7?%, and we found no significant difference between the patients with or without diabetes. Compared with the nondiabetic patients, diabetic patients were older and exhibited higher serum levels of glucose and potassium on admission. Polymicrobial infection and monomicrobial NF caused by Klebsiella pneumoniae were also more frequently associated with diabetic patients. Moreover, diabetic NF patients exhibit a significantly higher chance of limb loss during hospitalization. In the combined diabetic and nondiabetic cohort, a high serum level of potassium (odds ratio, 2.2; 95?% confidence interval, 1.2 to 4.02; P?=?0.011) on admission was independently associated with mortality, whereas positive blood culture on admission was associated with mortality in the diabetic cohort (odds ratio, 7.36; 95?% confidence interval, 1.66 to 32.54; P?=?0.009).\n\nConclusions\nDiabetic patients are more susceptible to NF caused by polymicrobial infection or K. pneumoniae, and they are more likely to receive limb amputation for infection control. Bacteraemia on admission is a significant risk factor for mortality in diabetic NF patients.","DOI":"10.1186/s12879-015-1144-0","ISSN":"1471-2334","note":"PMID: 26463900\nPMCID: PMC4604726","journalAbbreviation":"BMC Infect Dis","author":[{"family":"Cheng","given":"Nai-Chen"},{"family":"Tai","given":"Hao-Chih"},{"family":"Chang","given":"Shan-Chwen"},{"family":"Chang","given":"Chin-Hao"},{"family":"Lai","given":"Hong-Shiee"}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} (14) in the searched fields. Given the topic of this study, it was not feasible to amend the search strategy to omit either terms related to diabetes or MRSA. Therefore, although we were unable to identify these two studies systematically or through review articles, we recognised that they contained relevant data and included them as ‘manual’ search results. This transparent approach enhances the reproducibility of the study, while acknowledging some of the inherent limitations of systematic approaches.This study may also be limited by not being pre-registered. Registration of reviews is a non-essential recommendation designed to encourage transparency, improve quality and reduce duplication. Pre-registration of reviews that are never completed is not recommended ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"lazKZsJ6","properties":{"formattedCitation":"(102)","plainCitation":"(102)","noteIndex":0},"citationItems":[{"id":17087,"uris":[""],"uri":[""],"itemData":{"id":17087,"type":"webpage","title":"PROSPERO","URL":"","author":[{"family":"University of York, Centre for Reviews and Dissemination","given":""}],"accessed":{"date-parts":[["2019",9,1]]}}}],"schema":""} (102). This study was conceived as a student project, many of which are not published, and the authors therefore decided it was inappropriate to register retrospectively. However, the authors are not aware of any similar studies underway and complied with the PRISMA statement throughout.Taken together, the results of this study suggest that diabetics interacting with the healthcare system are likely to have a higher rate of MRSA colonisation than non-diabetics, raising the question of whether diabetic staff and patients should be subject to targeted screening. Targeted screening of high-risk patients has been shown to offer a cost-effective, efficacious, alternative to universal screening ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HCmFdW3B","properties":{"formattedCitation":"(103\\uc0\\u8211{}105)","plainCitation":"(103–105)","noteIndex":0},"citationItems":[{"id":16756,"uris":[""],"uri":[""],"itemData":{"id":16756,"type":"article-journal","title":"Cost Analysis of Universal Screening vs. Risk Factor-Based Screening for Methicillin-Resistant Staphylococcus aureus (MRSA)","container-title":"PLOS ONE","page":"e0159667","volume":"11","issue":"7","source":"PLoS Journals","abstract":"Background The literature remains conflicted regarding the most effective way to screen for MRSA. This study was designed to assess costs associated with universal versus risk factor-based screening for the reduction of nosocomial MRSA transmission. Methods The study was conducted at The Ottawa Hospital, a large multi-centre tertiary care facility with approximately 47,000 admissions annually. From January 2006-December 2007, patients underwent risk factor-based screening for MRSA on admission. From January 2008 to August 2009 universal MRSA screening was implemented. A comparison of costs incurred during risk factor-based screening and universal screening was conducted. The model incorporated probabilities relating to the likelihood of being tested and the results of polymerase chain reaction (PCR) testing with associated effects in terms of MRSA bacteremia and true positive and negative test results. Inputted costs included laboratory testing, contact precautions and infection control, private room costs, housekeeping, and length of hospital stay. Deterministic sensitivity analyses were conducted. Results The risk factor-based MRSA screening program screened approximately 30% of admitted patients and cost the hospital over $780 000 annually. The universal screening program screened approximately 83% of admitted patients and cost over $1.94 million dollars, representing an excess cost of $1.16 million per year. The estimated additional cost per patient screened was $17.76. Conclusion This analysis demonstrated that a universal MRSA screening program was costly from a hospital perspective and was previously known to not be clinically effective at reducing MRSA transmission. These results may be useful to inform future model-based economic analyses of MRSA interventions.","DOI":"10.1371/journal.pone.0159667","ISSN":"1932-6203","journalAbbreviation":"PLOS ONE","language":"en","author":[{"family":"Roth","given":"Virginia R."},{"family":"Longpre","given":"Tara"},{"family":"Coyle","given":"Doug"},{"family":"Suh","given":"Kathryn N."},{"family":"Taljaard","given":"Monica"},{"family":"Muldoon","given":"Katherine A."},{"family":"Ramotar","given":"Karamchand"},{"family":"Forster","given":"Alan"}],"issued":{"date-parts":[["2016",7,27]]}}},{"id":16762,"uris":[""],"uri":[""],"itemData":{"id":16762,"type":"article-journal","title":"Universal vs Risk Factor Screening for Methicillin-Resistant Staphylococcus aureus in a Large Multicenter Tertiary Care Facility in Canada","container-title":"Infection Control & Hospital Epidemiology","page":"41-48","volume":"37","issue":"1","source":"Cambridge Core","abstract":"OBJECTIVE\nTo assess the clinical effectiveness of a universal screening program compared with a risk factor–based program in reducing the rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) among admitted patients at the Ottawa Hospital.\n\n\nDESIGN\nQuasi-experimental study.\n\n\nSETTING\nOttawa Hospital, a multicenter tertiary care facility with 3 main campuses, approximately 47,000 admissions per year, and 1,200 beds.\n\n\nMETHODS\nFrom January 1, 2006 through December 31, 2007 (24 months), admitted patients underwent risk factor–based MRSA screening. From January 1, 2008 through August 31, 2009 (20 months), all patients admitted underwent universal MRSA screening. To measure the effectiveness of this intervention, segmented regression modeling was used to examine monthly nosocomial MRSA incidence rates per 100,000 patient-days before and during the intervention period. To assess secular trends, nosocomial Clostridium difficile infection, mupirocin prescriptions, and regional MRSA rates were investigated as controls.\n\n\nRESULTS\nThe nosocomial MRSA incidence rate was 46.79 cases per 100,000 patient-days, with no significant differences before and after intervention. The MRSA detection rate per 1,000 admissions increased from 9.8 during risk factor–based screening to 26.2 during universal screening. A total of 644 new nosocomial MRSA cases were observed in 1,448,488 patient-days, 323 during risk factor–based screening and 321 during universal screening. Secular trends in C. difficile infection rates and mupirocin prescriptions remained stable after the intervention whereas population-level MRSA rates decreased.\n\n\nCONCLUSION\nAt Ottawa Hospital, the introduction of universal MRSA admission screening did not significantly affect the rates of nosocomial MRSA compared with risk factor–based screening.\n\nInfect. Control Hosp. Epidemiol. 2015;37(1):41–48","DOI":"10.1017/ice.2015.230","ISSN":"0899-823X, 1559-6834","language":"en","author":[{"family":"Roth","given":"V. R."},{"family":"Longpre","given":"T."},{"family":"Taljaard","given":"M."},{"family":"Coyle","given":"D."},{"family":"Suh","given":"K. N."},{"family":"Muldoon","given":"K. A."},{"family":"Ramotar","given":"K."},{"family":"Forster","given":"A."}],"issued":{"date-parts":[["2016",1]]}}},{"id":16758,"uris":[""],"uri":[""],"itemData":{"id":16758,"type":"article-journal","title":"Targeted versus universal screening and decolonization to reduce healthcare-associated meticillin-resistant Staphylococcus aureus infection","container-title":"Journal of Hospital Infection","page":"33-44","volume":"85","issue":"1","source":"ScienceDirect","abstract":"Summary\nBackground\nThe benefits of universal meticillin-resistant Staphylococcus aureus (MRSA) admission screening, compared with screening targeted patient groups and the additional impact of discharge screening, are uncertain.\nAims\nTo quantify the impact of MRSA screening plus decolonization treatment on MRSA infection rates. To compare universal with targeted screening policies, and to evaluate the additional impact of screening and decolonization on discharge.\nMethods\nA stochastic, individual-based model of MRSA transmission was developed that included patient movements between general medical and intensive care unit (ICU) wards, and between the hospital and community, informed by 18 months of individual patient data from a 900-bed tertiary care hospital. We simulated the impact of universal and targeted [for ICU, acute care of the elderly (ACE) or readmitted patients] MRSA screening and decolonization policies, both on admission and discharge.\nFindings\nUniversal admission screening plus decolonization resulted in 77% (95% confidence interval: 76–78) reduction in MRSA infections over 10 years. Screening only ACE specialty or ICU patients yielded 62% (61–63) and 66% (65–67) reductions, respectively. Targeted policies reduced the number of screens by up to 95% and courses of decolonization by 96%. In addition to screening on admission, screening on discharge had little impact, with a maximum 7% additional reduction in infection.\nConclusions\nCompared with universal screening, targeted screening substantially reduced the amount of screening and decolonization required to achieve only 12% lower reduction in infection. Targeted screening and decolonization could lower the risk of resistance emerging as well as offer a more efficient use of resources.","DOI":"10.1016/j.jhin.2013.03.011","ISSN":"0195-6701","journalAbbreviation":"Journal of Hospital Infection","author":[{"family":"Deeny","given":"S. R."},{"family":"Cooper","given":"B. S."},{"family":"Cookson","given":"B."},{"family":"Hopkins","given":"S."},{"family":"Robotham","given":"J. V."}],"issued":{"date-parts":[["2013",9,1]]}}}],"schema":""} (103–105). In the UK, patients admitted to high-risk specialties or with previous MRSA colonisation or infection are targeted for screening ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"MU4wqZee","properties":{"formattedCitation":"(106)","plainCitation":"(106)","noteIndex":0},"citationItems":[{"id":16765,"uris":[""],"uri":[""],"itemData":{"id":16765,"type":"report","title":"Implementation of modified admission MRSA screening guidance for NHS (2014)","URL":"","author":[{"family":"UK Department of Health","given":""}],"issued":{"date-parts":[["2014"]]}}}],"schema":""} (106). Given the rates of colonisation and infection recorded in this analysis, many diabetic patients may therefore be eligible for screening under the current policy. However, research is warranted to evaluate the potential benefits of amending current guidelines to specifically and proactively target colonisation among high-risk patient groups, such as diabetics. While screening of staff is not current policy, more work is required to evaluate the potential benefits of screening diabetic HCWs to reducing the spread of MSRA. However, any screening of specific patient or staff groups must avoid stigmatisation. Lastly, the high prevalence of MRSA among DFI patients and consequent long-term antibiotic administration has wider implications for anti-microbial resistance. While prevention of such infections should remain the goal, with increasing levels of antimicrobial resistance it is also important that alternative therapies are investigated ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mYgpPINM","properties":{"formattedCitation":"(107)","plainCitation":"(107)","noteIndex":0},"citationItems":[{"id":16766,"uris":[""],"uri":[""],"itemData":{"id":16766,"type":"article-journal","title":"Bacteriophage treatment of intransigent Diabetic toe ulcers: A case series","container-title":"Journal of Wound Care","page":"S27-S33","volume":"25","source":"ResearchGate","abstract":"Objective: \nDiabetic foot ulcer (DFU) infections are a growing public health problem, with increasing prevalence, poor response to antibiotics and bacterial resistance to traditional antimicrobials leading to increased morbidity and mortality. Bacteriophages (phages), the viruses that target specific bacteria, are one option for addressing bacterial infections, especially where antibiotics fail. Of particular value is a class of virulent staphylococcal phages that hit almost all Staphylococcus aureus, including most methicillin-resistant Staphylococcus aureus (MRSA) strains. Here we report a continuous case series assessing the effectiveness of treating infected and poorly vascularised toe ulcers with exposed bone, after failure of recommended antibiotic therapy, using topically applied Staphylococcus aureus-specific phage.\n\nMethod:\nThis was a compassionate-use case series of nine patients with diabetes and poorly perfused toe ulcers containing culture-proven Staphylococcus aureus infected bone and soft tissue, who had responded poorly to recommended antibiotic therapy. Six representative cases are presented here. The only generally accepted other option in each case was toe amputation. Exposed portions of the infected phalanges were removed in three cases and left in place in two cases. One case presented as a micro-clot induced gangrene following vascular stenting. In this case, phage were used to prevent infection. The phage used was a commercially available fully sequenced preparation of staphylococcal phage Sb-1. Phage solution was applied topically to the ulcerations once weekly, following standard good wound care. The amount of phage solution applied varied from 0.1 to 0.5 cc depending on volume and area of the ulceration.\n\nResults:\nAll infections responded to the phage applications and the ulcers healed in an average of seven weeks with infected bone debridement. One ulcer, where vascularity was extremely poor and bone was not removed to preserve hallux function, required 18 weeks of treatment. In the case of the toe with the micro-clot gangrene, the toe was salvaged and healed in seven weeks without complications.\n\nConclusion:\nTopical application of a staph mono-phage preparation can be used successfully to treat infected toe ulcerations with bone involvement, despite very poor vascularity and failure of antibiotic treatment. The success within this small series provides the groundwork for controlled clinical trials of staph phage for diabetic foot infections.","DOI":"10.12968/jowc.2016.25.7.S27","shortTitle":"Bacteriophage treatment of intransigent Diabetic toe ulcers","author":[{"family":"Fish","given":"R"},{"family":"Kutter","given":"Elizabeth"},{"family":"Wheat","given":"G"},{"family":"Blasdel","given":"Bob"},{"family":"Kutateladze","given":"Mzia"},{"family":"Kuhl","given":"Sarah"}],"issued":{"date-parts":[["2016",7,1]]}}}],"schema":""} (107). DeclarationsEthics approval and consent to participateThis article does not contain any studies with human participants or animals performed by any of the authors.Consent for publicationNot applicableAvailability of data and materialsData sharing is not applicable to this article as no datasets were generated or analysed during the current peting interestsThe authors declare that they have no competing interestsFunding statementThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Access to MedCalc was obtained through a license provided by the Biomedical Teaching Organisation, University of Edinburgh.Contributions Conceived and designed the experiments: JDJ, SCWPerformed the experiments: HJS, CSC, JDJAnalysed the data: HJS, CSC, JDJWrote the manuscript: JDJReviewed the manuscript: HJS, CSC, SCW, JDJAcknowledgementsThe authors wish to thank Dr Medhat Khattar (School of Biomedical Sciences, University of Edinburgh) for useful discussions. We would also like to thank the three anonymous reviewers for their invaluable constructive criticism. Author’s informationHJS holds a BSc (Hons) in Medicine from St Andrew’s University and an MSc in the Psychology of Mental Health from the University of Edinburgh, where she is a student of Clinical Medicine.CSC graduated with a BSc (Hons) in Medical Sciences from the University of Edinburgh in 2018.SCW is Professor of Molecular Epidemiology, Director of the Global Health Academy and Vice Principal for Global Access at the University of Edinburgh, and Executive Dean of the Zhejiang-Edinburgh Institute, China. JDJ is a Research and Teaching Fellow in Infection Medicine at the University of Edinburgh and Zhejiang-Edinburgh Institute, China. References ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1. Cosgrove SE, Sakoulas G, Perencevich EN, Schwaber MJ, Karchmer AW, Carmeli Y. Comparison of Mortality Associated with Methicillin-Resistant and Methicillin-Susceptible Staphylococcus aureus Bacteremia: A Meta-analysis. Clin Infect Dis. 2003 Jan 1;36(1):53–9. 2. 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Fish R, Kutter E, Wheat G, Blasdel B, Kutateladze M, Kuhl S. Bacteriophage treatment of intransigent Diabetic toe ulcers: A case series. J Wound Care. 2016 Jul 1;25:S27–33. Additional filesAdditional file 1.docPRISMA checklistAdditional file 2.docCritical appraisalFigure legendsFigure 1. Flow diagram of study selection. Figure 2. The prevalence of MRSA colonisation amongst diabetic patients. (A) Forest plot of the proportion of diabetic patients colonised with MRSA (n = 11577). (B) Funnel plot. Figure 3. The prevalence of MRSA amongst DFI patients. (A) Forest plot of the proportion of MRSA positive DFI patients (n = 10994). (B) Funnel plot. ................
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