1887
Research Open Access
Like 0

Abstract

Background: In 2015, Bristol (South West England) experienced a large increase in cases of meticillin-resistant (MRSA) infection in people who inject drugs (PWID).

Aim: We aimed to characterise and estimate the prevalence of MRSA colonisation among PWID in Bristol and test evidence of a clonal outbreak.

Methods: PWID recruited through an unlinked-anonymous community survey during 2016 completed behavioural questionnaires and were screened for MRSA. Univariable logistic regression examined associations with MRSA colonisation. Whole-genome sequencing used lineage-matched MRSA isolates, comparing PWID (screening and retrospective bacteraemia samples from 2012-2017) with non-PWID (Bristol screening) in Bristol and national reference laboratory database samples.

Results: The MRSA colonisation prevalence was 8.7% (13/149) and was associated with frequently injecting in public places (odds ratio (OR): 5.5; 95% confidence interval (CI):1.34–22.70), recent healthcare contact (OR: 4.3; 95% CI: 1.34–13.80) and injecting in groups of three or more (OR: 15.8; 95% CI: 2.51–99.28). People reporting any one of: injecting in public places, injection site skin and soft tissue infection or hospital contact accounted for 12/13 MRSA positive cases (sensitivity 92.3%; specificity 51.5%). Phylogenetic analysis identified a dominant clade associated with infection and colonisation among PWID in Bristol belonging to ST5-SCCmecIVg.

Conclusions: MRSA colonisation in Bristol PWID is substantially elevated compared with general population estimates and there is evidence of clonal expansion, community-based transmission and increased infection risk related to the colonising strain. Targeted interventions, including community screening and suppression therapy, education and basic infection control are needed to reduce MRSA infections in PWID.

Loading

Article metrics loading...

/content/10.2807/1560-7917.ES.2019.24.13.1800124
2019-03-28
2019-08-17
http://instance.metastore.ingenta.com/content/10.2807/1560-7917.ES.2019.24.13.1800124
Loading
Loading full text...

Full text loading...

/deliver/fulltext/eurosurveillance/24/13/eurosurv-24-13-3.html?itemId=/content/10.2807/1560-7917.ES.2019.24.13.1800124&mimeType=html&fmt=ahah

References

  1. Gordon RJ, Lowy FD. Pathogenesis of methicillin-resistant Staphylococcus aureus infection. Clin Infect Dis. 2008;46(S5) Suppl 5;S350-9.  https://doi.org/10.1086/533591  PMID: 18462090 
  2. Thomer L, Schneewind O, Missiakas D. Pathogenesis of Staphylococcus aureus Bloodstream Infections. Annu Rev Pathol. 2016;11(1):343-64.  https://doi.org/10.1146/annurev-pathol-012615-044351  PMID: 26925499 
  3. Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired meticillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5(5):275-86.  https://doi.org/10.1016/S1473-3099(05)70112-2  PMID: 15854883 
  4. Bal AM, Coombs GW, Holden MTG, Lindsay JA, Nimmo GR, Tattevin P, et al. Genomic insights into the emergence and spread of international clones of healthcare-, community- and livestock-associated meticillin-resistant Staphylococcus aureus: Blurring of the traditional definitions. J Glob Antimicrob Resist. 2016;6:95-101.  https://doi.org/10.1016/j.jgar.2016.04.004  PMID: 27530849 
  5. Török ME, Harris SR, Cartwright EJ, Raven KE, Brown NM, Allison ME, et al. Zero tolerance for healthcare-associated MRSA bacteraemia: is it realistic? J Antimicrob Chemother. 2014;69(8):2238-45.  https://doi.org/10.1093/jac/dku128  PMID: 24788657 
  6. Department of Health and Social Care (DHSC). Technical Guidance for the 2012/13 Operating Framework. London: DHSC; 2011. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/216413/dh_132045.pdf
  7. Price LB, Stegger M, Hasman H, Aziz M, Larsen J, Andersen PS, et al. Staphylococcus aureus CC398: host adaptation and emergence of methicillin resistance in livestock. MBio. 2012;3(1):1-6.  https://doi.org/10.1128/mBio.00305-11  PMID: 22354957 
  8. Wertheim HF, Melles DC, Vos MC, van Leeuwen W, van Belkum A, Verbrugh HA, et al. The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis. 2005;5(12):751-62.  https://doi.org/10.1016/S1473-3099(05)70295-4  PMID: 16310147 
  9. Nimmo GR, Coombs GW. Community-associated methicillin-resistant Staphylococcus aureus (MRSA) in Australia. Int J Antimicrob Agents. 2008;31(5):401-10.  https://doi.org/10.1016/j.ijantimicag.2007.08.011  PMID: 18342492 
  10. Leung NS, Padgett P, Robinson DA, Brown EL. Prevalence and behavioural risk factors of Staphylococcus aureus nasal colonization in community-based injection drug users. Epidemiol Infect. 2015;143(11):2430-9.  https://doi.org/10.1017/S0950268814003227  PMID: 25434806 
  11. Gilbert M, MacDonald J, Gregson D, Siushansian J, Zhang K, Elsayed S, et al. Outbreak in Alberta of community-acquired (USA300) methicillin-resistant Staphylococcus aureus in people with a history of drug use, homelessness or incarceration. CMAJ. 2006;175(2):149-54.  https://doi.org/10.1503/cmaj.051565  PMID: 16804118 
  12. Otter JA, French GL. Community-associated meticillin-resistant Staphylococcus aureus in injecting drug users and the homeless in south London. J Hosp Infect. 2008;69(2):198-200.  https://doi.org/10.1016/j.jhin.2008.02.014  PMID: 18387697 
  13. Fleisch F, Zbinden R, Vanoli C, Ruef C. Epidemic spread of a single clone of methicillin-resistant Staphylococcus aureus among injection drug users in Zurich, Switzerland. Clin Infect Dis. 2001;32(4):581-6.  https://doi.org/10.1086/318716  PMID: 11181121 
  14. Al-Rawahi GN, Schreader AG, Porter SD, Roscoe DL, Gustafson R, Bryce EA. Methicillin-resistant Staphylococcus aureus nasal carriage among injection drug users: six years later. J Clin Microbiol. 2008;46(2):477-9.  https://doi.org/10.1128/JCM.01596-07  PMID: 18039800 
  15. Harbarth S, François P, Shrenzel J, Fankhauser-Rodriguez C, Hugonnet S, Koessler T, et al. Community-associated methicillin-resistant Staphylococcus aureus, Switzerland. Emerg Infect Dis. 2005;11(6):962-5.  https://doi.org/10.3201/eid1106.041308  PMID: 15963298 
  16. Abudu L, Blair I, Fraise A, Cheng KK. Methicillin-resistant Staphylococcus aureus (MRSA): a community-based prevalence survey. Epidemiol Infect. 2001;126(3):351-6.  https://doi.org/10.1017/S0950268801005416  PMID: 11467791 
  17. Zanelli G, Sansoni A, Zanchi A, Cresti S, Pollini S, Rossolini GM, et al. Staphylococcus aureus nasal carriage in the community: a survey from central Italy. Epidemiol Infect. 2002;129(2):417-20.  https://doi.org/10.1017/S0950268802007434  PMID: 12403117 
  18. Maudsley J, Stone SP, Kibbler CC, Iliffe SR, Conaty SJ, Cookson BD, et al. The community prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in older people living in their own homes: implications for treatment, screening and surveillance in the UK. J Hosp Infect. 2004;57(3):258-62.  https://doi.org/10.1016/j.jhin.2004.03.023  PMID: 15236857 
  19. Hope V, Kimber J, Vickerman P, Hickman M, Ncube F. Frequency, factors and costs associated with injection site infections: findings from a national multi-site survey of injecting drug users in England. BMC Infect Dis. 2008;8(1):120.  https://doi.org/10.1186/1471-2334-8-120  PMID: 18801177 
  20. Public Health England (PHE). Data tables of the Unlinked Anonymous Monitoring Survey of HIV and Hepatitis in People Who Inject Drugs. London: PHE; 2017. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/633204/UAM_Survey_of_PWID_data_tables_2017.pdf
  21. Hope VD, Ncube F, Parry JV, Hickman M. Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England. Epidemiol Infect. 2015;143(1):120-31.  https://doi.org/10.1017/S0950268814000284  PMID: 24568684 
  22. Ward Z, Platt L, Sweeney S, Hope VD, Maher L, Hutchinson S, et al. Impact of current and scaled-up levels of hepatitis C prevention and treatment interventions for people who inject drugs in three UK settings-what is required to achieve the WHO’s HCV elimination targets? Addiction. 2018;113(9):1727-38.  https://doi.org/10.1111/add.14217  PMID: 29774607 
  23. Public Health England (PHE). Opiate and crack cocaine use: prevalence estimates by local area. Estimates of the number of opiate and crack cocaine users in local areas from 2014 to 2015. [Accessed 21 Mar 2019]. Available from: https://www.gov.uk/government/publications/opiate-and-crack-cocaine-use-prevalence-estimates-for-local-populations.
  24. Public Health England (PHE). Annual Epidemiological Commentary: Mandatory MRSA, MSSA and E. coli bacteraemia and C. difficile infection data. London: PHE; 2017. Available from: https://webarchive.nationalarchives.gov.uk/20180410202808/https://www.gov.uk/government/statistics/mrsa-mssa-and-e-coli-bacteraemia-and-c-difficile-infection-annual-epidemiological-commentary
  25. Public Health England (PHE). Unlinked anonymous HIV and viral hepatitis monitoring among PWID: 2016 report. London: PHE; 2016. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/538321/hpr2316_uampwid.pdf
  26. Noone A, Durante AJ, Brady AR, Majid F, Swan AV, Parry JV, et al. HIV infection in injecting drug users attending centres in England and Wales, 1990-1991. AIDS. 1993;7(11):1501-7.  https://doi.org/10.1097/00002030-199311000-00015  PMID: 8280418 
  27. Hope VD, Judd A, Hickman M, Sutton A, Stimson GV, Parry JV, et al. HIV prevalence among injecting drug users in England and Wales 1990 to 2003: evidence for increased transmission in recent years. AIDS. 2005;19(11):1207-14.  https://doi.org/10.1097/01.aids.0000176222.71355.a1  PMID: 15990575 
  28. Cumming RG. Is probability sampling always better? A comparison of results from a quota and a probability sample survey. Community Health Stud. 1990;14(2):132-7.  https://doi.org/10.1111/j.1753-6405.1990.tb00033.x  PMID: 2208977 
  29. Public Health England (PHE). Unlinked anonymous HIV and viral hepatitis monitoring among PWID: 2017 report. London: PHE; 2017. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/633688/hpr2617_uam-pwid.pdf
  30. Christiansen TB, Lauritsen JM, editors. EpiData - Comprehensive Data Management and Basic Statistical Analysis System. Odense: EpiData Association; 2010. Available from: https://www.epidata.dk/credit.htm
  31. R Core Team. (2017) R: A language and environment for statistical computing. Available from: https://www.r-project.org/
  32. Bewick V, Cheek L, Ball J. Statistics review 13: receiver operating characteristic curves. Crit Care. 2004;8(6):508-12.  https://doi.org/10.1186/cc3000  PMID: 15566624 
  33. Lahuerta-Marin A, Guelbenzu-Gonzalo M, Pichon B, Allen A, Doumith M, Lavery JF, et al. First report of lukM-positive livestock-associated methicillin-resistant Staphylococcus aureus CC30 from fattening pigs in Northern Ireland. Vet Microbiol. 2016;182:131-4.  https://doi.org/10.1016/j.vetmic.2015.11.019  PMID: 26711039 
  34. Journal of statistical Software. Daniel Müllner. Fastcluster: Fast Hierarchical, Agglomerative Clustering Routines for R and Python. Published online 2013. Available from: https://www.jstatsoft.org/article/view/v053i09
  35. Stamatakis A. RAxML version 8: a tool for phylogenetic analysis and post-analysis of large phylogenies. Bioinformatics. 2014;30(9):1312-3.  https://doi.org/10.1093/bioinformatics/btu033  PMID: 24451623 
  36. University Hospitals Bristol, National Health Service (NHS) Foundation Trust. MRSA screening Policy and protocol. Bristol: NHS; 2009. Available from: http://www.uhbristol.nhs.uk/files/nhs-ubht/MRSA%20Screening%20UH%20Bristol%20(V01,%20Mar%2009).pdf
  37. Planet PJ, Diaz L, Kolokotronis SO, Narechania A, Reyes J, Xing G, et al. Parallel epidemics of community-associated methicillin-resistant staphylococcus aureus USA300 infection in North and South America. J Infect Dis. 2015;212(12):1874-82.  https://doi.org/10.1093/infdis/jiv320  PMID: 26048971 
  38. Gwizdala RA, Miller M, Bhat M, Vavagiakis P, Henry C, Neaigus A, et al. Staphylococcus aureus colonization and infection among drug users: identification of hidden networks. Am J Public Health. 2011;101(7):1268-76.  https://doi.org/10.2105/AJPH.2010.300028  PMID: 21653250 
  39. Colombo C, Senn G, Bürgel A, Ruef C. Clearance of an epidemic clone of methicillin-resistant Staphylococcus aureus in a drug-use network: a follow-up study in Switzerland. Scand J Infect Dis. 2012;44(9):650-5.  https://doi.org/10.3109/00365548.2012.672766  PMID: 22497490 
  40. Kwiatkowska RM, Manley P, Sims B, Lamagni T, Ready D, Coelho J, et al. Outbreak Control Team. Outbreak of group A Streptococcus emm94.0 affecting people who inject drugs in southwest England, April 2017. Am J Infect Control. 2018;46(2):238-40.  https://doi.org/10.1016/j.ajic.2017.08.011  PMID: 29031429 
  41. Bundle N, Bubba L, Coelho J, Kwiatkowska R, Cloke R, King S, et al. Ongoing outbreak of invasive and non-invasive disease due to group A Streptococcus (GAS) type emm66 among homeless and people who inject drugs in England and Wales, January to December 2016. Euro Surveill. 2017;22(3):30446.  https://doi.org/10.2807/1560-7917.ES.2017.22.3.30446  PMID: 28128090 
  42. Athey TBT, Teatero S, Sieswerda LE, Gubbay JB, Marchand-Austin A, Li A, et al. High Incidence of Invasive Group A Streptococcus Disease Caused by Strains of Uncommon emm Types in Thunder Bay, Ontario, Canada. J Clin Microbiol. 2016;54(1):83-92.  https://doi.org/10.1128/JCM.02201-15  PMID: 26491184 
  43. Septimus EJ, Schweizer ML. Decolonization in Prevention of Health Care-Associated Infections. Clin Microbiol Rev. 2016;29(2):201-22.  https://doi.org/10.1128/CMR.00049-15  PMID: 26817630 
  44. European Centre for Disease Prevention and Control and European Monitoring Centre for Drugs and Drug Addiction (ECDC and EMCDDA). Prevention and control of infectious diseases among people who inject drugs. Stockholm: ECDC/EMCDDA; 2011. Available from: http://www.emcdda.europa.eu/publications/ecdc-emcdda-guidance_en
  45. Phillips KT, Stein MD. Risk practices associated with bacterial infections among injection drug users in Denver, Colorado. Am J Drug Alcohol Abuse. 2010;36(2):92-7.  https://doi.org/10.3109/00952991003592311  PMID: 20337504 
  46. Vlahov D, Sullivan M, Astemborski J, Nelson KE. Bacterial infections and skin cleaning prior to injection among intravenous drug users. Public Health Rep. 1992;107(5):595-8. PMID: 1410243 
  47. Somers CJ, Bridgeman J, Keenan E. Nasal carriage prevalence of meticillin resistant (MRSA) and meticillin sensitive (MSSA) Staphylococcus aureus for subjects attending a Dublin methadone clinic. J Infect. 2010;60(6):494-6.  https://doi.org/10.1016/j.jinf.2010.03.012  PMID: 20346974 
  48. Small W, Wood E, Lloyd-Smith E, Tyndall M, Kerr T. Accessing care for injection-related infections through a medically supervised injecting facility: a qualitative study. Drug Alcohol Depend. 2008;98(1-2):159-62.  https://doi.org/10.1016/j.drugalcdep.2008.05.014  PMID: 18650034 
  49. Semaan S, Fleming P, Worrell C, Stolp H, Baack B, Miller M. Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend. 2011;118(2-3):100-10.  https://doi.org/10.1016/j.drugalcdep.2011.03.006  PMID: 21515001 
  50. Harris RE, Richardson J, Frasso R, Anderson ED. Perceptions about supervised injection facilities among people who inject drugs in Philadelphia. Int J Drug Policy. 2018;52:56-61.  https://doi.org/10.1016/j.drugpo.2017.11.005  PMID: 29241143 
  51. Cimolai N. MRSA and the environment: implications for comprehensive control measures. Eur J Clin Microbiol Infect Dis. 2008;27(7):481-93.  https://doi.org/10.1007/s10096-008-0471-0  PMID: 18273652 
/content/10.2807/1560-7917.ES.2019.24.13.1800124
Loading

Data & Media loading...

Comment has been disabled for this content
Submit comment
Close
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error