Nonmenstrual toxic shock syndrome (TSS) due to Staphylococcus aureus can lead to significant morbidity and mortality. While drotrecogin alfa (DA) has been employed in patients with Methicillin-resistant Staphylococcus aureus (MRSA) severe sepsis and septic shock, its utility in TSS remains unclear. The authors report a case of severe sepsis in the setting of MRSA-associated TSS that responded to treatment with DA. This case illustrates a potential role for DA in the treatment of toxic shock syndromes and emphasizes the importance of aggressive diagnostic and therapeutic modalities in approaching these conditions.

Vancomycin has been considered first-line treatment for bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA) despite treatment failures in up to 20% of patients with MRSA bacteremia secondary to endocarditis. However, trimethoprim-sulfamethoxazole (TMP-SMX) is as effective as vancomycin for the management of MRSA bacteremia. secondary to endocarditis in injection drug users. We report the successful management of a left ventricular assist device-related MRSA infection with persistent MRSA bacteremia that failed to respond to vancomycin, linezolid, and quinupristin/dalfopristin but did respond to TMP-SMX.

Staphylococcus aureus is a common bacterium found on the skin and mucosal membranes of about 20% of the population. S. aureus growth on the skin is harmless, but if it bypasses the skin it can causes life-threatening diseases such as pneumonia, meningitis, bacteremia, and sepsis. Antibiotic-resistant strains of S. aureus, called Methicillin Resistant S. aureus (MRSA), are resistant to most antibiotics except vancomycin. However, vancomycin resistant strains of MRSA are becoming more common. In this study, 12 phages were isolated capable of infecting human S. aureus and/or MRSA strains. Five phages were discovered through mitomycin C induction of prophages and seven phages were found through enrichment of environmental samples. Primary S. aureus strains were also isolated from environmental sources to be used as tools for phage discovery and isolation as well as to examine the target cell host range of the phage isolates. S. aureus isolates were tested for susceptibility to oxacillin in order to determine methicillin-resistance. Experiments were performed to assess the host range and killing potential of newly discovered phage. The M1M4 phage had the broadest host range and lysed 12% of the S. aureus strains that were tested. The host ranges were reinforced by spectrophotometric assay data which showed a reduction in bacterial optical density of 1.3 OD600. The phages were used to decontaminate MRSA from fomites (glass and cloth) and successfully reduced colony forming units by 1-2 logs, including tests of a phage cocktail against a cocktail of MRSA isolates. Our findings suggest that phage treatment can be used as an effective tool to decontaminate human MRSA from both hard surfaces and fabrics.

Meticillinresistent staphylococcus aureus (MRSA) är en bakterie som är resistent mot ett flertal antibiotika. Det är en bakterie som har ökat både i Sverige och i resten av världen. Tidigare var smittspridningen av MRSA vanligt förekommande på sjukhusen men har på senare tid även blivit allt mer förekommande utanför sjukvården. Att smittas av MRSA kan innebära svåra infektionssjukdomar som pneumoni, urinvägsinfektion och sepsis. För att minimera smittspridningen av MRSA flyttas patienter till isoleringssalar, vilket kan resulterat i lidande för patienten. Syfte är att belysa MRSA smittade patienters upplevelse av möten med hälso- och sjukvårdspersonal. Denna litteraturöversikt är baserad på tio vetenskapligt granskade artiklar, nio av artiklarna är kvalitativa och en är kvantitativ. De vetenskapliga artiklarna har noggrant granskats och därifrån har en sammanställning med teman till resultatet bildats. Databaserna CINAHL Complete, PubMed och Academic Search Complete har använts. Utifrån de tio artiklarna sammanställdes fyra teman som belyser patienters upplevelser. Dessa redovisas under i följande rubriker: Hälso- och sjukvård samt närståendes bemötande av patienter med MRSA, Psykologiskt trauma, Negativa och positiva upplevelser av isolering samt Kunskap om MRSA. Katie Erikssons teori med fokus på lidande diskuteras tillsammans med resultatet, utifrån patientens perspektiv. En av sjuksköterskornas centrala roll inom omvårdnadsarbetet är förebyggandet av smittspridning av MRSA, främst genom basala handhygienrutiner. Resultatet påvisade faktorer som kan påverka patienters syn på vården gällande MRSA. Där många patienter upplever att hälso- och sjukvårdspersonalen saknar kunskap angående smittspridning, infektioner och isoleringsrestriktioner. / Meticillin-resistant staphylococcus aureus (MRSA) is a bacteria that is resistant to a variety of antibiotics. This bacteria has increased both in Sweden and worldwide. Previously, the spread of MRSA was common in hospitals, but has recently become more common outside the healthcare sector. To be infected with MRSA often involves severe infectious such as pneumonia, urinary tract infection and sepsis. To minimize the spread of MRSA, patients are moved to isolation, which can result in suffering. To shed light on the experiences of MRSA-infected patients’ interactions with healthcare professionals. This literature review is based on ten scientifically reviewed articles, nine are qualitative and one is quantitative. The scientific articles have been carefully reviewed and from there have a summary with the themes to the result, been formed. Databases CINAHL Complete, PubMed and Academic Search Complete have been used. Based on the ten articles, four themes summarized the patient's experiences. These are listed under the following headings: Healthcare, and relatives response to patients with MRSA, Psychological trauma, Negative and positive experiences of insulation, and Knowledge of patients and healthcare professionals. Katie Eriksson's theory on suffering is discussed with the result, based on patient's perspective. One of the nurses' central role in nursing work is preventing contagious spread of MRSA, primarily through basic hand hygiene routines. Our results indicate that there are factors that may affect patients' views on the care of MRSA. Where many patients experience that healthcare professionals lack knowledge about spread of infection, infections and isolation restrictions.

Bakgrund: Methicillin-resistent Staphylococcus aureus (MRSA) är en variant av gula stafylokocker som är resistenta mot meticillin vilket resulterar i att MRSA är svår behandlat. MRSA är infektioner som finns på bland annat huden och i slemhinnor, bakterien kan orsaka svåra livshotande infektioner. Vilket resulterar i ett stort lidande för patienten och höga samhällskostnader. Syfte: Syftet var att beskriva faktorer i sjuksköterskans omvårdnadsarbete som kan påverka smittspridningen av Methicillin-resistent Staphylococcus aureus (MRSA). Metod: Denna litteraturöversikt utgår från åtta kvalitativa och kvantitativa vetenskapliga artiklar som systematiskt söktes fram i databaserna PubMed och Cinahl Complete. Artiklarnas resultat tematiserades enligt Fribergs analysmodell. Resultat: Resultatet visade att sjuksköterskor behöver få mer kunskap genom upprepade utbildningar av MRSA och smittspridning samt ha en god handhygien för att påverka smittspridning. De hygienrutiner och riktlinjer som finns angående MRSA och smittspridning behöver utvecklas och förtydligas.  Sammanfattning: Sjuksköterskor behöver ta ansvar för sin yrkesmässiga utveckling genom att initiera utbildning för att kunna bidra till en säker vård. Sjuksköterskor behöver ta ansvar för att ständigt utvecklas och söka nya kunskaper. Kunskap och utbildning bidrar till evidensbaserad vård vilket kan förhindra smittspridning av MRSA. / Background: Methicillin-resistant Staphylococcus aureus (MRSA) is a variant of staphylococcus aureus that is resistant to methicillin, which results in MRSA being difficult to treat. MRSA infections can be found on the skin and in mucous membranes of afflicted patients. Which results in great suffering for the patient and high societal costs. Aim: The aim of this study was to describe how nurse’s nursing care can affect spread of infection of Methicillin-resistant Staphylococcus aureus (MRSA). Method: This literature review is based on eight qualitative and quantitative scientific articles that were systematically searched in the databases PubMed and Cinahl Complete. The results of the articles were themed according to Friberg's analysis model. Results: The results showed that nurses need to gain more knowledge through repeated training on MRSA and the spread of infection and have good hand hygiene to affect spread of infection. The hygiene routines and guidelines that exist regarding MRSA and the spread of infection need to be developed and clarified. Summary: Nurses need to take responsibility for their professional development by initiating training in order to contribute to safe care. Nurses need to take responsibility for constantly developing and seeking new knowledge. Knowledge and education contribute to evidence-based care, which can prevent the spread of MRSA.

BACKGROUND: The risk factors, microbial etiology, differentiation, and clinical features of purulent and non-purulent cellulitis are not well defined in Taiwan. METHODS: We conducted a retrospective cohort study of hospitalized adults with cellulitis in Taiwan in 2013. The demographic characteristics, underlying diseases, clinical manifestations, laboratory and microbiological findings, treatments, and outcomes were compared for patients with purulent and non-purulent cellulitis. RESULTS: Of the 465 patients, 369 had non-purulent cellulitis and 96 had purulent cellulitis. The non-purulent group was significantly older (p = 0.001) and was more likely to have lower limb involvement (p < 0.001), tinea pedis (p = 0.003), stasis dermatitis (p = 0.025), a higher Charlson comorbidity score (p = 0.03), and recurrence at 6 months post-infection (p = 0.001) than the purulent group. The purulent group was more likely to have a wound (p < 0.001) and a longer hospital stay (p = 0.001) and duration of antimicrobial therapy (p = 0.003) than the non-purulent group. The etiological agent was identified in 35.5 % of the non-purulent cases, with β-hemolytic streptococci the most frequent cause (70.2 %). The etiological agent was identified in 83.3 % of the purulent cases, with Staphylococcus aureus the predominant pathogen (60 %): 50 % of these were methicillin-resistant S. aureus (MRSA). In multivariable analysis, purulent group (odds ratio (OR), 5.188; 95 % confidence interval (CI), 1.995-13.493; p = 0.001) was a positive predictor of MRSA. The prescribed antimicrobial agents were significantly different between the purulent and non-purulent groups, with penicillin the most frequently used antimicrobial agent in the non-purulent group (35.2 %), and oxacillin the most frequent in the purulent group (39.6 %). The appropriate antimicrobial agent was more frequently prescribed in the non-purulent group than in the purulent group (83.2 % vs. 53.8 %, p < 0.001). CONCLUSIONS: The epidemiology, clinical features, and microbiology of purulent and non-purulent cellulitis were significantly different in hospitalized Taiwanese adults. Purulence was a positive predictor of MRSA as the causal agent of cellulitis. These findings provide added support for the adoption of the IDSA guidelines for empirical antimicrobial therapy of cellulitis in Taiwan.

The Gram positive bacterium Staphylococcus aureus is a major cause of human disease in industrialized countries. This multifaceted pathogen is adapted to thrive in a variety of host niches, including the intracellular compartment. S. aureus rapidly develops antibiotic resistance, and infections due to resistant clones pose a global threat, calling for novel therapeutic approaches. The ability to exploit host nutrients and efficiently metabolize these resources for growth is paramount for bacterial pathogenesis. Understanding the nutritional and metabolic determinants that underpin bacterial virulence may lead to the identification of novel antimicrobial targets. This thesis investigates carbon nutrition and metabolism of community-acquired methicillin resistant S. aureus (CA-MRSA) USA300, a widely spread, hyper virulent multi-resistant strain. The dependence of S. aureus on carbohydrates for growth was considered first. In vitro studies in supplemented chemically defined media showed that sugar phosphates, such as hexose phosphates and glycerol phosphates, promote staphylococcal growth more efficiently than glucose. Deletion mutations were introduced to the two putative sugar phosphate transporter genes present in the S. aureus genome, uhpT (hexose phosphate permease) and glpT (glycerol phosphate permease). Phenotypic analysis of USA300 mutants and heterologous expression of the transporters in a previously described Listeria monocytogenes Δhpt mutant, totally unable to use sugar phosphates, confirmed that S. aureus UhpT and GlpT have different substrate specificities. Whilst both can transport glycerol monophosphate (excluding glycerol-2-phosphate) and the organophosphate antibiotic fosfomycin, hexose monophosphates are only imported via UhpT. Since sugar phosphates are only present in significant amounts inside living tissues, particularly the intracellular compartment, the role of S. aureus UhpT and GlpT in pathogenesis was investigated by constructing a double deletion mutant. The ΔuhpTΔglpT USA300 mutant was used to infect several relevant mammalian cell lines. In the conditions tested, it was found that UhpT and GlpT played no role in the intracellular replication of S. aureus. By contrast, Listeria exploits sugar phosphates from the host cell cytosol via the homologous hexose phosphate transporter, Hpt, to maximise replication and enhance virulence. The distinct requirement of sugar phosphates for intracellular proliferation may reflect intrinsic differences in carbon nutrient dependence between the two organisms. It was confirmed that S. aureus can efficiently use other readily available carbon sources for growth, such as amino acids. In contrast, Listeria is strictly dependent upon sugar-derived carbon for growth, due to an incomplete tricarboxylic acid cycle. Whilst the double ∆uhpT∆glpT mutation had no effect in S. aureus, expression of staphylococcal uhpT or glpT restored wild-type intracellular growth in the L. monocytogenes ∆hpt mutant. Taken together, the results illustrate that sugar phosphate permeases have a contextual role in bacterial virulence, where the background in which the genes are expressed determine their contribution as a virulence factor. The intracellular dynamics of S. aureus was also explored using immunofluorescence microscopy. It was observed that, during epithelial cell infection, USA300 remains enclosed in a membrane-bound vacuole. This localisation may form a barrier to cytosolic sugar phosphates and potentially explain the absence of effect of the sugar phosphate permease deletions in intracellular proliferation. Preliminary characterisation of the S. aureus containing vacuole (SACV) was performed and it was found to be positive for the Rab7 late-endosomal GTPase and for trans-Golgi markers. This suggests that SACVs converge at the Golgi apparatus. Interestingly, a USA300 mutant lacking the global regulatory system agr was unable to proliferate intracellularly and did not acquire Rab7 or Golgi markers. Since the Δagr mutation did not cause any impairment in carbon source dependent growth, these preliminary data suggest that modification of the SACV by Agr-regulated effectors may play a key role in modulating cellular processes that control staphylococcal intracellular survival and/or replication. Evidence presented in this thesis provides a platform for further exploration of S. aureus host cell nutrient dependence and the mechanisms that drive replication.

Historiskt sett har personer med smittsamma infektioner uteslutits från samhället. Personerna har setts med avsky och rädsla från omgivningen med risk för att överföra smittan. Multiresistenta bakterier (MRB) är ett ökande problem världen över och orsakar stort lidande för patienter. Syftet med litteraturstudien var att undersöka patienters upplevelse av att vara smittbärare av meticillinresistenta staphylococcus aureus (MRSA). Litteraturstudiens resultat baseras på nio vetenskapliga artiklar, där resultatet utföll i två kategorier. I kategorin känslan av att vara smittsam framkom underkategorierna att vara smutsig, skuld och skam samt rädsla och oro. I kategorin känslan av att vara annorlunda framkom underkategorierna känna sig kränkt, ilska och frustration samt känna sig stigmatiserad. För att patienter med MRSA-smitta ska få en god vård krävs det att vårdpersonalen har evidensbaserad kunskap. Därför skulle det vara av stort intresse att forskning i framtiden fokuserar på patienters upplevelse av att vara smittbärare. Ytterligare forskning behövs inom området på grund av ett ökat globalt problem med MRB. / Historically, people with contagious infections has been excluded from society. The characters have been seen with disgust and fear from the environment with the risk of transmitting the infection. Multi-drug resistant bacteria (MRB) is a growing problem worldwide and causes great suffering for patients. The purpose of this study was to investigate patients' experience of being carriers of methicillin-resistant staphylococcus aureus (MRSA). Literature study results are based on nine scientific articles, which precipitated the result of two categories. In the category of feeling of being contagious emerged subcategories to be dirty, guilt and shame and fear and anxiety. In the category of the feeling of being different subcategories emerged feel hurt, anger and frustration, and feel stigmatized. For patients with MRSA infection should get good care requires that health professionals have evidence-based knowledge. Therefore, it would be of great interest to future research focusing on patient experience of being contaminated. Further research is needed in this area because of the increasing global problem of MRB.

Background: Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus (MRSA) represent the most worrying Gram-negative and Gram-positive nosocomial pathogens of the present age. They are of increasing concern in the clinical environment due to their multi-drug resistance and the dwindling therapeutic options available. A. baumannii is the most frequently isolated clinical species of the genus, and is able to rapidly acquire resistance. Hypermutators, most frequently deficient in mismatch repair (MMR) via defects in the mutS gene, have been associated with antimicrobial resistance in several bacterial populations. To date, however, the potential role of MMR-deficient mutators in the development of resistance in clinical Acinetobacter spp. has not been investigated. Biocides, most notably chlorhexidine (CHX), are increasingly used in the hospital environment to prevent bacterial spread. This has led to concerns about the development of reduced biocide susceptibility and associated antibiotic resistance in hospital bacterial populations, where there is frequent exposure to both of these factors. The effect of CHX upon defined clinical MRSA isolates is examined here. Methods: The mutS gene of clinical Acinetobacter spp. isolates with varying sensitivities was sequenced and compared to establish whether any variations were present. Mutation studies were performed on isolates by challenging them with ciprofloxacin to determine whether different mutS types correlated with any variation in their ability to develop significant fluoroquinolone resistance. The response of clinical MRSA isolates to a range of CHX concentrations was examined with susceptibility testing methods, and effects were compared with standard strains. Determination of post-exposure minimum inhibitory concentrations (MICs) of a range of antibiotics enabled evaluation of whether exposure to CHX had an effect on susceptibility to antibiotics. Results: Variation was observed in the mutS gene of clinical Acinetobacter spp. isolates, with greater homology observed as resistance increased. A highly conserved and previously unreported amino acid sequence was discovered in resistant isolates. Nonresistant isolates with this ‘R-type’ mutS sequence appeared to have a greater ability to develop significant ciprofloxacin resistance. Clinical MRSA isolates had varying susceptibility to CHX, and there were differences in the susceptibility of standard strains compared to clinical isolates. CHX residues exerted a prolonged minimal inhibitory effect, and several increases in antibiotic MICs following CHX exposure were observed. Conclusions: The correlation of the mutS sequence with mutation ability suggests that defects in the mutS gene may have a role to play in the ability of certain Acinetobacter spp. to rapidly acquire resistance. This could have implications for the treatment of Acinetobacter spp. infections, and may enable quick determination of which clinical isolates have the potential to develop clinically significant resistance. Incomplete eradication due to the prolonged minimal effect of CHX residues may act as a selective pressure in the hospital environment, allowing survival of reduced susceptibility MRSA isolates. Increases in antibiotic MICs following CHX exposure is of grave concern for the future of biocide usage.

Bakgrund: Antibiotikaresistenta bakterier är idag ett stort hot mot folkhälsan. Det här arbetet fokuserar på MRSA och lyfter fram problematiken som dess spridning innebär för patienten, samhället och vårdpersonal. MRSA-bärarskap kan ge både fysiskt och psykiskt lidande och en infektion orsakad av MRSA kan i värsta fall leda till döden för patienten. Sjuksköterskan har en viktig roll i att upprätthålla sin kompetens och arbeta preventivt för att förhindra spridning av MRSA. Syfte: Syftet var att identifiera och beskriva faktorer som leder till spridning av MRSA vid vårdarbetet av patienter på somatisk vårdavdelning. Metod: En litteraturstudie där 11 kvantitativa och en kvalitativ artikel analyserades utifrån Graneheim och Lundmans (2004) metod för innehållsanalys. Artiklarna kvalitetsgranskades med hjälp av Forsberg och Wengströms (2016) granskningsmallar. Resultat: Resultatet delades in i fem huvudkategorier med nio underkategorier som var och en visar på kompetensbrist hos sjuksköterskor. Litteraturstudien påvisar att faktorerna som leder till spridning av MRSA kan vara flera och att hela vårdteamet bär ett ansvar för att förhindra smittspridning. Sjuksköterskans roll i vårdteamet är att undervisa patienter och närstående, följa gällande rutiner och att upprätthålla sin egen kompetens för att arbeta evidensbaserat. Slutsats: Förhindra spridning av antibiotikaresistenta bakterier är en av sjuksköterskans viktigaste arbetsuppgifter i sin roll att lindra lidande hos patienten. Det är många faktorer som kan göra att MRSA sprids, sjuksköterskor måste reflektera och vara självkritiska i sitt arbete på vårdavdelningar. Evidensbaserat arbete var enligt Nightingale sjuksköterskans möjlighet att förhindra lidande för patienten och ligger till grund för den sjuksköterskeutbildning som finns idag. / Background: Antibiotic resistant bacteria are today a major threat to the public health. This work focuses on methicillin resistant staphylococcus aureus, highlighting the problem that it involves for the patient, society and healthcare professionals. MRSA carriership can cause both physical and mental suffering and an infection caused by MRSA can in worst case lead to the patient’s death. Nurses play an important role in maintaining their work skills to prevent MRSA from spreading in the somatic care. Aim: The aim of this study was to identify and describe factors that lead to the spread of MRSA to patients in somatic care. Method: A literature study where 11 quantitative and one qualitative article were analyzed based on Graneheim and Lundman's (2004) method. The articles quality were reviewed using Forsberg and Wengström’s (2016) checklists. Results: The results were divided into five main categories with nine subcategories; each showing that nurses had a lack of competence. The study shows that the factors that lead to the spread of MRSA may be several, and that the entire healthcare team has a responsibility to prevent infection. The nurse's role in the team is to teach patients and close relatives, follow current procedures and maintain their own skills to work evidence based. Conclusion: Preventing the spread of antibiotic resistant bacteria is one of the most important tasks in role of nursing and in alleviating patient suffering. There are many factors that can cause MRSA to spread. Nurses must reflect and be self-critical in their work in health care departments. Evidence based work was, according to Nightingale, the nurse's ability to prevent suffering for the patient and is the baseline in nursing education currently available today.