Kernaussagen
Erreger. Als „CA-MRSA” werden Varianten von S. aureus bezeichnet, die eine erhöhte Antibiotikaresistenz
(Beta-Laktame und andere) in Kombination mit besonderen Virulenzeigenschaften aufweisen.
„CA” steht dabei für „community-associated” (wahlweise auch „adapted”, „acquired”),
weil die Stämme im Unterschied zu bisherigen MRSA-Isolaten außerhalb medizinischer
Einrichtungen bei Patienten ohne nosokomiale Risikofaktoren auftreten.
Krankheitsbilder. CA-MRSA verursachen typischerweise Haut-Weichteilinfektionen, die bei bis zu 30 %
der Fälle multipel oder rezidivierend auftreten. Übertragungen auf Personen mit engem
körperlichem Kontakt sind häufig. Selten kommt es zur Bildung von Abszessen in tiefen
Kompartimenten oder schweren systemischen Erkrankungen mit hoher Letalität (Nekrotisierende
Pneumonie, Nekrotisierende Fasziitis).
Diagnostik. Kultur, Resistenzbestimmung und Bestimmung des Virulenzmarkers „Panton-Valentine
Leukozidin” sollten durchgeführt werden, wenn der klinische Verlauf bzw. anamnestische
Angaben (Häufung von Erkrankungsfällen, Reiseanamnese) auf CA-MRSA hinweisen.
Therapie. Die primäre Therapie folgt allgemeinen Grundsätzen. Die Antibiotikaresistenz sollte
beachtet werden. Zur Verhütung von rezidivierenden Infektionen bzw. schwerer Komplikationen
sollte eine Sanierung des Trägerstatus durchgeführt werden.
Prävention. In medizinischen Einrichtungen, insbesondere im Bereich der Primärversorgung, sollten
die bestehenden Hygienerichtlinien optimal umgesetzt werden. Infizierte oder kolonisierte
Patienten sollten saniert werden. Für medizinisches Personal wird die Impfung gegen
Influenza A empfohlen.
Epidemiologie. Weltweit wird in den letzten Jahren eine starke Zunahme von CA-MRSA bei Patienten
ohne Risikofaktoren und ohne Kontakt zu medizinischen Einrichtungen beobachtet. In
den USA sind CA-MRSA der häufigste Verursacher von ambulant erworbenen Haut-/Weichteilinfektionen
geworden. In Deutschland sind CA-MRSA noch selten.
Ausblick. Wegen der Bedeutung von CA-MRSA für die allgemeine Gesundheit ist es notwendig, in
Deutschland regelmäßige Studien zur Verbreitung von CA-MRSA durchzuführen. Medizinisches
Personal muss über Krankheitsbilder, Diagnostik, Therapie und Prävention geschult
sein. Infizierte und Träger sollten behandelt und der Trägerstatus saniert werden.
Ziel ist es, die Verbreitung von CA-MRSA bestmöglich zu kontrollieren.
Literatur
- 1
Lowy F D.
Staphylococcus aureus infections.
N Engl J Med.
1998;
339
520-532
- 2
Deurenberg R H, Nieuwenhuis R F, Driessen C. et al .
The prevalence of the Staphylococcus aureus tst gene among community- and hospital-acquired
strains and isolates from Wegener’s Granulomatosis patients.
FEMS Microbiol Lett.
2005;
245
185-189
- 3
Diep B A, Gill S R, Chang R F. et al .
Complete genome sequence of USA 300, an epidemic clone of community-acquired meticillin-resistant
Staphylococcus aureus.
Lancet.
2006;
367
731-739
- 4
Monecke S, Berger-Bachi B, Coombs G.
Comparative genomics and DNA array-based genotyping of pandemic Staphylococcus aureus
strains encoding Panton-Valentine leukocidin.
Clin Microbiol Infect.
2007;
13
236-249
- 5
Robinson D A, Enright M C.
Multilocus sequence typing and the evolution of methicillin-resistant Staphylococcus
aureus.
Clin Microbiol Infect.
2004;
10
92-97
- 6
Tenover F C, McDougal L K, Goering R V. et al .
Characterization of a strain of community-associated methicillin-resistant Staphylococcus
aureus widely disseminated in the United States.
J Clin Microbiol.
2006;
44
108-118
- 7
Chambers H F.
Community-associated MRSA-resistance and virulence converge.
N Engl J Med.
2005;
352
1485-1487
- 8
Ellis M W, Hospenthal D R, Dooley D P, Gray P J, Murray C K.
Natural history of community-acquired methicillin-resistant Staphylococcus aureus
colonization and infection in soldiers.
Clin Infect Dis.
2004;
39
971-979
- 9
Seybold U, Talati N J, Kizilbash Q, Shah M, Blumberg H M, Franco-Paredes C.
Hematogenous Osteomyelitis Mimicking Osteosarcoma due to Community Associated Methicillin-Resistant
Staphylococcus aureus.
Infection.
2007;
35
190-193
- 10
Mitchell P D, Hunt D M, Lyall H, Nolan M, Tudor-Williams G.
Panton-Valentine leukocidin-secreting Staphylococcus aureus causing severe musculoskeletal
sepsis in children: A NEW THREAT.
J Bone Joint Surg Br.
2007;
89
1239-1242
- 11
DeWitt C A, Bishop A B, Buescher L S, Stone S P.
Hyperimmunoglobulin E syndrome: two cases and a review of the literature.
J Am Acad Dermatol.
2006;
54
855-865
- 12
Kars M, van Dijk H, Salimans M M, Bartelink A K. et al .
Association of furunculosis and familial deficiency of mannose-binding lectin.
Eur J Clin Invest.
2005;
35
531-534
- 13
Friedman N D, Peterson N B, Sumner W T, Alexander B D.
Spontaneous dermal abscesses and ulcers as a result of Serratia marcescens.
J Am Acad Dermatol.
2003;
49
193-194
- 14
Silvestre Salvador J F, Betlloch M I, Alfonso R, Ramon R L, Morell A M, Navas J.
Disseminated skin infection due to Mycobacterium fortuitum in an immunocompetent patient.
J Eur Acad Dermatol Venereol.
1998;
11
158-161
- 15
Ribeiro A, Dias C, Silva-Carvalho M C. et al .
First report of infection with community-acquired methicillin-resistant Staphylococcus
aureus in South America.
J Clin Microbiol.
2005;
43
1985-1988
- 16
Tang C T, Nguyen D T, Ngo T H. et al .
An outbreak of severe infections with community-acquired MRSA carrying the Panton-Valentine
leukocidin following vaccination.
PLoS ONE.
2007;
2
e822
- 17
Gonzalez B E, Hulten K G, Dishop M K. et al .
Pulmonary manifestations in children with invasive community-acquired Staphylococcus
aureus infection.
Clin Infect Dis.
2005;
41
583-590
- 18
Gillet , Y , B I ssartel, P V anhems. et al .
Association between Staphylococcus aureus strains carrying gene for Panton-Valentine
leukocidin and highly lethal necrotising pneumonia in young immunocompetent patients.
Lancet.
2002;
359
753-759
- 19
Petros S, Eggers B, Heuer M. et al .
Severe community acquired pneumonia due to Staphylococcus aureus.
Intensive Care Med.
1998;
24
189
- 20
Quadri A M, Hock Y L.
Pulmonary pathology of Panton-Valentine leukocidin gene carrying methicillin- resistant
Staphylococcus aureus pneumonia.
Histopathology.
2007;
51
712-713
- 21
Adem P V, Montgomery C P, Husain A N. et al .
Staphylococcus aureus sepsis and the Waterhouse-Friderichsen syndrome in children.
N Engl J Med.
2005;
353
1245-1251
- 22 Bagnulo H, Pedreira W, Soca A, Galiana A, Uruguayan C A. MRSA Study Group .Pulmonary
involvement during an outbreak of community-acquired methicillin-resistant Staphlyococcus
aureus infections 2006. International Congress of Infectious Disease Lisbon; 2006
- 23
Hsu L, Koh T, Anantham D. et al .
Panton-Valentine Leukocidin-positive Staphylococcus aureus, Singapore.
Emerg Infect Dis.
2004;
10
1509-1510
- 24
Kravitz G R, Dries D J, Peterson M L, Schlievert P M.
Purpura fulminans due to Staphylococcus aureus.
Clin Infect Dis.
2005;
40
941-947
- 25
Miller L G, Perdreau-Remington F, Rieg G. et al .
Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus
aureus in Los Angeles.
N Engl J Med.
2005;
352
1445-1453
- 26 Reyes M T, Beenhouwer D O, Rocha M A, Barack B, Drasin T, Schwartzmann W A. Serious
pvl+ MRSA pulmonary infections with bacteremia and nodular infiltrates. 2006. International
Congress of Infectious Disease Lisbon; 2006
- 27
Rutar T, Chambers H F, Crawford J B. et al .
Ophthalmic manifestations of infections caused by the USA 300 clone of community-associated
methicillin-resistant Staphylococcus aureus.
Ophthalmology.
2006;
113
1455-1462
- 28
Okuma K, Iwakawa K, Turnidge J D. et al .
Dissemination of new methicillin-resistant Staphylococcus aureus clones in the community.
J Clin Microbiol.
2002;
40
4289-4294
- 29
Kaneko J, Kamio Y.
Bacterial two-component and hetero-heptameric pore-forming cytolytic toxins: structures,
pore-forming mechanism, and organization of the genes.
Biosci Biotechnol Biochem.
2004;
68
981-1003
- 30
Panton P N, Valentine F CO.
Staphylococcal toxin.
Lancet.
1932;
222
506-508
- 31
Wang R, Braughton K R, Kretschmer D. et al .
Identification of novel cytolytic peptides as key virulence determinants for community-associated
MRSA.
Nat Med.
2007;
13
1510-1514
- 32
Lina G, Piemont Y, Godail-Gamot F. et al .
Involvement of Panton-Valentine leukocidin-producing Staphylococcus aureus in primary
skin infections and pneumonia.
Clin Infect Dis.
1999;
29
1128-1132
- 33
Boyle-Vavra S, Daum R S.
Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine
leukocidin.
Lab Invest.
2007;
87
3-9
- 34
Labandeira-Rey M, Couzon F, Boisset S. et al .
Staphylococcus aureus Panton Valentine Leukocidin Causes Necrotizing Pneumonia.
Science.
2007;
315
1130-1133
- 35
Baba T, Takeuchi F, Kuroda M. et al .
Genome and virulence determinants of high virulence community-acquired MRSA.
Lancet.
2002;
359
1819-1827
- 36
Enright M C, Robinson D A, Randle G, Feil E J, Grundmann H, Spratt B G.
The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA).
Proc Natl Acad Sci USA.
2002;
99
7687-7692
- 37
Tiwari H K, Sen M R.
Emergence of vancomycin resistant Staphylococcus aureus (VRSA) from a tertiary care
hospital from northern part of India.
BMC Infect Dis.
2006;
6
156
- 38
Faden H, Ferguson S.
Community-acquired methicillin-resistant Staphylococcus aureus and intrafamily spread
of pustular disease.
Pediatr Infect Dis J.
2001;
20
554-555
- 39
Huijsdens X W, Santen-Verheuvel M G, Spalburg E. et al .
Multiple cases of familial transmission of community-acquired methicillin-resistant
Staphylococcus aureus.
J Clin Microbiol.
2006;
44
2994-2996
- 40
Nordmann P, Naas T.
Transmission of methicillin-resistant Staphylococcus aureus to a microbiologist.
N Engl J Med.
2005;
352
1489-1490
- 41
Chalumeau M, Bidet P, Lina G. et al .
Transmission of Panton-Valentine leukocidin-producing Staphylococcus aureus to a physician
during resuscitation of a child.
Clin Infect Dis.
2005;
41
e29-e30
- 42
Linde H, Wagenlehner F, Strommenger B. et al .
Healthcare-associated outbreaks and community-acquired infections due to MRSA carrying
the Panton-Valentine leucocidin gene in southeastern Germany.
Eur J Clin Microbiol Infect Dis.
2005;
24
419-422
- 43
Centers for Disease Control .
Methicillin-resistant Staphylococcus aureus infections in correctional facilities
- Georgia, California and Texas, 2001 - 2003.
MMWR.
2004;
52
992-996
- 44
Kazakova S V, Hageman J C, Matava M. et al .
A clone of methicillin-resistant Staphylococcus aureus among professional football
players.
N Engl J Med.
2005;
352
468-475
- 45
Nguyen D B, Mascola L, Bancroft E.
Recurring methicillin-resistant Staphylococcus aureus infections in a football team.
Emerg Infect Dis.
2005;
11
526-532
- 46
Centers for Disease Control. .
Methicillin-resistant Staphylococcus aureus infections among competitive sports participants
- Colorado, Indiana, Pennsylvania and Los Angeles County, 2000 - 2003.
MMWR.
2004;
52
793-795
- 47
Huijsdens X W, van Lier A MC, van Kregten E. et al .
Methicillin-resistant Staphylococcus aureus in Dutch Soccer Team.
Emerg Infect Dis.
2006;
12
1584-1586
- 48
Begier E M, Frenette K, Barrett N L. et al .
A high-morbidity outbreak of methicillin-resistant Staphylococcus aureus among players
on a college football team, facilitated by cosmetic body shaving and turf burns.
Clin Infect Dis.
2004;
39
1446-1453
- 49
Fergie J E, Purcell K.
Community-acquired methicillin-resistant Staphylococcus aureus infections in south
Texas children.
Pediatr Infect Dis J.
2001;
20
860-863
- 50
Cuny C, Kuemmerle J, Stanek C, Willey B, Strommenger B, Witte W.
Emergence of MRSA infections in horses in a veterinary hospital: strain characterisation
and comparison with MRSA from humans.
Euro Surveill.
2006;
11
44-47
- 51
van Loo I HM, Diederen B MW, Savelkoul P HM. et al .
Methicillin-Resistant Staphylococcus aureus in Meat Products, the Netherlands.
Emerg Infect Dis.
2007;
13
1753-1755
- 52
Said-Salim B, Mathema B, Kreiswirth B N.
Community-acquired methicillin-resistant Staphylococcus aureus: an emerging pathogen.
Infect Control Hosp Epidemiol.
2003;
24
451-455
- 53
Smith J M, Cook G M.
A decade of community MRSA in New Zealand.
Epidemiol Infect.
2005;
133
899-904
- 54
Maier J, Melzl H, Reischl U.
Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus in
Germany associated with travel or foreign family origin.
Eur J Clin Microbiol Infect Dis.
2005;
24
637-639
- 55
Moran G J, Krishnadasan A, Gorwitz R J. et al .
Methicillin-resistant S. aureus infections among patients in the emergency department.
N Engl J Med.
2006;
355
666-674
- 56
McCaig L F, McDonald L C, Mandal S, Jernigan D B.
Staphylococcus aureus-associated skin and soft tissue infections in ambulatory care.
Emerg Infect Dis.
2006;
12
1715-1723
- 57
Ma X X, Ito T, Chongtrakool P, Hiramatsu K.
Predominance of clones carrying Panton-Valentine leukocidin genes among methicillin-resistant
Staphylococcus aureus strains isolated in Japanese hospitals from 1979 to 1985.
J Clin Microbiol.
2006;
44
4515-4527
- 58
Turnidge J D, Bell J M.
Methicillin-resistant Staphylococcal aureus evolution in Australia over 35 years.
MicrobDrug Resist.
2000;
6
223-229
- 59
Chini V, Petinaki E, Foka A, Paratiras S, Dimitracopoulos G, Spiliopoulou I.
Spread of Staphylococcus aureus clinical isolates carrying Panton-Valentine leukocidin
genes during a 3-year period in Greece.
Clin Microbiol Infect.
2006;
12
29-34
- 60
Lo W T, Lin W J, Tseng M H, Lu J J, Chu M L, Wang C C.
Nasal carriage of a single clone of community-acquired methicillin-resistant Staphylococcus
aureus among kindergarten attendees in northern Taiwan.
BMC Infect Dis.
2007;
7
51
- 61
Salgado C D, Farr B M, Calfee D P.
Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of
prevalence and risk factors.
Clin Infect Dis.
2003;
36
131-139
- 62
Witte W, Strommenger B, Cuny C, Heuck D, Nuebel U.
Methicillin-resistant Staphylococcus aureus containing the Panton-Valentine leucocidin
gene in Germany in 2005 and 2006.
J Antimicrob Chemother.
2007;
66
1258-1263
- 63
Kluytmans-Vandenbergh M F, Kluytmans J A.
Community-acquired methicillin-resistant Staphylococcus aureus: current perspectives.
Clin Microbiol Infect.
2006;
12 Suppl 1
9-15
- 64
Furuya E Y, Cook H A, Lee M H. et al .
Community-associated methicillin-resistant Staphylococcus aureus prevalence: how common
is it? A methodological comparison of prevalence ascertainment.
Am J Infect Control.
2007;
35
359-366
- 65
Grayson M L.
The treatment triangle for staphylococcal infections.
N Engl J Med.
2006;
355
724-727
- 66
Zetola N, Francis J S, Nuermberger E L, Bishai W R.
Community-acquired meticillin-resistant Staphylococcus aureus: an emerging threat.
Lancet Infect Dis.
2005;
5
275-286
- 67
Witte W.
cMRSA: Heteroresistenztyp erfordert besondere diagnostische Aufmerksamkeit.
Epidemiologisches Bulletin.
2005;
50
466-467
- 68
Obed A, Schnitzbauer A A, Bein T, Lehn N, Linde H J, Schlitt H J.
Fatal Pneumonia Caused by Panton-Valentine Leucocidine-Positive Methicillin-Resistant
Staphylococcus aureus (PVL-MRSA) Transmitted from a Healthy Donor in Living-Donor
Liver Transplantation.
Transplantation.
2006;
81
121-124
- 69
Miller L G, Quan C, Shay A. et al .
A prospective investigation of outcomes after hospital discharge for endemic, community-acquired
methicillin-resistant and -susceptible Staphylococcus aureus skin infection.
Clin Infect Dis.
2007;
44
483-492
- 70
Davis S L, Perri M B, Donabedian S M. et al .
Epidemiology and outcomes of community-associated methicillin-resistant Staphylococcus
aureus infection.
J Clin Microbiol.
2007;
45
1705-1711
- 71
Bernardo K, Pakulat N, Fleer S. et al .
Subinhibitory concentrations of linezolid reduce Staphylococcus aureus virulence factor
expression.
Antimicrob Agents Chemother.
2004;
48
546-444
- 72
Ohlsen K, Ziebuhr W, Koller K P, Hell W, Wichelhaus T A, Hacker J.
Effects of subinhibitory concentrations of antibiotics on alpha-toxin (hla) gene expression
of methicillin-sensitive and methicillin-resistant Staphylococcus aureus isolates.
Antimicrob Agents Chemother.
1998;
42
2817-2823
- 73
Micek S T, Dunne M, Kollef M H.
Pleuropulmonary complications of Panton-Valentine leukocidin-positive community-acquired
methicillin-resistant Staphylococcus aureus: importance of treatment with antimicrobials
inhibiting exotoxin production.
Chest.
2005;
128
2732-2738
- 74
Morgan M S.
Diagnosis and treatment of Panton-Valentine leukocidin (PVL)-associated staphylococcal
pneumonia.
Int J Antimicrob Agents.
2007;
30
289-296
- 75
Gauduchon V, Cozon G, Vandenesch F. et al .
Neutralization of Staphylococcus aureus Panton Valentine leukocidin by intravenous
immunoglobulin in vitro.
J Infect Dis.
2004;
189
346-353
- 76
Fatkenheuer G, Preuss M, Salzberger B. et al .
Long-term outcome and quality of care of patients with Staphylococcus aureus bacteremia.
Eur J Clin Microbiol Infect Dis.
2004;
23
157-162
- 77
Ringberg H, Thoren A, Lilja B.
Metastatic complications of Staphylococcus aureus septicemia. To seek is to find.
Infection.
2000;
28
132-136
- 78 Gorwitz R, Jernigan D B, Jernigan J A. Minimizing the impact of Methicillin-resistant
Staphylococcus aureus in the community [conference summary]. Emerg Infect Dis June/2006
http://Available from http://www.gov/ncidod/EID/vol12no06/06-0292.htm
- 79
Wagenlehner F M, Naber K G, Bambl E.
Management of a large healthcare-associated outbreak of Panton-Valentine leucocidin-positive
meticillin-resistant Staphylococcus aureus in Germany.
J Hosp Infect.
2007;
67
114-120
- 80
Wiese-Posselt M, Heuck D, Draeger A. et al .
Successful termination of a furunculosis outbreak due to lukS-lukF-positive, methicillin-susceptible
Staphylococcus aureus in a German village by stringent decolonization, 2002 - 2005.
Clin Infect Dis.
2007;
44
e88-e95
- 81
Roesch A, Linde H J, Landthaler M, Vogt T.
Elimination of a community-acquired methicillin-resistant Staphylococcus aureus infection
in a nurse with atopic dermatitis.
Arch Dermatol.
2005;
141
1520-1522
- 82
Witte W, Wiese-Posselt M, Jappe U.
Community-based MRSA A new challenge for dermatology.
Hautarzt.
2005;
56
731-738
- 83
Levy R, Shriker O, Porath A, Riesenberg K, Schlaeffer F.
Vitamin C for the treatment of recurrent furunculosis in patients with imparied neutrophil
functions.
J Infect Dis.
1996;
173
1502-1505
- 84
Raz R, Miron D, Colodner R, Staler Z, Samara Z, Keness Y.
A 1-year trial of nasal mupirocin in the prevention of recurrent staphylococcal nasal
colonization and skin infection.
Arch Intern Med.
1996;
156
1109-1112
- 85
Klempner M S, Styrt B.
Prevention of recurrent staphylococcal skin infections with low-dose oral clindamycin
therapy.
JAMA.
1988;
260
2682-2685
- 86
Nahmias A J, Lepper M H, Hurst V, Mudd S.
Epidemiology and treatment of chronic staphylococcal infections in the household.
Am J Public Health.
1962;
52
1828-1843
- 87
Massey R C, Horsburgh M J, Lina G, Hook M, Recker M.
The evolution and maintenance of virulence in Staphylococcus aureus: a role for host-to-host
transmission.
Nat Rev Microbiol.
2006;
4
953-958
- 88
Tietz A, Frei R, Widmer A F.
Transatlantic spread of the USA 300 clone of MRSA.
N Engl J Med.
2005;
353
532-533
Priv.-Doz. Dr. med. Hans-Jörg Linde
Institut für Medizinische Mikrobiologie und Hygiene, Universität Regensburg
Franz-Josef-Strauß-Allee 11
93043 Regensburg
Telefon: 0941/9446414
Fax: 0941/9446402
eMail: Hans-Joerg.Linde@klinik.uni-regensburg.de
