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Original Investigation
March 30, 2020

Environmental Methicillin-resistant Staphylococcus aureus Contamination, Persistent Colonization, and Subsequent Skin and Soft Tissue Infection

Author Affiliations
  • 1Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 2Graduate Program in the Biophysical Sciences, University of Chicago, Chicago, Illinois
  • 3Committee of Microbiology, University of Chicago, Chicago, Illinois
  • 4Institute for Genomics and Systems Biology, University of Chicago, Chicago, Illinois
  • 5Department of Molecular Microbiology, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 6Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 7Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 8Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 9Department of Human Genetics, University of Chicago, Chicago, Illinois
JAMA Pediatr. 2020;174(6):552-562. doi:10.1001/jamapediatrics.2020.0132
Key Points

Question  Is there an association between environmental contamination, persistent personal colonization, and recurrent skin and soft tissue infection among households with children with community-associated methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection?

Findings  In this cohort study of 692 household members from 150 households with children with community-associated MRSA skin and soft tissue infection, 39% of participants were persistently colonized with S aureus. A total of 53% of index patients and 19% of household contacts reported interval skin and soft tissue infections, more often when persistently colonized with MRSA.

Meaning  The findings suggest that MRSA colonization of household members and contamination of environmental surfaces in the household may be associated with MRSA skin and soft tissue infections in children.

Abstract

Importance  The longitudinal association among persistent Staphylococcus aureus colonization, household environmental contamination, and recurrent skin and soft tissue infection (SSTI) is largely unexplored to date.

Objectives  To identify factors associated with persistent S aureus colonization and recurrent SSTI in households with children with community-associated methicillin-resistant S aureus (MRSA) SSTI.

Design, Setting, and Participants  This 12-month prospective cohort study included 150 children with community-associated MRSA SSTI, 542 household contacts, and 154 pets enrolled from January 3, 2012, through October 20, 2015. A total of 5 quarterly home visits were made to 150 households in the St Louis, Missouri, region. Statistical analysis was performed from September 18, 2018, to January 7, 2020.

Exposures  Covariates used in S aureus strain persistence and interval SSTI models included S aureus colonization and contamination measures, personal hygiene and sharing habits, health history, activities external to the home, and household characteristics (eg, cleanliness, crowding, home ownership, and pets). Serial samples to detect S aureus were collected from household members at 3 anatomic sites, from pets at 2 anatomic sites, and from environmental surfaces at 21 sites.

Main Outcomes and Measures  Molecular epidemiologic findings of S aureus isolates were assessed via repetitive-sequence polymerase chain reaction. Individual persistent colonization was defined as colonization by an identical strain for 2 consecutive samplings. Longitudinal, multivariable generalized mixed-effects logistic regression models were used to assess factors associated with persistent S aureus personal colonization, environmental contamination, and interval SSTI.

Results  Among 692 household members in 150 households, 326 (47%) were male and 366 (53%) were female, with a median age of 14.82 years (range, 0.05-82.25 years). Of 540 participants completing all 5 samplings, 213 (39%) were persistently colonized with S aureus, most often in the nares and with the strain infecting the index patient at enrollment. Nine pets (8%) were persistently colonized with S aureus. Participants reporting interval intranasal mupirocin application were less likely to experience persistent colonization (odds ratio [OR], 0.44; 95% credible interval [CrI], 0.30-0.66), whereas increasing strain-specific environmental contamination pressure was associated with increased individual persistent colonization (OR, 1.17; 95% CrI, 1.06-1.30). Strains with higher colonization pressure (OR, 1.47; 95% CrI, 1.25-1.71) and MRSA strains (OR, 1.57; 95% CrI, 1.16-2.19) were more likely to persist. Seventy-six index patients (53%) and 101 household contacts (19%) reported interval SSTIs. Individuals persistently colonized with MRSA (OR, 1.56; 95% CrI, 1.17-2.11), those with a history of SSTI (OR, 2.55; 95% CrI, 1.88-3.47), and index patients (OR, 1.54; 95% CrI, 1.07-2.23) were more likely to report an interval SSTI.

Conclusions and Relevance  The study findings suggest that recurrent SSTI is associated with persistent MRSA colonization of household members and contamination of environmental surfaces. Future studies may elucidate the effectiveness of specific combinations of personal decolonization and environmental decontamination efforts in eradicating persistent strains and mitigating recurrent SSTIs.

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