Patients with Rheumatic Diseases do not have an Increased Risk of MRSA Carrier Status

Patients with Rheumatic Diseases do not have an Increased Risk of MRSA Carrier Status Rheumatol Ther https://doi.org/10.1007/s40744-018-0116-4 ORIGINAL RESEARCH Patients with Rheumatic Diseases do not have an Increased Risk of MRSA Carrier Status . . . Judith Kra ¨mer Konstantinos Triantafyllias Wolfgang Kohnen . . . Martin Leber Ute Dederichs-Masius Andrea Zucker Ju ¨ rgen Ko ¨ rber Andreas Schwarting Received: May 21, 2018 The Author(s) 2018 Results: Nine (1.1%) of the 842 patients were ABSTRACT colonized with MRSA. Only five of them should have been tested according to the commission’s Introduction: The aim of this study was to recommendations. The prevalence was 0.5% determine the prevalence of methicillin-resis- (n = 207) in rheumatologic, 0.9% (n = 224) in tant Staphylococcus aureus (MRSA) both in psychosomatic, 1.4% (n = 209) in oncologic rheumatologic and non-rheumatologic rehabil- and 1.5% (n = 202) in cardiologic patients. We itation centers. In addition, we sought to eval- found a greater exposure to risk factors in car- uate the practice value of existing screening diologic and oncologic patients. Among recommendations of the German Commission patients with carrier status, a higher percentage for Hospital Hygiene and Infection Prevention was exposed to three potential risk factors not (KRINKO). applied by the commission. Methods: The analysis was performed in four Conclusions: The prevalence of MRSA in our rehabilitation clinics (rheumatology, psychoso- cohort correlates with data from previous stud- matic medicine, oncology, and cardiology) with ies. The low percentage among rheumatologic at least 200 patients per clinic tested for MRSA. patients suggests that they are not more likely to reveal MRSA carrier status than other patient Enhanced digital features To view enhanced digital groups and that long-term immunosuppression features for this article go to https://doi.org/10.6084/ m9.figshare.6295037. does not necessarily represent a risk factor for MRSA colonization. Since only five out of nine J. Kra ¨mer  W. Kohnen  A. Schwarting (&) patients with carrier status would have been University Medical Center, Johannes Gutenberg detected following the recommendations of the University, Mainz, Germany KRINKO, further studies on potential risk fac- e-mail: schwarting@uni-mainz.de tors are warranted. K. Triantafyllias  A. Schwarting ACURA Rheumatology Center, Bad Kreuznach, Keywords: Bacterial infections; Methicillin- Germany resistant Staphylococcus aureus; Prevalence; M. Leber Rehabilitation centers; Risk factors St. Franziska-Stift, Bad Kreuznach, Germany U. Dederichs-Masius  A. Zucker Drei-Burgen-Clinic, Bad Munster, Germany J. Ko ¨ rber Nahetal-Clinic, Bad Kreuznach, Germany Rheumatol Ther compared the prevalence of MRSA in patients of INTRODUCTION four medical rehabilitation centers of the Rehabilitation competence center in Bad MRSA colonization is known to entail a high Kreuznach (Germany). Similar studies on MRSA risk for subsequent MRSA morbidity and mor- prevalence in rehabilitation centers have been tality, especially among critically and chroni- led in other regions in Germany by Heudorf cally ill carriers, as shown by Huang et al. [1]. et al. [5], Rollnik et al. [6], Gieffers et al. [7] and Thus, it is an important aim to reduce the per- Ko ¨ ck et al. [8]. However, in these studies, centage of MRSA carriers in medical establish- rheumatologic patients have only been investi- ments. Nevertheless, it would be very expensive gated as a subgroup. There is a high rate of and time consuming to perform MRSA screen- MRSA carrier status in immunosuppressed ing on every new hospitalized patient in every patients (up to 12%) [9]. Even if immune sup- medical establishment, as shown by Roth et al. pression in rheumatologic patients is not com- [2]. Criteria for an effective MRSA screening of parable to chemotherapy-induced patients with high risk for colonization are immunosuppression, rheumatologic patients therefore indispensable to detect economically, mostly receive immunosuppressive therapy for in terms of both time and money, the major a long time and have generally a higher risk of part of patients with MRSA carrier status. The infection. A potential infection with MRSA implementation of such a screening was proved could progress to a more severe form than in cost saving by Chowers et al. [3]. Based on immunocompetent patients. studies about risk factors for MRSA coloniza- Consequently, we investigated whether the tion, there are official recommendations for risk of MRSA colonization is elevated in such a screening from the German Commission rheumatologic patients. for Hospital Hygiene and Infection Prevention (KRINKO) [4]. According to available data, they consider patients with one of the following risk METHODS factors as patients with a high risk for MRSA carriage and consequently recommend screen- Study Period and Participating Hospitals ing patients presenting one of these risk factors: previous history of MRSA, the stay in a region From 4/2016 to 8/2016, 842 patients were tested with elevated prevalence of MRSA, dependence on MRSA by throat and nasal swabs during their on dialysis, hospital stay of more than 3 days first 24 h in the medical rehabilitation center. In within the previous 12 months, contact with each of the four rehabilitation centers, about MRSA in a work setting (e.g., contact with farm 200 patients were tested. More precisely, 207 animals), contact with patients with MRSA patients of a center for rheumatologic and carrier status during a hospital stay, chronic orthopedic rehabilitation (Karl-Aschoff-Klinik, skin lesions, and long-term care dependency. Bad Kreuznach), 224 psychosomatic patients However, long-term care dependency only rep- (St. Franziska-Stift, Bad Kreuznach), 209 onco- resents a risk factor if one of the following two logic patients (Nahetal-Klinik, Bad Kreuznach), factors occurs simultaneously: antibiotic treat- and 202 patients of a center for cardiologic and ment within 6 months or catheterization. We orthopedic rehabilitation (Drei-Burgen-Klinik, compared risk factors in patients with carrier Bad Kreuznach) were tested on MRSA. There- status with these recommendations in order to fore, during several weeks in each of these obtain the percentage of patients with carrier rehabilitation centers, every incoming patient status we would have detected by following the was asked to participate. Refusals to participate recommendations. in this internal quality control were rarely The main aim of this investigation was to reported (\ 0.1%). compare the prevalence of MRSA between rheumatologic and non-rheumatologic rehabil- itation centers. Therefore, we determined and Rheumatol Ther Compliance with Ethics Guidelines calculated using RStudio version 1.1.442 and a permutation test. The study was conducted within an internal quality control exploration following the state- Questionnaire ment of the local ethics committee (Rhineland- Palatinate). In addition to the above-described risk factors of the recommendations of the KRINKO, we col- Study Population lected and analyzed further risk factors for MRSA colonization using a questionnaire (any surgery? immunosuppressive therapy? living The mean age was 54.0 ± 11.3 years, standard with a pet and regular contact with people deviation (SD). More precisely, it was working in direct patient care?). Thus, our 53.6 ± 9.8 years (SD) for patients of the center questionnaire contained 15 questions: ten for rheumatologic and orthopedic rehabilita- about all risk factors included in the screening tion, 47.4 ± 10.2 years (SD) for psychosomatic recommendations of the KRINKO and five patients, 62.2 ± 11.4 years (SD) for oncologic additional questions about putative risk factors patients, and 53.3 ± 7.9 years (SD) for those of reported in the literature. Complete medication the center for cardiologic and orthopedic reha- lists were collected to unravel immunosuppres- bilitation. The mean age of patients with carrier sive therapy. Following informed consent, every status was 48.6 ± 10.6 years (SD). incoming patient was consecutively tested and Forty-nine percent of the patients were male interviewed. The questionnaires were delivered and 51% were female. Among the patients of to the patient at the beginning of their stay in the center for rheumatologic and orthopedic the rehabilitation center. If patients did not rehabilitation, 43% were male and 58% female. answer one or more questions, the study per- Among psychosomatic patients, 44% were male sonnel interviewed them personally about the and 56% were female, and among oncologic missing data to obtain complete questionnaires patients, 32% were male and 68% female; 81% from all participating patients. of the patients of the center for cardiologic and orthopedic rehabilitation were male and only 19% female. We detected five male and four Microbiological Analyses female patients among those with MRSA carrier status. Swabs were carried out using the Copan Liquid Amies Elution Swab Collection and Transport Statistical Methods System (eSwab, Art. No.: 490 CE.A; COPAN Flock Technologies srl. Via F. Perotti 16/18 in 25125 Brescia, Italy). Two swabs per patient All statistical evaluations were done using IBM were carried out by the staff of each medical SPSS Version 23.0. Gender distribution was rehabilitation center, one of the nasal vestibule determined using a cross table and the average of both nares and another one of the pharyn- age by performing an explorative data analysis geal site. Both were directly transferred into and by creation of histograms. The frequency of transport medium and, following the instruc- the presence of risk factors was determined tions of ESwab (Copan), stored in a fridge. If the using frequency tables. The percentages both of processing in the laboratory could not be per- all patients and of patients with MRSA carrier formed within 6 days, the swabs were frozen status, who should have been screened accord- and processed at a later point in time, always ing to the recommendations of the KRINKO, respecting the instructions of ESwab (Copan). were calculated using cross tables. The MRSA The samples were processed at the Department prevalence and the analysis of risk factors in for Hygiene and Infection Prevention of the patients with MRSA carrier status were also University Medical Center of the Johannes performed using cross tables. P values were Gutenberg University Mainz. During processing Rheumatol Ther of the samples, specimens were directly plated participating in the screening is shown in on blood agar (PB5039A, Oxoid) and MRSA Table 1, whereas Table 2 shows the number and TM detecting CHROM agar (CHROMagar MRSA, percentage of MRSA positive and negative 201402, Mast Diagnostica Laboratorium- patients within the different risk factor groups. spra ¨parate GmbH) and incubated for 24–48 h at Overall, 4.3% of the 842 patients revealed a 37 C. Since not every bacterial culture on the previous history of MRSA. In oncologic patients MRSA CHROM agar can be considered as MRSA and patients of the center for cardiologic and culture, all potentially MRSA-positive culture orthopedic rehabilitation, the percentage was isolates were further confirmed as Staphylococcus more than twice as high as in patients of the aureus by coagulase test (Pastorex Staph plus, two other rehabilitation centers, which corre- Bio-Rad Laboratories GmbH) and a method for lates with the higher percentage of MRSA in the TM TM biochemical identification (BBL Crystal two first named rehabilitation centers. Of the Gram-Positive ID Kit; BD). After confirmation, a patients, 6.7% had stayed abroad in a risk region cefoxitin disk diffusion test, whose accuracy was for more than 4 weeks within the past evaluated by Jain et al. [10] was performed. 12 months or were living in a risk region in Therefore, the culture isolates were plated on Germany. Countries and regions considered as Mu ¨ ller-Hinton agar (254032, BD) and a cefox- risk regions abroad were Portugal, Italy, Roma- itin disk (MAST-DISC cefoxitin, 30 lg, 113133, nia, Slovakia, Greece, Turkey, Cyprus, Malta, Mast Diagnostica Laboratoriumspra ¨parate Israel, North Africa, Japan, Russia, the USA, GmbH) was added in the middle of each smear. countries in Central, East, Southeast and After incubating for 24 h at 37 C, the inhibi- Southwest Asia, as well as war and crisis zones. tion zone around the cefoxitin disk was mea- Places considered as risk regions in Germany sured. If it was lower than 22 mm, the culture were establishments such as long-term care isolate was confirmed as MRSA due to its resis- facilities. Chronic skin lesions were rarely tance to the antibiotic cefoxitin according to reported (3.3%). Recently operated patients EUCAST guidelines. with wounds (hip, knee replacement) in the cardiologic and orthopedic rehabilitation center were tested on demand (in case of wound- RESULTS healing problems). All tests were negative for MRSA. Of the 842 patients, 50.8% had been MRSA Prevalence hospitalized for more than 3 days during the previous months, predominantly among both Of the 842 patients tested, nine patients (1.1%) oncologic patients and those of the center for were colonized with MRSA. The lowest preva- cardiologic and orthopedic rehabilitation. On lence of MRSA was found in patients of the the other hand, contact with MRSA in a work center for rheumatologic and orthopedic reha- setting, for example due to work with livestock bilitation (0.5% of n = 207). In patients of the or in direct patient care, was reported in 8.1% of center for psychosomatic rehabilitation, the the cases, but more often among psychosomatic prevalence was 0.9% (of n = 224) and in those patients and those of the center for rheumato- of the center for oncologic rehabilitation it was logic and orthopedic rehabilitation. Contact 1.4% (of n = 209). The highest prevalence of with people with carrier status and dependence MRSA was found in patients of the center for on renal dialysis were rarely reported for all cardiologic and orthopedic rehabilitation (1.5% investigated rehabilitation indications of n = 202). (B 1.5%). Long-term care dependency was often seen among oncologic patients, but was in general rare (1.8%). Twenty-three percent of the Risk Factor Analysis patients had received an antibiotic treatment within the previous 6 months and only 1.8% The relative presence of risk factors both in each was wearing a catheter, a port, or another rehabilitation center and for all patients medical tool injuring the skin barrier, in both Rheumatol Ther Table 1 Risk factors in patients of the different medical rehabilitation centers Risk factor Rheumatology/ Oncology, Psychosomatics, Cardiology/ Overall, orthopedy, n = 207 n = 209 n = 224 orthopedy, n = 842 n = 202 MRSA carrier status 0.5% 1.4% 0.9% 1.5% 1.1% Previous history of MRSA 2.9% 6.2% 2.2% 5.9% 4.3% Stay in risk region 5.3% 5.7% 8.9% 6.4% 6.7% Stay in hospital for [ 3 days 50.2% 72.2% 25.4% 57.4% 50.8% during the past months Contact to person with carrier 0.0% 1.0% 0.4% 0.5% 0.5% status Dependence on renal dialysis 0.0% 1.0% 0.4% 1.5% 0.7% Contact with MRSA at work 10.6% 5.3% 12.1% 4.0% 8.1% setting Chronical skin lesions 2.4% 2.4% 5.8% 2.5% 3.3% Chronical care dependency 0.5% 5.3% 0.0% 1.5% 1.8% Antibiotic treatment within 17.9% 36.8% 16.5% 21.3% 23.0% 6 months Catheter or other medical tools 1.9% 3.3% 0.0% 2.0% 1.8% injuring the skin barrier Screening recommended 57.0% 76.6% 41.5% 61.4% 58.8% Current immune suppression 26.6% 11.0% 0.9% 3.0% 10.2% Immune suppression within 28.0% 30.6% 2.7% 6.9% 16.9% 12 months Surgery within 12 months 37.2% 76.6% 15.2% 46.5% 43.3% Contact to persons working in 29.0% 45.0% 33.0% 29.7% 34.2% direct patient care Pet within 12 months 39.1% 28.2% 52.2% 44.6% 41.2% cases especially oncologic patients. A current the previous year (16.9%), we encountered immunosuppressive therapy was reported in especially rheumatologic (28%) and oncologic 10.2% of the cases, mainly among patients of patients (30.6%), since rheumatologic patients the center for rheumatologic and orthopedic often take immunosuppressive medication and rehabilitation (26.6%). Patients admitted to this most of the oncologic patients have received rehabilitation center exclusively had rheumatic chemotherapy within the months before their diseases and were under DMARD therapy (pre- rehabilitation. Of the patients, 43.3% had dominantly methotrexate and low-dose corti- undergone surgery within the previous year. costeroids). Among the patients who had Again, the percentage was the highest among received immunosuppressive therapy within oncologic patients and patients of the center for Rheumatol Ther Table 2 Number and percentage of MRSA-positive and -negative patients within the different risk factor groups Risk factor MRSA-positive MRSA-negative Overall, n = 842 Previous history of MRSA 0.0% (0/36) 25.0% (9/36) 4.3% (36/842) Stay in risk region 0.0% (0/56) 16.1% (9/56) 6.7% (56/842) Stay in hospital for [ 3 days during the past months 0.9% (4/428) 1.2% (5/428) 50.8% (428/842) Contact to person with carrier status 0.0% (0/4) 100.0% (4/4) 0.5% (4/842) Dependence on renal dialysis 0.0% (0/6) 100.0% (6/6) 0.7% (6/842) Contact with MRSA at work setting 1.5% (1/68) 11.8% (8/68) 8.1% (68/842) Chronical skin lesions 0.0% (0/28) 32.1% (9/28) 3.3% (28/842) Chronical care dependency 6.7% (1/15) 53.3% (8/15) 1.8% (15/842) Antibiotic treatment within 6 months 2.1% (4/194) 2.6% (5/194) 23.0% (194/842) Catheter or other medical tools injuring the skin barrier 0.0% (0/15) 60.0% (9/15) 1.8% (15/842) Screening recommended 1.0% (5/495) 0.8% (4/495) 58.8% (495/842) Current immune suppression 0.0% (0/86) 10.5% (9/86) 10.2% (86/842) Immune suppression within 12 months 2.1% (3/142) 4.2% (6/142) 16.9% (142/842) Surgery within 12 months 0.8% (3/366) 1.6% (6/366) 43.3% (366/842) Contact to persons working in direct patient care 1.7% (5/288) 1.4% (4/288) 34.2% (288/842) Pet within 12 months 1.4% (5/346) 1.2% (4/346) 41.2% (346/842) cardiologic and orthopedic rehabilitation. Fre- admitted to the non-rheumatologic rehabilita- quent contact with people working in direct tion centers did not suffer from rheumatic dis- patient care was reported in 34.2% of the cases. eases that required immunosuppressive Frequent contact caused by illness was taken treatment or DMARD therapy. into account as well as private contact with In total, a greater exposure to risk factors for people working in this sector (e.g., friends or MRSA colonization was encountered in patients family members). Furthermore, we investigated of the center for cardiologic and orthopedic the number of patients having a pet, since there rehabilitation and in patients with oncologic are reports suggesting that animals play a role in rehabilitation. However, based on the overall MRSA transmission, even if so far the impor- low number of positive MRSA carriers in our tance of animals as reservoir for MRSA is poorly cohort, further statistical analysis was not sig- understood, as shown by Bramble et al. [11] and nificant. This is illustrated in Table 3, which Weese [12]; 41.2% of the 842 patients have had shows p values for the statistical relationship a pet within the previous year or had one at the between risk factors and actual MRSA status. moment of the investigation, especially patients Furthermore, the p value for the association with psychosomatic rehabilitation indication between the MRSA prevalence in rheumatologic (52.2%). Contact with livestock was covered by patients and non-rheumatologic patients is the question about contact with MRSA in a p = 0.53. work setting, which is already listed as a risk factor in the recommendations of the KRINKO. In addition, we determined that patients Rheumatol Ther Table 3 p values for the statistical relationship between risk factors and actual MRSA status Risk factor MRSA positive p value (risk factor <2> MRSA status) Previous history of MRSA 0.0% (0/36) 1.00 Stay in risk region 0.0% (0/56) 0.66 Stay in hospital for [ 3 days during the past months 0.9% (4/428) 0.82 Contact to person with carrier status 0.0% (0/4) 1.00 Dependence on renal dialysis 0.0% (0/6) 0.94 Contact with MRSA at work setting 1.5% (1/68) 1.00 Chronical skin lesions 0.0% (0/28) 1.00 Chronical care dependency 6.7% (1/15) 0.15 Antibiotic treatment within 6 months 2.1% (4/194) 0.28 Catheter or other medical tools injuring the skin barrier 0.0% (0/15) 1.00 Screening recommended 1.0% (5/495) 1.00 Current immune suppression 0.0% (0/86) 0.63 Immune suppression within 12 months 2.1% (3/142) 0.41 Surgery within 12 months 0.8% (3/366) 0.65 Contact to persons working in direct patient care 1.7% (5/288) 0.39 Pet within 12 months 1.4% (5/346) 0.60 Comparison of the Results present any of the risk factors of the screening with the KRINKO Recommendations recommendations of the KRINKO. Most fre- quent risk factors in these patients were hospital stays for more than 3 days and an antibiotic According to the recommendations of the treatment, both in the previous months (both KRINKO, 58.8% of the patients should have 44.4%); 33.3% had undergone immunosup- been tested, with the highest percentage among pressive therapy or surgery, both within oncologic patients (76.6%), who were revealing 12 months. Also, 55.6% of the patients cur- the highest rate of risk factors. However, among rently had a pet or had had one within the the patients with MRSA carrier status, only five previous year and/or had frequent contact with out of nine (55.6%) would have been tested people working in direct patient care. Among according to the recommendations. Thus, four patients with carrier status, 55.6% were male out of nine (44.4%) colonized patients would and 44.4% female patients. not have been detected according to the rec- ommendations of the KRINKO. DISCUSSION Analysis of Risk Factors in Patients with Carrier Status The prevalence of MRSA among rheumatologic patients was found to be lower than among The absolute presence of risk factors in the nine non-rheumatologic patients, with an overall patients with MRSA colonization is shown in prevalence of MRSA of 1.1%. In addition, only Table 4. Three of these nine patients did not five out of nine colonized patients would have Rheumatol Ther Table 4 Risk factors in the nine MRSA-positive patients Risk factor R O1 O2 O3 P1 P2 C1 C2 C3 Previous history of MRSA – – – – – – – – – Stay in risk region – – – – – – – – – Stay in hospital for [ 3 days during the past months – 444 –– 4 –– Contact to person with carrier status – – – – – – – – – Dependence on renal dialysis – – – – – – – – – Contact with MRSA at work setting – – – – – 4 –– – Chronical skin lesions – – – – – – – – – Chronical care dependency – – 4 – ––– – – Antibiotic treatment within 6 months 4 444 4 4 –– – Catheter or other medical tools injuring the skin barrier – – – – – – – – – Screening recommended – 444 – 44 –– Current immune suppression – – – – – – – – – Immune suppression within 12 months – 444 ––– – – Surgery within 12 months 44 – 4 ––– – – Contact to persons working in direct patient care 44 –– 444 –– Pet within 12 months 44 –– – 44 4 – R rheumatologic patient, O1-3 oncologic patients, P1-2 psychosomatic patients, C1-3 cardiologic patients been tested according to the recommendations in comparison to patients of the center for of the KRINKO. rheumatologic and orthopedic rehabilitation The finding of a rather high percentage and those with psychosomatic rehabilitation among patients of the center for rheumatologic could be caused by several factors. Patients of and orthopedic rehabilitation, who had under- the two rehabilitation centers previously men- gone immunosuppressive therapy (26.6% under tioned were more often hospitalized, had current immune suppression and 28% within undergone surgery more often and/or had more the previous year), in comparison with the low often been under antimicrobial therapy in the percentage of MRSA colonization among the previous months. Furthermore, a higher num- same patients (0.5%), suggests that long-term ber of them is in long-term care dependency, is immunosuppression does not inevitably con- depending on renal dialysis, has a previous stitute a risk factor for MRSA colonization. This history of MRSA and/or is wearing a catheter, a is a reassuring result, since it is an important port, or similar. Consequently, a higher per- aim to avoid MRSA colonization in patients centage of these patients were exposed to with long-term immunosuppression because of known risk factors for MRSA colonization. This their higher risk of progression to a more severe may explain the higher prevalence of MRSA form in case of an MRSA infection. among these patients and may thus confirm the The higher prevalence among patients of the respective risk factors named in the recom- center for cardiologic and orthopedic rehabili- mendations of the KRINKO. tation and those with oncologic rehabilitation Rheumatol Ther The overall prevalence of MRSA of 1.1% in participating patients have had a pet (currently our study correlates with the prevalence for the or within 12 months), while the percentage was German general population (0.5–2%), estimated 55.6% among patients with carrier status. This by the German Commission for Hospital trend is applicable for neither current Hygiene and Infection Prevention [4] and the immunosuppressive therapy, nor surgery German Federal Institute for Risk Assessment within the previous year. The latter is in line [13]. Compared to similar studies mentioned with the fact that operations are considered as a above, this prevalence is quite similar to that risk factor for MRSA infection, but not for MRSA found by Ko ¨ ck et al. (1.2%) [8]. It is higher than colonization according to the Commission for the prevalence (0.7%) found by Heudorf et al. Hospital Hygiene and Infection Prevention [4]. [5], whereas it is lower than the one found by Nevertheless, the three first mentioned risk Gieffers et al. (2.1%) [7] and much lower than factors might have an impact on MRSA colo- the prevalence found in a study in neurologic nization, suggesting that further investigation is rehabilitation (11.4%) by Rollnik et al. [6]. required. If further investigation allowed to Again, our study shows that the MRSA carrier determine risk factors that accurately identify status in a rehabilitation center specialized for colonized patients, we would suggest including patients with rheumatic diseases is not them in the official screening recommendations increased compared to the prevalence of MRSA of the KRINKO. in the general population. To date, there are no clear recommendations Among the nine patients colonized with for rehabilitation clinics regarding the test of MRSA, only five should definitely have been the MRSA status in their patients. The present tested according to the recommendations of the study served as an internal quality control KRINKO. The remaining four patients would showing that currently there is no increased not have been detected, since they did not ful- risk. However, this study has potential limita- fill the criteria. Therefore, the question arises of tions. In the first place, the number of 842 whether these recommendations should be screened patients might not be sufficient expanded, particularly with the three patients enough to unravel a statistically significant not presenting any of these risk factors at all. difference between the groups. The p value for On the other hand, the collected data are not the association between the MRSA prevalence sufficient to make a clear statement and would in rheumatologic and non-rheumatologic demand further investigation to verify this patients is p = 0.53. This demonstrates that hypothesis. In any case, it is questionable whe- there is no statistically significant difference ther there are more risk factors that should between the MRSA prevalence among rheuma- constantly be taken into account for the choice tologic patients and the MRSA prevalence of patients to be screened by default when among non-rheumatologic patients. Due to our hospitalized. found prevalence of 0.5% among rheumato- We therefore additionally explored some logic patients, we would have had to screen a more potential risk factors, which are currently total number of almost 4800 instead of 842 not included in the recommendations of the patients to yield a p value of \ 0.05 for this KRINKO. From the above described data, we can association. see that overall 16.9% of the patients had In the second place, refusals to participate undergone immunosuppressive treatment were rare, but they occurred. Furthermore, some within the previous year, while among the of the patients did not speak German very well, patients with carrier status we encounter 33.3% so that they had difficulties in answering the instead. Overall, 34.2% of the patients had questions. Based on conversations with these regular contact with people working in direct same patients, we guess that there might be a patient care, either privately, within their small number of patients who were not sure everyday lives, or in a healthcare environment, about the answers they gave, even if we tried to whereas this was the case for 55.6% of the col- formulate them as simply as possible. However, onized patients. In addition, only 41.2% of all this small number of patients might have Rheumatol Ther influenced the questionnaire but not the results impact of these and other potential factors on of the MRSA carrier status. In addition, the nine MRSA carriage. patients identified as MRSA carriers were native speakers and therefore, did not have any prob- lems with the language. ACKNOWLEDGEMENTS Besides, only swabs from the nasal vestibule and from the pharyngeal site were taken, but First, we would like to thank the participating not from chronic wounds or other body areas rehabilitation centers (Karl-Aschoff-Klinik in (e.g., the inguinal region). This was done on Bad Kreuznach, Klinik Nahetal in Bad Kreuz- purpose, since MRSA is mainly found in the nach, St. Franziska-Stift in Bad Kreuznach and nasal vestibule and colonizes on this basis Drei-Burgen-Klinik in Bad Kreuznach), their especially the pharyngeal site, as shown by the personnel, as well as their residents for their Commission for Hospital Hygiene and Infection great help and support to conduct the study. Prevention [4]. It could have been interesting to Furthermore, our thanks extend to the person- screen these two other sites as well, though it nel of the Department for Hygiene and Infec- might have reduced the number of patients tion Prevention at the University Medical willing to participate. Furthermore, we could Center of the Johannes Gutenberg University have tried to cover more potential risk factors in Mainz, especially to the medical technical the questionnaire. However, we tried to keep assistants Miss Kraft and Miss Ku ¨ nstler for their the questionnaire manageable for both the assistance with the microbiological analyses. patients and the clinical personnel. Funding. The study was supported by a fel- lowship (Rehabilitation research fellowship) of CONCLUSIONS the Wirtschaftsfo ¨ rderung of the administrative district of Bad Kreuznach to JK. No funding or In conclusion, the low MRSA prevalence in sponsorship was received for publication of this patients of the center for rheumatologic and article. orthopedic rehabilitation (0.5%) despite the frequent long-term immunosuppression in this Authorship. All named authors meet the patient group suggests that rheumatologic International Committee of Medical Journal patients are not more likely to reveal MRSA Editors (ICMJE) criteria for authorship for this carrier status than other patient groups and that article, take responsibility for the integrity of long-term immunosuppression does not neces- the work as a whole, and have given their sarily represent a risk factor for MRSA colo- approval for this version to be published. nization. The higher prevalence in patients of the center for cardiologic and orthopedic reha- Disclosures. Judith Kra ¨mer, Konstantinos bilitation and in patients with oncologic reha- Triantafyllias, Wolfgang Kohnen, Martin Leber, bilitation may be explained by greater exposure Ute Dederichs-Masius, Andrea Zucker, Ju ¨ rgen to several risk factors for MRSA colonization Ko ¨ rber, and Andreas Schwarting having noth- compared to the patients of the two other ing to disclose. rehabilitation centers. The overall prevalence of MRSA (1.1%) correlates with what we suspected Compliance with Ethics Guidelines. The from previous studies. study was conducted within an internal quality Since only five out of nine patients with control exploration following the statement of the carrier status would have been detected by fol- local ethics committee (Rhineland-Palatinate). lowing the recommendations of the KRINKO and since we detected a higher percentage of Data Availability. The datasets during and/ other potential risk factors in colonized patients or analyzed during the current study are avail- compared to the entirety of the patients, we able from the corresponding author on reason- suggest a further investigation of the exact able request. Rheumatol Ther (MDRO) in rehabilitation clinics in the Rhine-Main- Open Access. This article is distributed District. Germany. Rehabilitation. under the terms of the Creative Commons 2015;54(5):339–45. https://doi.org/10.1055/s-0035- Attribution-NonCommercial 4.0 International 1559642 (epub 2015 Oct 27. German). License (http://creativecommons.org/licenses/ 6. Rollnik JD, Samady AM, Gru ¨ ter L. Multidrug-resis- by-nc/4.0/), which permits any noncommer- tant germs in neurological early rehabilitation. cial use, distribution, and reproduction in any Rehabilitation. 2014;53(5):346–50. https://doi.org/ medium, provided you give appropriate credit 10.1055/s-0034-1375640 (epub 2014 Oct 15. to the original author(s) and the source, provide German). a link to the Creative Commons license, and 7. Gieffers Jens, Ahuja Andre ´, Giemulla Ronald. Long indicate if changes were made. term observation of MRSA prevalence in a German rehabilitation center: risk factors and variability of colonization rate. GMS Hyg Infect Control. 2016. https://doi.org/10.3205/dgkh000281 (11:Doc21. Published online). REFERENCES 8. Ko ¨ ck R, Winner K, Schaumburg F, Jurke A, Rossen 1. Huang SS, Hinrichsen VL, Datta R, Spurchise L, JW, Friedrich AW. Admission prevalence and Miroshnik I, Nelson K, et al. Methicillin-resistant acquisition of nasal carriage of methicillin-resistant Staphylococcus aureus infection and hospitalization Staphylococcus aureus (MRSA) in German rehabilita- in high-risk patients in the year following detec- tion centres. J Hospital Infect. 2014;87(2):115–8. tion. PLoS ONE. 2011;6(9):e24340. https://doi.org/ https://doi.org/10.1016/j.jhin. 10.1371/journal.pone.0024340. 9. Varley CD, et al. Persistence of Staphylococcus aureus 2. Roth VR, Longpre T, Coyle D, Suh KN, Taljaard M, colonization among individuals with immune-me- Muldoon KA, et al. Cost analysis of universal diated inflammatory diseases treated with TNF-a screening vs. risk factor-based screening for methi- inhibitor therapy. Rheumatology. cillin-resistant Staphylococcus aureus (MRSA). PLoS 2014;53(2):332–7. ONE. 2016;11(7):e159667. 10. Jain A, Agarwal A, Verma RK. Cefoxitin disc diffu- 3. Chowers M, Carmeli Y, Shitrit P, Elhayany A, Gef- sion test for detection of methicillin-resistant fen K. Cost analysis of an intervention to prevent staphylococci. J Med Microbiol. 2008;57(Pt methicillin-resistant Staphylococcus aureus (MRSA) 8):957–61. transmission. PLoS One. 2015;10(9):e0138999. https://doi.org/10.1371/journal.pone.0138999 11. Bramble M, Morris D, Tolomeo P, Lautenbach E. (eCollection 2015). Potential role of pet animals in household trans- mission of methicillin-resistant Staphylococcus aur- 4. Empfehlungen zur Pra ¨vention und Kontrolle von eus: a narrative review. Vector Borne Zoonotic Dis. Methicillin-resistenten Staphylococcus aureus-Sta ¨m- 2011;11(6):617–20 Epub 2010 Dec 13. men (MRSA) in medizinischen und pflegerischen Einrichtungen; Empfehlung der Kommission fu ¨ r 12. Weese JS. Methicillin-resistant Staphylococcus aureus Krankenhaushygiene und Infektionspra ¨vention in animals. ILAR J. 2010;51(3):233–44. (KRINKO) beim Robert Koch-Institut. [Recommen- dations for the prevention and control of methi- 13. Fragen und Antworten zu Methicillin-resistentem cillin-resistant Staphylococcus aureus strains (MRSA) Staphylococcus aureus (MRSA) vom Bundesinstitut in medical and nursing facilities; recommendations fu ¨ r Risikobewertung. [Questions and answers about of the Commission for Hospital Hygiene and methicillin-resistant Staphylococcus aureus (MRSA) Infection Prevention (KRINKO) of the Robert-Koch- by the Federal Institute for Risk Assessment.] [In- Institute.] Bundesgesundheitsblatt—Gesundheits- ternet] 2014 Nov 18. Available from: http://www. forschung—Gesundheitsschutz. 2014; 57:696–732. bfr.bund.de/de/fragen_und_antworten_zu_ doi:10.1007/s00103-014-1980-x (in German). methicillin_resistenten_staphylococcus_aureus__ mrsa_-11172.html (in German). 5. Heudorf U, Farber D, Mischler D, Schade M, Zinn C, Cuny C, et al. Multidrug-resistant organisms http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Rheumatology and Therapy Springer Journals

Patients with Rheumatic Diseases do not have an Increased Risk of MRSA Carrier Status

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Medicine & Public Health; Rheumatology; Orthopedics; General Practice / Family Medicine; Internal Medicine; Quality of Life Research
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Rheumatol Ther https://doi.org/10.1007/s40744-018-0116-4 ORIGINAL RESEARCH Patients with Rheumatic Diseases do not have an Increased Risk of MRSA Carrier Status . . . Judith Kra ¨mer Konstantinos Triantafyllias Wolfgang Kohnen . . . Martin Leber Ute Dederichs-Masius Andrea Zucker Ju ¨ rgen Ko ¨ rber Andreas Schwarting Received: May 21, 2018 The Author(s) 2018 Results: Nine (1.1%) of the 842 patients were ABSTRACT colonized with MRSA. Only five of them should have been tested according to the commission’s Introduction: The aim of this study was to recommendations. The prevalence was 0.5% determine the prevalence of methicillin-resis- (n = 207) in rheumatologic, 0.9% (n = 224) in tant Staphylococcus aureus (MRSA) both in psychosomatic, 1.4% (n = 209) in oncologic rheumatologic and non-rheumatologic rehabil- and 1.5% (n = 202) in cardiologic patients. We itation centers. In addition, we sought to eval- found a greater exposure to risk factors in car- uate the practice value of existing screening diologic and oncologic patients. Among recommendations of the German Commission patients with carrier status, a higher percentage for Hospital Hygiene and Infection Prevention was exposed to three potential risk factors not (KRINKO). applied by the commission. Methods: The analysis was performed in four Conclusions: The prevalence of MRSA in our rehabilitation clinics (rheumatology, psychoso- cohort correlates with data from previous stud- matic medicine, oncology, and cardiology) with ies. The low percentage among rheumatologic at least 200 patients per clinic tested for MRSA. patients suggests that they are not more likely to reveal MRSA carrier status than other patient Enhanced digital features To view enhanced digital groups and that long-term immunosuppression features for this article go to https://doi.org/10.6084/ m9.figshare.6295037. does not necessarily represent a risk factor for MRSA colonization. Since only five out of nine J. Kra ¨mer  W. Kohnen  A. Schwarting (&) patients with carrier status would have been University Medical Center, Johannes Gutenberg detected following the recommendations of the University, Mainz, Germany KRINKO, further studies on potential risk fac- e-mail: schwarting@uni-mainz.de tors are warranted. K. Triantafyllias  A. Schwarting ACURA Rheumatology Center, Bad Kreuznach, Keywords: Bacterial infections; Methicillin- Germany resistant Staphylococcus aureus; Prevalence; M. Leber Rehabilitation centers; Risk factors St. Franziska-Stift, Bad Kreuznach, Germany U. Dederichs-Masius  A. Zucker Drei-Burgen-Clinic, Bad Munster, Germany J. Ko ¨ rber Nahetal-Clinic, Bad Kreuznach, Germany Rheumatol Ther compared the prevalence of MRSA in patients of INTRODUCTION four medical rehabilitation centers of the Rehabilitation competence center in Bad MRSA colonization is known to entail a high Kreuznach (Germany). Similar studies on MRSA risk for subsequent MRSA morbidity and mor- prevalence in rehabilitation centers have been tality, especially among critically and chroni- led in other regions in Germany by Heudorf cally ill carriers, as shown by Huang et al. [1]. et al. [5], Rollnik et al. [6], Gieffers et al. [7] and Thus, it is an important aim to reduce the per- Ko ¨ ck et al. [8]. However, in these studies, centage of MRSA carriers in medical establish- rheumatologic patients have only been investi- ments. Nevertheless, it would be very expensive gated as a subgroup. There is a high rate of and time consuming to perform MRSA screen- MRSA carrier status in immunosuppressed ing on every new hospitalized patient in every patients (up to 12%) [9]. Even if immune sup- medical establishment, as shown by Roth et al. pression in rheumatologic patients is not com- [2]. Criteria for an effective MRSA screening of parable to chemotherapy-induced patients with high risk for colonization are immunosuppression, rheumatologic patients therefore indispensable to detect economically, mostly receive immunosuppressive therapy for in terms of both time and money, the major a long time and have generally a higher risk of part of patients with MRSA carrier status. The infection. A potential infection with MRSA implementation of such a screening was proved could progress to a more severe form than in cost saving by Chowers et al. [3]. Based on immunocompetent patients. studies about risk factors for MRSA coloniza- Consequently, we investigated whether the tion, there are official recommendations for risk of MRSA colonization is elevated in such a screening from the German Commission rheumatologic patients. for Hospital Hygiene and Infection Prevention (KRINKO) [4]. According to available data, they consider patients with one of the following risk METHODS factors as patients with a high risk for MRSA carriage and consequently recommend screen- Study Period and Participating Hospitals ing patients presenting one of these risk factors: previous history of MRSA, the stay in a region From 4/2016 to 8/2016, 842 patients were tested with elevated prevalence of MRSA, dependence on MRSA by throat and nasal swabs during their on dialysis, hospital stay of more than 3 days first 24 h in the medical rehabilitation center. In within the previous 12 months, contact with each of the four rehabilitation centers, about MRSA in a work setting (e.g., contact with farm 200 patients were tested. More precisely, 207 animals), contact with patients with MRSA patients of a center for rheumatologic and carrier status during a hospital stay, chronic orthopedic rehabilitation (Karl-Aschoff-Klinik, skin lesions, and long-term care dependency. Bad Kreuznach), 224 psychosomatic patients However, long-term care dependency only rep- (St. Franziska-Stift, Bad Kreuznach), 209 onco- resents a risk factor if one of the following two logic patients (Nahetal-Klinik, Bad Kreuznach), factors occurs simultaneously: antibiotic treat- and 202 patients of a center for cardiologic and ment within 6 months or catheterization. We orthopedic rehabilitation (Drei-Burgen-Klinik, compared risk factors in patients with carrier Bad Kreuznach) were tested on MRSA. There- status with these recommendations in order to fore, during several weeks in each of these obtain the percentage of patients with carrier rehabilitation centers, every incoming patient status we would have detected by following the was asked to participate. Refusals to participate recommendations. in this internal quality control were rarely The main aim of this investigation was to reported (\ 0.1%). compare the prevalence of MRSA between rheumatologic and non-rheumatologic rehabil- itation centers. Therefore, we determined and Rheumatol Ther Compliance with Ethics Guidelines calculated using RStudio version 1.1.442 and a permutation test. The study was conducted within an internal quality control exploration following the state- Questionnaire ment of the local ethics committee (Rhineland- Palatinate). In addition to the above-described risk factors of the recommendations of the KRINKO, we col- Study Population lected and analyzed further risk factors for MRSA colonization using a questionnaire (any surgery? immunosuppressive therapy? living The mean age was 54.0 ± 11.3 years, standard with a pet and regular contact with people deviation (SD). More precisely, it was working in direct patient care?). Thus, our 53.6 ± 9.8 years (SD) for patients of the center questionnaire contained 15 questions: ten for rheumatologic and orthopedic rehabilita- about all risk factors included in the screening tion, 47.4 ± 10.2 years (SD) for psychosomatic recommendations of the KRINKO and five patients, 62.2 ± 11.4 years (SD) for oncologic additional questions about putative risk factors patients, and 53.3 ± 7.9 years (SD) for those of reported in the literature. Complete medication the center for cardiologic and orthopedic reha- lists were collected to unravel immunosuppres- bilitation. The mean age of patients with carrier sive therapy. Following informed consent, every status was 48.6 ± 10.6 years (SD). incoming patient was consecutively tested and Forty-nine percent of the patients were male interviewed. The questionnaires were delivered and 51% were female. Among the patients of to the patient at the beginning of their stay in the center for rheumatologic and orthopedic the rehabilitation center. If patients did not rehabilitation, 43% were male and 58% female. answer one or more questions, the study per- Among psychosomatic patients, 44% were male sonnel interviewed them personally about the and 56% were female, and among oncologic missing data to obtain complete questionnaires patients, 32% were male and 68% female; 81% from all participating patients. of the patients of the center for cardiologic and orthopedic rehabilitation were male and only 19% female. We detected five male and four Microbiological Analyses female patients among those with MRSA carrier status. Swabs were carried out using the Copan Liquid Amies Elution Swab Collection and Transport Statistical Methods System (eSwab, Art. No.: 490 CE.A; COPAN Flock Technologies srl. Via F. Perotti 16/18 in 25125 Brescia, Italy). Two swabs per patient All statistical evaluations were done using IBM were carried out by the staff of each medical SPSS Version 23.0. Gender distribution was rehabilitation center, one of the nasal vestibule determined using a cross table and the average of both nares and another one of the pharyn- age by performing an explorative data analysis geal site. Both were directly transferred into and by creation of histograms. The frequency of transport medium and, following the instruc- the presence of risk factors was determined tions of ESwab (Copan), stored in a fridge. If the using frequency tables. The percentages both of processing in the laboratory could not be per- all patients and of patients with MRSA carrier formed within 6 days, the swabs were frozen status, who should have been screened accord- and processed at a later point in time, always ing to the recommendations of the KRINKO, respecting the instructions of ESwab (Copan). were calculated using cross tables. The MRSA The samples were processed at the Department prevalence and the analysis of risk factors in for Hygiene and Infection Prevention of the patients with MRSA carrier status were also University Medical Center of the Johannes performed using cross tables. P values were Gutenberg University Mainz. During processing Rheumatol Ther of the samples, specimens were directly plated participating in the screening is shown in on blood agar (PB5039A, Oxoid) and MRSA Table 1, whereas Table 2 shows the number and TM detecting CHROM agar (CHROMagar MRSA, percentage of MRSA positive and negative 201402, Mast Diagnostica Laboratorium- patients within the different risk factor groups. spra ¨parate GmbH) and incubated for 24–48 h at Overall, 4.3% of the 842 patients revealed a 37 C. Since not every bacterial culture on the previous history of MRSA. In oncologic patients MRSA CHROM agar can be considered as MRSA and patients of the center for cardiologic and culture, all potentially MRSA-positive culture orthopedic rehabilitation, the percentage was isolates were further confirmed as Staphylococcus more than twice as high as in patients of the aureus by coagulase test (Pastorex Staph plus, two other rehabilitation centers, which corre- Bio-Rad Laboratories GmbH) and a method for lates with the higher percentage of MRSA in the TM TM biochemical identification (BBL Crystal two first named rehabilitation centers. Of the Gram-Positive ID Kit; BD). After confirmation, a patients, 6.7% had stayed abroad in a risk region cefoxitin disk diffusion test, whose accuracy was for more than 4 weeks within the past evaluated by Jain et al. [10] was performed. 12 months or were living in a risk region in Therefore, the culture isolates were plated on Germany. Countries and regions considered as Mu ¨ ller-Hinton agar (254032, BD) and a cefox- risk regions abroad were Portugal, Italy, Roma- itin disk (MAST-DISC cefoxitin, 30 lg, 113133, nia, Slovakia, Greece, Turkey, Cyprus, Malta, Mast Diagnostica Laboratoriumspra ¨parate Israel, North Africa, Japan, Russia, the USA, GmbH) was added in the middle of each smear. countries in Central, East, Southeast and After incubating for 24 h at 37 C, the inhibi- Southwest Asia, as well as war and crisis zones. tion zone around the cefoxitin disk was mea- Places considered as risk regions in Germany sured. If it was lower than 22 mm, the culture were establishments such as long-term care isolate was confirmed as MRSA due to its resis- facilities. Chronic skin lesions were rarely tance to the antibiotic cefoxitin according to reported (3.3%). Recently operated patients EUCAST guidelines. with wounds (hip, knee replacement) in the cardiologic and orthopedic rehabilitation center were tested on demand (in case of wound- RESULTS healing problems). All tests were negative for MRSA. Of the 842 patients, 50.8% had been MRSA Prevalence hospitalized for more than 3 days during the previous months, predominantly among both Of the 842 patients tested, nine patients (1.1%) oncologic patients and those of the center for were colonized with MRSA. The lowest preva- cardiologic and orthopedic rehabilitation. On lence of MRSA was found in patients of the the other hand, contact with MRSA in a work center for rheumatologic and orthopedic reha- setting, for example due to work with livestock bilitation (0.5% of n = 207). In patients of the or in direct patient care, was reported in 8.1% of center for psychosomatic rehabilitation, the the cases, but more often among psychosomatic prevalence was 0.9% (of n = 224) and in those patients and those of the center for rheumato- of the center for oncologic rehabilitation it was logic and orthopedic rehabilitation. Contact 1.4% (of n = 209). The highest prevalence of with people with carrier status and dependence MRSA was found in patients of the center for on renal dialysis were rarely reported for all cardiologic and orthopedic rehabilitation (1.5% investigated rehabilitation indications of n = 202). (B 1.5%). Long-term care dependency was often seen among oncologic patients, but was in general rare (1.8%). Twenty-three percent of the Risk Factor Analysis patients had received an antibiotic treatment within the previous 6 months and only 1.8% The relative presence of risk factors both in each was wearing a catheter, a port, or another rehabilitation center and for all patients medical tool injuring the skin barrier, in both Rheumatol Ther Table 1 Risk factors in patients of the different medical rehabilitation centers Risk factor Rheumatology/ Oncology, Psychosomatics, Cardiology/ Overall, orthopedy, n = 207 n = 209 n = 224 orthopedy, n = 842 n = 202 MRSA carrier status 0.5% 1.4% 0.9% 1.5% 1.1% Previous history of MRSA 2.9% 6.2% 2.2% 5.9% 4.3% Stay in risk region 5.3% 5.7% 8.9% 6.4% 6.7% Stay in hospital for [ 3 days 50.2% 72.2% 25.4% 57.4% 50.8% during the past months Contact to person with carrier 0.0% 1.0% 0.4% 0.5% 0.5% status Dependence on renal dialysis 0.0% 1.0% 0.4% 1.5% 0.7% Contact with MRSA at work 10.6% 5.3% 12.1% 4.0% 8.1% setting Chronical skin lesions 2.4% 2.4% 5.8% 2.5% 3.3% Chronical care dependency 0.5% 5.3% 0.0% 1.5% 1.8% Antibiotic treatment within 17.9% 36.8% 16.5% 21.3% 23.0% 6 months Catheter or other medical tools 1.9% 3.3% 0.0% 2.0% 1.8% injuring the skin barrier Screening recommended 57.0% 76.6% 41.5% 61.4% 58.8% Current immune suppression 26.6% 11.0% 0.9% 3.0% 10.2% Immune suppression within 28.0% 30.6% 2.7% 6.9% 16.9% 12 months Surgery within 12 months 37.2% 76.6% 15.2% 46.5% 43.3% Contact to persons working in 29.0% 45.0% 33.0% 29.7% 34.2% direct patient care Pet within 12 months 39.1% 28.2% 52.2% 44.6% 41.2% cases especially oncologic patients. A current the previous year (16.9%), we encountered immunosuppressive therapy was reported in especially rheumatologic (28%) and oncologic 10.2% of the cases, mainly among patients of patients (30.6%), since rheumatologic patients the center for rheumatologic and orthopedic often take immunosuppressive medication and rehabilitation (26.6%). Patients admitted to this most of the oncologic patients have received rehabilitation center exclusively had rheumatic chemotherapy within the months before their diseases and were under DMARD therapy (pre- rehabilitation. Of the patients, 43.3% had dominantly methotrexate and low-dose corti- undergone surgery within the previous year. costeroids). Among the patients who had Again, the percentage was the highest among received immunosuppressive therapy within oncologic patients and patients of the center for Rheumatol Ther Table 2 Number and percentage of MRSA-positive and -negative patients within the different risk factor groups Risk factor MRSA-positive MRSA-negative Overall, n = 842 Previous history of MRSA 0.0% (0/36) 25.0% (9/36) 4.3% (36/842) Stay in risk region 0.0% (0/56) 16.1% (9/56) 6.7% (56/842) Stay in hospital for [ 3 days during the past months 0.9% (4/428) 1.2% (5/428) 50.8% (428/842) Contact to person with carrier status 0.0% (0/4) 100.0% (4/4) 0.5% (4/842) Dependence on renal dialysis 0.0% (0/6) 100.0% (6/6) 0.7% (6/842) Contact with MRSA at work setting 1.5% (1/68) 11.8% (8/68) 8.1% (68/842) Chronical skin lesions 0.0% (0/28) 32.1% (9/28) 3.3% (28/842) Chronical care dependency 6.7% (1/15) 53.3% (8/15) 1.8% (15/842) Antibiotic treatment within 6 months 2.1% (4/194) 2.6% (5/194) 23.0% (194/842) Catheter or other medical tools injuring the skin barrier 0.0% (0/15) 60.0% (9/15) 1.8% (15/842) Screening recommended 1.0% (5/495) 0.8% (4/495) 58.8% (495/842) Current immune suppression 0.0% (0/86) 10.5% (9/86) 10.2% (86/842) Immune suppression within 12 months 2.1% (3/142) 4.2% (6/142) 16.9% (142/842) Surgery within 12 months 0.8% (3/366) 1.6% (6/366) 43.3% (366/842) Contact to persons working in direct patient care 1.7% (5/288) 1.4% (4/288) 34.2% (288/842) Pet within 12 months 1.4% (5/346) 1.2% (4/346) 41.2% (346/842) cardiologic and orthopedic rehabilitation. Fre- admitted to the non-rheumatologic rehabilita- quent contact with people working in direct tion centers did not suffer from rheumatic dis- patient care was reported in 34.2% of the cases. eases that required immunosuppressive Frequent contact caused by illness was taken treatment or DMARD therapy. into account as well as private contact with In total, a greater exposure to risk factors for people working in this sector (e.g., friends or MRSA colonization was encountered in patients family members). Furthermore, we investigated of the center for cardiologic and orthopedic the number of patients having a pet, since there rehabilitation and in patients with oncologic are reports suggesting that animals play a role in rehabilitation. However, based on the overall MRSA transmission, even if so far the impor- low number of positive MRSA carriers in our tance of animals as reservoir for MRSA is poorly cohort, further statistical analysis was not sig- understood, as shown by Bramble et al. [11] and nificant. This is illustrated in Table 3, which Weese [12]; 41.2% of the 842 patients have had shows p values for the statistical relationship a pet within the previous year or had one at the between risk factors and actual MRSA status. moment of the investigation, especially patients Furthermore, the p value for the association with psychosomatic rehabilitation indication between the MRSA prevalence in rheumatologic (52.2%). Contact with livestock was covered by patients and non-rheumatologic patients is the question about contact with MRSA in a p = 0.53. work setting, which is already listed as a risk factor in the recommendations of the KRINKO. In addition, we determined that patients Rheumatol Ther Table 3 p values for the statistical relationship between risk factors and actual MRSA status Risk factor MRSA positive p value (risk factor <2> MRSA status) Previous history of MRSA 0.0% (0/36) 1.00 Stay in risk region 0.0% (0/56) 0.66 Stay in hospital for [ 3 days during the past months 0.9% (4/428) 0.82 Contact to person with carrier status 0.0% (0/4) 1.00 Dependence on renal dialysis 0.0% (0/6) 0.94 Contact with MRSA at work setting 1.5% (1/68) 1.00 Chronical skin lesions 0.0% (0/28) 1.00 Chronical care dependency 6.7% (1/15) 0.15 Antibiotic treatment within 6 months 2.1% (4/194) 0.28 Catheter or other medical tools injuring the skin barrier 0.0% (0/15) 1.00 Screening recommended 1.0% (5/495) 1.00 Current immune suppression 0.0% (0/86) 0.63 Immune suppression within 12 months 2.1% (3/142) 0.41 Surgery within 12 months 0.8% (3/366) 0.65 Contact to persons working in direct patient care 1.7% (5/288) 0.39 Pet within 12 months 1.4% (5/346) 0.60 Comparison of the Results present any of the risk factors of the screening with the KRINKO Recommendations recommendations of the KRINKO. Most fre- quent risk factors in these patients were hospital stays for more than 3 days and an antibiotic According to the recommendations of the treatment, both in the previous months (both KRINKO, 58.8% of the patients should have 44.4%); 33.3% had undergone immunosup- been tested, with the highest percentage among pressive therapy or surgery, both within oncologic patients (76.6%), who were revealing 12 months. Also, 55.6% of the patients cur- the highest rate of risk factors. However, among rently had a pet or had had one within the the patients with MRSA carrier status, only five previous year and/or had frequent contact with out of nine (55.6%) would have been tested people working in direct patient care. Among according to the recommendations. Thus, four patients with carrier status, 55.6% were male out of nine (44.4%) colonized patients would and 44.4% female patients. not have been detected according to the rec- ommendations of the KRINKO. DISCUSSION Analysis of Risk Factors in Patients with Carrier Status The prevalence of MRSA among rheumatologic patients was found to be lower than among The absolute presence of risk factors in the nine non-rheumatologic patients, with an overall patients with MRSA colonization is shown in prevalence of MRSA of 1.1%. In addition, only Table 4. Three of these nine patients did not five out of nine colonized patients would have Rheumatol Ther Table 4 Risk factors in the nine MRSA-positive patients Risk factor R O1 O2 O3 P1 P2 C1 C2 C3 Previous history of MRSA – – – – – – – – – Stay in risk region – – – – – – – – – Stay in hospital for [ 3 days during the past months – 444 –– 4 –– Contact to person with carrier status – – – – – – – – – Dependence on renal dialysis – – – – – – – – – Contact with MRSA at work setting – – – – – 4 –– – Chronical skin lesions – – – – – – – – – Chronical care dependency – – 4 – ––– – – Antibiotic treatment within 6 months 4 444 4 4 –– – Catheter or other medical tools injuring the skin barrier – – – – – – – – – Screening recommended – 444 – 44 –– Current immune suppression – – – – – – – – – Immune suppression within 12 months – 444 ––– – – Surgery within 12 months 44 – 4 ––– – – Contact to persons working in direct patient care 44 –– 444 –– Pet within 12 months 44 –– – 44 4 – R rheumatologic patient, O1-3 oncologic patients, P1-2 psychosomatic patients, C1-3 cardiologic patients been tested according to the recommendations in comparison to patients of the center for of the KRINKO. rheumatologic and orthopedic rehabilitation The finding of a rather high percentage and those with psychosomatic rehabilitation among patients of the center for rheumatologic could be caused by several factors. Patients of and orthopedic rehabilitation, who had under- the two rehabilitation centers previously men- gone immunosuppressive therapy (26.6% under tioned were more often hospitalized, had current immune suppression and 28% within undergone surgery more often and/or had more the previous year), in comparison with the low often been under antimicrobial therapy in the percentage of MRSA colonization among the previous months. Furthermore, a higher num- same patients (0.5%), suggests that long-term ber of them is in long-term care dependency, is immunosuppression does not inevitably con- depending on renal dialysis, has a previous stitute a risk factor for MRSA colonization. This history of MRSA and/or is wearing a catheter, a is a reassuring result, since it is an important port, or similar. Consequently, a higher per- aim to avoid MRSA colonization in patients centage of these patients were exposed to with long-term immunosuppression because of known risk factors for MRSA colonization. This their higher risk of progression to a more severe may explain the higher prevalence of MRSA form in case of an MRSA infection. among these patients and may thus confirm the The higher prevalence among patients of the respective risk factors named in the recom- center for cardiologic and orthopedic rehabili- mendations of the KRINKO. tation and those with oncologic rehabilitation Rheumatol Ther The overall prevalence of MRSA of 1.1% in participating patients have had a pet (currently our study correlates with the prevalence for the or within 12 months), while the percentage was German general population (0.5–2%), estimated 55.6% among patients with carrier status. This by the German Commission for Hospital trend is applicable for neither current Hygiene and Infection Prevention [4] and the immunosuppressive therapy, nor surgery German Federal Institute for Risk Assessment within the previous year. The latter is in line [13]. Compared to similar studies mentioned with the fact that operations are considered as a above, this prevalence is quite similar to that risk factor for MRSA infection, but not for MRSA found by Ko ¨ ck et al. (1.2%) [8]. It is higher than colonization according to the Commission for the prevalence (0.7%) found by Heudorf et al. Hospital Hygiene and Infection Prevention [4]. [5], whereas it is lower than the one found by Nevertheless, the three first mentioned risk Gieffers et al. (2.1%) [7] and much lower than factors might have an impact on MRSA colo- the prevalence found in a study in neurologic nization, suggesting that further investigation is rehabilitation (11.4%) by Rollnik et al. [6]. required. If further investigation allowed to Again, our study shows that the MRSA carrier determine risk factors that accurately identify status in a rehabilitation center specialized for colonized patients, we would suggest including patients with rheumatic diseases is not them in the official screening recommendations increased compared to the prevalence of MRSA of the KRINKO. in the general population. To date, there are no clear recommendations Among the nine patients colonized with for rehabilitation clinics regarding the test of MRSA, only five should definitely have been the MRSA status in their patients. The present tested according to the recommendations of the study served as an internal quality control KRINKO. The remaining four patients would showing that currently there is no increased not have been detected, since they did not ful- risk. However, this study has potential limita- fill the criteria. Therefore, the question arises of tions. In the first place, the number of 842 whether these recommendations should be screened patients might not be sufficient expanded, particularly with the three patients enough to unravel a statistically significant not presenting any of these risk factors at all. difference between the groups. The p value for On the other hand, the collected data are not the association between the MRSA prevalence sufficient to make a clear statement and would in rheumatologic and non-rheumatologic demand further investigation to verify this patients is p = 0.53. This demonstrates that hypothesis. In any case, it is questionable whe- there is no statistically significant difference ther there are more risk factors that should between the MRSA prevalence among rheuma- constantly be taken into account for the choice tologic patients and the MRSA prevalence of patients to be screened by default when among non-rheumatologic patients. Due to our hospitalized. found prevalence of 0.5% among rheumato- We therefore additionally explored some logic patients, we would have had to screen a more potential risk factors, which are currently total number of almost 4800 instead of 842 not included in the recommendations of the patients to yield a p value of \ 0.05 for this KRINKO. From the above described data, we can association. see that overall 16.9% of the patients had In the second place, refusals to participate undergone immunosuppressive treatment were rare, but they occurred. Furthermore, some within the previous year, while among the of the patients did not speak German very well, patients with carrier status we encounter 33.3% so that they had difficulties in answering the instead. Overall, 34.2% of the patients had questions. Based on conversations with these regular contact with people working in direct same patients, we guess that there might be a patient care, either privately, within their small number of patients who were not sure everyday lives, or in a healthcare environment, about the answers they gave, even if we tried to whereas this was the case for 55.6% of the col- formulate them as simply as possible. However, onized patients. In addition, only 41.2% of all this small number of patients might have Rheumatol Ther influenced the questionnaire but not the results impact of these and other potential factors on of the MRSA carrier status. In addition, the nine MRSA carriage. patients identified as MRSA carriers were native speakers and therefore, did not have any prob- lems with the language. ACKNOWLEDGEMENTS Besides, only swabs from the nasal vestibule and from the pharyngeal site were taken, but First, we would like to thank the participating not from chronic wounds or other body areas rehabilitation centers (Karl-Aschoff-Klinik in (e.g., the inguinal region). This was done on Bad Kreuznach, Klinik Nahetal in Bad Kreuz- purpose, since MRSA is mainly found in the nach, St. Franziska-Stift in Bad Kreuznach and nasal vestibule and colonizes on this basis Drei-Burgen-Klinik in Bad Kreuznach), their especially the pharyngeal site, as shown by the personnel, as well as their residents for their Commission for Hospital Hygiene and Infection great help and support to conduct the study. Prevention [4]. It could have been interesting to Furthermore, our thanks extend to the person- screen these two other sites as well, though it nel of the Department for Hygiene and Infec- might have reduced the number of patients tion Prevention at the University Medical willing to participate. Furthermore, we could Center of the Johannes Gutenberg University have tried to cover more potential risk factors in Mainz, especially to the medical technical the questionnaire. However, we tried to keep assistants Miss Kraft and Miss Ku ¨ nstler for their the questionnaire manageable for both the assistance with the microbiological analyses. patients and the clinical personnel. Funding. The study was supported by a fel- lowship (Rehabilitation research fellowship) of CONCLUSIONS the Wirtschaftsfo ¨ rderung of the administrative district of Bad Kreuznach to JK. No funding or In conclusion, the low MRSA prevalence in sponsorship was received for publication of this patients of the center for rheumatologic and article. orthopedic rehabilitation (0.5%) despite the frequent long-term immunosuppression in this Authorship. All named authors meet the patient group suggests that rheumatologic International Committee of Medical Journal patients are not more likely to reveal MRSA Editors (ICMJE) criteria for authorship for this carrier status than other patient groups and that article, take responsibility for the integrity of long-term immunosuppression does not neces- the work as a whole, and have given their sarily represent a risk factor for MRSA colo- approval for this version to be published. nization. The higher prevalence in patients of the center for cardiologic and orthopedic reha- Disclosures. Judith Kra ¨mer, Konstantinos bilitation and in patients with oncologic reha- Triantafyllias, Wolfgang Kohnen, Martin Leber, bilitation may be explained by greater exposure Ute Dederichs-Masius, Andrea Zucker, Ju ¨ rgen to several risk factors for MRSA colonization Ko ¨ rber, and Andreas Schwarting having noth- compared to the patients of the two other ing to disclose. rehabilitation centers. The overall prevalence of MRSA (1.1%) correlates with what we suspected Compliance with Ethics Guidelines. The from previous studies. study was conducted within an internal quality Since only five out of nine patients with control exploration following the statement of the carrier status would have been detected by fol- local ethics committee (Rhineland-Palatinate). lowing the recommendations of the KRINKO and since we detected a higher percentage of Data Availability. The datasets during and/ other potential risk factors in colonized patients or analyzed during the current study are avail- compared to the entirety of the patients, we able from the corresponding author on reason- suggest a further investigation of the exact able request. Rheumatol Ther (MDRO) in rehabilitation clinics in the Rhine-Main- Open Access. This article is distributed District. Germany. Rehabilitation. under the terms of the Creative Commons 2015;54(5):339–45. https://doi.org/10.1055/s-0035- Attribution-NonCommercial 4.0 International 1559642 (epub 2015 Oct 27. German). License (http://creativecommons.org/licenses/ 6. Rollnik JD, Samady AM, Gru ¨ ter L. Multidrug-resis- by-nc/4.0/), which permits any noncommer- tant germs in neurological early rehabilitation. cial use, distribution, and reproduction in any Rehabilitation. 2014;53(5):346–50. https://doi.org/ medium, provided you give appropriate credit 10.1055/s-0034-1375640 (epub 2014 Oct 15. to the original author(s) and the source, provide German). a link to the Creative Commons license, and 7. Gieffers Jens, Ahuja Andre ´, Giemulla Ronald. Long indicate if changes were made. term observation of MRSA prevalence in a German rehabilitation center: risk factors and variability of colonization rate. GMS Hyg Infect Control. 2016. https://doi.org/10.3205/dgkh000281 (11:Doc21. Published online). REFERENCES 8. 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Rheumatology and TherapySpringer Journals

Published: Jun 2, 2018

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