Community-genotype methicillin-resistant <i>Staphylococcus aureus</i> skin and soft tissue infections in Latin America: a systematic review

Leme, Rodrigo Cuiabano Paes; Bispo, Paulo José Martins; Salles, Mauro José

doi:10.1016/j.bjid.2021.101539

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Brazilian Journal of Infectious Diseases

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Review article • Braz J Infect Dis 25 (1) • Jan-Feb 2021 • https://doi.org/10.1016/j.bjid.2021.101539 copy

Community-genotype methicillin-resistant Staphylococcus aureus skin and soft tissue infections in Latin America: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Background:

Community-genotype methicillin-resistant Staphylococcus aureus (CG-MRSA) emerged in the 1990s as a global community pathogen primarily involved in skin and soft tissue infections (SSTIs) and pneumonia. To date, the CG-MRSA SSTI burden in Latin America (LA) has not been assessed.

Objective:

The main objective of this study was to report the rate and genotypes of community-genotype methicillin-resistant Staphylococcus aureus (CG-MRSA) causing community-onset skin and soft tissue infections (CO-SSTIs) in LA over the last two decades. In addition, this research determined relevant data related to SSTIs due to CG-MRSA, including risk factors, other invasive diseases, and mortality.

Data sources:

Relevant literature was searched and extracted from five major databases: Embase, PubMed, LILACS, SciELO, and Web of Science.

Methods:

A systematic review was performed, and a narrative review was constructed.

Results:

An analysis of 11 studies identified epidemiological data across LA, with Argentina presenting the highest percentage of SSTIs caused by CG-MRSA (88%). Other countries had rates of CG-MRSA infection ranging from 0 to 51%. Brazil had one of the lowest rates of CG-MRSA SSTI (4.5–25%). In Argentina, being younger than 50 years of age and having purulent lesions were predictive factors for CG-MRSA CO-SSTIs. In addition, the predominant genetic lineages in LA belonged to sequence types 8, 30, and 5 (ST8, ST30, and ST5).

Conclusion:

There are significant regional differences in the rates of CG-MRSA causing CO-SSTIs. It is not possible to conclude whether or not CG-MRSA CO-SSTIs resulted in more severe SSTI presentations or in a higher mortality rate.

Keywords:
CG-MRSA; CA-MRSA; Genetic lineages; Community-onset SSTI

Reference	Study period	Location	Study design	Exclusive SSTI study?	Aim of study and commentaries
Pardo et al. (2013)³³33 Pardo L, Vola M, Macedo-Viñas M, et al. Community-associated methicillin-resistant Staphylococcus aureus in children treated in Uruguay. J Infect Dev Ctries. 2013;7:010-6.	2003-2006	Montevideo, Uruguay	Retrospective, observational	No	To describe the relevancy and microbiological aspects of S. aureus isolates from children treated at a tertiary-care; focus on invasive CA-MRSA disease
Sola et al. (2008)³²32 Sola C, Saka HA, Vindel A, et al. Emergence and dissemination of a community-associated methicillin-resistant panton-valentine leucocidin-positive Staphylococcus aureus clone sharing the sequence type 5 lineage with the most prevalent nosocomial clone in the same region of Argentina. J Clin Microbiol. 2008;46:1826-31.	2005	Cordoba, Argentina	Prospective, observational and multicenter	No	To investigate the prevalence of CA-MRSA infections during a surveillance period in 2005. This study was the first report of the prevalence of CA-MRSA in Argentina. Fourteen hospitals participated. The results showed the emergence of CA-MRSA in the community in Argentina
De los Monteros et al. (2013)³¹31 De los Monteros LEE, Memije MEV, Carreón AAR, Rojas LVJ, Calderón EM. Caracterización de Staphylococcus aureus resistente a meticilina aislado de pacientes con piodermitis. Dermatol Rev Mex. 2013.	2006-2008	Mexico City, Mexico	Cross-sectional	Yes	To determine MRSA prevalence in outpatients presenting with pyodermitis
Gelatti et al. (2013)²⁷27 Gelatti LC, Bonamigo RR, Inoue FM, et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying SCCmec type IV in southern Brazil. Rev Soc Bras Med Trop. 2013;46:34-8.	2007-2008	Porto Alegre, Brazil	Prospective, observational	Yes	To characterize S. aureus isolates from community-acquired skin and soft tissue infection but searching for CA-MRSA; it did not evaluate the risk factors for CA-MRSA SSTI
Bonesso et al. (2014)²⁵25 Bonesso MF, Marques SA, Camargo CH, Fortaleza CMCB, de LR de S da Cunha M. Community-associated methicillin-resistant Staphylococcus aureus in non-outbreak skin infections. Braz J Microbiol. 2014;45:1401-7.	2008-2009	Botucatu, Brazil	Prospective, observational	Yes	To establish the prevalence of MRSA in outpatients attended at a dermatologic treatment center; patients with previous hospitalization and healthcare employees were considered to be at risk to acquired S. aureus SSTI
Egea et al. (2014)²⁶26 Egea AL, Gagetti P, Lamberghini R, et al. New patterns of methicillin-resistant Staphylococcus aureus (MRSA) clones, community-associated MRSA genotypes behave like healthcare-associated MRSA genotypes within hospitals, Argentina. Int J Med Microbiol. 2014;304:1086-99.	2009	Argentina (several regions)	Prospective, cross-sectional, multicentre	No	To evaluate the molecular and clinical epidemiology of CA- and HA-MRSA in community and healthcare settings. Surgical site infection was not counted as skin disease
Furst et al. (2013)¹⁴14 Furst MJL, de Vedia L, Fernández S, et al. Prospective multicenter study of community-associated skin and skin structure infections due to methicillin-resistant Staphylococcus aureus in Buenos Aires, Argentina. PLoS One. 2013;8:1-8.	2010-2011	Santa Fe province and Buenos Aires, Argentina	Prospective, observational, and multicentre	Yes	To establish the prevalence, clinical and molecular attributes of CA-MRSA in adolescents and adults with SSTI
Baba-Moussa et al. (2011)³⁰30 Baba-Moussa L, Sina H, Scheftel J-M, et al. Staphylococcal Panton-Valentine Leucocidin as a major virulence factor associated to furuncles. PLoS One. 2011;6:e25716.	Unknown (2010 or 2011)	Cayenne, French Guyana	Case-control	Yes	To establish the association of virulence factors, especially in HIV and non-HIV patients, regarding secondary skin infections
Dozois et al. (2015)²⁹29 Dozois A, Thomsen I, Jimenez-Truque N, et al. Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus among skin and soft tissue infections in an emergency department in Guyana. Emerg Med J. 2015;32:800-3.	2012	Georgetown, Guyana	Prospective, observational	Yes	The aim was to determine the frequency of MRSA among S. aureus isolates at an emergency department and to identify molecular characteristics of MRSA strains
Tomatis et al. (2018)³⁴34 Tomatis C, Baroni MR, Mendosa MA, et al. Tipos de spa no reportados en nuestro país en Staphylococcus aureus de pacientes adultos de un hospital escuela, Santa Fe, Argentina. Rev Argent Microbiol. 2018;50:244-8.	2013	Santa Fe, Argentina	Cross-sectional	No	To describe S. aureus strains regarding genotypic study of mecA, SCCmec cassette, PVL and polymorphisms; also, to relate patient data with pheno- and genotypic findings of isolates
Souza (2017)²⁸28 de Souza ACL. Colonização e infecção cutânea por Staphylococcus aureus resistente à meticilina associado à comunidade em crianças e adolescentes com afecções dermatológicas. Universidade Federal Fluminense; 2017.	2015	Niterói, Brazil	Cross-sectional cohort study	Yes	To analyze the prevalence of colonization and cutaneous infection by CA-MRSA in pediatric dermatology outpatients and the factors associated with skin infections

Reference	Study period	Inclusion criteria	No. of Staphylococcus aureus CO-SSTI	No. of CG-MRSA SSTI infection (%)^a a Except for the study by Dozois et al. confidence intervals were not described by the authors or were not calculated when determining the prevalence in studies without this information.	CG-MRSA clone
Furst et al. (2013)¹⁴14 Furst MJL, de Vedia L, Fernández S, et al. Prospective multicenter study of community-associated skin and skin structure infections due to methicillin-resistant Staphylococcus aureus in Buenos Aires, Argentina. PLoS One. 2013;8:1-8.	2010-2011	Outpatients ≥14 years, with SSTI and had culture obtained	248	218 (88)	Number of CG-MRSA isolates = 146
					ST5-SCCmec IV (24%)
		Outpatients ≥ 14 years, with SSTI and had culture obtained			ST30-SCCmec IV (48%)
					SCCmec V (0.7%)
					(ST not determined)
Gelatti et al. (2013)²⁷27 Gelatti LC, Bonamigo RR, Inoue FM, et al. Community-acquired methicillin-resistant Staphylococcus aureus carrying SCCmec type IV in southern Brazil. Rev Soc Bras Med Trop. 2013;46:34-8.	2007-2008	Outpatients or patients admitted to the hospital for up to 48 h and presence of superficial cutaneous and soft tissue infections	58	5 (8.6)	Number of CG-MRSA isolates = 5
					ST30-SCCmec IV (60%)
					ST8-SCCmec IV (20%)
					ST5-SCCmec IV (20%)
Bonesso et al. (2014)²⁵25 Bonesso MF, Marques SA, Camargo CH, Fortaleza CMCB, de LR de S da Cunha M. Community-associated methicillin-resistant Staphylococcus aureus in non-outbreak skin infections. Braz J Microbiol. 2014;45:1401-7.	2008-2009	Outpatients of all ages with pyodermitis, diabetes-related infected foot, suppurative osteomyelitis, secondarily infected dermatitis, and secondarily infected traumatic lesions	66	3 (4.5)	The three strains had 81% similarity by PGFE, but there was no association with known CG-MRSA clones.
Dozois et al. (2015)²⁹29 Dozois A, Thomsen I, Jimenez-Truque N, et al. Prevalence and molecular characteristics of methicillin-resistant Staphylococcus aureus among skin and soft tissue infections in an emergency department in Guyana. Emerg Med J. 2015;32:800-3.	2012	Outpatients of all ages with SSTI with obtainable purulent material	47	24 (51.1)^b b (95% CI, 37%-65%).	Number of CG-MRSA isolates = 24
					ST8-SCCmec IV (100%)
Baba-Moussa et al. (2011)³⁰30 Baba-Moussa L, Sina H, Scheftel J-M, et al. Staphylococcal Panton-Valentine Leucocidin as a major virulence factor associated to furuncles. PLoS One. 2011;6:e25716.	Unknown (2010 or 2011)	Outpatients: HIV, non-HIV, and non-infectious dermatosis patients (control) presenting lesions like furuncles or skin infection of a pre-existing non-infectious dermatosis due to S. aureus	55	0 (0)	NA
De los Monteros et al. (2013)³¹31 De los Monteros LEE, Memije MEV, Carreón AAR, Rojas LVJ, Calderón EM. Caracterización de Staphylococcus aureus resistente a meticilina aislado de pacientes con piodermitis. Dermatol Rev Mex. 2013.	2006-2008	Adults and children outpatients with pyodermitis (impetigo, folliculitis, furunculosis and cellulitis)	37	16 (38)	CG-MRSA clone was not determined, only SCCmec
Tomatis et al. (2018)³⁴34 Tomatis C, Baroni MR, Mendosa MA, et al. Tipos de spa no reportados en nuestro país en Staphylococcus aureus de pacientes adultos de un hospital escuela, Santa Fe, Argentina. Rev Argent Microbiol. 2018;50:244-8. (data extracted from outpatients)	2013	Outpatients and inpatients (16-65 years)	13	10 (77)	Number of CG-MRSA isolates = 10
		Consecutive positive samples			ST30-SCCmec IV (50%)
					ST5-SCCmec IV (50%)
Souza (2017)²⁸28 de Souza ACL. Colonização e infecção cutânea por Staphylococcus aureus resistente à meticilina associado à comunidade em crianças e adolescentes com afecções dermatológicas. Universidade Federal Fluminense; 2017.	2015	Age ranging from 0 to 19 years old	16	4 (25)	Not determined
		Non-infectious dermatosis outpatients from public hospital or private clinic

Reference	Study period	Inclusion criteria	No. of CG-MRSA infections	No. of CG-MRSA SSTI (%)^a a Confidence intervals were not described by the authors or were not calculated when determining the prevalence in studies without this information.	CG-MRSA clone
Sola et al. (2008)³²32 Sola C, Saka HA, Vindel A, et al. Emergence and dissemination of a community-associated methicillin-resistant panton-valentine leucocidin-positive Staphylococcus aureus clone sharing the sequence type 5 lineage with the most prevalent nosocomial clone in the same region of Argentina. J Clin Microbiol. 2008;46:1826-31. (data extracted from 2005 period)	2005	All ages	22	20 (91)	Number of CG-MRSA isolates = 20
		Outpatients			ST5-SCCmec IV
		Single patient with HA-MRSA and CA-MRSA isolates
Egea et al. (2014)²⁶26 Egea AL, Gagetti P, Lamberghini R, et al. New patterns of methicillin-resistant Staphylococcus aureus (MRSA) clones, community-associated MRSA genotypes behave like healthcare-associated MRSA genotypes within hospitals, Argentina. Int J Med Microbiol. 2014;304:1086-99. (data extracted from hospitalized patients)	2009	All ages	105	43 (41)	Number of CG-MRSA isolates = 43
		Outpatients and inpatients			ST5-SCCmec IV
		Only the first isolate from each patient was evaluated			ST30-SCCmec IV
Tomatis et al. (2018)³⁴34 Tomatis C, Baroni MR, Mendosa MA, et al. Tipos de spa no reportados en nuestro país en Staphylococcus aureus de pacientes adultos de un hospital escuela, Santa Fe, Argentina. Rev Argent Microbiol. 2018;50:244-8. (data extracted from outpatients)	2013	Adults (16-65 years)	11	10 (91)	Number of CG-MRSA isolates = 10
		Outpatients and inpatients			ST30-SCCmec IV (50%)
		Consecutive positive samples			ST5-SCCmec IV (50%)

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[1] ⁎ Corresponding author at: Graduate Program in Infectious Disease, Rua Leandro Dupret, 188, Vila Clementino, São Paulo, Brazil. rodrigo.cpaesleme@gmail.com