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  Table of Contents    
ORIGINAL ARTICLE  
Year : 2014  |  Volume : 57  |  Issue : 3  |  Page : 418-422
Prevalence and invasiveness of community-acquired methicillin-resistant Staphylococcus aureus: A meta-analysis


Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, Beijing 100045, China

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Date of Web Publication14-Aug-2014
 

   Abstract 

Background: Reports suggest that the prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has increased, and that CA-MRSA is more virulent than healthcare-associated (HA)-MRSA. Aims: The aim of this study is to gain a better understanding of the invasiveness and prevalence of CA-MRSA in patients; we systematically reviewed the literature by conducting a meta-analysis. Materials and Methods: We searched the MEDLINE and PUBMED databases from the year these databases were established to January 2013. Results: The pooled CA-MRSA prevalence among 50,737 patients from 33 studies was 39.0% (range, 30.8-47.8%). The pooled CA-MRSA prevalence rates among pediatric and adult patients with MRSA infection were 50.2% (range, 37.5-62.8%) and 42.3% (range, 16.4-73.3%), respectively. The pooled CA-MRSA prevalence rates of MRSA-infected patients in Asia, Europe, and North America were 23.1% (range, 12.0-39.8%), 37.4% (range, 21.1-56.4%), and 47.4% (range, 35.8-59.4%), respectively. Using the random effects model, we determined that the pooled odds ratio of invasive infections in CA- and HA-MRSA was 0.30 (95% confidence interval: 0.08-1.10; P = 0.07, test for heterogeneity P < 0.00001). Conclusions: The prevalence of CA-MRSA in MRSA infection varied with area and population. No difference in the ability to cause invasive infections was found between CA- and HA-MRSA. This finding challenges the view that CA-MRSA is more virulent than HA-MRSA.

Keywords: Community-acquired methicillin-resistant Staphylococcus aureus, invasive infection, virulence

How to cite this article:
Li S, Li J, Qiao Y, Ning X, Zeng T, Shen X. Prevalence and invasiveness of community-acquired methicillin-resistant Staphylococcus aureus: A meta-analysis. Indian J Pathol Microbiol 2014;57:418-22

How to cite this URL:
Li S, Li J, Qiao Y, Ning X, Zeng T, Shen X. Prevalence and invasiveness of community-acquired methicillin-resistant Staphylococcus aureus: A meta-analysis. Indian J Pathol Microbiol [serial online] 2014 [cited 2019 Oct 21];57:418-22. Available from: http://www.ijpmonline.org/text.asp?2014/57/3/418/138737



   Introduction Top


Staphylococcus aureus is one of the most common human pathogenic bacteria and the most frequent cause of skin and soft tissue infections, osteomyelitis, and bacteremia. S. aureus infections, particularly those caused by methicillin-resistant strains, have been recognized as a serious problem in both inpatient and outpatient settings and are now endemic in several regions worldwide. [1] For approximately three decades until the late 1980s, methicillin-resistant S. aureus (MRSA) remained a predominantly nosocomial infection. Since the 1990s, however, new strains of community-acquired (CA)-MRSA caused infections in previously healthy people. Outbreaks of CA-MRSA infections have been reported worldwide, although prevalence varied geographically. A number of studies have reported the frequency of MRSA acquired in communities, but no meta-analysis has been carried out in the last decade.

Previous studies showed that CA-MRSA infections more likely involve soft tissue, whereas health care-associated (HA)-MRSA infections are considerably more likely to involve the blood stream, respiratory system, or urinary tract. [1],[2] Despite research progress, few studies have compared the prevalence of invasive infections caused by CA- and HA-MRSA. To address this gap, we carried out a systematic review of the literature using meta-analysis to provide a quantitative estimate of the difference in invasiveness between CA- and HA-MRSA.


   Materials and methods Top


Study strategy

A search of literature (in MEDLINE and PUBMED) published before January 2013 was conducted using the following keywords in various combinations: "S. aureus," "methicillin resistance," "CA," "incidence," "prevalence," "epidemiology," and "infection." We also performed manual searches on citations retrieved from relevant original studies and review articles. Only the studies that list the count or the prevalence of CA-MRSA infection in all MRSA infection were included. The search was limited to studies published in English. We excluded review articles, case reports, outbreaks, and studies in immunocompromised patients, such as those with HIV infection.

Data extraction

Two investigators independently extracted the data and reached agreement on all conclusions. The characteristics of each research article were recorded, including author, year of publication, geographic location, gender distribution, population, study size, definition of CA-MRSA used in the study, number of CA-MRSA isolates, and distribution of diseases (if reported).

Invasive MRSA infection is defined as the isolation of MRSA from a normally sterile body site of an individual. Sterile sites include blood, pleural fluid, cerebrospinal fluid, pericardial fluid, peritoneal fluid, joint/synovial fluid, bone, and internal body sites (lymph node, brain, heart, liver, spleen, vitreous fluid, kidney, pancreas, or ovary). [3]

Statistical analysis

Pooled odd ratios (ORs) and their corresponding 95% confidence intervals (CI) were estimated using the fixed effects model of Mantel-Haenszel. The DerSimonian and Laird random effects model was used when heterogeneity was present. The pooled prevalence of CA-MRSA was calculated for each group by adding the number of isolates from patients classified as having CA-MRSA and dividing the number of these patients by the total number of patients with MRSA. No study on the prevalence of CA-MRSA among hospitalized patients has provided the total number of patients with culture results. Thus, the calculated prevalence of CA-MRSA was limited to prevalence among patients with MRSA. We calculated and compared the ORs of invasive infections in CA- and HA-MRSA to compare the pathogenicity of CA-MRSA and HA-MRSA.

Statistical analysis was performed using REVMAN software, version 5.0 (Cochrane) and Meta Analyst software, version 3.13 (Tufts Medical Center). A P < 0.05 was considered statistically significant.


   Results Top


Eligible studies

After excluding duplicate studies, the search identified 781 articles [Figure 1]. We excluded 658 studies on abstract reviews. Among the remaining 123 articles, 33 satisfied our inclusion criteria [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36] . The most commonly excluded articles were those that did not report data on the prevalence of CA-MRSA among hospital patients with MRSA. Studies were conducted over a wide range of geographical settings, including those with subjects from North America, Asia, Europe, and Australia.
Figure 1: Study flow diagram

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The study population of 9 articles was children and that of 5 articles were adults. 16 articles involved both children and adults, and three did not indicate the study population. 11 of the 33 articles discussed the disease spectrum of CA-and HA-MRSA infections.

Prevalence of community-acquired-methicillin-resistant Staphylococcus aureus in MRSA infections

Thirty-three publications reported the prevalence of CA-MRSA among hospital patients with MRSA. Seven different definitions of CA-MRSA were provided in 32 of these studies. One study did not report the definition used [Table 1]. The pooled CA-MRSA prevalence among the 50,737 MRSA-infected patients from 33 studies was 39.0% [range, 30.8-47.8%; [Figure 2]. The prevalence of CA-MRSA in children and adults was also studied. The pooled CA-MRSA prevalence rates among pediatric and adult patients with MRSA infection were 50.2% (range, 37.5-62.8%) and 42.3% (range, 16.4-73.3%), respectively. We also studied the CA-MRSA prevalence in different areas and periods. The pooled CA-MRSA prevalence rates in MRSA-infected patients in Asia, Europe, and North America were 23.1% (range, 12.0-39.8%), 37.4% (range, 21.1-56.4%), and 47.4% (range, 35.8-59.4%), respectively. The pooled CA-MRSA prevalence rates before and after 2003 were 49.4% (range, 39.3-59.6%) and 24.1% (range, 14.6-37.2%), respectively. The prevalence of CA-MRSA before 2003 was reported in 11 (71.4%) articles on North America and 3 (21.4%) articles on Asia. The prevalence of CA-MRSA after 2003 was reported in 3 (27.3%) articles on North America and 6 (54.5%) articles on Asia.
Table 1: Reported definitions of CA-MRSA

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Figure 2: Forest plot of studies on the prevalence of communityacquired methicillin-resistant Staphylococcus aureus (MRSA) in MRSA infections for entire populations. The confidence interval (CI) for each study is represented by a horizontal line, and the point estimate is represented by a square. The size of the square corresponds to the weight of the study in the meta-analysis. The total CI is represented by a diamond

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Invasive infections in community-acquired-and healthcare-associated-methicillin-resistant Staphylococcus aureus

Data on the invasiveness of CA- and HA-MRSA were available in 11 studies. These studies described a total of 3014 patients with MRSA infections. A total of 160 patients (out of 1272) had invasive infection with CA-MRSA, and 189 patients (out of 1742) had invasive infection with HA-MRSA. We compared the odds of invasive infection for CA- and HA-MRSA cases. Intra-study heterogeneity was found in 11 studies [test for heterogeneity P <0.00001; [Figure 3]. Thus, the random effects model was used. Among the 11 studies, only one reported that CA-MRSA had a significantly higher prevalence of invasive infections than did HA-MRSA. Four studies revealed that the prevalence of invasive infections in HA-MRSA was higher than that in CA-MRSA, and 6 studies found no significant difference in prevalence of invasive infections between CA- and HA-MRSA. The random effects model generated a pooled OR of 0.30 [95% CI: 0.08-1.10; P = 0.07, [Figure 3]. This result indicates that no difference in invasiveness exists between CA- and HA-MRSA.
Figure 3: Forest plot of invasive methicillin-resistant Staphylococcus aureus infections. The confidence interval (CI) for each study is represented by a horizontal line, and the point estimate is represented by a square. The size of the square corresponds to the weight of the study in the metaanalysis. The total CI is represented by a diamond

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   Discussion Top


Since the early 1990s, CA-MRSA infections have begun to cause infections in previously healthy people, and its prevalence continues to intensify. So far, CA-MRSA isolates have already become the dominant MRSA isolates in some regions. [8],[19],[20] Beilman et al.[36] have reported that the prevalence rate of CA-MRSA is up to 92%. The prevalence of CA-MRSA in MRSA in the current study reached 39%. A meta study reported in 2003 show that the prevalence of CA-MRSA in MRSA was 30.2-37.3%, [37] similar to our study. This review showed that the prevalence of CA-MRSA varied geographically. The prevalence of CA-MRSA in North America was higher than that in Europe and Asia. Dukic et al.[38] have reported that the prevalence of CA-MRSA in MRSA infections is increasing in the United States. By contrast, the current work showed that the pooled CA-MRSA prevalence after 2003 was lower than that before 2003. This result may be attributed to publication bias. In the past 10 years, reports on the prevalence of CA-MRSA outside the USA have increased. Most of the 33 articles (71.4%) published before 2003 reported high CA-MRSA prevalence in North America and Europe. Most articles (54.5%) published after 2003, however, reported low CA-MRSA prevalence in Asia. In addition, the prevalence of CA-MRSA in MRSA was up to 50.2% in children, which is higher than that in adults.

The virulence of CA-MRSA is higher than that of HA-MRSA, as confirmed by the comparison of the expression of virulence genes and the disease severity of animal infection models. [39],[40],[41] However, we did not find a difference in ability to cause invasive infections between CA-and HA-MRSA after performing the meta-analysis on 11 related studies. This finding may be attributed to the fact that the ability to cause the disease is related not only to the virulence of the pathogen, but also to the immune status of the host. Until date, studies on CA-MRSA infections mostly focus on strains, and only few studies involve the hosts. Therefore, more research is required to understand the interaction between host factors and bacterial virulence.

Potential sources of heterogeneity were explored in this review. First, the articles included in this study provided seven different definitions of CA-MRSA. These differences in definition may constrain data pooling. Second, the uniformity of the study size and age of the study population may have caused the heterogeneity. For example, the study size varied from 42 to 18226, and the age of the study population varied from less than 28 days to older than 70 years. Moreover, the samples in the 19 studies covered both children and adults. Third, this review included studies from different nations, and the prevalence of CA-MRSA varied with region.

There are limitations in this study. Papers written in nonEnglish may be not included in this study, because only papers written in English were searched. As a result of the limitation of data, this study did not show the changing of prevalence trend of CA-MRSA infection over time in an area, such as in Asia, Europe or other areas.

The prevalence of CA-MRSA in MRSA infection varied with area and population. No difference in the ability to cause invasive infections was found between CA- and HA-MRSA. The findings of the present analysis don't support the previous reports that CA-MRSA exhibits higher virulence than does HA-MRSA. Additional research about the virulence of CA-MRSA is warranted with sufficiently powered studies.


   Acknowledgments Top


This study was supported by the National Natural Science Foundation of China (Grant no. 81171648), the National Natural Science Foundation of China, and the Research Grants Council of Hong Kong Joint Research Scheme (Grant no. 81061160509).

 
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Correspondence Address:
Xuzhuang Shen
No. 56, Nan-li-shi Road, Beijing - 100 045
China
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Source of Support: This study was supported by the National Natural Science Foundation of China (Grant No. 81171648), the National Natural Science Foundation of China, and the Research Grants Council of Hong Kong Joint Research Scheme (Grant No. 81061160509), Conflict of Interest: None


DOI: 10.4103/0377-4929.138737

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