Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles
Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles
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DOI：
10.1056/nejmoa042683
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发表时间：
2005-04-07
影响因子：
158.5
通讯作者：
Spellberg, B
中科院分区：
文献类型：
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作者：
Miller, LG;Perdreau-Remington, F;Spellberg, B
背景：坏死性筋膜炎是一种危及生命的感染，需要紧急手术和药物治疗。金黄色葡萄球菌一直是坏死性筋膜炎的一个非常罕见的原因，但我们最近注意到，社区相关的耐甲氧西林金黄色葡萄球菌引起的感染数量惊人。方法：我们回顾了2003年1月15日至2004年4月15日在我们中心伤口培养出MRSA的843例患者的记录。在该队列中，14例患者来自社区，临床和术中发现坏死性筋膜炎、坏死性肌炎或两者兼而有之。结果：患者的中位年龄为46岁（范围为28至68岁），71%为男性。共存的条件或风险因素包括当前或过去的注射药物使用（43%）;以前的MRSA感染，糖尿病和慢性丙型肝炎（各21%）;癌症和人类免疫缺陷病毒感染或获得性免疫缺陷综合征（各7%）。4名患者（29%）没有严重的共存条件或风险因素。所有患者都接受了内科和外科联合治疗，没有人死亡，但他们都有严重的并发症，包括需要进行重建手术和在重症监护室长期住院。86%的伤口培养物是MRSA的单一微生物，40%的患者（10人中有4人）的血培养结果呈阳性。所有MRSA分离株在体外对克林霉素、甲氧苄啶-磺胺甲恶唑和利福平敏感。所有回收的菌株属于相同的基因型（多位点序列型ST 8，脉冲场型USA 300，和葡萄球菌盒式染色体mec IV型[SCCmecIV]），并进行潘顿-瓦伦丁杀白细胞素（pvl），lukD，和lukE基因，但没有其他毒素基因被检测到。结论：社区相关的MRSA引起的坏死性筋膜炎是一个新兴的临床实体。在社区相关MRSA感染流行的地区，疑似坏死性筋膜炎的经验性治疗应包括可预测的抗该病原体的抗生素。
BACKGROUND:Necrotizing fasciitis is a life-threatening infection requiring urgent surgical and medical therapy. Staphylococcus aureus has been a very uncommon cause of necrotizing fasciitis, but we have recently noted an alarming number of these infections caused by community-associated methicillin-resistant S. aureus (MRSA).METHODS:We reviewed the records of 843 patients whose wound cultures grew MRSA at our center from January 15, 2003, to April 15, 2004. Among this cohort, 14 were identified as patients presenting from the community with clinical and intraoperative findings of necrotizing fasciitis, necrotizing myositis, or both. Results: The median age of the patients was 46 years (range, 28 to 68), and 71 percent were men. Coexisting conditions or risk factors included current or past injection-drug use (43 percent); previous MRSA infection, diabetes, and chronic hepatitis C (21 percent each); and cancer and human immunodeficiency virus infection or the acquired immunodeficiency syndrome (7 percent each). Four patients (29 percent) had no serious coexisting conditions or risk factors. All patients received combined medical and surgical therapy, and none died, but they had serious complications, including the need for reconstructive surgery and prolonged stay in the intensive care unit. Wound cultures were monomicrobial for MRSA in 86 percent, and 40 percent of patients (4 of 10) for whom blood cultures were obtained had positive results. All MRSA isolates were susceptible in vitro to clindamycin, trimethoprim-sulfamethoxazole, and rifampin. All recovered isolates belonged to the same genotype (multilocus sequence type ST8, pulsed-field type USA300, and staphylococcal cassette chromosome mec type IV [SCCmecIV]) and carried the Panton-Valentine leukocidin (pvl), lukD, and lukE genes, but no other toxin genes were detected.CONCLUSIONS:Necrotizing fasciitis caused by community-associated MRSA is an emerging clinical entity. In areas in which community-associated MRSA infection is endemic, empirical treatment of suspected necrotizing fasciitis should include antibiotics predictably active against this pathogen.