Staphylococcus aureus

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Staphylococcus aureus
Staphylococcus aureus secondary electron micrograph

Staphylococcus aureus
secondary electron micrograph

Systematics
Department : Firmicutes
Class : Bacilli
Order : Bacillales
Family : Staphylococcaceae
Genre : Staphylococcus ( staphylococcus )
Type : Staphylococcus aureus
Scientific name
Staphylococcus aureus
Rosenbach , 1884

Staphylococcus aureus is a spherical, gram-positive bacterium that is often arranged in clusters ( grape- shaped )( cluster cocci ). Staphylococci do not move actively and do not form spores . The size is usually between 0.8 and 1.2  µm . Staphylococcus aureus is widespread, occurs in many habitats , lives mostly as a harmless saprobiont and commensal belongingto the normal colonization flora of the skin and mucous membranein humans, but can also be pathogenicand, in addition to skin and soft tissue infections, cause pneumonia, meningitis, endocarditis and even toxic shock syndrome and sepsis . With regard to their response to antibiotics, staphylococci were divided into methicillin-sensitive (MSSA) and methicillin-resistant (MRSA) strains.

Surname

Staphylococcus aureus on casein peptone yeast extract glucose agar

The name Staphylococcus aureus consists of a Latinized singular of two ancient Greek components, namely σταφυλή staphylé 'grape' and κόκκος kókkos 'core', 'grain', 'berry', as well as the Latin aureus 'golden'. The color name comes from the fact that most of the strains of Staphylococcus aureus are orange-yellow ("golden yellow") (its colonies on agar gel plates are colored this way) and that Staphylococcus aureus was long considered to be the cause of the so-called "golden yellow" pus .

The orange-yellow color is caused by the dye staphyloxanthin in the cell membrane of the bacterium, a carotenoid from the group of xanthophylls . This pigment acts as an antioxidant and prevents chemical reactions with oxygen or other oxidizing agents . In this way, the bacterium protects itself from some substances that an immune system uses for defense.

Occurrence

Staphylococcus aureus occurs almost everywhere in nature, including on the skin and mucous membrane of warm-blooded animals, in 25 to 30% of all people on the skin and in the upper respiratory tract . In addition comes Staphylococcus aureus in food and water before.

Physiological properties

Staphylococcus aureus is chemoorganotrophic , respiratory and fermentative , i.e. facultative anaerobic : If oxygen is present, organic substances are oxidized and this oxidation is used as an energy source; if , on the other hand, no oxygen is available, the bacterium forms lactic acid from carbohydrates in a fermentative energy metabolism or, if nitrate is available, it can use this instead of oxygen as an oxidant in a respiratory energy metabolism. Staphylococcus aureus forms coagulase and has a hemolytic effect .

Pathogenicity

Most of the time, Staphylococcus aureus does not trigger any symptoms of disease in humans or animals. In this case one speaks of a clinically asymptomatic colonization or colonization of the host with the potentially pathogenic bacterium (" colonization germ "). If the bacterium gets the opportunity to spread due to favorable conditions or a weak immune system of the host, symptoms of the disease develop. In humans, skin inflammations ( furuncles , carbuncles ), muscle diseases ( pyomyositis ), in unfavorable cases also life-threatening diseases such as pneumonia , heart inflammation ( endocarditis ), toxic shock syndrome (TSS) and blood poisoning ( sepsis ) occur. If these bacteria resistance to several important antibiotics have purchased ( multidrug resistance ), they are particularly difficult to eliminate and when transferred to third parties for them to danger.

In humans and animals, Staphylococcus aureus is one of the main causes of inflammation of the mammary gland ( mastitis ).

Pathomechanisms

Staphylococcus aureus in the Gram color , you can see the characteristic grape-shaped clusters that give it its name.
Staphylococcus aureus on Baird-Parker agar with clear halo

Staphylococcus aureus has numerous pathogenicity factors , including a polysaccharide capsule with protein A , which protects the bacterium from being absorbed by macrophages ( phagocytosis ). Protein A binds antibodies to their Fc fragment, ie exactly “upside down” than would be necessary for effective opsonization . As a result, macrophages do not recognize the Fc part and it is not absorbed and destroyed. Staphylococcus aureus is a facultative intracellular pathogen and can indirectly bind to integrin α5β1 by means of fibronectin- binding proteins and enter the host cell via a zipper mechanism . This is important both for the persistence of the pathogen and for the development of invasive clinical pictures such as endocarditis , sepsis and mastitis .

The coagulase and the clumping factor A cause local coagulation of fibrin and thus the formation of a fibrin wall, with which Staphylococcus aureus is clad and is no longer recognized by antibodies. The clumping factor is a fibrinogen receptor located on the cell surface. Only when the bacterium has multiplied strongly is fibrinolysin formed with the help of staphylokinase and the wall broken up. By means of the bacterial enzymes hyaluronidase , DNase , lipase and the hemolysins , it is now able to lyse intercellular connective tissue and parenchymal cells and invasively invade the host organism . Leukocidine helps damage the cellular components of the immune response ( granulocytes and macrophages). Caused in this way Staphylococcus aureus pyogenic (pus) infection, the locally-surface (for example, boils , carbuncles ) may occur, but also serious deep, systemic processes ( osteomyelitis , pneumonia , endocarditis , abscesses , empyema , sepsis ) with high lethality can cause .

The coagulase and the clumping factor are used to detect Staphylococcus aureus .

Staphylococcus aureus can produce several toxins that lead to several typical diseases:

  • Enterotoxins are superantigens . Since they are very heat-resistant and cannot be destroyed by cooking, they play a major role in food poisoning (diarrhea, vomiting with a short incubation period of a few hours).
  • Exfoliatins A and B (present in around 5% of Staphylococcus aureus isolates) are involved in bacterial invasion and staphylococcal scalded skin syndrome (Ritter von Rittershain's disease, pemphigus neonatorum or scalded skin syndrome: blistering of the skin, reddening) , Itching, lethargy, fever or hypothermia , mucous membranes not also affected (in contrast to Lyell's syndrome ), blisters without pathogens, mainly in small children and immunosuppressed adults over 60 years, therapy: symptomatic: fluid, skin as in burn injuries (ITS), clindamycin as the antibiotic of choice)
  • TSST-1 (Toxic Shock Syndrome Toxin 1): Causes the Toxic Shock Syndrome . The toxin acts as a superantigen and causes polyclonal CD4 T cell activation with an uncoordinated release of cytokines. This leads to exanthema, hypotension, fever, shock, multiple organ failure, and rarely to death. In principle, any purulent wound can be the gateway for the TSS pathogen, but tampons with staphylococci or streptococci are suspected behind some of the infections. Although the risk of TSS caused by tampons is small, tampons should be changed every four to eight hours.
  • Panton-Valentine-Leukocidin: necrotizing pneumonia with high mortality .
  • α-hemolysin : a pore-forming toxin

Staphylococcus aureus is one of the most important pathogens for hospital-acquired ( nosocomial ) infections. However, the pathogen can also be absorbed by humans and animals through the skin or mucous membranes. There is a possibility of transmission to food through coughing or sneezing.

The bacterium is extremely resistant to dehydration and can also show a number of resistances to antibiotics .

therapy

The antimicrobial treatment of Staphylococcus aureus infectious diseases is carried out (according to the antibiogram) with, for example, flucloxacillin, cefazolin, cefalexin, ampicillin-sulbactam, amoxicillin-clavulanic acid, cotrimoxazole, clindamycin or doxycycline. In the case of multi-resistant strains (see below), vancomycin, fosfomycin, linezolid, tigecycline, daptomycin, co-trimoxazole and other antibiotics are used.

Multi-resistance

Section from an MRSA colony ( electron microscope image)
Vancomycin in the E-test with Staphylococcus aureus

Common abbreviations:

  • MRSA = Originally M ethicillin- r esistenter S taphylococcus a ureus . Meanwhile, the label is additionally M Ultimatum r esistenter S taphylococcus a ureus as a designation for S. aureus nuclei commonly comprising (no more than drug commercially located) in addition to resistance to methicillin also have insensitivities against various other antibiotics.
  • MRE = M Ultimatum r esistente E rreger
  • ORSA = O xacillin- r esistenter S taphylococcus a ureus
  • VISA = V ancomycin- i ntermediate S taphylococcus a ureus
  • VRSA = V ancomycin- r esistenter S taphylococcus a ureus
Resistance overview of Staphylococcus aureus in the inpatient area of ​​hospitals 2014
antibiotic R. I. S. Total
n % n % n % n
Oxacillin 8147 17.6 0 0.0 38231 82.4 46378
penicillin 32852 75.7 0 0.0 10537 24.3 43389
Ciprofloxacin 8692 29.6 73 0.2 20609 70.2 29374
Levofloxacin 12982 27.6 130 0.3 33855 72.1 46967
Moxifloxacin 7046 26.5 377 1.4 19159 72.1 26582
Gentamicin 1066 2.2 5 0.0 47975 97.8 49046
Clindamycin 11037 22.5 27 0.1 37890 77.4 48954
Erythromycin 11538 23.6 34 0.1 37338 76.3 48910
Doxycycline 740 4.2 5 0.0 16840 95.8 17585
Tetracycline 1283 4.3 149 0.5 28588 95.2 30020
Teicoplanin 33 0.1 0 0.0 37666 99.9 37699
Co-trimoxazole 599 1.2 13 0.0 48511 98.8 49123
Fosfomycin 592 1.4 0 0.0 41487 98.6 42079
Fusidic acid 1018 2.6 74 0.2 37586 97.2 38678
Rifampicin 200 0.5 61 0.1 41447 99.4 41708
R = resistant; I = intermediate; S = sensitive; n = number of isolates

MRSA (also referred to as ORSA) is understood in the narrower sense to mean Staphylococcus aureus strains that are resistant to all β-lactam antibiotics (e.g. penicillin ) currently available on the market . However, they are usually multi-resistant, i.e. they are usually also resistant to other classes of antibiotics , such as quinolone antibiotics , tetracyclines , aminoglycosides , erythromycin and sulfonamides . VISAs are also less sensitive to vancomycin and other glycopeptide antibiotics . The few VRSA strains described so far are resistant to vancomycin and other glycopeptide antibiotics.

Methicillin was historically used for the antibiotic sensitivity test of bacteria ( MSSA = methicillin-sensitive Staphylococcus aureus ). In the positive case, therapy usually takes place with vancomycin , daptomycin or linezolid . Treatment should be based on the antibiogram , because resistance to vancomycin has already occurred (VRSA).

Methicillin and oxacillin belong to the penicillinase- stable penicillins. In Germany, among other things, oxacillin is used. Other representatives of this class of substances are cloxacillin, dicloxacillin and nafcillin (used in the USA). Methicillin is no longer used for therapy.

MRSA was first described in Great Britain in the early 1960s.

They also became known in Germany through the television documentary Tatort Krankenhaus by Tilman Wolff . In 2008 it was made clear that in German hospitals every year around 160,000 people are found to be infected with MRSA and that there is often a lack of elementary hygiene measures such as hand washing in everyday clinical practice.

In addition to these typical hospital-associated MRSA, MRSA that colonize people outside of health care facilities, so-called community acquired MRSA, have also been described for some years .

A third group are the livestock-associated (English livestock-associated ) is MRSA, which in virtually all animal species can be found, especially in pigs , Mast - calves and fattening turkey . These tribes not only colonize the animals, but often also those who take care of them. During slaughter, the bacteria can be transferred to the meat, which is often found in chicken and turkey meat. However, this does not seem to contribute to the spread of LA-MRSA in the population. In 2011 a study in the USA found pathogens in poultry meat that were resistant to nine antibiotics.

Mechanism of Resistance

Pathogens resistant to antibiotics are more common in places where antibiotics are constantly used. The antibiotics kill almost all individuals of the pathogen, but a few can survive because they are resistant to the antibiotic used due to a mutation. These resistant individuals then continue to multiply despite antibiotic therapy - a classic selection in the evolutionary sense. The genes that convey resistance are passed on across species, for example from Staphylococcus aureus to other species. However, the development of resistance to antibiotics is also promoted by the use of cleaning agents that contain so-called quaternary ammonium compounds (QAC) with disinfecting properties. This is because the same genes in the bacteria that provide QAV resistance also give them resistance to antibiotics. Most of the cationic surfactants available on the market are among the substances that are critical in this respect . The same applies to triclosan , which is contained as a disinfectant and preservative in household cleaners, laundry detergents, toothpastes, deodorants and soaps.

MRSA have the resistance gene mecA , which codes for a modified penicillin binding protein (PBP2a, syn. PBB2 '). This protein - the bacterial transpeptidase - is normally responsible for the correct linking of the building blocks of the cell wall. β-lactam antibiotics imitate such a building block, but bind irreversibly to the transpeptidase, which is thereby permanently inactivated. If enough transpeptidases are destroyed in this way, no new links can be formed and cell wall synthesis comes to a standstill. (Therefore, β-lactam antibiotics only act on growing cells.)

β-lactam antibiotics can no longer bind to the modified penicillin binding protein; this can continue to help with cell wall synthesis without hindrance. As a result, MRSA is resistant to all β-lactam antibiotics (penicillins, cephalosporins and carbapenems ). Until recently, MRSA was characterized by the fact that it had acquired resistance to other classes of antibiotics (for example tetracyclines , aminoglycosides , macrolides ) and thus exhibited multi- resistance. For a few years now, a new group of MRSA has also been observed that do not show this multi-resistance and are referred to as so-called community-acquired MRSA (also community onset MRSA).

Another mechanism of resistance to β-lactams, which is not only found in MRSA, is based on the formation of an enzyme that can break down penicillin ( beta-lactamase ).

However, infections with non-resistant Staphylococcus strains, for example in the middle ear or in the airways, are often very difficult to fight with antibiotics. These infections tend to become chronic , which means they keep flaring up. Apparently these bacteria are able to invade body cells . There the pathogens severely reduce their metabolism . Due to the inclusion in body cells, withdrawn from the host's immune system and protected from antibiotics by lowering the metabolism, they can hold out for days or possibly weeks in order to then re-start their metabolism, multiply and spread again.

Polymicrobial biofilms play another role in the development of resistance . Studies have found not only that Staphylococcus aureus can form strong biofilms together with the yeast Candida albicans, but also that the matrix secreted by the fungi is a protective layer that is impermeable to vancomycin. The staphylococci were killed by adding a biofilm remover. In addition to some antimycotics (e.g. Amphotericin-B), some NSAIDs are also able to “break open” Candida biofilms and thus make staphylococci accessible again for antibiotics. Not only are biofilms a problem in anti-infective treatment, they also pose an obstacle to the patient's immune system.

Spread of MRSA

Frequency of detection of MRSA in human blood and cerebrospinal fluid by clinical laboratories in countries that participated in the EARS-Net 2012.

International

What is striking are the large differences in the frequency of occurrence of MRSA in different countries, which otherwise have roughly the same levels in their health care systems. It should be noted that the data (see figure) collected and published by EARS-Net on behalf of the European Center for Disease Prevention and Control (ECDC) represent the results of routine tests in clinical laboratories on antibiotic sensitivity. Only data from invasive isolates (blood and cerebrospinal fluid ) are recorded. While the proportion of MRSA in hospitals among the Staphylococcus aureus strains is low in the Scandinavian countries and around 3% in the Netherlands , the MRSA rate in Germany is around 25%, although - presumably depending on hospital hygiene - there are strong local differences (up to over 50%). In the southern European countries, the USA and in many Asian countries (Japan) the values ​​are even between 30 and over 70%. MRSA can also be found in old people's and nursing homes, prisons, outpatient services, public showers and the like.

Outside of clinics

Methicillin-resistant Staphylococcus aureus strains were first described in 1993 in Australian aborigines who had never had any contact with the health service. Such strains were first observed in the United States in the late 1990s. Since then, MRSA colonization acquired on an outpatient basis has steadily gained in importance.

MRSA are also increasingly being found outside of hospitals. In English-language documents, these pathogens are referred to as community-acquired methicillin-resistant Staphylococcus aureus (cMRSA or caMRSA or CA-MRSA). Among them there are many strains such as the pulsed-field gel electrophoresis (PFGE) type USA300 (corresponds to the Multi Locus Sequence Typing (MLST) type ST 8) with particularly aggressive behavior, which have the so-called Panton Valentine leukocidine toxin (PVL -MRSA) and recurrent skin and soft tissue infections (furuncle, carbuncle, impetigo) as well as life-threatening infections such as sepsis or necrotizing pneumonia.

In some regions of the United States, CA-MRSA has been found in the majority of severe skin and soft tissue infections. In contrast to nosocomial MRSA strains, CA-MRSA often responds to therapy with some non-β-lactam antibiotics.

According to a French study, many patients who have become infected in hospital drag these bacteria into their homes after they are released.

Agriculture, industrial food production

In an international study, the rate of colonized pig breeder workers was found to be 12%, with protective clothing apparently not being of any use.

In an investigation by the State Health Office of Lower Saxony in 2011, 21% of the MRSA found had entered the human body from agriculture.

Outside of people

In the United States, MRSA was found on five out of ten public ocean beaches surveyed in the states of California and Washington in 2009; before the 2016 Summer Olympics in Brazil on five beaches off Rio de Janeiro .

About manure MRSA reach the floors of agriculturally used areas : In low concentrations they could already crops are detected. They can be active for months to years: Soil currently being examined in the Netherlands has 15 times more resistance genes than soils that were archived in 1940 (when there were hardly any antibiotics). Creeks and rivers that have to absorb purified sewage treatment plant wastewater or material washed out from agriculture showed the second highest pollution in samples from several years by the Karlsruhe Institute of Technology (KIT). MRSA is also found in rain clarification and overflow basins, in the seepage water from landfills and in small traces in the groundwater.

Sewage works, sewage sludge

In sewage sludge from different regions of England were resistant strains of Staphylococcus aureus demonstrated.

Samples over several years from water bodies, groundwater measuring points , sewage treatment plants , hospital waste water or rain overflow basins from the Karlsruhe Institute of Technology (KIT) showed the highest MRSA contamination in waste water from hospitals and sewage treatment plants.

In animals

MRSA aren't limited to humans either. In 2007, MRSA was found in a study on Canadian pig farms. Humans were colonized in half of these 20 farms, pigs in a quarter. The genetic information of the bacteria was identical in each case, which clearly indicates a transmission between humans and animals.

MRSA was encountered in pig fattening earlier in the Netherlands. It was shown there that in farms where pigs were routinely treated with antibiotics, 60% of the pigs were colonized with MRSA. In farms in which the pigs were not routinely given antibiotics, only 5% were colonized with MRSA.

In another Dutch study, 41% of 540 slaughter pigs were colonized with MRSA. The bacteria can also be carried over during the cattle trade and the slaughtering process and can then be detected in food from corresponding animals, for example in turkey, chicken or veal as well as in raw milk.

In facilities for the elderly and sick

MRSA pose a threat worldwide, especially in hospitals. The operative intensive care units , departments for burn injuries and neonatal units are particularly affected .

The proportion of people with MRSA compared to unaffected people ( prevalence ) in residents of old people's homes and patients in rehabilitation and acute clinics was z. B. 2008 in the Höxter district between 1.2 and 3.4%. In Germany around 50,000 patients are infected with MRSA every year. In some clinics, up to 30% of the infections acquired there are due to MRSA.

An unknown number of patients are already colonized when they are admitted to the clinic without knowing it. Only an initial examination can provide clarity here, such as B. is carried out in the Netherlands.

According to the Techniker Krankenkasse Schleswig-Holstein, the number of MRSA diseases in clinics in this state increased by 192% from 2006 to 2009 (from 191 to 557 cases). The increase in other federal states was sometimes over 200%.

In 2011, MRSA was detected in just under 2.6 percent of those examined as part of an investigation by the Lower Saxony State Health Office (127 smears from almost 5,000 patients from 33 clinics).

Deaths from MRSA

In the United States, around 19,000 people died from infections with MRSA in 2005 alone.

For Germany, the estimates of deaths from hospital-acquired infections vary widely, from around 1,500 deaths to around 40,000 annually. The German Society for Hospital Hygiene also estimated around 40,000 deaths annually in 2009 from infections in German hospitals. That would be significantly more than the average annual excess mortality from seasonal influenza . The inaccurate information is due, among other things, to the fact that in Germany - unlike in Great Britain, for example - MRSA is not recorded as a diagnosis in the death certificate. Above all, a distinction would have to be made as to whether the MRSA infection was actually the cause of death or whether there was only a clinically insignificant infection or colonization with MRSA. In 2014 the DGKH reiterated its estimate of the number of annual deaths from hospital infections at 40,000; half of them can be avoided through hygiene measures and overall the number of infections is significantly underestimated.

MRSA carrier status in Germany increases the risk of dying during a hospital stay by a factor of 2.7.

Therapy for multi-resistance

MRSA infections are treated with so-called reserve antibiotics such as vancomycin and, more recently, linezolid , daptomycin , tigecycline or a combination of quinupristine and dalfopristin . The latter are also effective against vancomycin-resistant Staphylococcus aureus , linezolid can also be administered orally. After there was increased mortality in connection with the use of linezolid, tigecycline, daptomycin and vancomycin are the drugs of choice. However, the treatment of patients with MRSA infections in everyday clinical practice is often difficult and lengthy. For some patients who are already on the mend, it is possible to stop antibiotic treatment. Then the normal microorganism community of the skin and mucous membrane can regenerate and displace the MRSA again.

Redevelopment

During the rehabilitation, MRSA-contaminated body parts or wounds are decolonized. The pathogens are mechanically removed or killed by cleaning and disinfecting with special bactericidal preparations (e.g. washing lotion containing octenidine ). Other hygiene measures include changing bed and body linen, towels and washcloths every day. In the case of colonization of the nose, the use of mupirocin ointment can be considered, in the case of one of the throat, gargle with antiseptic solutions such as chlorhexidine .

Search for alternatives and new or modified antibiotics

A joint research group from the Universities of Bonn and Düsseldorf, funded by the Deutsche Forschungsgemeinschaft , showed in various studies that acyldepsipeptides (ADEPs) act against gram-positive bacteria, including Staphylococcus aureus . While conventional antibiotics inhibit certain reactions in bacterial cells, the acyldepsipeptides (ADEPs) intervene at another key point in the metabolism of the bacteria. They lead to a malfunction of an important enzyme. Cell division and thus the multiplication of the pathogens is prevented.

When drugs were given to lower the cholesterol level, Staphylococcus aureus became more sensitive to disinfectants , since cholesterol biosynthesis is related to the synthesis of the yellow protective pigment staphyloxanthin . Recent Japanese studies have shown that a related bacterium, Staphylococcus epidermidis , produces an enzyme that is supposed to destroy the biofilm of Staphylococcus aureus and prevent the formation of new biofilms.

Extracts of different plant species show in-vitro (i.e. outside of a living organism) some high activity against multi-resistant MRSA with several resistances. Phenols and flavonoids were found in the plant extracts as carriers of antimicrobial activity. Garlic ( Allium sativum ) and orange ( Citrus sinensis ) are not very active. Indian basil, sesame oil, and soybean oil are moderately effective in vitro . The oil of the Himalayan variety of oregano ( Oreganum vulgare ) was proven to have an antimicrobial effect against MRSA in 2008. In in-vitro tests, it was more effective than 18 other substances known to be antibiotic. The antimicrobial effects of the Mediterranean variety oil were already known. The effect is due to the carvacrol content .

To the unchecked contamination z. If, for example, to reduce waste water into the environment via agriculture and (clinical) sewage, antibiotics could contain a “predetermined breaking point” in order to ensure rapid degradation.

Bacteriophages could offer a treatment option against multi-resistant bacteria. So far, there is only current experience with phage therapy in the former Soviet Union and Poland .

Researchers at ETH Zurich have developed an endolysin , Staphefect SA.100, which only kills the bacterium Staphylococcus aureus , as well as MRSA.

In July 2016, it was reported that a bacterium - Staphylococcus lugdunensis - was found in the nasal flora of humans that could kill MRSA. The active ingredient found was called lugdunin and was to be tested for compatibility with humans.

prevention

Clinics and hospitals

Typical protective clothing in hospitals when dealing with MRSA patients

The occurrence of MRSA strains in hospitals requires targeted anti- epidemic measures with isolation of the patient or several patients colonized with MRSA in one room ( cohort isolation ). Since the pathogens in hospitals are mostly spread by nursing staff and doctors ( iatrogenic ), the most important measure against the spread of multi-resistant pathogens is thorough hand disinfection . Depending on the activity to be performed on the patient or the location of the MRSA on the patient, disposable gloves, protective gowns and face masks are also worn. Strict adherence to hand hygiene is the most important part of prevention. Managers have an important role model function. Isolation measures can significantly reduce the transmission rate in hospitals.

The Robert Koch Institute (RKI) has so far only recommended screening examinations in hospitals for certain groups:

  1. For patients with chronic need for care, for example, catheters lying down, chronic wounds
  2. For hospital staff in the event of an outbreak, i. H. if MRSA is found frequently in more than two patients who are spatially and temporally related, and if the clonal identity of the MRSA is proven.

In contrast, the RKI in 2009 considered the screening of all admitted patients and all staff to be too time-consuming, and the Federal Ministry of Health referred to the responsibility of the federal states. At the end of 2009, the Bavarian State Office for Health and Food Safety set up a State Working Group on Multi-Resistant Pathogens (LARE), which also maintains a telephone hotline and website.

In Germany only five percent of German clinics have a hygienist - and the trend is falling. In the Netherlands, on the other hand, protective measures include the screening of all admitted patients, the appointment of a hygienist in each clinic and the coordination of every antibiotic treatment with a microbiologist. This resulted in a massive decrease in the MRSA prevalence with a frequency of 20% of the cases occurring in neighboring Germany. The frequency of MRSA in the neighboring Münster area has also decreased after a procedure similar to the Dutch one was introduced in over 40 clinics there since 2006 as part of the Euregio project MRSA-net.

Experts consider a similar approach to be useful for the ambulance service and ambulance transport . Since many patients undergoing clinical treatment are carriers of MRSA without knowing it or showing the corresponding symptoms, emergency medical personnel should also take a medical history for such diseases. The transport of an MRSA-positive patient requires the rescue personnel to wear protective clothing and disposable gloves as well as a final disinfection of the entire vehicle. The focus here is not on protecting staff (colonization with MRSA generally has no consequences for healthy people), but rather containment of the spread of MRSA, since the rescue and ambulance service is due to the high number of patient contacts and frequent visits to clinics represents an effective vector . This is also because so far there has been no decolonization when colonized patients are discharged, since their costs are still not borne by the health insurance companies.

On January 1, 2011, a new hygiene ordinance for clinics, preventive care and rehabilitation facilities should be introduced in Baden-Württemberg in order to curb the number of clinic infections and to create a national system for infection prevention. It was planned to set up an efficient hygiene management and to regulate the creation of hygiene plans as well as the naming of contact persons and agents who should take care of compliance with regulations. The regulation came into force on July 31, 2012 as the “Ordinance on Hygiene and Infection Prevention in Medical Institutions”. In § 4 of the regulation the establishment of hygiene commissions is regulated, which u. a. "Develop recommendations in hospitals on how to record nosocomial infections, the occurrence of pathogens with special and multi-resistance and antibiotic consumption, evaluate these records and draw appropriate conclusions for measures of hygiene and infection prevention as well as the use of antibiotics". The tasks of the hygiene specialists are regulated in § 6 of the regulation, hygiene plans are addressed in § 2 paragraph 4 of the regulation. The ordinance on hygiene and infection prevention in medical institutions, which has been in force in North Rhine-Westphalia since March 31, 2012, is structured in a similar manner . Bavaria has had the regulation on hygiene and infection prevention in medical facilities for a long time; There are similar ordinances in Bremen , Hamburg and Saxony .

In summary, the emergence and spread of MRSA can be combated by three approaches:

  • Through the rational and pathogen-oriented use of antibiotics and their non-use if it is not necessary (for example, in the case of minor viral infections of the respiratory tract without a greater risk of a second infection with bacteria)
  • Through consistent implementation of (preventive) hygiene measures in the hospital
  • By screening all patients as soon as they are admitted to the hospital with the isolation and rehabilitation of affected patients, as described above under “Netherlands”. It should now be possible to compare the costs of the Dutch system with the one that has prevailed in Germany so far. Even so, costs alone would not be relevant, as avoiding deaths and serious complications naturally has priority.

The psychosocial effects of an MRSA colonization have so far (March 2010) been "completely inadequately researched" in Germany.

Domestic area

In the domestic area, the usual conservative hygiene measures should be observed, i. H. without the use of disinfectants (see above: resistance build-up due to disinfectants ). Meat should not be consumed raw and young children in particular should not be given raw milk to drink.

Food preparation and kitchen hygiene

Avoid contamination of food during preparation by the following measures:

  • Keep pets away from food and do not stroke them while food is being prepared
  • Pay attention to personal hygiene before starting work (clean clothes, clean hands and fingernails, if necessary tie up hair and remove hand jewelry).
  • Avoid touching the food with your mouth, nose and hair.
  • If possible, it is better to prepare food with clean cutlery than with your hands.

If there is sufficient cooling capacity, the following sequence of food preparation is recommended:

  • First prepare food that will not be heated before consumption (e.g. dessert or dressed salads),
  • then vegetable foods to be consumed raw, such as lettuce or cut vegetables,
  • Finally, raw food from animals (e.g. meat, poultry).

If this sequence cannot be adhered to for organizational reasons, the work surfaces and devices as well as the hands must be cleaned thoroughly between the individual work steps.

Cross-contamination can be avoided by the following measures:

  • Never use the same kitchen utensils when handling raw and cooked food
  • Use one cutting board for cutting meat and poultry and another for fruit and vegetables
  • Do not cut cooked or otherwise heated food on boards on which raw food was previously cut, if it has not been cleaned properly afterwards
  • Wash hands thoroughly immediately after contact with raw food.

Plastic cutting boards can usually be cleaned in dishwashers at high temperatures (well above +60 ° C) and are therefore more suitable than wooden boards for cutting raw food. Basically, cutting boards made of wood or plastic should have a smooth surface so that they can be cleaned easily. Cutting boards with incisions and furrows in which bacteria can adhere and multiply should therefore be replaced with new boards.

Sewage treatment plants

An ozone treatment of wastewater destroyed particularly robust strains of bacteria (which also tend to be MRSA carriers are) not.

Textile hygiene

In the case of MRSA-colonized people in the household, their laundry should be washed in a temperature range of> 65 degrees Celsius if possible.

Reporting requirement

In the Netherlands, MRSA infections have been notifiable since 2007.

This article or paragraph presents the situation in Germany . Help us to describe the situation in other countries.

In Germany, the detection of methicillin-resistant strains of Staphylococcus aureus must be reported by name in accordance with Section 7 of the Infection Protection Act , as long as the evidence indicates an acute infection and the direct evidence is made from blood or liquor . In addition, the occurrence of two or more nosocomial infections for which an epidemic connection is likely or suspected must not be reported by name. ( § 6 Paragraph 3 IfSG).

literature

Web links

Commons : Staphylococcus aureus  - album with pictures, videos and audio files
Wiktionary: MRSA  - explanations of meanings, word origins, synonyms, translations

Individual evidence

  1. ^ Wilhelm Gemoll : Greek-German school and hand dictionary. Munich / Vienna 1965.
  2. ↑ George Y. Liu, Anthony Essex et al. a .: Staphylococcus aureus golden pigment impairs neutrophil killing and promotes virulence through its antioxidant activity. In: Journal of Experimental Medicine . Volume 202, 2005. PMID 16009720 , doi: 10.1084 / jem.20050846 , pp. 209-215.
  3. ↑ Mark A. Holmes, Ruth N. Zadoks: Methicillin Resistant S. aureus in Human and Bovine Mastitis
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