methicillin-resistant staphylococcus aureus and the emerging risk factors for infection in dogs and...

METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS AND THE EMERGING RISK FACTORS

FOR INFECTION IN DOGS AND CATS

Jonathan M. Chapman, DVM, MPH, CPHSmall Animal Veterinarian Intern

VCA Arboretum View Animal HospitalAdvancing Topics in Veterinary Medicine Seminar

June 22, 2016

PRESENTATION OUTLINE Brief overview and history of Methicillin-

Resistant Staphylococcus aureus (MRSA) MRSA in the 21st century Emerging risk factors for infection Prevention Summary and recommendations

FACTS ABOUT METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Methicillin Resistant Staphylococcus aureus (MRSA) is a S. aureus organism that acquired the mecA gene The mecA gene encodes a protein (PBP2A) that

reduces the binding affinity of beta-lactam drugs1, 2

May also possess mutations for resistance to other antimicrobials3

1Weese JS. Methicillin-Resistant Staphylococcus aureus: An Emerging Pathogen in Small Animals. J Am Anim Hosp Assoc 2005;41[3]:150-7 2Duquette RA, Nuttall TJ. Methicillin-Resistant Staphylococcus aureus in dogs and cats: an emerging problem? J Small Anim Pract 2004;45[12]:591-73Rich M. Staphylococci in animal: prevalence, identification and antimicrobial susceptibility, with an emphasis on methicillin-resistant Staphylococcus aureus. Br J

Biomed Sci. 2005;62(2):98-105

FACTS ABOUT METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS

Staphylococcus aureus is often a commensal organism in humans Colonized in the nasal passages of 29-38% of

people Between 30-40% of S. aureus infections are

methicillin resistant Colonization estimated to be in 0.8-3.5% of

people Increased risk in healthcare workers

Veterinarians Veterinary technicians Human physicians Nurses1

1Kottler, S., Middleton, J., Perry, J., Weese, J., & Cohn, L. (2010). Prevalence of Staphylococcus aureus and Methicillin-Resistant Staphylococcus aureus Carriage in Three Populations. Journal of Veterinary Internal Medicine, 24(1), 132-139. doi:10.1111/j.1939-1676.2009.0424.x

CLINICAL OVERVIEW OF MRSA Low overall prevalence of MRSA in companion animals

Suspected to first arise from human contact Reverse zoonosis1

Clinical signs Most companion animals do not develop clinical signs Superficial pyoderma

Papules, pustules, crusts, scaling, erythema, hair loss Deep pyoderma

Nodules, bullae, thick crusts, or ulcerations Diagnosis

Optimal screening tests have not been identified Cytology

Confirms presence of bacteria Bacterial culture and antimicrobial sensitivity

Culture swab of otic exudate or skin lesions Punch biopsy of skin lesions

Treatment Antimicrobial therapy based on culture and sensitivity for active infections Topical antimicrobial shampoos (ie. containing chlorhexidine) Owners to practice appropriate hand hygiene2

1Coyner, K. S., DVM, DACVD. (2014). The emergence and prevalence of MRSA, MRSP, and MRSS in pets and people. Retrieved June 13, 2016, from http://veterinarymedicine.dvm360.com/emergence-and-prevalence-mrsa-mrsp-and-mrss-pets-and-people

2Coyner, K. S., DVM, DACVD. (2014). Managing MRSA, MRSP, and MRSS dermatologic infections in pets. Retrieved June 13, 2016, from http://veterinarymedicine.dvm360.com/managing-mrsa-mrsp-and-mrss-dermatologic-infections-pets

HISTORY OF MRSA MRSA was first recognized as a human infection in 1961 in the U.K.

One year after methicillin was introduced for treating Staphylococcus aureus

Hospital-associated (HA-MRSA) infection The first documented MRSA outbreak in the U.S. occurred in 1968

at a human hospital in Boston1

MRSA was first reported in animals in 1972 during a case of mastitis in a dairy cow2

Community-associated (CA-MRSA) infections started occurring in the 1990’s in humans Minimal to no known hospital exposure Identification of MRSA in various animal species increased

Companion animals3

1Minnesota Department of Health. (n.d.). MRSA. Retrieved June 13, 2016, from http://www.health.state.mn.us/divs/idepc/diseases/mrsa/basics.html 2Datz, C. A., DVM, ABVP, Evans, A. G., DVM, MBA, ACVD, Griffeth, G. C., DVM, Weese, S., DVM, DACVIM, & Wolf, A., DVM, DACVIM, ABVP. (2005, May 06).

Methicillin-Resistant Staphylococcus Aureus. Retrieved June 13, 2016, from http://www.vin.com/members/cms/project/defaultadv1.aspx?id=3854891&pid=11200& 3Dawson, S., BVMS, PhD. (n.d.). MRSA: An Update in Humans and Animals: British Small Animal Veterinary Congress 2011. Retrieved June 13, 2016, from

http://www.vin.com/members/cms/project/defaultadv1.aspx?id=4823204&pid=11328&

STUDYING MRSA IN THE 21ST CENTURY

Study conducted in 2012 enrolled 50 households of children with active or recent MRSA infection in St. Louis, MO Examined the prevalence of environmental MRSA

Culture samples were collected Nares, axillae, inguinal folds of people Environmental surfaces Pet dogs and cats

MRSA was recovered from culture samples Colonized people in 30% of households Recovered from environmental surfaces in 23 households (46%)

Bed linens (18%) TV remote (16%) Bathroom towels (15%)

Colonized 3/26 (12%) of dogs and 1/14 (7%) of cats All reportedly healthy at the time of study 1/7 colonized pets (14%, dog) had a skin infection in past 6 months

compared to 4/33 (12%, all dogs) non-colonized pets1

1Fritz, S. A., Hogan, P. G., Singh, L. N., Thompson, R. M., Wallace, M. A., Whitney, K., . . . Fraser, V. J. (2014). Contamination of Environmental Surfaces With Staphylococcus

aureus in Households With Children Infected With Methicillin-Resistant S aureus. JAMA Pediatrics JAMA Pediatr, 168(11), 1030. doi:10.1001/jamapediatrics.2014.1218

STUDYING MRSA IN THE 21ST CENTURY

Study in 2007 of 197 animals from 150 veterinary practices in the U.K. aimed to identify risk factors 105 cases with MRSA 92 controls with methicillin-susceptible S. aureus (MSSA)

Identified several risk factors Number of antimicrobial courses Number of days admitted to a veterinary hospital Having received surgical implants Contact with humans having been ill or admitted to a

hospital Highlighted future needs regarding MRSA infection

Increase priority for identifying at-risk companion animal groups

Promote responsible and careful use of antimicrobial therapy1

1Magalhães, R. J., Loeffler, A., Lindsay, J., Rich, M., Roberts, L., Smith, H., . . . Pfeiffer, D. U. (2010). Risk factors for methicillin-resistant Staphylococcus aureus

(MRSA) infection in dogs and cats: A case-control study. Vet. Res. Veterinary Research, 41(5), 55. doi:10.1051/vetres/2010028

EMERGING RISK FACTORS FOR MRSA IN DOGS AND CATS

Study performed in 2013 at The Ohio State University Veterinary Medical Center Identified risk factors in MRSA carrier dogs Enrolled 435 dogs over a 1-year study period

through the OSU MRSA active surveillance program

Dogs were screened for MRSA on arrival to the hospital Regardless of health status, sex, breed, or age

Epidemiological survey and medical history were obtained for each dog Identify risk factors up to 1 year prior to

screening11Hoet, A. E., Balen, J. V., Nava-Hoet, R. C., Bateman, S., Hillier, A., Dyce, J., & Wittum, T. E. (2013). Epidemiological Profiling of Methicillin-Resistant Staphylococcus aureus –

Positive Dogs Arriving at a Veterinary Teaching Hospital. Vector-Borne and Zoonotic Diseases, 13(6), 385-393. doi:10.1089/vbz.2012.1089


25/435 (5.7%) dogs were MRSA positive 4/25 of the MRSA carrier dogs were healthy 20/25 dogs had health issues unrelated to MRSA 1/25 dogs had an active MRSA infection

MRSA was detected in several areas around the dogs Nares (18/25, 72%) Skin lesions (6/25, 24%) Perianal area (4/25, 16%)1

1Hoet, A. E., Balen, J. V., Nava-Hoet, R. C., Bateman, S., Hillier, A., Dyce, J., & Wittum, T. E. (2013). Epidemiological Profiling of Methicillin-Resistant Staphylococcus aureus –



Variables insignificant to MRSA infection Previous medical history

Except previous surgery within <90 days Dog’s management Home environment

Factors significantly associated with MRSA infection Previous surgery within <90 days Profession of the owner

Dogs owned by veterinary students were 20.5 x more likely to be positive for MRSA infection1




Creating an epidemiological profile was difficult Attempted early recognition of potential MRSA

carrier dogs upon arrival to a veterinary hospital MRSA-positive dogs were dispersed into different

categories Study highlighted concerns in need of further

evaluation Association between veterinary students or personnel and

MRSA-positive dogs1

To date, no such study has been performed




A concurrent study at OSU aimed to better understand the dynamics of MRSA in the hospital 1-year study period through the OSU MRSA active

surveillance program Conducted monthly sampling events of

surfaces around the hospital1

1Balen, J. V., Kelley, C., Nava-Hoet, R. C., Bateman, S., Hillier, A., Dyce, J., . . . Hoet, A. E. (2013). Presence, Distribution, and Molecular Epidemiology of Methicillin-Resistant

Staphylococcus aureus in a Small Animal Teaching Hospital: A Year-Long Active Surveillance Targeting Dogs and Their Environment. Vector-Borne and Zoonotic Diseases, 13(5), 299-311. doi:10.1089/vbz.2012.1142


13.5% of surfaces in the hospital were contaminated with MRSA at 1 or more sampling events throughout the year

Some surfaces were consistently contaminated Carts Gurneys Doors Examination tables Exam room floors1




Further analysis discovered other findings Incoming MRSA-positive dogs introduced

different strains of MRSA into the hospital The different strains of MRSA would be

maintained and spread throughout the hospital for extended periods of time

The findings from this study were proposed to help develop biosecurity and biocontainment protocols at OSU Reduce environmental contamination Reduce potential exposure to MRSA in veterinary

hospital staff, clients, and patients1




Numerous other studies reiterated similar results for MRSA-related risk factors Number of antibiotics treatments Surgical implantation or surgical site infection Number of days admitted to a veterinary hospital Veterinary-related occupation of owner Contact with humans having been ill or admitted

to a human hospital1, 2, 3

1Dowling, P., DVM, MSc, DACVIM, DACVCP. (2012). MRSA and MRSP in Small Animals - WVC2012. Western Veterinary Conference 2012. Retrieved May 4, 2016. 2Eckholm, N. G., Outerbridge, C. A., White, S. D., & Sykes, J. E. (2013). Prevalence of and risk factors for isolation of meticillin-resistant Staphylococcus spp. from dogs with

pyoderma in northern California, USA. Veterinary Dermatology, 24(1). doi:10.1111/j.1365-3164.2012.01051.x 3Vincze, S., Brandenburg, A. G., Espelage, W., Stamm, I., Wieler, L. H., Kopp, P. A., . . . Walther, B. (2014). Risk factors for MRSA infection in companion animals: Results from a

case–control study within Germany. International Journal of Medical Microbiology, 304(7), 787-793. doi:10.1016/j.ijmm.2014.07.007

PREVENTION The key to preventing or minimizing MRSA

colonization is stringent infection control practices Limit high risk contact

Ex. Surgery patients, hospital staff pets Designate certain areas to high risk patients Thorough disinfection of designated areas

Ex. ICU, surgical areas, kennels Frequent hand hygiene1

Other actions to prevent or minimize MRSA colonization Judicious use of antibiotics Limit hospital admissions and length of hospital stay Limit contact with hospital staff pets

1Coyner, K. S., DVM, DACVD. (2014). Managing MRSA, MRSP, and MRSS dermatologic infections in pets. Retrieved June 13, 2016, from http://veterinarymedicine.dvm360.com/managing-mrsa-mrsp-and-mrss-dermatologic-infections-pets

SUMMARY AND RECOMMENDATIONS There are several risk factors for MRSA infection We as veterinary professionals need to be more

cognizant of the risk factors for MRSA infection during everyday practice

Prevention measures need to be put in place and enforced for human and animal health

Further studies need to be done regarding MRSA, especially in veterinary staff

Overall, the occurrence of MRSA in apparently healthy pets in addition to diseased animals further illustrates the importance of MRSA as an emerging veterinary pathogen and a public health burden

ACKNOWLEDGEMENTS Intern director: Joao Felipe de Brito Galvao, MV, MS,

DACVIM My mentor: Kathleen Van Lanen, DVM, DACVECC My Internmates:

Christina Mazulis, DVM Jenifer Sniezek, DVM Scott Wood, DVM

Lindsay McKay, DVM, DACVD All the doctors and staff at VCA Arboretum View

Animal Hospital

ANY QUESTIONS?

REFERENCESBalen, J. V., Kelley, C., Nava-Hoet, R. C., Bateman, S., Hillier, A., Dyce, J., . . . Hoet, A. E. (2013). Presence, Distribution, and Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus in a Small Animal Teaching Hospital: A Year-Long Active Surveillance Targeting Dogs and Their Environment. Vector-Borne and Zoonotic Diseases, 13(5), 299-311. doi:10.1089/vbz.2012.1142 Coyner, K. S., DVM, DACVD. (2014). Managing MRSA, MRSP, and MRSS dermatologic infections in pets. Retrieved June 13, 2016, from http://veterinarymedicine.dvm360.com/managing-mrsa-mrsp-and-mrss-dermatologic-infections-pets Coyner, K. S., DVM, DACVD. (2014). The emergence and prevalence of MRSA, MRSP, and MRSS in pets and people. Retrieved June 13, 2016, from http://veterinarymedicine.dvm360.com/emergence-and-prevalence-mrsa-mrsp-and-mrss-pets-and-people Datz, C. A., DVM, ABVP, Evans, A. G., DVM, MBA, ACVD, Griffeth, G. C., DVM, Weese, S., DVM, DACVIM, & Wolf, A., DVM, DACVIM, ABVP. (2005, May 06). Methicillin-Resistant Staphylococcus Aureus. Retrieved June 13, 2016, from http://www.vin.com/members/cms/project/defaultadv1.aspx?id=3854891&pid=11200& Dawson, S., BVMS, PhD. (n.d.). MRSA: An Update in Humans and Animals: British Small Animal Veterinary Congress 2011. Retrieved June 13, 2016, from

http://www.vin.com/members/cms/project/defaultadv1.aspx?id=4823204&pid=11328& Dowling, P., DVM, MSc, DACVIM, DACVCP. (2012). MRSA and MRSP in Small Animals - WVC2012. Western Veterinary Conference 2012. Retrieved May 4,

2016. Duquette RA, Nuttall TJ. Methicillin-Resistant Staphylococcus aureus in dogs and cats: an emerging problem? J Small Anim Pract 2004;45[12]:591-7Eckholm, N. G., Outerbridge, C. A., White, S. D., & Sykes, J. E. (2013). Prevalence of and risk factors for isolation of meticillin-resistant Staphylococcus spp. from dogs with pyoderma in northern California, USA. Veterinary Dermatology, 24(1). doi:10.1111/j.1365-3164.2012.01051.x Fritz, S. A., Hogan, P. G., Singh, L. N., Thompson, R. M., Wallace, M. A., Whitney, K., . . . Fraser, V. J. (2014). Contamination of Environmental Surfaces With

Staphylococcus aureus in Households With Children Infected With Methicillin-Resistant S aureus. JAMA Pediatrics JAMA Pediatr, 168(11), 1030. doi:10.1001/jamapediatrics.2014.1218 Hoet, A. E., Balen, J. V., Nava-Hoet, R. C., Bateman, S., Hillier, A., Dyce, J., & Wittum, T. E. (2013). Epidemiological Profiling of Methicillin-Resistant Staphylococcus aureus -Positive Dogs Arriving at a Veterinary Teaching Hospital. Vector-Borne and Zoonotic Diseases, 13(6), 385-393. doi:10.1089/vbz.2012.1089 Kottler, S., Middleton, J., Perry, J., Weese, J., & Cohn, L. (2010). Prevalence of Staphylococcus aureus and Methicillin-Resistant Staphylococcus aureus Carriage in Three Populations. Journal of Veterinary Internal Medicine, 24(1), 132-139. doi:10.1111/j.1939-1676.2009.0424.x Magalhães, R. J., Loeffler, A., Lindsay, J., Rich, M., Roberts, L., Smith, H., . . . Pfeiffer, D. U. (2010). Risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection in dogs and cats: A case-control study. Vet. Res. Veterinary Research, 41(5), 55. doi:10.1051/vetres/2010028 Minnesota Department of Health. (n.d.). MRSA. Retrieved June 13, 2016, from http://www.health.state.mn.us/divs/idepc/diseases/mrsa/basics.htmlRich M. Staphylococci in animal: prevalence, identification and antimicrobial susceptibility, with an emphasis on methicillin-resistant Staphylococcus aureus. Br J Biomed Sci. 2005;62(2):98-105Vincze, S., Brandenburg, A. G., Espelage, W., Stamm, I., Wieler, L. H., Kopp, P. A., . . . Walther, B. (2014). Risk factors for MRSA infection in companion animals: Results from a case–control study within Germany. International Journal of Medical Microbiology, 304(7), 787-793. doi:10.1016/j.ijmm.2014.07.007 Weese JS. Methicillin-Resistant Staphylococcus aureus: An Emerging Pathogen in Small Animals. J Am Anim Hosp Assoc 2005;41[3]:150-7

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methicillin-resistant staphylococcus aureus and the emerging risk factors for infection in dogs and...

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