Environmental Methicillin-resistant <i>Staphylococcus aureus</i> Contamination, Persistent Colonization, and Subsequent Skin and Soft Tissue Infection
Authors: Patrick G. Hogan, Ryan L. Mork, Ryley M. Thompson, Carol E. Muenks, Mary G. Boyle, Melanie L. Sullivan, John J. Morelli, Caroline V. Williams, Nataly Sanchez, David A. Hunstad, Juliane Bubeck Wardenburg, Sarah J. Gehlert, Carey-Ann D. Burnham, Andrey Rzhetsky, Stephanie A. Fritz
Journal: JAMA Pediatrics (2020)

<h3>Importance</h3> The longitudinal association among persistent<i>Staphylococcus aureus</i>colonization, household environmental contamination, and recurrent skin and soft tissue infection (SSTI) is largely unexplored to date. <h3>Objectives</h3> To identify factors associated with persistent<i>S aureus</i>colonization and recurrent SSTI in households with children with community-associated methicillin-resistant<i>S aureus</i>(MRSA) SSTI. <h3>Design, Setting, and Participants</h3> This 12-month prospective cohort study included 150 children with community-associated MRSA SSTI, 542 household contacts, and 154 pets enrolled from January 3, 2012, through October 20, 2015. A total of 5 quarterly home visits were made to 150 households in the St Louis, Missouri, region. Statistical analysis was performed from September 18, 2018, to January 7, 2020. <h3>Exposures</h3> Covariates used in<i>S aureus</i>strain persistence and interval SSTI models included<i>S aureus</i>colonization and contamination measures, personal hygiene and sharing habits, health history, activities external to the home, and household characteristics (eg, cleanliness, crowding, home ownership, and pets). Serial samples to detect<i>S aureus</i>were collected from household members at 3 anatomic sites, from pets at 2 anatomic sites, and from environmental surfaces at 21 sites. <h3>Main Outcomes and Measures</h3> Molecular epidemiologic findings of<i>S aureus</i>isolates were assessed via repetitive-sequence polymerase chain reaction. Individual persistent colonization was defined as colonization by an identical strain for 2 consecutive samplings. Longitudinal, multivariable generalized mixed-effects logistic regression models were used to assess factors associated with persistent<i>S aureus</i>personal colonization, environmental contamination, and interval SSTI. <h3>Results</h3> Among 692 household members in 150 households, 326 (47%) were male and 366 (53%) were female, with a median age of 14.82 years (range, 0.05-82.25 years). Of 540 participants completing all 5 samplings, 213 (39%) were persistently colonized with<i>S aureus</i>, most often in the nares and with the strain infecting the index patient at enrollment. Nine pets (8%) were persistently colonized with<i>S aureus</i>. Participants reporting interval intranasal mupirocin application were less likely to experience persistent colonization (odds ratio [OR], 0.44; 95% credible interval [CrI], 0.30-0.66), whereas increasing strain-specific environmental contamination pressure was associated with increased individual persistent colonization (OR, 1.17; 95% CrI, 1.06-1.30). Strains with higher colonization pressure (OR, 1.47; 95% CrI, 1.25-1.71) and MRSA strains (OR, 1.57; 95% CrI, 1.16-2.19) were more likely to persist. Seventy-six index patients (53%) and 101 household contacts (19%) reported interval SSTIs. Individuals persistently colonized with MRSA (OR, 1.56; 95% CrI, 1.17-2.11), those with a history of SSTI (OR, 2.55; 95% CrI, 1.88-3.47), and index patients (OR, 1.54; 95% CrI, 1.07-2.23) were more likely to report an interval SSTI. <h3>Conclusions and Relevance</h3> The study findings suggest that recurrent SSTI is associated with persistent MRSA colonization of household members and contamination of environmental surfaces. Future studies may elucidate the effectiveness of specific combinations of personal decolonization and environmental decontamination efforts in eradicating persistent strains and mitigating recurrent SSTIs.