NASAL CARRIAGE OF STAPHYLOCOCCUS AUREUS: THE KEY TO
PREVENTING STAPHYLOCOCCAL DISEASE

II

Nasal carriage of Staphylococcus aureus: the key to preventing staphylococcal d(sease
Jan Kluytmans.
Thesis Erasmus University Rotterdam, The Netherlands
ISBN 90-9009776-7
NUGI742
Subject headings: Staphylococcus aureus; surgical site infection; epidemiology; mupirocin.
Cover design by Dick Bezem
Uthografie by DataLitho bY, Aalsmeer, The Netherlands
Typografie by MegaSet by, Aalsmeer, The Netherlands
Printing by MurKostver[oren by, Aalsmeer, The Netherlands

©1996 Jan AJ.W. Kluytmans. No part of this material protected by this copyright notice may be reproduced, or utilized in any form or by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission of the author or, where appropiate, of the publishers of the publications.

III

NASAL CARRIAGE OF STAPHYLOCOCCUS AUREUS:
THE KEY TO PREVENTING STAPHYLOCOCCAL DISEASE

NEUSDRAGERSCHAP VAN STAPHYLOCOCCUS AUREUS:
DE SLEUTEL TOT DE PREVENTIE VAN STAPHYLOCOCCEN INFECTIES

PROEFSCHRIFT ter verkrijging van de graad van doctor aan de Erasmus Universiteit Rotterdam op gezag van de Rector Magni!icus
Prof. dr. P.W.C. Akkermans M.A. en volgens besluit van het college voor promoties.

De open bare verdediging zal plaatsvinden op woensdag 30 oktober 1996 am 13.45 uur

door
Johannes Adrianus Jacobus Wilhelm us Kluytmans geboren te Oisterwijk

IV
PROMOTIECOMMISSIE
Promotor:

Prof. Dr. H. A. Verbrugh

Promotor:

Prof. Dr. M. F. Michel

Overige leden:

Prof. Dr. H. A. Bruining
Prof. Dr. J. Dankert
Prof. Dr. C. M. J. E. VandenBroucke-Grauls

Copromotor:

Dr. J. H. T. Wagenvoort

v

Aan mljn Duders

VI
CONTENTS

Introduction
Chapter 1:
Part 1:
Part 2:
Part 3:
Part 4:

Surgical wound infections in cardio-thoracic surgery
Surveillance of postoperative infections in thoracic surgery
Nasal carriage of Staphylococcus aureus as a major risk factor for wound infections after cardiac surgery
Reduction of surgical site infections in cardio-thoracic surgery by elimination of nasal carriage of Staphylococcus aureus
Cost-effectiveness of perioperative mupirocin nasal ointment in cardia-thoracic surgery

7

17

25
35

Chapter 2: Bacteremia in patients on hemodialysis
Part 1:

Prevention of Staphylococcus aureus bacteremia in hemodialysis patients by. elimination of nasal carriage using mupirocin

47

Chapter 3: Epidemiology
Part 1:

Global epidemiology of methicillin-resistant Staphylococcus

aureus
Part 2:

55

Epidemiology and risks associated with nasal carriage of
Staphylococcus aureus

61

Chapter 4: Molecular biological typing methods
Part 1:
Part 2:

Multicenter evaluation of arbitrarily primed PCR for typing of
Staphylococcus Bureus strains
Food-initiated outbreak of methicillin-resistant Staphylococcus aureus analyzed by pheno- and genotyping

91
109

Summary and conclusions

127

Publications

135

Curriculum vitae

138

INTRODUCTION

4

INTRODUCTION

environment. Strains which cause outbreaks in hospitals are often resistent against commonly used antimicrobial agents, e.g. Jj-Iactams. In chaper 3 the extensive literature on this subject was critically reviewed. The focus in part 1 was on the current epidemiology of methicillin-resistant S. aureus and in part 2 on nasal carriage. The epidemiology, underlying mechanisms, identification of patients at risk of infection and effects of elimination strategies are discussed.
To elucidate the epidemiological behaviour of S. aureus it is essential to have reliable typing methods available. Recently developed molecular typing techniques seem highly promising.
Several of these genotyping techniques are evaluated in chapter 4. In a multicenter study the reproducibility of the arbitrary primer polymerase chain reaction was