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Multidrug-resistant staphylococcal skin infections
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Management of multidrug-resistant staphylococcal infections poses a considerable challenge to veterinary practices, but the problem is not insurmountable with the right protocols in place, as this article describes.
Laura M. Buckley
BVetMed, CertVD, Dip ECVD, PgCLTHE, FHEA, MRCVS
Dr. Buckley qualified from London’s Royal Veterinary College in 2003 and worked for six years in general practice before undertaking a dermatology residency at the University of Liverpool. She then spent a year at a private referral dermatology practice before returning to the university in 2014, where she currently holds the post of Senior Lecturer in Veterinary Dermatology. She is both a RCVS and EBVS® European Specialist in Veterinary Dermatology.
![Laura Buckley](/sites/default/files/images/media/image/Buckley%20L_0.jpg)
Eleanor K. Wyatt
BVSc, MRCVS
Dr. Wyatt qualified from the University of Liverpool in 2016 and worked for two years in small animal first opinion practice before returning to the University’s Small Animal Teaching Hospital to complete a 13-month rotating internship. She is currently undertaking an ECVD Residency in veterinary dermatology.
![Eleanor K Wyatt](/sites/default/files/images/media/image/Wyatt%20EK.jpg)
Keypoints
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Multidrug-resistant Staphylococcus species may be transmitted between dogs, from dogs to humans, and from humans to dogs.
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Known risk factors for colonization by multidrug-resistant Staphylococci may serve as a guide for clinicians to initiate testing.
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If antibiotics are required, a suitable protocol must be selected in order to reduce the risk of development of further multidrug-resistant organisms.
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The prognosis for recovery from multidrug-resistant staphylococcal infection is comparable to wild-type infection, as long as any underlying disease is treatable.
Introduction
Infections with multidrug-resistant staphylococci (MDRS) are commonly encountered in both human and veterinary medicine, and such infections are challenging on both an individual case basis and a community level. The prevention of colonization and infection with MDRS is important in maintaining the health of patients, veterinary staff and the public, and there have been numerous publications concerning the risk factors for development of, testing for, and treatment of MDRS in recent years. This article provides a practical overview of MDRS infection in dogs, including how and when to test, the implications for the home and veterinary practice environments, and management strategies to both resolve infection and prevent re-infection.
What’s the background of Staphylococcus species?
Staphylococcus is a genus of Gram-positive, coccoid bacteria that can be classified into several groups. In the veterinary field the most significant groups are coagulase-positive S. intermedius (S. pseudintermedius, S. delphini and S. intermedius) and S. aureus (1).
S. pseudintermedius is the most common bacteria isolated from healthy dogs, with the highest carriage rates (in descending order) on the oral mucosa, perianal skin, nasal mucosa and groin (1), and it has been shown that dogs with atopic dermatitis have a higher colonization rate compared to their healthy counterparts (2). S. aureus is a commensal of the skin and nasopharynx of healthy humans and, as with S. pseudintermedius, can also be an opportunistic pathogen (3).
Colonization and subsequent infection by staphylococci occur via bacterial adhesion to corneocytes, but this is variable. It is known that S. pseudintermedius adheres with greater affinity to canine over human corneocytes (1), whereas S. aureus has a lower affinity for canine compared to human corneocytes, and canine nasal carriage of methicillin-resistant S. aureus (MRSA) is thought to resolve rapidly without treatment (4). Transmission of S. pseudintermedius from dogs to humans is possible but uncommon. Following adhesion to corneocytes, indirect transmission of both susceptible and MDRS species may occur via shedding of desquamated cells into the environment, and it is therefore important to implement infection control whether there is active infection or simply colonization with MDRS.
How is multidrug resistance defined?
Multidrug resistance (MDR) is not a term exclusive to staphylococci, as it defines any bacteria showing resistance to one or more antibiotics in at least three different classes; for example, S. pseudintermedius showing resistance to cephalexin, clindamycin and doxycycline, or Pseudomonas aeruginosa showing resistance to marbofloxacin (or enrofloxacin), gentamicin and polymyxin B (5). Methicillin-resistant staphylococci (MRS) defines a genetically distinct group of staphylococci with resistance to β-lactam antibiotics. The resistance is due to acquisition of the mecA gene that encodes for penicillin-binding protein (PBP2a), a transpeptidase involved in bacterial cell wall synthesis. PBP2a has a lower affinity for β-lactam antibiotics than other transpeptidases (6), and the mecA gene confers resistance to most β-lactam antibiotics including methicillin, penicillin and the majority of cephalosporins. With MRSA, progression to multidrug resistance occurs with the accumulation of multiple resistance genes around the mecA gene inside the bacterial “cassette” (the SCCmec) (7).
In humans there are two main routes of infection by MRSA: hospital associated, and community acquired. The hospital infections are nosocomial (i.e., acquired whilst the patient is hospitalized or undergoes a medical procedure) whilst the latter occur in patients with no healthcare contact, and have distinct pheno- and genotypes distinguishing them from hospital-acquired MRSA (8). In dogs, cutaneous infections with MRSA are much less common than infections with methicillin-resistant S. pseudintermedius (MRSP) (9).
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