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Research since the early 1970s has generated significant support for the concept that clinical manifestations of infectious diseases are often due more to the host immune response rather than to direct effects of a particular microbe. Perhaps the longest recognized example of the dominance of an immune response in determining a clinical presentation occurs in Mycobacterium leprae infection. However, the introduction of highly active antiretroviral therapy (HAART) for the treatment of human immunodeficiency virus (HIV) infection has markedly increased the appreciation for the dramatic interaction that can occur between microbes and a recovering immune system. The immune restoration mediated by HAART has markedly decreased the rates of opportunistic infections among HIV-infected patients, leading to dramatically lower mortality rates. However, in some patients, the recovery of immune function can lead to an inflammatory reaction aimed at either previously recognized or subclinical microbes or even autoimmune disorders. Multiple names have been given to this syndrome, including immune recovery disease, immune restoration disease, and immunoreconstitution disease. For the purposes of this chapter, we will utilize the term immune reconstitution inflammatory syndrome (IRIS) as it includes one of the defining features of these patients' presentations, i.e., inflammation.
Methicillin-resistant Staphylococcus aureus (MRSA) isolates from patients with community-associated infection have been described as strains genetically distinct from the strains isolated from patients with healthcare-associated infection. This study examines the hypothesis that community-associated MRSA (CA-MRSA) strains now cause serious infections in hospitalized patients.
Thirty-seven clinical MRSA isolates were randomly selected from blood isolates obtained from July 2003 through June 2004. Strains were tested for staphylococcal chromosomal cassette mec (SCCmec) type, pulsed-field gel electrophoresis (PFGE) type, and presence of Panton-Valentine leukocidin (PVL) genes. Medical records review and epidemiologic classification was performed by an investigator blinded to the results of the bacterial strain analysis. Episodes of bloodstream infection were independently classified as either community-associated or healthcare-associated infections, and bacterial isolates were independently classified as either CA-MRSA strains or healthcare-associated MRSA (HA-MRSA) strains, according to established definitions.
A tertiary care Veterans Affairs Medical Center.
Twenty-four (65%) of 37 MRSA isolates were SCCmec type IV, a genetic type characteristic of CA-MRSA strains; 22 of these 24 isolates belonged to the CA-MRSA clone USA300 and carried PVL genes. Thirteen (35%) of the 37 strains were SCCmec type II, of which 12 were USA100-ST5 and 12 lacked PVL genes. Thirty patients (81%) had healthcare-associated infections; 18 (60%) of these 30 were infected with isolates carrying markers of CA-MRSA strains. Of 7 patients with CA-MRSA infections, 6 were infected with isolates belonging to the USA300 clone. Patients with healthcare-associated bloodstream infections were as likely to be infected with a CA-MRSA strain as patients with a community-associated infection (P = .38).
MRSA strains with molecular characteristics of CA-MRSA strains have emerged as an important cause of serious health-care-associated infection in our hospital.
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