Influenza - Staphylococcus aureus co-infection - CDC Advisory

[sharon sanders]

<center>This is an official
CDC HEALTH ADVISORY</center>

Distributed via Health Alert Network
Wednesday, May 09, 2007, 11:15 EDT (11:15 AM EDT)
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<!-- font size="4"><center>Influenza-Associated Pediatric Mortality and the Increase of Staphylococcus aureus co-infection </center></font -->

Influenza-Associated Pediatric Mortality and the Increase of Staphylococcus aureus co-infection

CDC is requesting that states report all cases of influenza-related pediatric mortality from the 2006-2007 influenza season.
Since 2004, the Influenza-Associated Pediatric Mortality Surveillance System, part of the Nationally Notifiable Disease Surveillance System, has collected information on deaths among children due to laboratory-confirmed influenza, including the presence of other medical conditions and bacterial infections at the time of death. From October 1, 2006 through May 7, 2007, 55 deaths from influenza in children have been reported to CDC from 23 state health departments and two city health departments. Data on bacterial co-infections were reported for 51 cases; 20 (39%) had a bacterial co-infection, and 16/20 were infected with Staphylococcus aureus. While the number of pediatric influenza associated deaths is similar to that reported during the two previous years, there has been an increase in the number of deaths in which both influenza and pneumonia or bacteremia due to S. aureus were identified. Only one influenza and S. aureus co-infection was identified in 2004-2005, and 3 were identified in 2005-2006. Of the 16 children reported with S. aureus so far in 2006-2007, 11children had methicillin-resistant (MRSA) isolated from a sterile site (9) or sputum (2), and 5 had methicillin-susceptible S.aureus isolated from a sterile site (3) or sputum (2). The median age of children with S. aureus co-infection was older than children without S.aureus co-infection (11 years versus 4 years, p<.01) Children with influenza and S. aureus co-infections were reported to be in good health before illness onset but progressed rapidly to severe illness. Influenza strains isolated from these children have not been different from common strains circulating in the community and the MRSA strains have been typical of those associated with MRSA skin infection outbreaks in the United States.


Healthcare providers should be alerted to the possibility of bacterial co-infection among children with influenza, and request bacterial cultures when bacterial co-infection is suspected.



Clinicians, clinical agencies and medical examiners are asked to contact their local or state health department as soon as possible when deaths among children due to laboratory-confirmed influenza are identified. CDC requests that all cases of pediatric influenza-associated deaths be reported promptly by state health departments to CDC through http://sdn.cdc.gov and that information about bacterial pathogens isolated from sterile sites and/or from sputum or endotracheal aspirates be completed on the Influenza-Associated Pediatric Mortality Surveillance System case report form. If the influenza death was complicated by S. aureus infection, please contact the clinical agency to determine if the S. aureus isolate is available. CDC is interested in receiving S. aureus isolates to better characterize those from fatal cases of influenza in children.
If you have any questions about this Health Advisory, please call the Influenza Division, Epidemiology and Prevention Branch at 404-639-3727.

##This Message was distributed to State Epidemiologists##

[hawkeye]

Re: CDC Advisory - Staphylococcus aureus co-infection

Study: Superbugs Emerge Among Urban Poor
May 28, 4:48 PM (ET)

By CARLA K. JOHNSON
CHICAGO (AP) - Drug-resistant staph infections have spread to the urban poor, rising almost seven-fold in recent years in some Chicago neighborhoods, a new study finds.

Researchers said the crowded living conditions of public housing and jails may speed up the person-to-person spread of infection.

The superbugs, first seen mainly in hospitals and nursing homes, have turned up recently among athletes, prisoners and people who get illegal tattoos.

Called methicillin-resistant staphylococcus aureus, or MRSA, these staph germs can cause skin infections that in rare cases have led to pneumonia, bloodstream infections and a painful, flesh-destroying condition. MRSA is hard to treat because the bacteria have developed resistance to the penicillin drug family.

From 2000 to 2005, the infection rate seen in patients seeking care at Chicago's main public hospital and its affiliated clinics climbed from 24 cases per 100,000 to 164 cases per 100,000, the study found.

Dr. Bala Hota of Chicago's Stroger Hospital, a lead author of the study, said the increase is similar to that seen in other cities.

Public housing could be a bridge between high-risk people, the researchers wrote in their study, which appears in Monday's Archives of Internal Medicine.

Dr. Susan Gerber of Chicago's Department of Public Health said it would be a mistake to assume the infection isn't also in affluent neighborhoods. The study looked only at people using the public hospital system. The infection rate in the general population is unknown.

"This is an equal opportunity bacteria," Gerber said.

To prevent staph's spread, the U.S. Centers for Disease Control and Prevention recommends washing hands with soap and water or an alcohol-based sanitizer, keeping cuts clean and covered with a clean bandage until healed, avoiding contact with other people's wounds and bandages and avoiding shared personal items such as towels and razors.

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[Sally Furniss]

Re: Staphylococcus aureus co-infection - CDC Advisory

Rising Staphylococcus aureus Co-infection among Pediatric Influenza Deaths
By Amesh A. Adalja, M.D., October 10, 2008
The results of a study of pediatric influenza mortality for 3 influenza seasons (2004-2007), by investigators at the Centers for Disease Control and Prevention (CDC), were published in the October 2008 issue of Pediatrics. The authors report an increase in the incidence of bacterial co-infection in fatal pediatric influenza from 6% to 34% over the 3 year period. The chief pathogen was Staphylococcus aureus, with 64% of S.aureus isolates displaying resistance to methicillin (i.e. MRSA). Among the S.aureus co-infected children, pneumonia and acute respiratory distress syndrome (ARDS) were more common complications than in those not harboring the organism. Additionally, progression to death was quite rapid, occurring within 72 hours of onset in 45% of fatalities. Only 6% of victims who met indications for vaccination were fully immunized.¹
The study data was collected from reports of pediatric influenza deaths to CDC by state and local health departments, a requirement since October 2004. In total, 166 influenza-associated pediatric deaths were reported by 41 jurisdictions. The average age of the decedents was 5 years, and 45% of those studied had an Advisory Committee on Immunization Practices (ACIP) high-risk condition, such as asthma or cerebral palsy. While 45% of the victims died within 3 days, the median time between onset and death was 4 days, and 44% died at home or in the emergency department.¹
S.aureus-associated Complications
Bacterial co-infection among fatal pediatric cases was found to increase over the 3 seasons, peaking in 2006-07 with a rate of 34%. S.aureus was the major pathogen in each season. Older age, a higher prevalence of a radiographically confirmed pneumonia (64% vs. 28%), and a higher incidence of ARDS (45% vs. 10%) were found to be significantly more common in those co-infected with S.aureus.¹
Importance of MRSA
Although pediatric deaths from influenza remain rare, this study emphasizes the role of bacterial co-infection, exemplified by S.aureus, as an important etiologic factor that can result in deaths of pediatric flu patients. As indicated in a recent study, bacterial superinfection may have played a significant role in many deaths during the 1918 influenza pandemic.² The emergence of MRSA, and possibly its toxin-laden USA 300 strain, as the major bacterial co-pathogen may be behind the increased severity of illness seen in these patients.³
Call for Vaccination

Also underscored is the importance of vaccination in attenuating and halting influenza infection. Of note, the most recent CDC guidelines call for vaccination of all children above 6 months of age⁴, and a recent study by Zaman and colleagues highlighted the role of maternal immunization during pregnancy in protecting infants too young to receive the vaccine themselves.⁵
References

1. Finelli L, Fiore A, Dhara R, et al. Influenza-Associated Pediatric Mortality in the United States: Increase of Staphylococcus aureus Coinfection. Pediatrics. 2008;4:805-11. http://pediatrics.aappublications.or...ract/122/4/805. Accessed October 2, 2008
2. Morens DM, Taubenberger JK, Fauci AS. Predominant role of bacterial pneumonia as a cause of death in pandemic influenza: implications for pandemic influenza preparedness. J Infect Dis. 2008;198:962?70. http://www.journals.uchicago.edu/doi...10.1086/591708. Accessed October 2, 2008.
3. Micek ST, Dunne M, Kollef MH. Pleuropulmonary complications of Panton-Valentine leukocidin-positive community-acquired methicillin-resistant Staphylococcus aureus: importance of treatment with antimicrobials inhibiting exotoxin production. Chest. 2005;128:2732-38. http://www.chestjournal.org/cgi/content/full/128/4/2732. Accessed October 2, 2008.
4. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR. 2008;57[No. RR-7]:1-60. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5707a1.htm. Accessed October 2, 2008.
5. Zaman K, Roy E, Arifeen SE, et al. Effectiveness of Maternal Influenza Immunization in Mothers and Infants. N Engl J Med. 2008;359. Published online September 17, 2008. http://content.nejm.org/cgi/reprint/NEJMoa0708630v1.pdf. Accessed October 2, 2008.

http://www.upmc-cbn.org/report_archive/2008/10_October_2008/cbnreport_10092008.html