Methicillin-resistant Staphylococcus aureus

MRSA redirects here. For other uses, see MRSA

(disambiguation).

initial topical symptoms. After 72 hours, MRSA can

take hold in human tissues and eventually become resistant to treatment. The initial presentation of MRSA is
small red bumps that resemble pimples, spider bites, or
boils; they may be accompanied by fever and, occasionally, rashes. Within a few days, the bumps become larger
and more painful; they eventually open into deep, puslled boils.[5] About 75 percent of community-associated
(CA-) MRSA infections are localized to skin and soft
tissue and usually can be treated eectively.[6] Some
CA-MRSA strains display enhanced virulence, spreading
more rapidly and causing illness much more severe than
traditional HA-MRSA infections, and they can aect vital organs and lead to widespread infection (sepsis), toxic
shock syndrome, and necrotizing pneumonia. This is
thought to be due to toxins carried by CA-MRSA strains,
such as PVL and PSM, though PVL was recently found
not to be a factor in a study by the National Institute of Allergy and Infectious Diseases at the National Institutes of
Health. It is not known why some healthy people develop
CA-MRSA skin infections that are treatable while others
infected with the same strain develop severe infections or
die.[7]

Methicillin-resistant Staphylococcus aureus (MRSA)

(/mrse/ or /mrs/) is a bacterium responsible for
several dicult-to-treat infections in humans. It is
also called oxacillin-resistant Staphylococcus aureus
(ORSA).[1] MRSA is any strain of Staphylococcus aureus that has developed, through the process of natural
selection, resistance to beta-lactam antibiotics, which include the penicillins (methicillin, dicloxacillin, nafcillin,
oxacillin, etc.) and the cephalosporins. Strains unable
to resist these antibiotics are classied as methicillinsensitive Staphylococcus aureus, or MSSA. The evolution
of such resistance does not cause the organism to be more
intrinsically virulent than strains of S. aureus that have no
antibiotic resistance, but resistance does make MRSA infection more dicult to treat with standard types of antibiotics and thus more dangerous.
MRSA is especially troublesome in hospitals, prisons,
and nursing homes, where patients with open wounds,
invasive devices, and weakened immune systems are
at greater risk of nosocomial infection than the general public. MRSA began as a hospital-acquired infection, but has developed limited endemic status and is
now sometimes community-acquired. The terms HAMRSA (healthcare-associated MRSA) and CA-MRSA
(community-associated MRSA) reect this distinction.

People are occasionally colonized with CA-MRSA and

are completely asymptomatic. The most common manifestations of CA-MRSA are simple skin infections, such
as impetigo, boils, abscesses, folliculitis, and cellulitis.
Rarer, but more serious, manifestations can occur, such
as necrotizing fasciitis and pyomyositis (most commonly found in the tropics), necrotizing pneumonia, and
infective endocarditis (which aects the valves of the
heart), and bone and joint infections.[8] CA-MRSA often results in abscess formation that requires incision and
drainage. Before the spread of MRSA into the community, abscesses were not considered contagious, because
infection was assumed to require violation of skin integrity and the introduction of staphylococci from normal
skin colonization. However, newly emerging CA-MRSA
is transmissible (similar, but with very important dierences) from HA-MRSA. CA-MRSA is less likely than
other forms of MRSA to cause cellulitis.

Signs and symptoms

S. aureus most commonly colonizes under the anterior

nares (the nostrils).[2] The rest of the respiratory tract,
open wounds, intravenous catheters, and the urinary
tract are also potential sites for infection. Healthy individuals may carry MRSA asymptomatically for periods ranging from a few weeks to many years. Patients
with compromised immune systems are at a signicantly
greater risk of symptomatic secondary infection.

In most patients, MRSA can be detected by swabbing the

nostrils and isolating the bacteria found inside the nostrils.
Combined with extra sanitary measures for those in con- 2 Risk factors
tact with infected patients, swab screening patients admitted to hospitals has been found to be eective in min- Some of the populations at risk:
imizing the spread of MRSA in hospitals in the United
States,[3] Denmark, Finland, and the Netherlands.[4]
People who are frequently in crowded places, esMRSA may progress substantially within 2448 hours of
pecially with shared equipment and skin-to-skin
1

RISK FACTORS

contact[9]

reported on the changing epidemiology of MRSA skin

infection in the San Francisco County Jail, noting MRSA
People with weak immune systems (HIV/AIDS, accounted for more than 70% of S. aureus infection in
lupus, or cancer suerers; transplant recipients, se- the jail by 2002. Lowy and colleagues reported on frevere asthmatics, etc.)
quent MRSA skin infections in New York state prisons.
Two reports on inmates in Maryland have demonstrated
[10]
Diabetics
frequent colonization with MRSA.
Intravenous drug users[11][12]
In the news media, hundreds of reports of MRSA out Users of quinolone antibiotics[13]
The elderly[14]
College students living in dormitories[9]
Women with frequent urinary tract or kidney infections due to infections in the bladder
People staying or working in a health care facility
for an extended period of time[9]
People who spend time in coastal waters where
MRSA is present, such as some beaches in Florida
and the west coast of the United States[15][16]

breaks in prisons appeared between 2000 and 2008. For

example, in February 2008, the Tulsa County jail in
Oklahoma started treating an average of 12 S. aureus
cases per month.[21] A report on skin and soft tissue infections in the Cook County jail in Chicago in 2004
05 demonstrated MRSA was the most common cause
of these infections among cultured lesions, and few risk
factors were more strongly associated with MRSA infections than infections caused by methicillin-susceptible S.
aureus. In response to these and many other reports on
MRSA infections among incarcerated and recently incarcerated persons, the Federal Bureau of Prisons has released guidelines for the management and control of the
infections, although few studies provide an evidence base
for these guidelines.

People who spend time in conned spaces with

other people, including occupants of homeless shelters and warming centers, prison inmates, military 2.3 Livestock
recruits in basic training,[17] and individuals who
spend considerable time in changing rooms or gyms Cases of MRSA have increased in livestock animals.
CC398, a new variant of MRSA, has emerged in ani Veterinarians, livestock handlers, and pet owners[18]
mals and is found in intensively reared production animals (primarily pigs, but also cattle and poultry), where it
can be transmitted to humans. Though dangerous to hu2.1 Hospital patients
mans, CC398 is often asymptomatic in food-producing
[22]
In a single study conducted in Denmark,
Many MRSA infections occur in hospitals and health- animals.
MRSA
was
shown
to originate in livestock and spread to
care facilities. Infections occurring in this manner are
[23]
humans,
though
the MRSA strain may have originated
known as healthcare acquired MRSA (HA-MRSA). The
in
humans
and
was
transmitted to livestock.[24]
rates of MRSA infection are also increased in hospitalized patients who are treated with quinolones. Healthcare
provider-to-patient transfer is common, especially when
healthcare providers move from patient to patient without performing necessary hand-washing techniques between patients.[13][19] Online tools predicting probability
of nasal carriage in hospital admissions are available.[20]

2.2

Prison inmates, military recruits, and

the homeless

Prisons, military barracks, and homeless shelters can be

crowded and conned, and poor hygiene practices may
proliferate, thus putting inhabitants at increased risk of
contracting MRSA.[18] Cases of MRSA in such populations were rst reported in the United States, and then in
Canada. The earliest reports were made by the Center for
Disease Control (CDC) in US state prisons. Subsequent
reports of a massive rise in skin and soft tissue infections
were reported by the CDC in the Los Angeles County
Jail system in 2001, and this has continued. Pan et al.

A 2011 study reported 47% of the meat and poultry sold

in surveyed U.S. grocery stores was contaminated with
S. aureus, and of those, 52% or 24.4% of the total
were resistant to at least three classes of antibiotics.
Now we need to determine what this means in terms of
risk to the consumer, said Dr. Keim, a co-author of the
paper.[25] Some samples of commercially sold meat products in Japan were also found to harbor MRSA strains.[26]

2.4 Athletes
Locker rooms, gyms, and related athletic facilities oer
potential sites for MRSA contamination and infection.[27]
A study linked MRSA to the abrasions caused by articial turf.[28] Three studies by the Texas State Department of Health found the infection rate among football
players was 16 times the national average. In October
2006, a high-school football player was temporarily paralyzed from MRSA-infected turf burns. His infection returned in January 2007 and required three surgeries to

3
remove infected tissue, as well as three weeks of hospital stay.[29] In 2013, Lawrence Tynes, Carl Nicks, and
Johnthan Banks of the Tampa Bay Buccaneers were diagnosed with MRSA. Tynes and Nicks apparently did not
contract the infection from each other, but it is unknown
if Banks contracted it from either individual.[30] In 2015,
Los Angeles Dodgers' inelder Justin Turner was infected
while the team visited the New York Mets.[31] In October
2015, New York Giants tight end Daniel Fells was hospitalized with a serious MRSA infection.[32]

2.5

Children

MRSA is becoming a critical problem in pediatric

settings;[33] recent studies found 4.6% of patients in U.S.
health-care facilities, (presumably) including hospital
nurseries,[34] were infected or colonized with MRSA.[35]
Children (and adults, as well) who come in contact with
The MRSA resistance to oxacillin being tested, the top s. aureus
day-care centers, playgrounds, locker rooms, camps, dor- isolate is control and sensitive to oxacillin, the other three isolates
mitories, classrooms and other school settings, and gyms are MRSA positive
and workout facilities are at higher risk of getting MRSA.
Parents should be especially cautious of children who participate in activities where sports equipment is shared,
such as football helmets and uniforms.[36]

Diagnosis

Mueller Hinton agar showing MRSA resistant to oxacillin disk

or other body-uid samples, and in sucient quantities

to perform conrmatory tests early-on. Still, because no
quick and easy method exists to diagnose MRSA, initial
treatment of the infection is often based upon 'strong suspicion' and techniques by the treating physician; these include quantitative PCR procedures, which are employed
in clinical laboratories for quickly detecting and identifying MRSA strains.[38][39]

A selective and dierential chromogenic medium for the qualitative direct detection of MRSA.

Another common laboratory test is a rapid latex agglutination test that detects the PBP2a protein. PBP2a is a
variant penicillin-binding protein that imparts the ability
of S. aureus to be resistant to oxacillin.[40]

Diagnostic microbiology laboratories and reference laboratories are key for identifying outbreaks of MRSA. 4 Genetics
Faster techniques for identifying and characterizing
MRSA have recently been developed.[37] Normally, the Antimicrobial resistance is genetically based; resistance
bacterium must be cultured from blood, urine, sputum, is mediated by the acquisition of extrachromosomal ge-

netic elements containing resistance genes. Exemplary

are plasmids, transposable genetic elements, and genomic islands, which are transferred between bacteria by
horizontal gene transfer.[41] A dening characteristic of
MRSA is its ability to thrive in the presence of penicillinlike antibiotics, which normally prevent bacterial growth
by inhibiting synthesis of cell wall material. This is due to
a resistance gene, mecA, which stops -lactam antibiotics
from inactivating the enzymes (transpeptidases) critical
for cell wall synthesis.

4.1

SCCmec

Staphylococcal cassette chromosome mec (SCCmec) is a

genomic island of unknown origin containing the antibiotic resistance gene mecA.[42][43] SCCmec contains additional genes beyond mecA, including the cytolysin gene
psm-mec, which may suppress virulence in HA-acquired
MRSA strains.[44] SCCmec also contains ccrA and ccrB;
both genes encode recombinases that mediate the sitespecic integration and excision of the SCCmec element
from the S. aureus chromosome.[42][43] Currently, six
unique SCCmec types ranging in size from 2167 kb
have been identied;[42] they are designated types I-VI
and are distinguished by variation in mec and ccr gene
complexes.[41] Owing to the size of the SCCmec element
and the constraints of horizontal gene transfer, a limited number of clones is thought to be responsible for the
spread of MRSA infections.[42]
Dierent SCCmec genotypes confer dierent microbiological characteristics, such as dierent antimicrobial resistance rates.[45] Dierent genotypes are also associated
with dierent types of infections. Types I-III SCCmec
are large elements that typically contain additional resistance genes and are characteristically isolated from HAMRSA strains.[43][45] Conversely, CA-MRSA is associated with types IV and V, which are smaller and lack resistance genes other than mecA.[43][45]

4.2

mecA

GENETICS

moter and functions as a repressor.[41][43] In the presence of a -lactam antibiotic, MecR1 initiates a signal
transduction cascade that leads to transcriptional activation of mecA.[41][43] This is achieved by MecR1-mediated
cleavage of MecI, which alleviates MecI repression.[41]
mecA is further controlled by two co-repressors, BlaI
and BlaR1. blaI and blaR1 are homologous to mecI
and mecR1, respectively, and normally function as regulators of blaZ, which is responsible for penicillin
resistance.[42][47] The DNA sequences bound by MecI
and BlaI are identical;[42] therefore, BlaI can also bind
the mecA operator to repress transcription of mecA.[47]

4.3 Arginine catabolic mobile element

The arginine catabolic mobile element (ACME) is a virulence factor present in many MRSA strains but not prevalent in MSSA.[48] SpeG-positive ACME compensates for
the polyamine hypersensitivity of S. aureus and facilitates
stable skin colonization, wound infection, and person-toperson transmission.

4.4 Strains
enzyme

antibiotic
sensitive

active site

blocked
active site

4
Alanine (L or D)
D-glutamate

reactive
serine

cell wall cross-links

L-lysine

working
active site

Pentaglycine chain
NAM
NAG

antibiotic
resistant

-lactam antibiotic

Diagram depicting antibiotic resistance through alteration of the

antibiotics target site, modeled after MRSAs resistance to penicillin. Beta-lactam antibiotics permanently inactivate PBP enzymes, which are essential for bacterial life, by permanently
binding to their active sites. Some forms of MRSA, however, express a PBP that will not allow the antibiotic into their active site.

Acquisition of SCCmec in methicillin-sensitive staphylococcus aureus (MSSA) gives rise to a number of genetically dierent MRSA lineages. These genetic variations
within dierent MRSA strains possibly explain the variability in virulence and associated MRSA infections.[49]
The rst MRSA strain, ST250 MRSA-1 originated from
SCCmec and ST250-MSSA integration.[49] Historically,
major MRSA clones: ST2470-MRSA-I, ST239-MRSAIII, ST5-MRSA-II, and ST5-MRSA-IV were responsible for causing hospital-acquired MRSA (HA-MRSA)
infections.[49] ST239-MRSA-III, known as the Brazilian clone, was highly transmissible compared to others and distributed in Argentina, Czech Republic, and
Portugal.[49]

mecA is responsible for resistance to methicillin and other

-lactam antibiotics. After acquisition of mecA, the
gene must be integrated and localized in the S. aureus
chromosome.[42] mecA encodes penicillin-binding protein 2a (PBP2a), which diers from other penicillinbinding proteins as its active site does not bind methicillin
or other -lactam antibiotics.[42] As such, PBP2a can continue to catalyze the transpeptidation reaction required
for peptidoglycan cross-linking, enabling cell wall synthesis in the presence of antibiotics. As a consequence of
the inability of PBP2a to interact with -lactam moieties,
acquisition of mecA confers resistance to all -lactam antibiotics in addition to methicillin.[42][46]
In the UK, the most common strains of MRSA are
mecA is under the control of two regulatory genes, mecI EMRSA15 and EMRSA16.[50] EMRSA16 is the best
and mecR1. MecI is usually bound to the mecA pro- described epidemiologically: it originated in Kettering,

5
England, and the full genomic sequence of this strain
has been published.[51] EMRSA16 has been found to
be identical to the ST36:USA200 strain, which circulates in the United States, and to carry the SCCmec
type II, enterotoxin A and toxic shock syndrome toxin
1 genes.[52] Under the new international typing system,
this strain is now called MRSA252. EMRSA 15 is
also found to be one of the common MRSA strains in
Asia. Other common strains include ST5:USA100 and
EMRSA 1.[53] These strains are genetic characteristics of
HA-MRSA.[54]

predominate among CA-MRSA strains; USA300 easily

tops the list in the U.S. and is becoming more common in
Canada after its rst appearance there in 2004. For example, in Australia ST93 strains are common, while in continental Europe ST80 strains, which carry SCCmec type
IV, predominate.[61][62] In Taiwan, ST59 strains, some of
which are resistant to many non-beta-lactam antibiotics,
have arisen as common causes of skin and soft tissue infections in the community. In a remote region of Alaska,
unlike most of the continental U.S., USA300 was found
rarely in a study of MRSA strains from outbreaks in 1996
[63]
It is not entirely certain why some strains are highly trans- and 2000 as well as in surveillance from 200406.
missible and persistent in healthcare facilities.[49] One ex- In June 2011, the discovery of a new strain of MRSA
planation is the characteristic pattern of antibiotic suscep- was announced by two separate teams of researchers in
tibility. Both the EMRSA15 and EMRSA16 strains are the UK. Its genetic makeup was reportedly more similar
resistant to erythromycin and ciprooxacin. It is known to strains found in animals, and testing kits designed to
that Staphylococcus aureus can survive intracellularly,[55] detect MRSA were unable to identify it.[64] This MRSA
for example in the nasal mucosa [56] and in the tonsil strain, Clonal Complex 398 (CC398), is responsible for
tissue.[57] Erythromycin and ciprooxacin are precisely Livestock-associated MRSA (LA-MRSA) infections.[53]
the antibiotics that best penetrate intracellularly; it may Although it is known to be more persistent in colonizing
be that these strains of S. aureus are therefore able to ex- pigs and calves, there have been cases of LA-MRSA carploit an intracellular niche.
riers with pneumonia, endocarditis, and necrotising fasci[65]
itis.
Community-acquired MRSA (CA-MRSA) strains
emerged in late 1990 to 2000, infecting healthy people
who had not been in contact with health care facilities.[54]
A later study that analyzed data from more than 300
microbiology labs associated with hospitals all over the
United States have found a seven-fold increase, jumping
from 3.6% of all MRSA infections to 28.2%, in the
proportion of community-associated strains of MRSA
between 1999 and 2006.[58] Researchers suggest that
CA-MRSA did not evolve from the HA-MRSA.[54] This
is further proven by molecular typing of CA-MRSA
strains[59] and genome comparison between CA-MRSA
and HA-MRSA, which indicate that novel MRSA
strains integrated SCCmec into MSSA separately on
its own.[54] By mid 2000, CA-MRSA was introduced
into the health care systems and distinguishing CAMRSA from HA-MRSA became a dicult process.[54]
Community-acquired MRSA (CA-MRSA) is more
easily treated and more virulent than hospital-acquired
MRSA (HA-MRSA).[54] The genetic mechanism for the
enhanced virulence in CA-MRSA remains an active area
of research. Especially the Panton-Valentine leukocidin
(PVL) genes are of interest because they are a unique
feature of CA-MRSA.[49]
In the United States, most cases of CA-MRSA are caused
by a CC8 strain designated ST8:USA300, which carries
SCCmec type IV, Panton-Valentine leukocidin, PSMalpha and enterotoxins Q and K,[52] and ST1:USA400.[60]
The ST8:USA300 strain results in skin infections, necrotizing fasciitis and toxic shock syndrome, whereas the
ST1:USA400 strain results in necrotizing pneumonia and
pulmonary sepsis.[49] Other community-acquired strains
of MRSA are ST8:USA500 and ST59:USA1000. In
many nations of the world, MRSA strains with dierent predominant genetic background types have come to

5 Prevention
5.1 Screening programs
Patient screening upon hospital admission, with nasal cultures, prevents the cohabitation of MRSA carriers with
non-carriers, and exposure to infected surfaces. The
test used (whether a rapid molecular method or traditional culture) is not as important as the implementation of active screening.[66] In the United States and
Canada, the Centers for Disease Control and Prevention
issued guidelines on October 19, 2006, citing the need
for additional research, but declined to recommend such
screening.[67][68]
In some UK hospitals screening for MRSA is performed
in every patient[69] and all NHS surgical patients, except for minor surgeries, are previously checked for
MRSA.[70] There is no community screening in the UK;
however, screening of individuals is oered by some private companies.[71]
In a US cohort of 1300 healthy children, 2.4% carried
MRSA in their nose.[72]

5.2 Surface sanitizing

Alcohol has been proven to be an eective surface sanitizer against MRSA. Quaternary ammonium can be used
in conjunction with alcohol to extend the longevity of
the sanitizing action. The prevention of nosocomial infections involves routine and terminal cleaning. Nonammable alcohol vapor in carbon dioxide systems

PREVENTION

ments (Ag-A and Ag-B) exhibited any meaningful ecacy against MRSA. Stainless steel S30400 did not exhibit any antimicrobial ecacy.
In 2004, the University of Southampton research team
was the rst to clearly demonstrate that copper inhibits
MRSA.[81] On copper alloys C19700 (99% copper),
C24000 (80% copper), and C77000 (55% copper)
signicant reductions in viability were achieved at room
temperatures after 1.5 hours, 3.0 hours and 4.5 hours,
respectively. Faster antimicrobial ecacies were associated with higher copper alloy content. Stainless steel did
not exhibit any bactericidal benets.
NAV-CO2 sanitizing in Pennsylvania hospital exam room

5.4 Hand washing

In September 2004,[82] after a successful pilot scheme

(NAV-CO2) do not corrode metals or plastics used in to tackle MRSA, the UK National Health Service anmedical environments and do not contribute to antibac- nounced its Clean Your Hands campaign. Wards were reterial resistance.
quired to ensure that alcohol-based hand rubs are placed
In healthcare environments, MRSA can survive on sur- near all beds so that sta can hand wash more regularly.
faces and fabrics, including privacy curtains or garments It is thought that even if this cuts infection by no more
worn by care providers. Complete surface sanitation is than 1%, the plan will pay for itself many times over.
necessary to eliminate MRSA in areas where patients are As with some other bacteria, MRSA is acquiring more
recovering from invasive procedures. Testing patients resistance to some disinfectants and antiseptics. Alfor MRSA upon admission, isolating MRSA-positive pa- though alcohol-based rubs remain somewhat eective,
tients, decolonization of MRSA-positive patients, and a more eective strategy is to wash hands with runterminal cleaning of patients rooms and all other clini- ning water and an antimicrobial cleanser with persistent
cal areas they occupy is the current best practice protocol killing action, such as chlorhexidine.[83] In another study
for nosocomial MRSA.
chlorhexidine (Hibiclens), p-chloro-m-xylenol (AcuteStudies published from 2004-2007 reported hydrogen
peroxide vapor could be used to decontaminate busy
hospital rooms, despite taking signicantly longer than
traditional cleaning. One study noted rapid recontamination by MRSA following the hydrogen peroxide
application.[73][74][75][76][77]

Kare), hexachlorophene (Phisohex), and povidone-iodine

(Betadine) were evaluated for their eectiveness. Of the
four most commonly used antiseptics, povidone-iodine,
when diluted 1:100, was the most rapidly bactericidal
against both MRSA and methicillin-susceptible S. aureus.[84]

Also tested, in 2006, was a new type of surface cleaner,

incorporating accelerated hydrogen peroxide, which was
pronounced a potential candidate for use against the
targeted microorganisms.[78]

A June 2008 report, centered on a survey by the Association for Professionals in Infection Control and Epidemiology, concluded that poor hygiene habits remain the principal barrier to signicant reductions in the spread of
MRSA.

5.3

Research on copper alloys

5.5 Proper disposal of hospital gowns

In 2008, after evaluating a wide body of research mandated specically by the United States Environmental Used paper hospital gowns are associated with MRSA
infections, which could be avoided by proper
Protection Agency (EPA), registration approvals were hospital [85]
disposal.
granted by EPA in 2008 granting that copper alloys kill
more than 99.9% of MRSA within two hours.
Subsequent research conducted at the University of
Southampton (UK) compared the antimicrobial ecacies of copper and several non-copper proprietary coating products to kill MRSA.[79][80] At 20 C, the dropo in MRSA organisms on copper alloy C11000 is dramatic and almost complete (over 99.9% kill rate) within
75 minutes. However, neither a triclosan-based product nor two silver-containing based antimicrobial treat-

5.6 Isolation
Excluding medical facilities, current US guidance does
not require workers with MRSA infections to be routinely
excluded from the general workplace.[86] Therefore, unless directed by a health care provider, exclusion from
work should be reserved for those with wound drainage
that cannot be covered and contained with a clean, dry

5.8

Public health considerations

bandage and for those who cannot maintain good hygiene practices.[86] Workers with active infections should
be excluded from activities where skin-to-skin contact is
likely to occur until their infections are healed. Health
care workers should follow the Centers for Disease Control and Preventions Guidelines for Infection Control in
Health Care Personnel.[87]
To prevent the spread of staph or MRSA in the workplace, employers should ensure the availability of adequate facilities and supplies that encourage workers to
practice good hygiene; that surface sanitizing in the workplace is followed; and that contaminated equipment are
sanitized with Environmental Protection Agency (EPA)registered disinfectants.[86]

5.7

Restricting antibiotic use

Glycopeptides, cephalosporins and in particular

quinolones are associated with an increased risk of
colonisation of MRSA. Reducing use of antibiotic
classes that promote MRSA colonisation, especially uoroquinolones, is recommended in current
guidelines.[13][19]

5.8

Public health considerations

The burden of MRSA is signicant. In 2009, there

were an estimated 463,017 (95% condence interval:
441,595, 484,439) MRSA-related hospitalizations, or a
rate of 11.74 (95% condence interval: 11.20, 12.28)
per 1,000 hospitalizations.[88] Many of these infections
are less serious, but the Centers for Disease Control and
Prevention (CDC) estimates that there are 80,461 invasive MRSA infections and 11,285 deaths due to MRSA
annually.[89]

7
occurred in the United States in 2002, with 99,000 associated deaths.[92] The estimated incidence is 4.5 nosocomial infections per 100 admissions, with direct costs
(at 2004 prices) ranging from $10,500 (5300, 8000
at 2006 rates) per case (for bloodstream, urinary tract,
or respiratory infections in immunocompetent patients)
to $111,000 (57,000, 85,000) per case for antibioticresistant infections in the bloodstream in patients with
transplants. With these numbers, conservative estimates
of the total direct costs of nosocomial infections are
above $17 billion. The reduction of such infections forms
an important component of eorts to improve healthcare
safety. (BMJ 2007) MRSA alone was associated with
8% of nosocomial infections reported to the CDC National Healthcare Safety Network from January 2006 to
October 2007.[93]
This problem is not unique to one country; the British National Audit Oce estimated that the incidence of nosocomial infections in Europe ranges from 4% to 10% of
all hospital admissions. As of early 2005, the number
of deaths in the United Kingdom attributed to MRSA
has been estimated by various sources to lie in the area
of 3,000 per year.[94] Staphylococcus bacteria account for
almost half of all UK hospital infections. The issue of
MRSA infections in hospitals has recently been a major
political issue in the UK, playing a signicant role in the
debates over health policy in the United Kingdom general
election held in 2005.

On January 6, 2008, half of 64 non-Chinese cases of

MRSA infections in Hong Kong in 2007 were Filipino
domestic helpers. Ho Pak-leung, professor of microbiology at the University of Hong Kong, traced the cause to
high use of antibiotics. In 2007, there were 166 community cases in Hong Kong compared with 8,000 hospitalacquired MRSA cases (155 recorded cases91 involved
Chinese locals, 33 Filipinos, 5 each for Americans and
Indians, and 2 each from Nepal, Australia, Denmark and
[95]
Mathematical models describe one way in which a loss England).
of infection control can occur after measures for screen- Worldwide, an estimated 2 billion people carry some
ing and isolation seem to be eective for years, as hap- form of S. aureus; of these, up to 53 million (2.7% of
pened in the UK. In the search and destroy strategy carriers) are thought to carry MRSA.[96] In the United
that was employed by all UK hospitals until the mid- States, 95 million carry S. aureus in their noses; of these,
1990s, all patients with MRSA were immediately iso- 2.5 million (2.6% of carriers) carry MRSA.[97] A populalated, and all sta were screened for MRSA and were pre- tion review conducted in three U.S. communities showed
vented from working until they had completed a course the annual incidence of CA-MRSA during 20012002 to
of eradication therapy that was proven to work. Loss of be 1825.7/100,000; most CA-MRSA isolates were ascontrol occurs because colonised patients are discharged sociated with clinically relevant infections, and 23% of
back into the community and then readmitted; when the patients required hospitalization.[98]
number of colonised patients in the community reaches
One possible contribution to the increased spread of
a certain threshold, the search and destroy strategy is
MRSA infections comes from the use of antibiotics in
overwhelmed.[90] One of the few countries not to have
intensive pig farming. A 2008 study in Canada found
been overwhelmed by MRSA is the Netherlands: An imMRSA in 10% of tested pork chops and ground pork; a
portant part of the success of the Dutch strategy may have
U.S. study in the same year found MRSA in the noses of
been to attempt eradication of carriage upon discharge
70% of the tested farm pigs and in 45% of the tested pig
from hospital.[91]
farm workers.[99] There have also been anecdotal reports
The Centers for Disease Control and Prevention (CDC) of increased MRSA infection rates in rural communities
estimated that about 1.7 million nosocomial infections

with pig farms.[100]

Healthcare facilities with high bed occupancy rates, high
levels of temporary nursing sta, or low cleanliness
scores no longer have signicantly higher MRSA rates.
Simple tabular evidence helps provide a clear picture of
these changes, showing, for instance, that hospitals with
occupancy over 90% had, in 20062007, MRSA rates little above those in hospitals with occupancy below 85%, in
contrast to the period 20012004. In one sense, the disappearance of these relationships is puzzling. Reporters
now blame IV cannula and catheters for spreading MRSA
in hospitals. (Hospital organisation and speciality mix,
2008)

5.9

Decolonization

Care should be taken when trying to drain boils, as disruption of surrounding tissue can lead to larger infections, or even infection of the blood stream (often with fatal consequences).[101] Any drainage should be disposed
of very carefully. After the drainage of boils or other
treatment for MRSA, patients can shower at home using
chlorhexidine (Hibiclens) or hexachlorophene (Phisohex)
antiseptic soap (available over-the-counter at many pharmacies) from head to toe. Alternatively, a dilute bleach
bath can be taken at a concentration of 2.5 L/mL dilution of bleach (about 1/2 cup bleach per 1/4-full bathtub
of water).[102] Care should be taken to use a clean towel,
and to ensure that nasal discharge doesn't infect the towel
(see below).
All infectious lesions should be kept covered with a
dressing.[101] Mupirocin (Bactroban) 2% ointment can be
eective at reducing the size of lesions. A secondary covering of clothing is preferred.[103] As shown in an animal
study with diabetic mice, the topical application of a mixture of sugar (70%) and 3% povidone-iodine paste is an
eective agent for the treatment of diabetic ulcers with
MRSA infection.[104]

TREATMENT

diluted tea tree oil (e.g. Melaleuca). Laundry soap containing tea tree oil may be eective at decontaminating
clothing and bedding, especially if hot water and heavy
soil cycles are used, however tea tree oil may cause a rash
which MRSA can re-colonize. Alcohol-based sanitizers
can be placed near bedsides, near sitting areas, in vehicles
etc. to encourage their use.
Doctors
may
also
prescribe
antibiotics
such
as
clindamycin,
doxycycline
or
trimethoprim/sulfamethoxazole.

5.10 Community settings

The CDC oers suggestions for preventing the contraction and spread MRSA infection which are applicable
to those in community settings, including incarcerated
populations, childcare center employees, and athletes.
To prevent MRSA infection, individuals should regularly
wash hands using soap and water or an alcohol-based sanitizer, keep wounds clean and covered, avoid contact with
other peoples wounds, avoid sharing personal items such
as razors or towels, shower after exercising at athletic facilities (including gyms, weight rooms, and school facilities), shower before using swimming pools or whirlpools,
and maintain a clean environment.[106]
It may be dicult for people to maintain the necessary
cleanliness if they do not have access to facilities such as
public toilets with handwashing facilities. In the United
Kingdom, the Workplace (Health, Safety and Welfare)
Regulations 1992 requires businesses to provide toilets
for their employees, along with washing facilities including soap or other suitable means of cleaning. Guidance on how many toilets to provide and what sort of
washing facilities should be provided alongside them is
given in the Workplace (Health, Safety and Welfare) Approved Code of Practice and Guidance L24, available
from Health and Safety Executive Books. But there is no
legal obligation on local authorities in the United Kingdom to provide public toilets, and although in 2008 the
House of Commons Communities and Local Government Committee called for a duty on local authorities to
develop a public toilet strategy [107] this was rejected by
the Government.[108]

The nose is a common refuge for MRSA, and a test swab

can be taken of the nose to indicate whether MRSA
is present.[105] If MRSA is detected via nasal culture,
Mupirocin (Bactroban) 2% ointment can be applied inside each nostril twice daily for 7 days, using a cottontipped swab. However, care should be taken so that the
swab doesn't penetrate into the sinus. Household members are recommended to follow the same decolonization 6 Treatment
protocol. After treatment, the nose should be swabbed
again to ensure that the treatment was eective. If not, Both CA-MRSA and HA-MRSA are resistant to tradithe process should be repeated.
tional anti-staphylococcal beta-lactam antibiotics, such
In the hospital setting toilet seats are a common vector for as cephalexin. CA-MRSA has a greater spectrum of
infection, and wiping seats clean before and/or after use antimicrobial susceptibility, including to sulfa drugs
can help to prevent the spread of MRSA. Door handles, (like co-trimoxazole/trimethoprim-sulfamethoxazole),
faucets, light switches (with care!), etc. can be disinfected tetracyclines (like doxycycline and minocycline) and
regularly with disinfectant wipes.[103] Spray disinfectants clindamycin (for osteomyelitis), but the drug of
can be used on upholstery. Carpets can be washed with choice for treating CA-MRSA is now believed to be
disinfectant, and hardwood oors can be scrubbed with vancomycin, according to a Henry Ford Hospital Study.

7.1

US and UK

HA-MRSA is resistant even to these antibiotics and

often is susceptible only to vancomycin. Newer drugs,
such as linezolid (belonging to the newer oxazolidinones
class) and daptomycin, are eective against both CAMRSA and HA-MRSA. The Infectious Disease Society
of America recommends vancomycin, linezolid, or
clindamycin (if susceptible) for treating patients with
MRSA pneumonia.[109] Ceftaroline, a fth generation
cephalosporin, is the rst beta-lactam antibiotic approved
in the US to treat MRSA infections (skin and soft tissue
or community acquired pneumonia only).[110]
Vancomycin and teicoplanin are glycopeptide antibiotics
used to treat MRSA infections.[111] Teicoplanin is a structural congener of vancomycin that has a similar activity
spectrum but a longer half-life.[112] Because the oral absorption of vancomycin and teicoplanin is very low, these
agents must be administered intravenously to control systemic infections.[113] Treatment of MRSA infection with
vancomycin can be complicated, due to its inconvenient
route of administration. Moreover, many clinicians believe that the ecacy of vancomycin against MRSA is
inferior to that of anti-staphylococcal beta-lactam antibiotics against methicillin-susceptible Staphylococcus aureus (MSSA).[114][115]

9
Legend
No Data
<1%
1-5%
5 - 10 %
10 - 25 %
25 - 50 %
> 50 %

Incidence of MRSA in human blood samples in countries which

took part in the study in 2008

increased to 22% by 1995, and by 1997 the percent of

hospital S. aureus infections attributable to MRSA had
reached 50%.

The rst report of CA-MRSA occurred in 1981, and in

1982 there was a large outbreak of CA-MRSA among
intravenous drug users in Detroit, Michigan.[121] Additional outbreaks of CA-MRSA were reported through the
1980s and 1990s, including outbreaks among Australian
Aboriginal populations that had never been exposed to
hospitals. In the mid-1990s there were scattered reports
of CA-MRSA outbreaks among US children. While HAMRSA rates stabilized between 19982008, CA-MRSA
rates continued to rise. A report released by the University of Chicago Childrens Hospital comparing two
time periods (19931995 and 19951997) found a 25Studies suggest that allicin, a compound found in garlic,
fold increase in the rate of hospitalizations due to MRSA
[120]
may prove to be eective in the treatment of MRSA.
among children in the United States.[123] In 1999 the
University of Chicago reported the rst deaths from invasive MRSA among otherwise healthy children in the
United States.[121] By 2004 MRSA accounted for 64%
7 History
of hospital-acquired S. aureus infections in the United
States.
Several newly discovered strains of MRSA show
antibiotic resistance even to vancomycin and teicoplanin.
These new evolutions of the MRSA bacterium have
been dubbed vancomycin intermediate-resistant
Staphylococcus aureus (VISA).[116] [117] Linezolid,
quinupristin/dalfopristin, daptomycin, ceftaroline, and
tigecycline are used to treat more severe infections that
do not respond to glycopeptides such as vancomycin.[118]
Current guidelines recommend daptomycin for VISA
bloodstream infections and endocarditis.[119]

7.1

US and UK

In 1959 methicillin was licensed in England to treat

penicillin-resistant S. aureus infections. Just as bacterial
evolution had allowed microbes to develop resistance to
penicillin, strains of S. aureus evolved to become resistant
to methicillin. In 1961 the rst known MRSA isolates
were reported in a British study, and between 1961-1967
there were infrequent hospital outbreaks in Western Europe and Australia.[121] The rst United States hospital
outbreak of MRSA occurred at the Boston City Hospital in 1968. Between 1968-mid-1990s the percent of S.
aureus infections that were caused by MRSA increased
steadily, and MRSA became recognized as an endemic
pathogen. In 1974 2% of hospital-acquired S. aureus infections could be attributed to MRSA.[122] The rate had

The Oce for National Statistics reported 1,629 MRSArelated deaths in England and Wales during 2005, indicating a MRSA-related mortality rate half the rate of that in
the United States for 2005, even though the gures from
the British source were explained to be high because of
improved levels of reporting, possibly brought about by
the continued high public prole of the disease[124] during the time of the 2005 United Kingdom General Election. MRSA is thought to have caused 1,652 deaths in
2006 in UK up from 51 in 1993.[125]
It has been argued that the observed increased mortality
among MRSA-infected patients may be the result of the
increased underlying morbidity of these patients. Several studies, however, including one by Blot and colleagues, that have adjusted for underlying disease still

10
found MRSA bacteremia to have a higher attributable
mortality than methicillin-susceptible S. aureus (MSSA)
bacteremia.[126]
A population-based study of the incidence of MRSA infections in San Francisco during 200405 demonstrated
that nearly 1 in 300 residents suered from such an infection in the course of a year and that greater than
85% of these infections occurred outside of the healthcare setting.[127] A 2004 study showed that patients in
the United States with S. aureus infection had, on average, three times the length of hospital stay (14.3 vs.
4.5 days), incurred three times the total cost ($48,824
vs $14,141), and experienced ve times the risk of inhospital death (11.2% vs 2.3%) than patients without this
infection.[128] In a meta-analysis of 31 studies, Cosgrove
et al.,[129] concluded that MRSA bacteremia is associated
with increased mortality as compared with MSSA bacteremia (odds ratio = 1.93; 95% CI = 1.93 0.39).[130] In
addition, Wyllie et al. report a death rate of 34% within
30 days among patients infected with MRSA, a rate similar to the death rate of 27% seen among MSSA-infected
patients.[131]
According to the CDC, the most recent estimates of the
incidence of healthcare-associated infections that are attributable to MRSA in the United States indicate a decline in such infection rates. Incidence of MRSA central line-associated blood stream infections as reported by
hundreds of intensive care units decreased 5070% from
20012007.[122] A separate system tracking all hospital
MRSA bloodstream infections found an overall 34% decrease between 20052008.[122]

8 RESEARCH

8 Research
8.1 Clinical
Many antibiotics against MRSA are in phase II and phase
III clinical trials. e.g.:
Phase III : ceftobiprole, ceftaroline, dalbavancin,
telavancin, torezolid, iclaprim and others.
Phase II : nemonoxacin.[133]
Development of Aurograb, a treatment intended to complement antibiotics used to treat MRSA, was discontinued after showing a lack of ecacy in Phase II trials.[134]
It has been reported that maggot therapy to clean out
necrotic tissue of MRSA infection has been successful. Studies in diabetic patients reported signicantly
shorter treatment times than those achieved with standard
treatments.[135][136][137]

8.2 Pre-clinical
8.2.1 Phage therapy
An entirely dierent approach is phage therapy (e.g., at
the Eliava Institute in Georgia[138] ). Experimental phage
therapy tested in mice had a reported ecacy against up
to 95% of tested Staphylococcus isolates.[139]

MRSA is sometimes sub-categorised as communityacquired MRSA (CA-MRSA) or healthcare-associated

8.2.2 Antibiotics
MRSA (HA-MRSA), although the distinction is complex. Some researchers have dened CA-MRSA by the
On May 18, 2006, a report in Nature identied a new
characteristics of patients whom it infects, while others
antibiotic, called platensimycin, that had demondene it by the genetic characteristics of the bacteria
strated successful use against MRSA.[140][141]
themselves. By 2005, identied CA-MRSA risk factors
included athletes, military recruits, incarcerated people,
A new class of non--lactam antibiotics,
emergency room patients, urban children, HIV-positive
oxadiazoles, was reported to be eective against
[121]
individuals,and indigenous populations.
MRSA infection in mouse models. The mechanisms of oxadiazoles antibacterial eect are
the inhibition of the penicillin binding protein,
7.2 Worldwide
PBP2a and biosynthesis of the bacterial cell wall.
It was found to have bactericidal activity against
The rst reported cases of CA-MRSA began to appear
vancomycin- and linezolid-resistant MRSA and
in the mid-1990s in Australia, New Zealand, the United
other Gram-positive bacterial strains.[142][143]
States, the United Kingdom, France, Finland, Canada and
Samoa, and were notable because they involved people
who had not been exposed to a healthcare setting.[8]
8.2.3 Natural products
Because measurement and reporting varies, it is dicult
to compare rates of MRSA in dierent countries. An
Some in vitro studies with honey have identied
international comparison of 2004 MRSA-attributable S.
components in honey that kill MRSA.[144][145]
aureus rates in middle and high income countries released
Ocean-dwelling living sponges produce comby the Center For Disease Dynamics, Economics, and
pounds that may make MRSA more susceptible to
Policy in showed that Iceland had the lowest rate of inantibiotics.[146]
fection, and Romania had the highest at over 70%.[132]

11
Some semi-toxic fungi/mushrooms excrete broad
spectrum antibiotics, not all of which have been
fully identied; some have been shown to inhibit the
growth of Staphylococcus aureus.[147]
An in vitro study showed that the cannabinoids CBD
and CBG inhibit MRSA,[148] in addition to the terpenoid pinene which occurs in cannabis.[149]
Cannabinoids (components of Cannabis sativa),
including cannabidiol (CBD), cannabinol (CBN),
cannabichromene (CBC), tetrahydrocannabinol
(THC) and cannabigerol (CBG), show activity
against a variety of MRSA strains.[150]
In vitro studies have shown that oakin, an oak extract, can kill MRSA.[151]
A 1,000-year-old eye salve recipe found in the medieval Balds Leechbook at the British Library, one
of the earliest known medical textbooks, was found
to have activity against MRSA in vitro and in skin
wounds in mice.[152]

Additional images
A colourised SEM of MRSA
Scanning electron micrograph of a human neutrophil ingesting MRSA
Scanning electron micrograph of a human neutrophil ingesting MRSA
Scanning electron micrograph of a human neutrophil ingesting MRSA

10

See also

Carbapenem resistant enterobacteriaceae

Necrotizing fasciitis
Staphylococcus aureus
Toxic shock syndrome
XF-73
Teixobactin

11

References

[1] McDougal, L.K.; Steward, C.D.; Killgore, G.E.;

Chaitram, J.M.; McAllister, S.K.; Tenover, F.C. (November 2003). Pulsed-eld gel electrophoresis typing of
oxacillin-resistant Staphylococcus aureus isolates from
the United States: establishing a national database.

Journal of Clinical Microbiology 41 (11): 5113

5120. doi:10.1128/JCM.41.11.5113-5120.2003. PMID
14605147.
[2] Yan M, Pamp SJ, Fukuyama J, Hwang PH, Cho DY,
Holmes S, Relman DA (2013). Nasal microenvironments and interspecic interactions inuence nasal microbiota complexity and S. aureus carriage. Cell Host Microbe 14 (6): 63140. doi:10.1016/j.chom.2013.11.005.
PMC 3902146. PMID 24331461.
[3] Science Daily. Archived from the original on August
11, 2007.
[4] McCaughey B. Unnecessary Deaths: The Human and Financial Costs of Hospital Infections (PDF) (2nd. ed.).
Archived from the original (PDF) on July 11, 2007. Retrieved 2007-08-05.
[5] Symptoms. Mayo Clinic.
[6] ISDA MRSA guidelines (PDF).
[7] MRSA Toxin Acquitted: Study Clears Suspected Key to
Severe Bacterial Illness. NIH news release. National Institute of Health. 2006-11-06.
[8] Raygada JL and Levine DP (March 30, 2009). Managing
CA-MRSA Infections: Current and Emerging Options.
Infections in Medicine 26 (2).
[9] General Information About MRSA in the Community.
Centers for Disease Control and Prevention. 10 September 2013. Retrieved 9 October 2014.
[10] Lipsky BA, Tabak YP, Johannes RS, Vo L, Hyde L,
Weigelt JA (May 2010). Skin and soft tissue infections
in hospitalised patients with diabetes: culture isolates and
risk factors associated with mortality, length of stay and
cost. Diabetologia 53 (5): 91423. doi:10.1007/s00125010-1672-5. PMID 20146051.
[11] Otter, J.A.; French, G.L. Community-associated
meticillin-resistant Staphylococcus aureus strains
as a cause of healthcare-associated infection.
Journal of Hospital Infection 79 (3):
189193.
doi:10.1016/j.jhin.2011.04.028.
[12] Golding, George R; Quinn, Brian; Bergstrom, Kirsten;
Stockdale, Donna; Woods, Shirley; Nsungu, Mandiangu; Brooke, Barb; Levett, Paul N; Horsman, Greg;
McDonald, Ryan; Szklarczuk, Brian; Silcox, Steve;
Paton, Shirley; Carson, Mary; Mulvey, Michael R;
Irvine, James. Community-based educational intervention to limit the dissemination of community-associated
methicillin-resistant Staphylococcus aureus in Northern
Saskatchewan, Canada. BMC Public Health 12 (1): 15.
doi:10.1186/1471-2458-12-15.
[13] Tacconelli E, De Angelis G, Cataldo MA, Pozzi E,
Cauda R (Jan 2008). Does antibiotic exposure increase the risk of methicillin-resistant Staphylococcus aureus (MRSA) isolation? A systematic review and metaanalysis. J Antimicrob Chemother 61 (1): 2638.
doi:10.1093/jac/dkm416. PMID 17986491.

12

[14] Elias, Johannes; Peter U Heuschmann, Corinna Schmitt,

Frithjof Eckhardt, Hartmut Boehm, Sebastian Maier,
Annette Kolb-Murer, Hubertus Riedmiller, Wolfgang Mllges, Christoph Weisser, Christian Wunder, Matthias Frosch and Ulrich Vogel (2013-02-28).
"<Prevalence dependent calibration of a predictive model
for nasal carriage of methicillin-resistant Staphylococcus
aureus.>". BMC Infectious Diseases 13 (111): 112.
doi:10.1186/1471-2334-13-111. Retrieved 2014-10-07.
[15] Reuters (2009-02-16). Study: Beachgoers More Likely
to Catch MRSA. FoxNews.com.
[16] Marilynn Marchione (2009-09-12). Dangerous staph
germs found at West Coast beaches. Associated Press.
[17] Zinderman CE, Conner B, Malakooti MA, LaMar JE,
Armstrong A, Bohnker BK (May 2004). CommunityAcquired Methicillin-Resistant Staphylococcus aureus
Among Military Recruits. Emerging Infectious Diseases
10 (5): 9414. doi:10.3201/eid1005.030604. PMC
3323224. PMID 15200838.
[18] David MZ, Daum RS (2010). Community-Associated
Methicillin-Resistant Staphylococcus aureus: Epidemiology and Clinical Consequences of an Emerging Epidemic (PDF). Clinical Microbiology Reviews (American Society for Microbiology) 23 (6): 616687.
doi:10.1128/CMR.00081-09. PMC 2901661. PMID
20610826.
[19] Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis
WR, Boyce JM, Farr BM (May 2003). SHEA guideline for preventing nosocomial transmission of multidrugresistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 24 (5): 36286.
doi:10.1086/502213. PMID 12785411.
[20] Johannes Elias (September 2014). Predict probability of
MRSA carriage in hospital admissions. Retrieved 201410-07.
[21] PURE Bioscience. purebio.com.
[22] Joint scientic report of ECDC, EFSA and EMEA on
meticillin resistant Staphylococcus aureus (MRSA) in livestock, companion animals and food (PDF). 2009-06-16.
Retrieved 2009-09-19.
[23] Harrison, Ewan M.; Paterson, Gavin K.; Holden, Matthew
T.G.; Larsen, Jesper; Stegger, Marc; Larsen, Anders
Rhod; Petersen, Andreas; Skov, Robert L.; et al. (2013).
Whole genome sequencing identies zoonotic transmission of MRSA isolates with the novelmecAhomologuemecC. EMBO Molecular Medicine 5 (4): 50915.
doi:10.1002/emmm.201202413. PMC 3628104. PMID
23526809.
[24] Tomasz, Alexander (April 2013). The use of whole
genome sequencing to solve an epidemiological puzzle. EMBO Molecular Medicine 5 (4): 486487.
doi:10.1002/emmm.201302622.
[25] US meat and poultry is widely contaminated with drugresistant Staph bacteria, study nds. ScienceDaily.

11

REFERENCES

[26] Ogata K, Narimatsu H, Suzuki M, Higuchi W, Yamamoto

T, Taniguchi H (2012-02-03). Commercially distributed
meat as a potential vehicle for community-acquired
methicillin-resistant Staphylococcus aureus". Applied
and environmental microbiology 78 (8): 2797802.
doi:10.1128/AEM.07470-11. PMC 3318828. PMID
22307310.
[27] Salgado, Cassandra D.; Farr, Barry M.; Calfee, David
P. (15 January 2003). CommunityAcquired MethicillinResistant Staphylococcus aureus: A MetaAnalysis
of Prevalence and Risk Factors. Clinical Infectious Diseases 36 (2): 131139. doi:10.1086/345436.
[28] Kazakova SV, Hageman JC, Matava M, Srinivasan A,
Phelan L, Garnkel B, Boo T, McAllister S, Anderson J,
Jensen B, Dodson D, Lonsway D, McDougal LK, Arduino
M, Fraser VJ, Killgore G, Tenover FC, Cody S, Jernigan DB (2005-02-03). A clone of methicillin-resistant
Staphylococcus aureus among professional football players. The New England Journal of Medicine 352 (5): 468
75. doi:10.1056/NEJMoa042859. PMID 15689585.
[29] Epstein, Victor (21 December 2007). Texas Football Succumbs to Virulent Staph Infection From Turf.
Bloomberg. Retrieved 10 June 2010.
[30] Yasinskas, Pat (11 October 2013). Third Tampa Bay
Buccaneers player tests positive for MRSA staph infection. ESPN. ESPN Internet Ventures. Retrieved 11 October 2013.
[31] Hernandez, Dylan (August 12, 2015). Dodgers Justin
Turner nears return from MRSA infection. Los Angeles
Times. Retrieved August 13, 2015.
[32] Rappoport, Ian (October 11, 2015). MRSA infection
leaves Giants Daniel Fells in dire situation. NFL.com.
Retrieved October 12, 2015.
[33] Gray JW (April 2004). MRSA: the problem reaches
paediatrics. Arch. Dis. Child. 89 (4): 2978.
doi:10.1136/adc.2003.045534. PMC 1719885. PMID
15033832.
[34] Bratu S, Eramo A, Kopec R, Coughlin E, Ghitan M,
Yost R, Chapnick EK, Landman D, Quale J (June
2005).
Community-associated methicillin-resistant
Staphylococcus aureus in hospital nursery and maternity units. Emerging Infect. Dis. 11 (6): 80813.
doi:10.3201/eid1106.040885. PMC 3367583. PMID
15963273.
[35] Association for Professionals in Infection Control & Epidemiology (June 25, 2007). National Prevalence Study
of Methicillin-Resistant Staphylococcus aureus (MRSA)
in U.S. Healthcare Facilities. Archived from the original
on September 7, 2007. Retrieved 2007-07-14.
[36] Staph Infections and MRSA in Children: Prevention,
Symptoms, and Treatment. webmd.com.
[37] Ceylan Koydemir H, Klah H, zgen C, Alp A, Haselik
G (2011). MEMS biosensors for detection of methicillin
resistant Staphylococcus aureus. Biosensors and Bioelectronics 29 (1): 112. doi:10.1016/j.bios.2011.07.071.
PMID 21856144.

13

[38] Francois P and Schrenzel J (2008). Rapid Diagnosis

and Typing of Staphylococcus aureus". Staphylococcus:
Molecular Genetics. Caister Academic Press. ISBN 9781-904455-29-5.
[39] Mackay I M (editor). (2007). Real-Time PCR in Microbiology: From Diagnosis to Characterization. Caister Academic Press. ISBN 978-1-904455-18-9.
[40] Seiken, Denka. MRSA latex test for PBP2.
[41] Jensen SO, Lyon BR (June 2009). Genetics of antimicrobial resistance in Staphylococcus aureus". Future Microbiol 4 (5): 56582. doi:10.2217/fmb.09.30. PMID
19492967.
[42] Lowy FD (May 2003). Antimicrobial resistance: the example of Staphylococcus aureus". J. Clin. Invest. 111 (9):
126573. doi:10.1172/JCI18535. PMC 154455. PMID
12727914.
[43] Pantosti A, Sanchini A, Monaco M (June 2007).
Mechanisms of antibiotic resistance in Staphylococcus aureus".
Future Microbiol 2 (3): 32334.
doi:10.2217/17460913.2.3.323. PMID 17661706.
[44] Kaito C, Saito Y, Nagano G, Ikuo M, Omae Y, Hanada Y,
Han X, Kuwahara-Arai K, Hishinuma T, Baba T, Ito T,
Hiramatsu K, Sekimizu K (2011). Cheung, Ambrose, ed.
Transcription and translation products of the cytolysin
gene psm-mec on the mobile genetic element SCCmec
regulate Staphylococcus aureus virulence. PLoS Pathog.
7 (2): e1001267. doi:10.1371/journal.ppat.1001267.
PMC 3033363. PMID 21304931.
[45] Kuo SC, Chiang MC, Lee WS, Chen LY, Wu HS, Yu
KW, Fung CP, Wang FD (January 2012). Comparison
of microbiological and clinical characteristics based
on SCCmec typing in patients with community-onset
meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia.
Int.
J. Antimicrob.
Agents 39 (1):
226. doi:10.1016/j.ijantimicag.2011.08.014. PMID
21982834.
[46] Sahebnasagh R, Saderi H, Owlia P. Detection of
methicillin-resistant Staphylococcus aureus strains from
clinical samples in Tehran by detection of the mecA
and nuc genes. The First Iranian International Congress
of Medical Bacteriology; 47 September; Tabriz, Iran.
2011. 195 pp.
[47] Berger-Bchi B (November 1999).
Genetic basis of methicillin resistance in Staphylococcus aureus". Cell. Mol. Life Sci. 56 (910): 76470.
doi:10.1007/s000180050023. PMID 11212336.
[48] Goering RV, McDougal LK, Fosheim GE, Bonnstetter
KK, Wolter DJ, Tenover FC (2007). Epidemiologic distribution of the arginine catabolic mobile element among
selected methicillin-resistant and methicillin-susceptible
Staphylococcus aureus isolates. J. Clin. Microbiol.
45 (6): 19814. doi:10.1128/JCM.00273-07. PMC
1933090. PMID 17409207.
[49] Gordon RJ, Lowy FD (June 2008). Pathogenesis
of methicillin-resistant Staphylococcus aureus infection.
Clin.
Infect.
Dis.
46 (Suppl 5): S3509.
doi:10.1086/533591. PMC 2474459. PMID 18462090.

[50] Johnson AP, Aucken HM, Cavendish S, Ganner M, Wale

MC, Warner M, Livermore DM, Cookson BD (2001).
Dominance of EMRSA-15 and 16 among MRSA causing nosocomial bacteraemia in the UK: analysis of isolates
from the European Antimicrobial Resistance Surveillance
System (EARSS)". J Antimicrob Chemother 48 (1): 143
4. doi:10.1093/jac/48.1.143. PMID 11418528.
[51] Holden MT, Feil EJ, Lindsay JA, Peacock SJ, Day NP,
Enright MC, Foster TJ, Moore CE, Hurst L, Atkin R,
Barron A, Bason N, Bentley SD, Chillingworth C, Chillingworth T, Churcher C, Clark L, Corton C, Cronin
A, Doggett J, Dowd L, Feltwell T, Hance Z, Harris B,
Hauser H, Holroyd S, Jagels K, James KD, Lennard
N, Line A, Mayes R, Moule S, Mungall K, Ormond
D, Quail MA, Rabbinowitsch E, Rutherford K, Sanders
M, Sharp S, Simmonds M, Stevens K, Whitehead S,
Barrell BG, Spratt BG, Parkhill J (2004). Complete
genomes of two clinical Staphylococcus aureus strains:
Evidence for the rapid evolution of virulence and drug resistance. Proc Natl Acad Sci USA 101 (26): 978691.
doi:10.1073/pnas.0402521101. PMC 470752. PMID
15213324.
[52] Diep BA, Carleton HA, Chang RF, Sensabaugh GF,
Perdreau-Remington F (2006). Roles of 34 virulence genes in the evolution of hospital- and communityassociated strains of methicillin-resistant Staphylococcus aureus".
J Infect Dis 193 (11): 1495503.
doi:10.1086/503777. PMID 16652276.
[53] Stefani S, Chung DR, Lindsay JA, Friedrich AW, Kearns
AM, Westh H, Mackenzie FM (2012). Meticillinresistant Staphylococcus aureus (MRSA): global epidemiology and harmonisation of typing methods. International Journal of Antimicrobial Agents 39 (4): 273
82. doi:10.1016/j.ijantimicag.2011.09.030. ISSN 09248579. PMID 22230333.
[54] Calfee DP (2011).
The epidemiology, treatment,
and prevention of transmission of methicillin-resistant
Staphylococcus aureus". J Infus Nurs 34 (6): 359
64. doi:10.1097/NAN.0b013e31823061d6. PMID
22101629.
[55] von Ei C, Becker K, Metze D, Lubritz G, Hockmann
J, Schwarz T, Peters G (2001). Intracellular persistence
of Staphylococcus aureus small-colony variants within keratinocytes: a cause for antibiotic treatment failure in a patient with Dariers disease. Clin Infect Dis 32 (11): 1643
7. doi:10.1086/320519. PMID 11340539.
[56] Clement S, Vaudaux P, Francois P, Schrenzel J, Huggler E, Kampf S, Chaponnier C, Lew D, Lacroix JS
(2005). Evidence of an intracellular reservoir in the
nasal mucosa of patients with recurrent Staphylococcus
aureus rhinosinusitis. J Infect Dis 192 (6): 10238.
doi:10.1086/432735. PMID 16107955.
[57] Zautner AE, Krause M, Stropahl G, Holtfreter S, Frickmann H, Maletzki C, Kreikemeyer B, Pau HW, Podbielski A (2010). Bereswill, Stefan, ed. Intracellular
persisting Staphylococcus aureus is the major pathogen
in recurrent tonsillitis.
PloS One 5 (3): e9452.
doi:10.1371/journal.pone.0009452.
PMC 2830486.
PMID 20209109.

14

[58] New Study nds MRSA on the rise in hospital outpatients. 2009.
[59] Daum RS (2007). Skin and Soft-Tissue Infections
Caused by Methicillin-Resistant Staphylococcus aureus".
New England Journal of Medicine 357 (4): 380390.
doi:10.1056/NEJMcp070747. PMID 17652653.
[60] Wang R, Braughton KR, Kretschmer D, Bach TH, Queck
SY, Li M, Kennedy AD, Dorward DW, Klebano SJ,
Peschel A, DeLeo FR, Otto M (December 2007). Identication of novel cytolytic peptides as key virulence
determinants for community-associated MRSA. Nat.
Med. 13 (12): 15104. doi:10.1038/nm1656. PMID
17994102.
[61] Tristan A, Bes M, Meugnier H, Lina G, Bozdogan B, Courvalin P, Reverdy ME, Enright MC, Vandenesch F, Etienne J (2007).
Global distribution of Panton-Valentine leukocidin--positive methicillinresistant Staphylococcus aureus, 2006. Emerging Infect.
Dis. 13 (4): 594600. doi:10.3201/eid1304.061316.
PMC 2725977. PMID 17553275.
[62] Gould IM, David MZ, Esposito S, Garau J, Lina
G, Mazzei T, Peters G (February 2012).
New
insights into meticillin-resistant Staphylococcus aureus (MRSA) pathogenesis, treatment and resistance. Int. J. Antimicrob. Agents 39 (2): 96
104. doi:10.1016/j.ijantimicag.2011.09.028. PMID
22196394.
[63] David MZ, Rudolph KM, Hennessy TW, Boyle-Vavra
S, Daum RS (2008). Molecular epidemiology of
methicillin-resistant Staphylococcus aureus, rural southwestern Alaska. Emerging Infect. Dis. 14 (11): 1693
9. doi:10.3201/eid1411.080381. PMC 2630737. PMID
18976551.
[64] Ahlstrom, Dick (2011-06-03). New strain of MRSA superbug discovered in Dublin hospitals. The Irish Times.
[65] Graveland H, Duim B, van Duijkeren E, Heederik D,
Wagenaar JA (December 2011). Livestock-associated
methicillin-resistant Staphylococcus aureus in animals and
humans. Int. J. Med. Microbiol. 301 (8): 6304.
doi:10.1016/j.ijmm.2011.09.004. PMID 21983338.
[66] Tacconelli E, De Angelis G, de Waure C, Cataldo MA,
La Torre G, Cauda R (September 2009). Rapid screening tests for meticillin-resistant Staphylococcus aureus at
hospital admission: systematic review and meta-analysis.
Lancet Infect Dis 9 (9): 54654. doi:10.1016/S14733099(09)70150-1. PMID 19695491.
[67] To Catch a Deadly Germ, New York Times opinion
[68] Healthcare-associated infections - HAI - CDC (PDF).
cdc.gov.
[69]
[70] MRSA test for surgical patients. BBC News. 2009-0331. Retrieved 2010-04-05.
[71] Home Mrsa Test - Home

11

REFERENCES

[72] Fritz SA, Garbutt J, Elward A, Shannon W, Storch GA

(2008). Prevalence of and risk factors for communityacquired methicillin-resistant and methicillin-sensitive
Staphylococcus aureus colonization in children seen in
a practice-based research network. Pediatrics 121
(6): 10908. doi:10.1542/peds.2007-2104. PMID
18519477.
[73] Otter JA, Puchowicz M, Ryan D, Salkeld JA, Cooper TA,
Havill NL, Tuozzo K, Boyce JM (June 2009). Feasibility
of routinely using hydrogen peroxide vapor to decontaminate rooms in a busy United States hospital. Infect Control Hosp Epidemiol 30 (6): 5747. doi:10.1086/597544.
PMID 19415969.
[74] Bartels MD, Kristoersen K, Slotsbjerg T, Rohde SM, Lundgren B, Westh H (September 2008).
Environmental
meticillin-resistant
Staphylococcus
aureus (MRSA) disinfection using dry-mist-generated
hydrogen peroxide. J. Hosp. Infect. 70 (1): 3541.
doi:10.1016/j.jhin.2008.05.018. PMID 18621434.
[75] French GL, Otter JA, Shannon KP, Adams NM, Watling
D, Parks MJ (May 2004). Tackling contamination of
the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour
decontamination. J. Hosp. Infect. 57 (1): 317.
doi:10.1016/j.jhin.2004.03.006. PMID 15142713.
[76] Otter JA, Cummins M, Ahmad F, van Tonder C, Drabu
YJ (October 2007). Assessing the biological ecacy
and rate of recontamination following hydrogen peroxide
vapour decontamination. J. Hosp. Infect. 67 (2): 1828.
doi:10.1016/j.jhin.2007.07.019. PMID 17884250.
[77] Hardy KJ, Gossain S, Henderson N, Drugan C, Oppenheim BA, Gao F, Hawkey PM (August 2007). Rapid
recontamination with MRSA of the environment of an
intensive care unit after decontamination with hydrogen
peroxide vapour. J. Hosp. Infect. 66 (4): 3608.
doi:10.1016/j.jhin.2007.05.009. PMID 17655975.
[78] Omidbakhsh N, Sattar SA (June 2006). Broad-spectrum
microbicidal activity, toxicologic assessment, and materials compatibility of a new generation of accelerated hydrogen peroxide-based environmental surface
disinfectant. Am J Infect Control 34 (5): 2517.
doi:10.1016/j.ajic.2005.06.002. PMID 16765201.
[79] Michels HT, Noyce JO, Keevil CW (2009). Eects of
temperature and humidity on the ecacy of methicillinresistant Staphylococcus aureus challenged antimicrobial
materials containing silver and copper (PDF). Letters in
Applied Microbiology 49 (2): 1915. doi:10.1111/j.1472765X.2009.02637.x. PMC 2779462. PMID 19413757.
[80] Keevil, C.W., Noyce, J.O. (2007), Antimicrobial Ecacies of Copper, Stainless Steel, Microban, BioCote and
AgIon with MRSA at 20 C, unpublished data
[81] Noyce, J.O. and Keevil, C.W. (2004), The Antimicrobial Eects of Copper and Copper-Based Alloys on
Methicillin-resistant Staphylococcus aureus, Copper Development Association Poster Q-193 from Proceedings of
the Annual General Meeting of the American Society for

15

Microbiology, 2427 May 2004, New Orleans; presented

at the American Society for Microbiology General Meeting, New Orleans, LA May 24th.
[82] NPSA - About us.
[83] DeMarco CE, Cushing LA, Frempong-Manso E, Seo SM,
Jaravaza TA, Kaatz GW (Sep 2007). Eux-Related
Resistance to Noroxacin, Dyes, and Biocides in Bloodstream Isolates of Staphylococcus aureus (Free full text).
Antimicrobial Agents and Chemotherapy 51 (9): 3235
3239. doi:10.1128/AAC.00430-07. ISSN 0066-4804.
PMC 2043220. PMID 17576828.
[84] Haley CE, Marling-Cason M, Smith JW, Luby JP, Mackowiak PA (June 1985). Bactericidal activity of antiseptics against methicillin-resistant Staphylococcus aureus".
J. Clin. Microbiol. 21 (6): 9912. PMC 271835. PMID
4008627.
[85] Simple techniques slash hospital infections: meeting.
Reuters. 2009-03-21.
[86] NIOSH MRSA and the Workplace. United States National Institute for Occupational Safety and Health. Retrieved 2007-10-29.
[87] CDC (1998). Guidelines for Infection Control in Health
Care Personnel, 1998. Centers for Disease Control and
Prevention. Retrieved December 18, 2007.

at the Centers for Disease Control and Prevention, 20062007. Infect Control Hosp Epidemiol 29 (11): 9961011.
doi:10.1086/591861. PMID 18947320.
[94] Johnson AP, Pearson A, Duckworth G (2005). Surveillance and epidemiology of MRSA bacteraemia in the
UK.
J Antimicrob Chemother 56 (3): 45562.
doi:10.1093/jac/dki266. PMID 16046464.
[95] Inquirer.net, Cases of RP maids with 'superbug' infection
growing in HK
[96] MRSA Infections. Keep Kids Healthy.
[97] Graham PL, Lin SX, Larson EL (2006). A U.S.
population-based survey of Staphylococcus aureus colonization. Annals of Internal Medicine 144 (5): 318
25. doi:10.7326/0003-4819-144-5-200603070-00006.
PMID 16520472.
[98] Jernigan JA, Arnold K, Heilpern K, Kainer M, Woods C,
Hughes JM (2006-05-12). Methicillin-resistant Staphylococcus aureus as community pathogen. Symposium on
Community-Associated Methicillin-resistant Staphylococcus aureus (Atlanta, Georgia, U.S.). Cited in Emerg Infect Dis. Centers for Disease Control and Prevention. Retrieved 2007-01-27.
[99] First study nds MRSA in U.S. pigs and farmers, seattlepi.com, 4 June 2008

[100] Our Pigs, Our Food, Our Health, The New York Times, 12
[88] Eili Y. Klein, Lova Sun, David L. Smith, and Ramanan
March 2009
Laxminarayan (2013). [DOI: 10.1093/aje/kws273 The
Changing Epidemiology of Methicillin-Resistant Staphy- [101] PubMed Health. US National Institutes of Health. Retrieved 20 November 2011.
lococcus aureus in the United States: A National Observational Study"] Check |url= scheme (help). American Jour- [102] Optimal Bleach Concentration Required to Kill MRSA
nal of Epidemiology 177 (7).
in Bath Water. American Academy of Pediatrics. Retrieved 23 August 2013.
[89] http://www.cdc.gov/drugresistance/threat-report-2013/
[103] Living With MRSA (PDF). Group Health
[90] Cooper BS, Medley GF, Stone SP, Kibbler CC, Cookson
Cooperative/Tacoma-Pierce
County
Health
BD, Roberts JA, Duckworth G, Lai R, Ebrahim S (2004).
Dept./Washington State Dept. of Health. Retrieved 20
Methicillin-resistant Staphylococcus aureus in hospitals
November 2011.
and the community: stealth dynamics and control catastrophes. Proc Natl Acad Sci USA 101 (27): 102238. [104] Shi CM, Nakao H, Yamazaki M, Tsuboi R, Ogawa H
doi:10.1073/pnas.0401324101. PMC 454191. PMID
(November 2007). Mixture of sugar and povidone15220470.
iodine stimulates healing of MRSA-infected skin ulcers
on db/db mice. Arch. Dermatol. Res. 299 (9): 44956.
[91] Bootsma MC, Diekmann O, Bonten MJ (2006).
doi:10.1007/s00403-007-0776-3. PMID 17680256.
Controlling methicillin-resistant Staphylococcus aureus: quantifying the eects of interventions and rapid [105] THE NOSE GROUND ZERO FOR MRSA COLONIZATION. Ondine Biomedical Inc. Retrieved 20
diagnostic testing. Proc Natl Acad Sci USA 103 (14):
November 2011.
56205. doi:10.1073/pnas.0510077103. PMC 1459403.
PMID 16565219.
[106] Personal Prevention of MRSA Skin Infections. CDC. 9
August 2010.
[92] Klevens RM, Edwards JR, Richards CL, Horan TC,
Gaynes RP, Pollock DA, Cardo DM (2007). Estimating
[107] The Provision of Public Toilets
health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 122 (2): 1606. PMC [108] Government Response to the Communities and Local
1820440. PMID 17357358.
Government Committee Report on the Provision of Public Toilets
[93] Hidron AI, Edwards JR, Patel J, Horan TC, Sievert DM,
Pollock DA, Fridkin SK (November 2008). NHSN an- [109] Clinical Practice Guidelines by the Infectious Diseases
nual update: antimicrobial-resistant pathogens associated
Society of America for the Treatment of Methicillinwith healthcare-associated infections: annual summary of
Resistant Staphylococcus Aureus Infections in Adults and
data reported to the National Healthcare Safety Network
Children (PDF).

16

11

REFERENCES

[110] FDA Approves Tearo for Bacterial Infections.

[120] Cutler RR, Wilson P (2004). Antibacterial activity of a

new, stable, aqueous extract of allicin against methicillin[111] Schentag JJ, Hyatt JM, Carr JR, Paladino JA, Birmingresistant Staphylococcus aureus. Br J Biomed Sci 52 (3):
ham MC, Zimmer GS, Cumbo TJ (1998). Genesis
7174. PMID 15250668.
of methicillin-resistant Staphylococcus aureus (MRSA),
how treatment of MRSA infections has selected for [121] MRSA History Timeline: The First Half-Century, 1959vancomycin-resistant Enterococcus faecium, and the im2009. The University of Chicago Medical Center. 2010.
portance of antibiotic management and infection control.
Clin. Infect. Dis. 26 (5): 120414. doi:10.1086/520287. [122] MRSA Surveillance. Centers for Disease Control and
Prevention. April 8, 2011.
PMID 9597254.
[112] Rybak MJ, Lerner SA, Levine DP, Albrecht LM, [123] Community-acquired MRSA in Children with no predisposing risk
McNeil PL, Thompson GA, Kenny MT, Yuh L
(1991). Teicoplanin pharmacokinetics in intravenous
drug abusers being treated for bacterial endocarditis. [124] UK Oce for National Statistics Online (February 22,
2007), "MRSA Deaths continue to rise in 2005"
Antimicrob. Agents Chemother. 35 (4): 696700.
doi:10.1128/AAC.35.4.696. PMC 245081. PMID
[125] Hospitals struck by new killer bug An article by Manch1829880.
ester free newspaper 'Metro', May 7, 2008
[113] Janknegt R (1997). The treatment of staphylococcal infections with special reference to pharmacokinetic, phar- [126] Blot SI, Vandewoude KH, Hoste EA, Colardyn FA
(2002). Outcome and attributable mortality in critically
macodynamic, and pharmacoeconomic considerations.
Ill patients with bacteremia involving methicillinPharmacy world & science : PWS 19 (3): 13341.
susceptible and methicillin-resistant Staphylococcus
doi:10.1023/A:1008609718457. PMID 9259029.
aureus".
Arch Intern Med 162 (19): 222935.
doi:10.1001/archinte.162.19.2229. PMID 12390067.
[114] Chang FY, Peacock JE, Musher DM, Triplett P, MacDonald BB, Mylotte JM, O'Donnell A, Wagener MM, Yu VL
(2003). "Staphylococcus aureus bacteremia: recurrence [127] Liu C, Graber CJ, Karr M, Diep BA, Basuino L, Schwartz
BS, Enright MC, O'Hanlon SJ, Thomas JC, Perdreauand the impact of antibiotic treatment in a prospective
Remington F, Gordon S, Gunthorpe H, Jacobs R, Jensen
multicenter study. Medicine (Baltimore) 82 (5): 333
P, Leoung G, Rumack JS, Chambers HF (June 2008).
9. doi:10.1097/01.md.0000091184.93122.09. PMID
A population-based study of the incidence and molec14530782.
ular epidemiology of methicillin-resistant Staphylococcus
aureus disease in San Francisco, 20042005. Clin. In[115] Siegman-Igra Y, Reich P, Orni-Wasserlauf R, Schwartz
fect. Dis. 46 (11): 163746. doi:10.1086/587893. PMID
D, Giladi M (2005). The role of vancomycin in
18433335.
the persistence or recurrence of Staphylococcus aureus
bacteraemia. Scand J Infect Dis 37 (8): 5728.
[128] Noskin GA, Rubin RJ, Schentag JJ, Kluytmans J,
doi:10.1080/00365540510038488. PMID 16138425.
Hedblom EC, Smulders M, Lapetina E, Gemmen E
(2005). The Burden of Staphylococcus aureus Infec[116] Sieradzki K, Tomasz A (1997). Inhibition of cell
tions on Hospitals in the United States: An Analywall turnover and autolysis by vancomycin in a highly
vancomycin-resistant mutant of Staphylococcus aureus".
sis of the 2000 and 2001 Nationwide Inpatient Sample Database. Arch Intern Med 165 (15): 17561761.
J. Bacteriol. 179 (8): 255766. PMC 179004. PMID
9098053.
doi:10.1001/archinte.165.15.1756. PMID 16087824.
[117] Schito GC (2006). The importance of the development [129] Cosgrove SE, Qi Y, Kaye KS, Harbarth S, Karchmer AW,
of antibiotic resistance in Staphylococcus aureus". Clin
Carmeli Y (2005). The impact of Methicillin ResisMicrobiol Infect 12 (Suppl 1): 38. doi:10.1111/j.1469tance in Staphylococcus aureus Bacteremia on Patient Out0691.2006.01343.x. PMID 16445718.
comes: Mortality, Length of Stay, and Hospital Charges
( Scholar search ). Infection Control and Hospital Epidemi[118] Mongkolrattanothai K, Boyle S, Kahana MD, Daum RS
ology 26 (2): 166174. doi:10.1086/502522. PMID
(2003). Severe Staphylococcus aureus infections caused
15756888.
by clonally related community-associated methicillinsusceptible and methicillin-resistant isolates. Clin. In- [130] Hardy KJ, Hawkey PM, Gao F, Oppenheim BA (2004).
fect. Dis. 37 (8): 10508. doi:10.1086/378277. PMID
Methicillin resistant Staphylococcus aureus in the criti14523769.
cally ill. British Journal of Anaesthesia 92 (1): 12130.
doi:10.1093/bja/aeh008. PMID 14665563.
[119] Liu C, Bayer A, Cosgrove SE, Daum RS, Fridkin SK,
Gorwitz RJ, Kaplan SL, Karchmer AW, Levine DP, Mur- [131] Wyllie DH, Crook DW, Peto TE (2006). Mortality afray BE, J Rybak M, Talan DA, Chambers HF (Feb 1,
ter Staphylococcus aureus bacteraemia in two hospitals
2011). Clinical practice guidelines by the Infectious Disin Oxfordshire, 19972003: cohort study. BMJ 333
eases Society of America for the treatment of methicillin(7562): 281. doi:10.1136/bmj.38834.421713.2F. PMC
resistant Staphylococcus aureus infections in adults and
1526943. PMID 16798756.
children: executive summary. Clin Infect Dis. 61 (2):
[132] Tools. cddep.org.
28592. doi:10.1093/cid/cir034. PMID 21217178.

17

[133] Clinical trial number NCT00685698 for Safety and Efcacy Study of TG-873870 (Nemonoxacin) in Diabetic
Foot Infections at ClinicalTrials.gov

Chile and Manuka honey against methicillin-resistant

Staphylococcus aureus, Escherichia coli and Pseudomonas
aeruginosa". BMC Complement Altern Med 10: 47.
doi:10.1186/1472-6882-10-47. PMC 2942791. PMID
20813024.

[134] Novartis Stops Development of Aurograb. Drug Discovery and Development. August 29, 2008.
[145]
[135] Bowling FL, Salgami EV, Boulton AJ (2007). Larval therapy: a novel treatment in eliminating methicillinresistant Staphylococcus aureus from diabetic foot ulcers.
Diabetes Care 30 (2): 3701. doi:10.2337/dc06-2348.
[146]
PMID 17259512.

Kwakman PH, te Velde AA, de Boer L, Speijer D,

Vandenbroucke-Grauls CM, Zaat SA (July 2010). How
honey kills bacteria. FASEB J. 24 (7): 257682.
doi:10.1096/fj.09-150789. PMID 20228250.
Sponges secret weapon restores antibiotics power. Science News.

[136] Maggots help cure MRSA patients. BBC News. 2007[147] Suay I, Arenal F, Asensio FJ, Basilio A, Cabello MA,
05-02.
Dez MT, Garca JB, del Val AG, Gorrochategui
[137] Maggots rid patients of MRSA. EurekAlert!/AAAS.
J, Hernndez P, Pelez F, Vicente MF (2000).
2007-05-03.
Screening of basidiomycetes for antimicrobial activities
(PDF). Antonie van Leeuwenhoek 78 (2): 12939.
[138] Murphy, Clare (2007-08-13). "'Red Army' virus to comdoi:10.1023/A:1026552024021. PMID 11204765.
bat MRSA. BBC News.
[148] Appendino G, Gibbons S, Giana A, Pagani A, Grassi G,
[139] Matsuzaki S, Yasuda M, Nishikawa H, Kuroda M, UjiStavri M, Smith E, Rahman MM (2008). Antibacterial
hara T, Shuin T, Shen Y, Jin Z, Fujimoto S, Nasimuzcannabinoids from Cannabis sativa: A structure-activity
zaman MD, Wakiguchi H, Sugihara S, Sugiura T, Koda
study. Journal of Natural Products 71 (8): 14271430.
S, Muraoka A, Imai S (2003). Experimental protection
doi:10.1021/np8002673. PMID 18681481.
of mice against lethal Staphylococcus aureus infection by
novel bacteriophage phi MR11. J. Infect. Dis. 187 (4): [149] Russo EB (2011). Taming THC: potential cannabis synergy and phytocannabinoid-terpenoid entourage eects.
61324. doi:10.1086/374001. PMID 12599078.
British Journal of Pharmacology 163 (7): 13441364.
[140] Bayston R, Ashraf W, Smith T (2007). Triclosan redoi:10.1111/j.1476-5381.2011.01238.x. PMC 3165946.
sistance in methicillin-resistant Staphylococcus aureus exPMID 21749363.
pressed as small colony variants: a novel mode of evasion of susceptibility to antiseptics. J. Antimicrob. [150] Appendino G, Gibbons S, Giana A, Pagani A, Grassi
G, Stavri M, Smith E, Rahman MM (2008). AntibacChemother. 59 (5): 84853. doi:10.1093/jac/dkm031.
terial Cannabinoids from Cannabis sativa: A StructurePMID 17337510.
Activity Study. J. Nat. Prod. 71 (8): 142730.
[141] Wang J, Soisson SM, Young K, Shoop W, Kodali S, Galdoi:10.1021/np8002673. PMID 18681481.
goci A, Painter R, Parthasarathy G, Tang YS, Cummings
R, Ha S, Dorso K, Motyl M, Jayasuriya H, Ondeyka J, [151] Graham GS (2014). Healing outcomes of MRSAinfected wounds with a protocol combining Oakin dressHerath K, Zhang C, Hernandez L, Allocco J, Basilio A,
ing with elements of the de-escalation theory. J Wound
Tormo JR, Genilloud O, Vicente F, Pelaez F, Colwell L,
Care 23 (2): S4, S68, S101. PMID 24600754.
Lee SH, Michael B, Felcetto T, Gill C, Silver LL, Hermes
JD, Bartizal K, Barrett J, Schmatz D, Becker JW, Cully [152] Thompson, Nick; Smith-Spark, Laura. Thousand-yearD, Singh SB (May 2006). Platensimycin is a selective
old Anglo-Saxon potion kills MRSA superbug. CNN
FabF inhibitor with potent antibiotic properties. Nature
News. CNN/Time Warner. Retrieved 1 April 2015.
441 (7091): 358361. doi:10.1038/nature04784. PMID
16710421.
[142] Mullin, Emily (11 March 2014). University of Notre
Dame team IDs new class of antibiotics. ercebiotechresearch.com. Retrieved 19 March 2014.
[143] O'Daniel PI, Peng Z, Pi H, Testero SA, Ding D, Spink
E, Leemans E, Boudreau MA, Yamaguchi T, Schroeder
VA, Wolter WR, Llarrull LI, Song W, Lastochkin E,
Kumarasiri M, Antunes NT, Espahbodi M, Lichtenwalter K, Suckow MA, Vakulenko S, Mobashery S,
Chang M (2014). Discovery of a New Class of Non-lactam Inhibitors of Penicillin-Binding Proteins with
Gram-Positive Antibacterial Activity. J. Am. Chem. Soc.
(ACS) 136 (9): 36643672. doi:10.1021/ja500053x.
PMID 24517363.
[144] Sherlock O, Dolan A, Athman R, Power A, Gethin
G, Cowman S, Humphreys H (2010). Comparison
of the antimicrobial activity of Ulmo honey from

12 Further reading
There are several web-based resources available for further research and treatment options.
The Center for Disease Control maintains MRSA
pages that provide information surrounding the bacteria, including prevention, statistics, at risk groups,
causes, educational resources, and environmental
factors.
The National Institute for Occupational Safety and
Health maintains a webpage providing information
on the bacteria, with respect to the workplace setting, and steps towards mitigating risk from MRSA
infection.

18
The National Institutes of Health maintains Medline
Plus, a site for patients that provides information
surrounding diseases, their causes, and treatments.
Their MRSA pages provide research and information surrounding causes and treatment options.
The Mayo Clinic maintains an online site, updated
by Mayo Clinic sta, that covers the basic denition,
symptoms, and patient education for MRSA.
The online medical resource site, WebMD, maintains on MRSA that provide basic information about
the bacteria, as well as some multimedia resources
for patient education.
MRSA MD is an online medical site devoted solely
to MRSA education, treatment, and prevention.
Maintained by Dr. Kirk Bortel, MRSA MD provides treatment information and prevention education.
Maryn McKenna (2011). Superbug: The Fatal Menace of MRSA. Free Press. ISBN 978-1416557289.

12 FURTHER READING

19

13
13.1

Text and image sources, contributors, and licenses

Text

Methicillin-resistant Staphylococcus aureus Source: https://en.wikipedia.org/wiki/Methicillin-resistant_Staphylococcus_aureus?oldid=

686855590 Contributors: AxelBoldt, Kpjas, The Anome, Ed Poor, Josh Grosse, Azhyd, Heron, Someone else, Leandrod, Edward, Michael
Hardy, Palnatoke, Fred Bauder, Jtdirl, Dominus, MartinHarper, Paul A, Mkweise, Docu, Julesd, Andres, Dod1, , Vivin, Victor Engel, Bemoeial, Wikiborg, Atuin, Topbanana, Nufy8, Robbot, Zandperl, Gak, Sanders muc, Donreed, Nyh, Tanuki Z, Diberri, TexasDex,
Xanzzibar, Timemutt, Unfree, Giftlite, Graeme Bartlett, Techelf, Marnanel, Prince~enwiki, Gil Dawson, Wolfkeeper, Nunh-huh, Everyking, Alison, Jfdwol, Jason Quinn, Golbez, Gadum, Utcursch, Alexf, Gzuckier, Antandrus, Beland, OverlordQ, SethTisue, Wiml,
Bodnotbod, Gscshoyru, Mike Rosoft, Rob cowie, Jayjg, MattKingston, Cow2001, Alexrexpvt, Discospinster, Rich Farmbrough, Guanabot,
Kbh3rd, JoeSmack, Sfahey, RoyBoy, Juela, Bobo192, Davidruben, PeteThePill, Foobaz, Arcadian, Chirag, Kjkolb, Pacula, MPerel, Hagerman, Jakew, Espoo, Ifny, Alansohn, Greba, Andrewpmk, Wouterstomp, Riana, Batmanand, Mrholybrain, Snowolf, Isaac, RJFJR, Zootm,
Dan East, Ceyockey, Japanese Searobin, Feezo, Richard Arthur Norton (1958- ), Woohookitty, Linas, LOL, Swamp Ig, Jftsang, Benbest,
FireTrack, Pol098, Before My Ken, WadeSimMiser, Sdgjake, MarcoTolo, Graham87, BD2412, David Levy, Kbdank71, Rjwilmsi, Boccobrock, Scorpionman, Eubot, Ground Zero, Intgr, Stevenfruitsmaak, Preslethe, Vonkje, Mallocks, Colenso, WriterHound, Gwernol, Wavelength, Jzylstra, Hairy Dude, Mukkakukaku, Jurijbavdaz, Crazytales, Sillybilly, Hydrargyrum, Wimt, United88, NawlinWiki, ENeville,
JohJak2, MiceHead, Nate1481, JHCaueld, Historymike, Mysid, WAS 4.250, Bckirkup, Ageekgal, Theda, Closedmouth, Arthur Rubin, Abune, Josh3580, Dspradau, Wsiegmund, Ray Chason, AnimeJanai, ArielGold, Andrew73, Jon Ace, North Wolf Inuit, Luk, Harrisony, Sarah, SmackBot, Verdafolio, Moeron, Reedy, KnowledgeOfSelf, Istvan, Etherealmuse, Matthuxtable, Delldot, Jab843, Canthusus,
Halfmike, HalfShadow, Shai-kun, Septegram, Gilliam, Quotemstr, Ohnoitsjamie, Choalbaton, David.Throop, Anwar saadat, Bluebot,
MikeParker, Agateller, Quinsareth, RDBrown, Achmelvic, SchftyThree, RayAYang, Uthbrian, Dlohcierekims sock, Sbharris, SillyWilly,
Dpalma01~enwiki, Galizur, Rogermw, Robogun, JoeOnSunset, DHeyward, DRahier, Cripipper, KaiserbBot, JonHarder, Whatthree16,
RedHillian, Essent, Threeafterthree, Dreadstar, Drphilharmonic, Kshieh, LizFL, Ged3000, Acdx, Scharks, Kukini, Panthro, Angela26,
Missamo80, GiollaUidir, Ioresult, Good Intentions, John, Sbmehta, Scientizzle, Heimstern, Jaganath, Coastergeekperson04, Tktktk, Kashmiri, Slakr, Makyen, Kyoko, Blueamedj, SandyGeorgia, AdjustablePliers, Hu12, Iridescent, TwistOfCain, Melnicki, Veganguy74, Yendor33, StephenBuxton, Jaksmata, Courcelles, Thricecube, CatherinePeng, Joshuagross, DKqwerty, Fvasconcellos, VoxLuna, Rumpenisse,
CmdrObot, Kaboom326, Deon, AlbertSM, Mcstrother, Ruslik0, Mriojas, Dgw, Jesse Viviano, Outriggr (2006-2009), Lazulilasher, Richard
Keatinge, Cybernetic, Abdullahazzam, Phatom87, UncleBubba, Gogo Dodo, ST47, Blackmetalbaz, Mycroft.Holmes, Odie5533, DumbBOT, OVERM1ND, Obrian7, MardiM2, IVIa5taK, Gimmetrow, DavidSteinle, Audry2, JamesAM, Thijs!bot, Epbr123, Hazmat2, N5iln,
Purple Paint, Powers.andy, James086, Grayshi, X96lee15, Jonathan Sykes, Ju66l3r, Tom dl, KrakatoaKatie, AntiVandalBot, Luna Santin,
Widefox, DarkAudit, Douglasjoseph, TimVickers, Smartse, LibLord, Darklilac, Vendettax, Keith111, David Shankbone, Lfstevens, JAnDbot, Wushupork, Barek, MER-C, Hydro, Hewinsj, Dcooper, Spathi, SiobhanHansa, Acroterion, Ratmaster, WolfmanSF, VoABot II,
NighthawkJ, Jdominguez, Dekimasu, MastCell, Mark PEA, Dulciana, Chuck921, Wikiality123, Cardamon, Collegehealth-e, Adrian J.
Hunter, Just James, Halogenated, DerHexer, Philg88, Ccjones, BenClark, Thompson.matthew, Arielle04, Gandydancer, Ariel., Fethers,
Mschel, R'n'B, Nono64, Fconaway, Cinnamon colbert, Radbug, N4nojohn, AlphaEta, J.delanoy, Pharaoh of the Wizards, CFCF, Think777,
Boghog, Myredroom, Ciotog, Cpiral, Rod57, Katalaveno, McSly, Hakufu Sonsaku, Mikael Hggstrm, Jcganus, SJP, Nebukadje, Spanglos, Hamburmk, Tiggerjay, Richard.urban, EarthRise33, Mike V, Vyn, Copcareer, Pdcook, Vnahum, Freakytiki34, Steel1943, Shethvoss,
Wikigirl2, Highelds, GIBBOUS3, VolkovBot, Wabed, Je G., Nburden, Bangvang, Philip Trueman, JoeyOkay, Oshwah, Pwnage8, Malljaja, Thesaent, Aymatth2, LeaveSleaves, Henryodell, Goodbye 2, Enigmaman, Haseo9999, ChnaDragn, Angelatomato, Rituido, Enviroboy, Softlavender, Why Not A Duck, Schomerus, Darraghfriel, Pete5887, Doc James, Eli81993, Undead warrior, Souad27, SieBot, Dusti,
ATinySliver, Calliopejen1, Tiddly Tom, Euryalus, Aaron Swain, Gary.van.domselaar, Winchelsea, Yorkshirelion, RatnimSnave, Aeharris,
Flyer22 Reborn, Man Its So Loud In Here, Mariacann, JALindsay, Doctoruy, Oxymoron83, Crashtech, Aircraftdesigner36, Mayalld,
Int21h, Deejaye6, Iknowyourider, Afterbrunel, Iiigoiii, Mike2vil, Owlmonkey, Mygerardromance, Maralia, Maherelharake, Florentino
oro, Hordaland, Literaturegeek, Invertzoo, Touchstone42, Smashville, ClueBot, Educated hillbilly, Avenged Eightfold, GorillaWarfare,
Boodlesthecat, Fadesga, Plastikspork, Darthveda, RODERICKMOLASAR, Wanderer57, SportCoatings, Boing! said Zebedee, A professional dancing weasel, Rruggero, Niceguyedc, Neorunner, Blanchardb, Genay13, Asdfasdfasdf2629, Khal0o0di, BillE7448, Jersey
emt, Penguinface, Tisdalepardi, Excirial, Three-quarter-ten, Walking Softly, Telioshaw, Grashaun, Theresa666, Sdagsdgasd, Sam907,
Gwguey, Salud101, Campdurning, JacksonNJ, Sun Creator, KMKcpwrtg, ParisianBlade, Rgrue, NuclearWarfare, Jackpot777, Jason526,
Blackhawk440, Ember of Light, Ubd06b0916, CowboySpartan, Paradisemaa, FullerBrushMan, Muro Bot, Faust921, Thehelpfulone,
La Pianista, Medwards6439, Lillydog42, 9metallica9, Mshemko, MelonBot, Jmcaughey, Tdslk, DumZiBoT, XLinkBot, Medix, ACguitar, Ljastangs21, Jytdog, Enthoven, Jbeans, ZooFari, Good Olfactory, Tayste, Addbot, Cjneversleeps, Brumski, Thewormsterror, Jacopo
Werther, DOI bot, Kastor48252, Guacmol, Morning277, Chamal N, Glane23, Quercus solaris, Splodgeness, Bwrs, Bavgang123, Lightbot,
Gugustiuci, Khawar.nehal, Gail, Luckas-bot, Vedran12, Divadleahcim, Yobot, Mutiman, Ptbotgourou, TaBOT-zerem, Terrictrid, Axelarater, Echtner, Medimicro, AnomieBOT, XL2D, Nutriveg, Faethon Ghost, Hello4321, Jim1138, Gab031206, Skyphoenix726, InsucientData, Kingpin13, Materialscientist, ImperatorExercitus, LPROCKS 14, Citation bot, LilHelpa, Krisoft79, Xqbot, Cureden, Meewam,
Ytfc23, Xeaa, J4sonb, FlagrantBoosh, Ardman2000, Br77rino, Ernielippert, Vesper, ADEgorov, GrouchoBot, O2riorob, Omnipaedista,
Itineranttrader, SURF24.7, STLCoder, Soapshift, Dougofborg, Thehelpfulbot, Phish362009, FrescoBot, Surv1v4l1st, Ethgold1234, Riventree, Tend birds, Area range, Justinmurray1996, Sebastiangarth, HJ Mitchell, Contentmaven, Djeikyb, OgreBot, Citation bot 1, Intelligentsium, Pinethicket, I dream of horses, Micromesistius, Jonesey95, AlternativeMedGal, Websoftwaremore, Jusses2, Amagriva, Destaph,
NZ Kunckles, Robo Cop, Turidstavelandnygaard, Kpaddock, Cnwilliams, Jbtank, Keri, Trappist the monk, PiRSquared17, Bartlettpaul,
Donnersaurus, MikeAllen, Kmw2700, Theo10011, RjwilmsiBot, Xishan01, Autumnalmonk, John of Reading, Oliverlyc, Orphan Wiki,
Acather96, Howard41, Cinosaur, WikitanvirBot, Ianbrettcooper, KSLo0lyDqT, Winner 42, Supbonkers, Wikipelli, Dcirovic, Odintrollmann, JSquish, ZroBot, WikiDCUser, H3llBot, Netha Hussain, Ocaasi, Nallac56, FluyFriedFish, Mjgreene27, Ubikwit, Donner60,
Kirsten Edwards, AnnaJune, ClueBot NG, Love2donuts, Gareth Grith-Jones, ProfessorAM, CocuBot, Chester Markel, Donaldtaylor1960,
Vacation9, Dmarshiee, Tabletrack, Redmitrow, Cattleannie, Lamfo, Tormarom123, Go Phightins!, Widr, Geoerybard, Helpful Pixie Bot,
Dannyyoung97, Praziquantel86, BG19bot, EuroAgurbash, EvilResident, Nen, MusikAnimal, Kendall-K1, Mark Arsten, Dipankan001,
Laird Glecairn, Hopperr13, AhmedAdoudi, Ginger Maine Coon, Rowan Adams, Achowat, SoCher, Rytyho usa, BattyBot, Bugdoc3,
Cyberbot II, Amandahockey, Jionpedia, Bio476wikiedit, Baekoeun, Khazar2, Gizmo.AT, Daeda~enwiki, Rebeccaann1988, Tamarixia,
JZNIOSH, Lugia2453, Tommy Pinball, Dfjke, Susan1433, Tehboyz, Vanamonde93, Yamaha5, Eyesnore, Nonsenseferret, Shannonstone,
Wuerzele, Mrdevinhill, UAInformatics, Swatisamtani, Jubemerald, Wrestlingfan129, Sahebnasagh, Maggiewoodlief, Ginsuloft, Hatagalow,
Rustynail127, Roksonarim, Mon3oturf, Lasttruwarrior, Anrnusna, Prensesperi, Monkbot, Renamed user 51g7z61hz5af2azs6k6, Vieque,
Mtimar, BethNaught, Drbhoyroo, LukasMatt, Teen12, Anon13377, Sms1983, Lycanewolfe, Breedentials, Bburnam, Oreo1014, Kim-

20

13

TEXT AND IMAGE SOURCES, CONTRIBUTORS, AND LICENSES

ble.82, Joheli74, Malapr, Whalestate, ThePagedChanger123, Kjdhf and Anonymous: 1014

13.2

Images

File:Ambox_globe_content.svg Source: https://upload.wikimedia.org/wikipedia/commons/b/bd/Ambox_globe_content.svg License:

Public domain Contributors: Own work, using File:Information icon3.svg and File:Earth clip art.svg Original artist: penubag
File:Commons-logo.svg Source: https://upload.wikimedia.org/wikipedia/en/4/4a/Commons-logo.svg License: ? Contributors: ? Original
artist: ?
File:EARSS_MRSA_2008-en.svg Source: https://upload.wikimedia.org/wikipedia/commons/5/50/EARSS_MRSA_2008-en.svg License: CC BY-SA 3.0 Contributors:
http://www.rivm.nl/earss/database/ Original artist:
conversion by Trex2001
File:ER_Terminal_cleaning.jpg Source: https://upload.wikimedia.org/wikipedia/commons/9/9e/ER_Terminal_cleaning.jpg License:
CC BY-SA 3.0 Contributors: Originally uploaded on en.wikipedia Original artist: Originally uploaded by Chuck921 (Transferred by
Cocoaguy)
File:MRSA_on_MHA_media_resistant_to_oxacillin_antibiotic_strip.jpg Source: https://upload.wikimedia.org/wikipedia/en/d/d7/
MRSA_on_MHA_media_resistant_to_oxacillin_antibiotic_strip.jpg License: CC-BY-SA-3.0 Contributors:
Own work
Original artist:
Xishan01
File:MRSA_on_a_selective_choromogenic_media_plate.jpg Source: https://upload.wikimedia.org/wikipedia/en/7/77/MRSA_on_a_
selective_choromogenic_media_plate.jpg License: CC-BY-SA-3.0 Contributors:
Own work
Original artist:
Xishan01
File:MecA_Resistance.svg Source: https://upload.wikimedia.org/wikipedia/commons/c/c8/MecA_Resistance.svg License: CC BY 3.0
Contributors: Own work Original artist: Mcstrother
File:Muller_Hinton_agar_with_MRSA.jpg Source: https://upload.wikimedia.org/wikipedia/commons/6/61/Muller_Hinton_agar_
with_MRSA.jpg License: Public domain Contributors: Own work Original artist: Medimicro

13.3

Content license

Creative Commons Attribution-Share Alike 3.0