Infection DOI 10.1007/s15010-015-0760-3
CASE REPORT
MRSA as a rare cause of vaginitis L. C. J. de Bree1 · M. M. L. van Rijen2 · H. P. M. Coertjens2 · P. van Wijngaarden1
Received: 15 October 2014 / Accepted: 25 February 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract We describe a 26-year-old otherwise healthy woman with MRSA vaginitis. Traditional MRSA risk factors were absent and additional screening sites were negative. Patient was treated successfully with oral antibiotics combined with topical lactic acid emulsion. Because her partner appeared to have solitary MRSA carriage on the glans, a suggestion of sexual transmission was made. He was treated successfully with topical mupirocin ointment. Although solitary vaginal MRSA carriage and infection seems to be rare and its clinical impact is yet undefined, clinicians should consider adding the genitourinary tract to traditional screening sites in case of recurrent MRSA infections. Keywords MRSA · Staphylococcus aureus · Vaginitis · Sexual transmission
Case report We describe a 26-year-old healthy woman who developed foul-smelling vaginal discharge. Screening for sexual transmitted diseases which could cause vaginitis including PCR for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis was negative. Vaginal cultures repeatedly yielded exclusively a methicillin-resistant Staphylococcus aureus (MRSA, MLVA type 2098, MLVA
complex 0632, PVL negative). Microscopy of the vaginal discharge has not been done. Classic risk factors for MRSA carriage like contact with livestock or recent hospital admission were not present. She was working in the home care. Cultures of the nares, oropharynx and perineum appeared to be negative. Her uncircumcised partner was screened for MRSA carriage as well, and cultures from the nares, oropharynx and perineum were negative. Although he did not have any genital symptoms, an additional culture from the glans yielded an identical MRSA strain as his partner. The woman was treated successfully with cotrimoxazole and rifampicin orally for one week, combined with topical application of a lactic acid emulsion in the vagina. Her vaginal discharge completely resolved. Afterwards cultures were repeatedly taken from the nares, oropharynx, perineum and vagina for a period of 8 months and remained negative. Her partner was treated topically on the glans with mupirocin ointment three times daily for one week combined with chlorhexidine total body washing once daily. The culture of the glans after this first treatment stayed positive. A second topical treatment for 1 week was successful. Also in his case, cultures taken frequently from all sites remained negative up till now (8 months).
MRSA and vaginal carriage * L. C. J. de Bree [email protected] 1
Department of Internal Medicine, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
2
Laboratory for Microbiology and Infection Prevention, Amphia Hospital Breda, Breda, The Netherlands
The growing incidence of MRSA colonization and infections is a worldwide problem [1]. MRSA colonization is a well-known risk factor for skin, soft tissue and postoperative infections and is associated with increased morbidity and mortality compared to methicillin-susceptible Staphylococcus aureus. While MRSA colonization
13
L. C. J. de Bree et al.
used to be healthcare associated, colonization in otherwise healthy individuals without established risk factors, so called community-associated MRSA (CA-MRSA), has emerged rapidly. Due to an aggressive search-anddestroy policy and restrictive antibiotic use in the Netherlands the prevalence of MRSA colonization is still low (in 2011: 0.11 %) despite its high prevalence in neighbouring countries [2]. The anterior nares, the ecological niche of S. aureus, serves as the preference screening site for MRSA colonization. In addition, MRSA can be found on other body sites like the skin and especially skin defects, the oropharynx and the pelvic region. Acton et al. [3] demonstrated that adding perineal screening enhances MRSA detection. The meta-analysis of 22 studies with a total of 2195 MRSA-colonized patients showed that 18 % of MRSApositive individuals presented with intestinal carriage in the absence of nasal carriage. Adding perineal screening not only increases MRSA detection, but may also have an important clinical impact. This was suggested by an observational study among intensive care and liver transplant patients, in which patients with both rectal and nasal MRSA colonization had significantly higher rates of S. aureus infections than patients with nasal carriage only (40.4 versus 18.2 %) [4]. Less is known about the frequency and clinical impact of vaginal colonization. With the increasing prevalence of CA-MRSA colonization, concerns were raised about MRSA-related post-partum infections as well as the potential for vertical MRSA transmission as seen with group B streptococcus (GBS). As a consequence, in the past decade combined anovaginal colonization has been comprehensively studied, mainly in pregnant women during the third semester as a part of GBS detection studies in countries with high MRSA prevalence. The lowest prevalence rate of MRSA detected was 0.47 % [5] and the highest rate amounted 10.4 % [6]. Nevertheless, vertical transmission and MRSA-related maternal or neonatal infections are rare [7]. However, most of the studies done in these pregnant women were based on anovaginal cultures. Studies with cultures concerning exclusively the vagina are scarce. Reusch et al. [8] took 288 cultures from the anterior nares and the vagina in pregnant women in active labour. They found six women with MRSA carriage. Five of them had solely nasal carriage and one woman (0.35 %) had nasal as well as vaginal MRSA carriage. The only study known to us where specifically vaginal colonization was studied was done by Huppert et al. [9]. In 315 sexually active women with a mean age of 18.1 years and a high prevalence of sexually transmitted diseases, vaginal cultures yielded 16 women (5.1 %) with S. aureus of which two (0.6 %) appeared to be MRSA. Although they conclude that the
13
vaginal colonization probably was a result of auto-inoculation, no information about the traditional sites of MRSA detection was available. Buehlmann et al. [10] found vaginal colonization in 26 % of hospitalized women with MRSA colonization or infection. Cook et al. [11] investigated household members of MRSA positive persons for MRSA carriage. Two (6.2 %) out of 32 women additionally tested for MRSA carriage in the pubic area and/or vagina had solitary vaginal MRSA carriage, another two (6.2 %) had pubic area carriage only and four (12.5 %) had positive MRSA cultures of the vagina as well as pubic area. Interestingly, of these eight women with vaginal and/ or pubic area MRSA carriage, six (75 %) appeared to have negative nasal cultures. Because the exact incidence of (solitary) vaginal carriage is still uncertain, in our opinion the above mentioned articles should lead to further investigations about vaginal MRSA carriage and its clinical impact.
MRSA vaginitis Vaginitis is an infectious inflammatory condition of the vagina that can result in discharge, itch and pain. Vaginitis is generally caused by microbes like Chlamydia trachomatis, Neisseria gonorrhoeae, Candida albicans or Trichomonas vaginalis. Bacterial vaginosis is the most common cause of vaginal discharge and Gardnerella vaginalis has been considered to play an important role in this condition [12]. Staphylococcal species are normally not considered as a vaginal pathogen. Vaginitis due to MRSA has only been reported once [13]. A 54-year-old woman, who was quadiplegic, bedridden and had an indwelling Foley catheter because of a neurogenic bladder, developed a symptomatic MRSA cystitis for which she was treated with vancomycin intravenously. After successful treatment with negative urine cultures, she developed foul-smelling vaginal discharge with a positive vaginal MRSA culture. She was treated with mupirocine topically, after which her complaints resolved and her vaginal culture became negative. It was suggested that the infected urine could have seeped into the vagina and propagated the vaginal infection. Our patient was an otherwise healthy young woman without preceding infections. The symptoms of our patient could theoretically by caused by an infection as well as bacterial vaginosis. However, bacterial vaginosis is very unlikely the cause in this case. As mentioned earlier MRSA was the only cultured pathogen. Moreover, the effective antibiotic treatment for bacterial vaginosis is oral metronidazole or vaginal clindamycin which was not given in this case [14]. Although lactic acid emulsion is used to prevent vaginal irritation, it is not an effective treatment for bacterial
MRSA as a rare cause of vaginitis
vaginitis or bacterial vaginosis [15]. We added the lactic acid emulsion to the antibiotic treatment because there is some evidence that lactic acid emulsion will help to restore the normal vaginal lactobacilli flora [16]. Bacterial vaginosis can resolve spontaneously. Our patient was symptomatic for already several weeks, whereas her complaints disappeared completely during the treatment for the MRSA. Although other micro-organism susceptible to the given treatment could have contributed to the infection, a symptomatic MRSA infection seems very feasible. Whether MRSA could be sexually transmitted and if genitourinary tract carriage could be a reservoir for transmission into the community is still a matter of debate. Cook described six couples in whom clinical and microbiological evidence of heterosexual transmission of CA-MRSA seems likely [11]. In our patient it is possible that the MRSA was sexually transmitted because she appeared to be negative at the traditional MRSA screening sites and her partner appeared to have solitary MRSA carriage on the glans. Because the incidence of solitary vaginal carriage appears to be low and symptomatic infections are very uncommon, there is not much known about the treatment of vaginal MRSA infections. In one study, six patients with vaginal MRSA carriage were eradicated successfully with povidone-iodine ovula, hexetidine ovula or octenidine suspension [10]. In case of the reported MRSA vaginitis, intravaginal application of mupirocin twice daily for 10 days was successful, although adding systemic antibiotic treatment was recommended by the infectious disease specialist [13]. Although our patient appeared to be negative on traditional MRSA screening sites, we decided to treat her with systemic antibiotics in combination with topical lactic acid emulsion. We opted for systemic treatment because of the severity of her complaints and the wish to avoid the risk of further local irritation with topical use of mupirocin ointment. Because her partner was asymptomatic and the glans is a relatively small area compared to the vagina, he was treated topically with mupirocin ointment thrice daily for 2 weeks in total.
Conclusion Vaginal MRSA carriage seems to be uncommon but has not been comprehensively studied. MRSA vaginitis is very rare and we found only one published case report of MRSA vaginitis, developed immediately after a catheterassociated urinary tract MRSA infection. We described a vaginitis in an otherwise healthy young woman. Although the causative pathogen of the vaginitis could theoretically have been another micro-organism susceptible for the
given therapy, the solitary vaginal MRSA detection and relief of symptoms after treatment are very suggestive of MRSA being the causative agent. The detection of MRSA on the glans penis of the partner of the patient is evocative of sexual transmission. In our case, therapy consisting of cotrimoxazole and rifampicin combined with topical treatment successfully eradicated vaginal MRSA infection. Local application of mupirocin ointment was sufficient for eradication of MRSA carriage of the glans. Although solitary vaginal MRSA carriage and infection seems to be rare and its clinical impact is yet undefined, clinicians should be aware of colonization of the genitourinary tract with recurrent or not understood MRSA infections. In case of MRSA-related genitourinary tract infections, multiple site screening including the genitourinary tract of the partner is recommended. Conflict of Interests The authors declare they have no conflict of interest.
References 1. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of meticillin-resistant Staphylococcus aureus as a public-health threat. Lancet. 2006;368:874–88. 2. Bode LG, Wertheim HF, Kluytmans JA, Bogaers-Hofman D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box ATA, Voss V, Van Belkum A, Verbrugh HA, Vos MC. Sustained low prevalence of methicillin-resistant Staphylococcus aureus upon admission to hospital in The Netherlands. J Hosp Infect. 2011;79:198–201. 3. Acton DS. Tempelmans Plat-Sinnige MJ, Van Wamel W, De Groot N, Van Belkum A. Intestinal carriage of Staphyloccocus aureus: how does its frequency compare with that of nasal carriage and what is its clinical impact. Eur J Clin Microbiol Infect Dis. 2009;28:115–27. 4. Squier C, Rihs JD, Risa KJ, Sagnimeni A, Wagener MM, Stout J, Muder RR, Singh N. Staphylococcus aureus rectal carriage and its association with infections in patients in a surgical intensive care unit and a liver transplant unit. Infect Control Hosp Epidemiol. 2002;23:495–501. 5. Chen KT, Huard RC, Della-Latta P, Saiman L. Prevalence of methicillin-sensitive and methicillin-resistant Staphylococcus aureus in pregnant women. Obstet Gynecol. 2006;108:482–7. 6. Creech CB, Litzner B, Talbot TR, Schaffner W. Frequency of detection of methicillin-resistant Staphylococcus aureus from rectovaginal swabs in pregnant women. Am J Infect Control. 2010;38:72–4. 7. Sheffield JS. Methicillin-resistant Staphylococcus aureus in Obstetrics. Am J Perinatol. 2013;30:125–30. 8. Reusch M, Ghosh P, Ham C, Klotchko A, Singapuri S, Everett G. Prevalence of MRSA colonization in peripartum mothers and their newborn infants. Scand J Infect Dis. 2008;40:667–71. 9. Huppert JS, Bennet K, Kollar LM, Pattullo L, Mortensen JE. MRSA: rare in the Vagina. J Pediatr Adolesc Gynecol. 2011;24:315–6. 10. Buehlmann M, Frei R, Fenner L, Dangel M, Fluckiger U, Widmer A. Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers. Infect Control Hosp Epidemiol. 2008;29:510–6.
13
L. C. J. de Bree et al. 11. Cook HA, Furuya EY, Larson E, Vasquez G, Lowy FD. Heterosexual transmission of community-associated methicillin resistant Staphylococcus aureus. Clin Infect Dis. 2007;44:410–3. 12. Schwebke JR, Muzny CA, Josey WE. Role of Gardnerella vaginalis in the pathogenesis of bacterial vaginosis: a conceptual model. J Infect Dis. 2014;210:338–43. 13. Cool-Foley AA, Nathan C, O’Donovan C 3rd, Simon D. Eradication of methicillin-resistant Staphylococcus aureus vaginitis with mupirocin. DICP Ann Pharmacother. 1991;25:1331–3. 14. Bradshaw CS, Pirotta M, De Guingand D, Hocking JS, Morton AN, Garland SM, Fehler G, Morrow A, Walker S, Vodstrcil
13
LA, Fairley CK. Efficacy of oral metronidazole with vaginal clindamycin or vaginal probiotic for bacterial vaginosis: randomized placebo-controlled double-blind trial. PLoS One. 2012;7:E34540. doi:10.1371/journal.pone.0034540. 15. Boeke AJ, Dekker JH, van Eijk JT, Kostense PJ, Bezemer PD. Effect of lactic acid suppositories compared with oral metronidazole and placebo in bacterial vaginosis: a randomised clinical trial. Genitourin Med. 1993;69:388–92. 16. Andersch B, Lindell D, Dahlén I, Brandberg A. Bacterial vaginosis and the effect of intermittent prophylactic treatment with an acid lactate gel. Gynecol Obstet Invest. 1990;30:144–9.
CASE REPORT
MRSA as a rare cause of vaginitis L. C. J. de Bree1 · M. M. L. van Rijen2 · H. P. M. Coertjens2 · P. van Wijngaarden1
Received: 15 October 2014 / Accepted: 25 February 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract We describe a 26-year-old otherwise healthy woman with MRSA vaginitis. Traditional MRSA risk factors were absent and additional screening sites were negative. Patient was treated successfully with oral antibiotics combined with topical lactic acid emulsion. Because her partner appeared to have solitary MRSA carriage on the glans, a suggestion of sexual transmission was made. He was treated successfully with topical mupirocin ointment. Although solitary vaginal MRSA carriage and infection seems to be rare and its clinical impact is yet undefined, clinicians should consider adding the genitourinary tract to traditional screening sites in case of recurrent MRSA infections. Keywords MRSA · Staphylococcus aureus · Vaginitis · Sexual transmission
Case report We describe a 26-year-old healthy woman who developed foul-smelling vaginal discharge. Screening for sexual transmitted diseases which could cause vaginitis including PCR for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis was negative. Vaginal cultures repeatedly yielded exclusively a methicillin-resistant Staphylococcus aureus (MRSA, MLVA type 2098, MLVA
complex 0632, PVL negative). Microscopy of the vaginal discharge has not been done. Classic risk factors for MRSA carriage like contact with livestock or recent hospital admission were not present. She was working in the home care. Cultures of the nares, oropharynx and perineum appeared to be negative. Her uncircumcised partner was screened for MRSA carriage as well, and cultures from the nares, oropharynx and perineum were negative. Although he did not have any genital symptoms, an additional culture from the glans yielded an identical MRSA strain as his partner. The woman was treated successfully with cotrimoxazole and rifampicin orally for one week, combined with topical application of a lactic acid emulsion in the vagina. Her vaginal discharge completely resolved. Afterwards cultures were repeatedly taken from the nares, oropharynx, perineum and vagina for a period of 8 months and remained negative. Her partner was treated topically on the glans with mupirocin ointment three times daily for one week combined with chlorhexidine total body washing once daily. The culture of the glans after this first treatment stayed positive. A second topical treatment for 1 week was successful. Also in his case, cultures taken frequently from all sites remained negative up till now (8 months).
MRSA and vaginal carriage * L. C. J. de Bree [email protected] 1
Department of Internal Medicine, Amphia Hospital Breda, Molengracht 21, 4818 CK Breda, The Netherlands
2
Laboratory for Microbiology and Infection Prevention, Amphia Hospital Breda, Breda, The Netherlands
The growing incidence of MRSA colonization and infections is a worldwide problem [1]. MRSA colonization is a well-known risk factor for skin, soft tissue and postoperative infections and is associated with increased morbidity and mortality compared to methicillin-susceptible Staphylococcus aureus. While MRSA colonization
13
L. C. J. de Bree et al.
used to be healthcare associated, colonization in otherwise healthy individuals without established risk factors, so called community-associated MRSA (CA-MRSA), has emerged rapidly. Due to an aggressive search-anddestroy policy and restrictive antibiotic use in the Netherlands the prevalence of MRSA colonization is still low (in 2011: 0.11 %) despite its high prevalence in neighbouring countries [2]. The anterior nares, the ecological niche of S. aureus, serves as the preference screening site for MRSA colonization. In addition, MRSA can be found on other body sites like the skin and especially skin defects, the oropharynx and the pelvic region. Acton et al. [3] demonstrated that adding perineal screening enhances MRSA detection. The meta-analysis of 22 studies with a total of 2195 MRSA-colonized patients showed that 18 % of MRSApositive individuals presented with intestinal carriage in the absence of nasal carriage. Adding perineal screening not only increases MRSA detection, but may also have an important clinical impact. This was suggested by an observational study among intensive care and liver transplant patients, in which patients with both rectal and nasal MRSA colonization had significantly higher rates of S. aureus infections than patients with nasal carriage only (40.4 versus 18.2 %) [4]. Less is known about the frequency and clinical impact of vaginal colonization. With the increasing prevalence of CA-MRSA colonization, concerns were raised about MRSA-related post-partum infections as well as the potential for vertical MRSA transmission as seen with group B streptococcus (GBS). As a consequence, in the past decade combined anovaginal colonization has been comprehensively studied, mainly in pregnant women during the third semester as a part of GBS detection studies in countries with high MRSA prevalence. The lowest prevalence rate of MRSA detected was 0.47 % [5] and the highest rate amounted 10.4 % [6]. Nevertheless, vertical transmission and MRSA-related maternal or neonatal infections are rare [7]. However, most of the studies done in these pregnant women were based on anovaginal cultures. Studies with cultures concerning exclusively the vagina are scarce. Reusch et al. [8] took 288 cultures from the anterior nares and the vagina in pregnant women in active labour. They found six women with MRSA carriage. Five of them had solely nasal carriage and one woman (0.35 %) had nasal as well as vaginal MRSA carriage. The only study known to us where specifically vaginal colonization was studied was done by Huppert et al. [9]. In 315 sexually active women with a mean age of 18.1 years and a high prevalence of sexually transmitted diseases, vaginal cultures yielded 16 women (5.1 %) with S. aureus of which two (0.6 %) appeared to be MRSA. Although they conclude that the
13
vaginal colonization probably was a result of auto-inoculation, no information about the traditional sites of MRSA detection was available. Buehlmann et al. [10] found vaginal colonization in 26 % of hospitalized women with MRSA colonization or infection. Cook et al. [11] investigated household members of MRSA positive persons for MRSA carriage. Two (6.2 %) out of 32 women additionally tested for MRSA carriage in the pubic area and/or vagina had solitary vaginal MRSA carriage, another two (6.2 %) had pubic area carriage only and four (12.5 %) had positive MRSA cultures of the vagina as well as pubic area. Interestingly, of these eight women with vaginal and/ or pubic area MRSA carriage, six (75 %) appeared to have negative nasal cultures. Because the exact incidence of (solitary) vaginal carriage is still uncertain, in our opinion the above mentioned articles should lead to further investigations about vaginal MRSA carriage and its clinical impact.
MRSA vaginitis Vaginitis is an infectious inflammatory condition of the vagina that can result in discharge, itch and pain. Vaginitis is generally caused by microbes like Chlamydia trachomatis, Neisseria gonorrhoeae, Candida albicans or Trichomonas vaginalis. Bacterial vaginosis is the most common cause of vaginal discharge and Gardnerella vaginalis has been considered to play an important role in this condition [12]. Staphylococcal species are normally not considered as a vaginal pathogen. Vaginitis due to MRSA has only been reported once [13]. A 54-year-old woman, who was quadiplegic, bedridden and had an indwelling Foley catheter because of a neurogenic bladder, developed a symptomatic MRSA cystitis for which she was treated with vancomycin intravenously. After successful treatment with negative urine cultures, she developed foul-smelling vaginal discharge with a positive vaginal MRSA culture. She was treated with mupirocine topically, after which her complaints resolved and her vaginal culture became negative. It was suggested that the infected urine could have seeped into the vagina and propagated the vaginal infection. Our patient was an otherwise healthy young woman without preceding infections. The symptoms of our patient could theoretically by caused by an infection as well as bacterial vaginosis. However, bacterial vaginosis is very unlikely the cause in this case. As mentioned earlier MRSA was the only cultured pathogen. Moreover, the effective antibiotic treatment for bacterial vaginosis is oral metronidazole or vaginal clindamycin which was not given in this case [14]. Although lactic acid emulsion is used to prevent vaginal irritation, it is not an effective treatment for bacterial
MRSA as a rare cause of vaginitis
vaginitis or bacterial vaginosis [15]. We added the lactic acid emulsion to the antibiotic treatment because there is some evidence that lactic acid emulsion will help to restore the normal vaginal lactobacilli flora [16]. Bacterial vaginosis can resolve spontaneously. Our patient was symptomatic for already several weeks, whereas her complaints disappeared completely during the treatment for the MRSA. Although other micro-organism susceptible to the given treatment could have contributed to the infection, a symptomatic MRSA infection seems very feasible. Whether MRSA could be sexually transmitted and if genitourinary tract carriage could be a reservoir for transmission into the community is still a matter of debate. Cook described six couples in whom clinical and microbiological evidence of heterosexual transmission of CA-MRSA seems likely [11]. In our patient it is possible that the MRSA was sexually transmitted because she appeared to be negative at the traditional MRSA screening sites and her partner appeared to have solitary MRSA carriage on the glans. Because the incidence of solitary vaginal carriage appears to be low and symptomatic infections are very uncommon, there is not much known about the treatment of vaginal MRSA infections. In one study, six patients with vaginal MRSA carriage were eradicated successfully with povidone-iodine ovula, hexetidine ovula or octenidine suspension [10]. In case of the reported MRSA vaginitis, intravaginal application of mupirocin twice daily for 10 days was successful, although adding systemic antibiotic treatment was recommended by the infectious disease specialist [13]. Although our patient appeared to be negative on traditional MRSA screening sites, we decided to treat her with systemic antibiotics in combination with topical lactic acid emulsion. We opted for systemic treatment because of the severity of her complaints and the wish to avoid the risk of further local irritation with topical use of mupirocin ointment. Because her partner was asymptomatic and the glans is a relatively small area compared to the vagina, he was treated topically with mupirocin ointment thrice daily for 2 weeks in total.
Conclusion Vaginal MRSA carriage seems to be uncommon but has not been comprehensively studied. MRSA vaginitis is very rare and we found only one published case report of MRSA vaginitis, developed immediately after a catheterassociated urinary tract MRSA infection. We described a vaginitis in an otherwise healthy young woman. Although the causative pathogen of the vaginitis could theoretically have been another micro-organism susceptible for the
given therapy, the solitary vaginal MRSA detection and relief of symptoms after treatment are very suggestive of MRSA being the causative agent. The detection of MRSA on the glans penis of the partner of the patient is evocative of sexual transmission. In our case, therapy consisting of cotrimoxazole and rifampicin combined with topical treatment successfully eradicated vaginal MRSA infection. Local application of mupirocin ointment was sufficient for eradication of MRSA carriage of the glans. Although solitary vaginal MRSA carriage and infection seems to be rare and its clinical impact is yet undefined, clinicians should be aware of colonization of the genitourinary tract with recurrent or not understood MRSA infections. In case of MRSA-related genitourinary tract infections, multiple site screening including the genitourinary tract of the partner is recommended. Conflict of Interests The authors declare they have no conflict of interest.
References 1. Grundmann H, Aires-de-Sousa M, Boyce J, Tiemersma E. Emergence and resurgence of meticillin-resistant Staphylococcus aureus as a public-health threat. Lancet. 2006;368:874–88. 2. Bode LG, Wertheim HF, Kluytmans JA, Bogaers-Hofman D, Vandenbroucke-Grauls CM, Roosendaal R, Troelstra A, Box ATA, Voss V, Van Belkum A, Verbrugh HA, Vos MC. Sustained low prevalence of methicillin-resistant Staphylococcus aureus upon admission to hospital in The Netherlands. J Hosp Infect. 2011;79:198–201. 3. Acton DS. Tempelmans Plat-Sinnige MJ, Van Wamel W, De Groot N, Van Belkum A. Intestinal carriage of Staphyloccocus aureus: how does its frequency compare with that of nasal carriage and what is its clinical impact. Eur J Clin Microbiol Infect Dis. 2009;28:115–27. 4. Squier C, Rihs JD, Risa KJ, Sagnimeni A, Wagener MM, Stout J, Muder RR, Singh N. Staphylococcus aureus rectal carriage and its association with infections in patients in a surgical intensive care unit and a liver transplant unit. Infect Control Hosp Epidemiol. 2002;23:495–501. 5. Chen KT, Huard RC, Della-Latta P, Saiman L. Prevalence of methicillin-sensitive and methicillin-resistant Staphylococcus aureus in pregnant women. Obstet Gynecol. 2006;108:482–7. 6. Creech CB, Litzner B, Talbot TR, Schaffner W. Frequency of detection of methicillin-resistant Staphylococcus aureus from rectovaginal swabs in pregnant women. Am J Infect Control. 2010;38:72–4. 7. Sheffield JS. Methicillin-resistant Staphylococcus aureus in Obstetrics. Am J Perinatol. 2013;30:125–30. 8. Reusch M, Ghosh P, Ham C, Klotchko A, Singapuri S, Everett G. Prevalence of MRSA colonization in peripartum mothers and their newborn infants. Scand J Infect Dis. 2008;40:667–71. 9. Huppert JS, Bennet K, Kollar LM, Pattullo L, Mortensen JE. MRSA: rare in the Vagina. J Pediatr Adolesc Gynecol. 2011;24:315–6. 10. Buehlmann M, Frei R, Fenner L, Dangel M, Fluckiger U, Widmer A. Highly effective regimen for decolonization of methicillin-resistant Staphylococcus aureus carriers. Infect Control Hosp Epidemiol. 2008;29:510–6.
13
L. C. J. de Bree et al. 11. Cook HA, Furuya EY, Larson E, Vasquez G, Lowy FD. Heterosexual transmission of community-associated methicillin resistant Staphylococcus aureus. Clin Infect Dis. 2007;44:410–3. 12. Schwebke JR, Muzny CA, Josey WE. Role of Gardnerella vaginalis in the pathogenesis of bacterial vaginosis: a conceptual model. J Infect Dis. 2014;210:338–43. 13. Cool-Foley AA, Nathan C, O’Donovan C 3rd, Simon D. Eradication of methicillin-resistant Staphylococcus aureus vaginitis with mupirocin. DICP Ann Pharmacother. 1991;25:1331–3. 14. Bradshaw CS, Pirotta M, De Guingand D, Hocking JS, Morton AN, Garland SM, Fehler G, Morrow A, Walker S, Vodstrcil
13
LA, Fairley CK. Efficacy of oral metronidazole with vaginal clindamycin or vaginal probiotic for bacterial vaginosis: randomized placebo-controlled double-blind trial. PLoS One. 2012;7:E34540. doi:10.1371/journal.pone.0034540. 15. Boeke AJ, Dekker JH, van Eijk JT, Kostense PJ, Bezemer PD. Effect of lactic acid suppositories compared with oral metronidazole and placebo in bacterial vaginosis: a randomised clinical trial. Genitourin Med. 1993;69:388–92. 16. Andersch B, Lindell D, Dahlén I, Brandberg A. Bacterial vaginosis and the effect of intermittent prophylactic treatment with an acid lactate gel. Gynecol Obstet Invest. 1990;30:144–9.
