Control of an outbreak of an epidemic methicillin-resistant Staphylococcus aureus also resistant to mupirocin

An epidemic methicillin-resistant Staphylococcus aureus (EMRSA-3) appeared in a District hospital in June 1989 as part of a regional outbreak. The dynamics of the outbreak were complex and involved patient transfer between hospitals and wards. Control measures followed UK guidelines and included the use of nasal mupirocin. During these efforts a mupirocin-resistant MRSA [MuMRSA: mupirocin minimum inhibitor concentration (MIC) >256 mg/L] emerged, probably in a patient who had been given eight mupirocin courses over nine months. The MuMRSA had a narrower phage-typing pattern than EMRSA-3, but was indistinguishable by pulsed-field gel electrophoresis of SmaI chromosomal restriction enzyme digests and its susceptibility pattern to other antibiotics. The results of in vitro curing and gene probing indicated that mupirocin resistance was encoded on a 48 Md plasmid. MuMRSA spread occurred in 12 patients and 11 staff. The affected patients were nursed on the same ward. The strain was eradicated from patients with oral ciprofloxacin and rifampicin, triclosan skin treatment and nasal fusidic acid and bacitracin cream. The control of the outbreak had significant medical, social and financial implications. Fortunately, there were alternative topical agents to mupirocin,an agent which has played such a key role in MRSA eradication in recent years.