Worms and Germs Blog : Animal Health & Diseases : University of Guelph : Ontario Veterinary College : Zoonotic Diseases : Guelph, Hamilton, Ontario

Methicillin-resistant S. aureus (MRSA) and methicillin-resistant S. pseudintermedius (MRSP) get a lot of media attention because of the ever increasing numbers of infections in dogs and cats, and concerns about transmission to people. However, there are many other methicllin-resistant staph of varying relevances. One is an interesting related bug called Staphylococcus schleiferi.

There are actually two types of S. schleiferi:

• S. schleiferi schleiferi: This is a coagulase-negative subspecies that occasionally causes skin and ear infections in dogs (and uncommonly cats). It can also be found in healthy animals. There are a few reports of infections in people, mainly surgical site and wound infections in individuals who are at high risk of infection because of hospitalization, surgery or other factors.
• S. schleiferi coagulans: This is a coagulase-positive subspecies that may be more common in dogs and cats than S. schleiferi schleiferi, causing skin and ear infections and also being found in healthy animals. Human infections are very rare.

Currently, there is little to no evidence the animals are a source of human infection with S. schleferi and human infections appear to be very uncommon. However, this is an area that hasn't been studied much so it's hard to say with any confidence that there is no risk. My assumption is that the risk is very low, but not zero, so while we shouldn't be paranoid, it makes sense to use some very basic infection control practices when dealing with infected animals to reduce any possible risk. These would include:

• avoiding contact with infected sites
• if contact with infected sites is necessary (e.g. cleaning or treating infected ears), gloves should be worn and hands washed after glove removal
• hands should be washed thoroughly after any contact with the infected site, and regularly after contact with the animal

Quarantine of infected animals in households isn't necessary, because of the limited evidence of transmission and because healthy dogs and cats can also carry this bacterium. In veterinary clinics, isolation of infected animals is reasonable because other animals in the clinic may be at higher risk of developing infections should they become exposed.

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It's amazing how attached people are to their cell phones. Many people will answer them without any thought of what else is going on. It's something I've seen in veterinary hospitals where wireless or cell phones are the primary mode of internal communication. The natural tendency to answer the phone often overrides the thought process of "are my hands covered in pus, blood or some other gross material that I should perhaps remove before touching this piece of plastic that will spend a lot of time against my face and which may go home with me?" We've grown some interesting things from cell phones and pagers, as have others.

A recent paper in the American Journal of Infection Control (Sadat-Ali et al 2010) provides yet another example of this. In this study, the authors cultured cell phones of 288 health care providers over a six-month period.

• 44% of phones were contaminated with "potentially harmful" bacteria. There's no description of what they considered "potentially harmful" and I'm surprised that the percentage wasn't even higher.
• MRSA was isolated from 7.3% of phones, from people in wards, the emergency room and the operating room.
• 31% of people said they occasionally wiped down their phones with alcohol swabs. People who said they did this were significantly less likely to have contaminated phones.

Is this really surprising? No, not at all. We don't live in a sterile environment, and the more contact with healthcare environments, the greater the chance of contamination with healthcare-associated microorganisms. We also know that hygiene practices associated with cell phones are certainly not very common, nor have optimal ways to reduce or remove contamination been investigated.

Is this a problem? It's hard to say. Just because cell phones can become contaminated, that doesn't mean they are sources of infection. They are one of many, many potentially contaminated environmental surfaces. However, given the close contact with them and the potential that someone would touch a cell phone and then a patient, it's something that shouldn't be ignored.

Are health care workers' phones worse than other people's phones? It's hard to say. This study didn't look at a control group of non-healthcare workers. I suspect that phones owned by the general public are often contaminated as well, though perhaps not with the same range of microorganisms.

How can we reduce the risk of contamination? It's simple: wash your hands regularly. If healthcare workers washed their hands when they are supposed to (especially before and after patient contacts), the risk of contamination and the implications of cell phone contamination would be greatly reduced.

Like a lot of things in infection control, reducing the risks of this potential problem is pretty easy in  theory, but harder in practice, because the draw of that ringing phone is pretty powerful psychologically.

Image from http://cancergrace.org

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A study we just published in the journal Veterinary Record (Floras et al 2010) described an MRSA outbreak in a dog breeding kennel. That's a little unusual in itself, but considering how MRSA is spreading amongst the dog population, it's not really astounding. What was unique about this outbreak was the strain of MRSA that was involved, sequence type 398 (ST398).

ST398 MRSA is commonly referred to as livestock-associated MRSA, since this strain seems to have originated in pigs, and is commonly found in pigs and calves in some regions of the world. It can also infect people, and high rates of carriage of this MRSA strain can be found in pig farmers, pig vets and other people with close contact with livestock. In some areas of Europe, this strain is a big problem, accounting for a large percentage of human MRSA infections. Interestingly, it seems to be a rare cause of illness in people in North America (at least at the moment).

Dogs seem to be innocent bystanders when it comes to MRSA. The vast majority of MRSA strains found in dogs are common human strains, indicating that, ultimately, MRSA in dogs originated in people. There are only two other reports of dogs with ST398, both from Europe. One was a dog with a skin infection. The other was a healthy dog (a carrier) who was owned by a pig vet. 

This kennel outbreak involved a larger number of dogs, including both healthy carriers and sick dogs. Overall, MRSA was isolated on at least one occasion from 23/42 (55%) dogs in the kennel. In a couple of litters, most of the puppies were identified as carriers, but fortunately most stayed healthy. MRSA caused skin infection in one puppy and mastitis in a mother dog, and was also found in the respiratory tract of a puppy that died (although it may or may not have been the cause of death).

The source of the ST398 was not identified. One of the owners worked on a pig farm, but MRSA was not isolated from either owner. It's most likely that the owner did bring MRSA home from the farm, either as a transient carrier (in their nose) or as a contaminant on their skin. Regardless, once it got into the kennel, it was able to move between dogs, either from dog-dog contact or with the help of human hands. Fortunately, ST398 MRSA carriage by dogs seemed to be transient in this situation, which is consistent with what we know about carriage of other strains. MRSA is not really adapted for long-term survival in dogs, so they only carry it for short periods of time. That's a big advantage when it comes to trying to control this pathogen.

While we have to be careful to not over-interpret data from only a few studies, this report indicates that ST398 can cause disease in dogs and it can be present in apparently healthy dogs. It can also be spread relatively easily amongst dogs in a breeding kennel situation. While a pig-link was not confirmed, it's reasonable to suspect that dogs with contact with pigs (and perhaps other livestock) might be at higher risk of developing ST398 infections, as is the case with people.

This is a perfect example of the one medicine concept, and why we need to think about infectious diseases in broad terms, not just focusing on specific populations or species. This situation involved a pig Staphylococcus aureus that somehow acquired methicillin-resistance, spread widely around the world (most likely in pigs, initially), spread to people, and then likely spread to another species, in this case dogs.

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I was giving a talk on infection control at a conference in Geneva a couple of days ago, and during a discussion with someone after the talk, I told them to "Live every day like you have MRSA." Not surprisingly, I got a bit of a strange look in response. I wasn't trying to say, "live your life to the fullest because you never know what will happen." Rather, I was trying to get the point across that healthcare workers in both the veterinary and human systems need to realize that at any point in time they could be carrying MRSA, along with various other harmful microorganisms.

People in patient care positions need to make the assumption that they are always a potential source of disease, and act accordingly while doing their jobs. If someone knew they were a carrier of a bug like MRSA, they'd likely do a better job with routine infection control practices such as handwashing. But, you rarely know whether you're carrying MRSA or not, and it's better to go on the assumption that you are and be diligent with your infection control measures.

The same basic concept applies to different situations, such as how people in the general population behave, and how they interact with other people and animals. In some ways, everyone should assume that they are carrying an infectious disease like influenza, and that every person or animal they encounter is carrying something infectious. (In reality, this is actually true, since everyone is carrying something potentially infectious in or on their body at any given time, it's just that most of the time it's not particularly serious or transmissible organisms).

There's a line between prudence and paranoia, and we don't want to create a population of germophobes who won't leave the house. However, we want to increase awareness so people do a better job of things like washing their hands and covering their mouths properly when coughing or sneezing. Assuming that you and everyone around you is mildly biohazardous maybe a way to do just that.

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I'm not sure what to think about the recent increase in scientific papers about Staphylococcus pseudintermedius infections in people. This dog-associated bacterium has been well known for quite a while, and human infections have been sporadically reported, but it seems like there has been a big increase in reported cases over the past year.

The latest case, published in the Journal of Clinical Microbiology (Chuang et al 2010) describes a bloodstream infection in a 6-year-old boy. The infection was associated with an intravenous catheter site. The bacterium was initially misidentified as Staphylococcus aureus, a related bacterium that is more commonly found in people. It seems that the patient's history of having contact with dogs led to further testing of the bacterium. That's pretty surprising (and encouraging) from a few standpoints:

• The attending physicians asked about pet contact. That's not always done.
• The physicians recognized the potential for dog-human transmission of bacteria and considered the possibility that there was a misidentification by the lab. I'm quite surprised that they did further testing, since S. aureus is so common.

Unfortunately (as is commonly the case), they didn't take the investigation any further. It would have been nice for them to have tested the patient's dogs to see if they carried the same strain of S. pseudintermedius, to provide more evidence that the infection was truly from the dogs.

Concern has been raised before regarding the potential that S. pseudintermedius infections might be misdiagnosed as S. aureus, such that we don't know the true extent of the problems caused by the dog-associated bacterium. The ability of medical diagnostic labs to differentiate these two bacteria is something that needs to be investigated to help determine whether there may be more going on than we realize.

The increase in reports of S. pseudintermedius infections in the literature could also just be because infections that have always been occurring at a low level are being properly diagnosed, and people are bothering to write them up. The fact that people are still finding single cases of this infection noteworthy suggests that it's still a very uncommon condition. When you consider that the majority of dogs are carrying this bacterium, and millions upon millions of people have close contact with dogs on a regular basis, it's clear that people get exposed to this bacterium very often. The fact that infections appear to be so rare indicates that the risks to humans is likely quite low.

It's also possible that there truly has been an increase in these infections. It's hard to think of a reason why that might be the case. There's no evidence that the types of S. pseudintermedius have changed such that current strains are better able to infect people than older strains. Most likely, this is still a rare infection in humans that is often associated with dogs, but is of pretty low risk for the average dog owner. Regardless, continued study in the area is required, to make sure that this is not an emerging problem, especially when you consider that multidrug-resistant forms of this bacterium are also becoming much more common in veterinary medicine. Increased physician awareness about pet contact and zoonotic diseases is required to properly diagnose this and other potentially zoonotic diseases.

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Warm spells in early spring, like the recent warm spell in our area, inevitably lead to (premature) thoughts of summer, and for many people, this includes thoughts of spending time in the swimming pool. I've previously written about the presumably low risk of disease transmission from dogs swimming in pools, and common sense measures that can be taken to reduce any risks. Since more and more people and dogs are carrying resistant bacteria like MRSA, there are increasing questions about the potential for pools to be a source of transmission. A recent paper in the journal Clinical Pediatrics (Gregg & LaCroix, 2010) sheds some light on the issue.

In this study, the researchers obtained different types of swimming pool water (chlorinated water, saltwater, and biguanide (Baquacil) nonchlorinated water) from local pools. No MRSA was identified in any of the samples. They then inoculated the water samples with MRSA. They used a lot of MRSA - roughly similar to the amount that would be released from an MRSA abscess (and much, much greater than the amount that would be released from someone who was just an MRSA carrier). MRSA numbers were greatly diminished after 30 minutes and no MRSA was detected after 1 hour.

This study suggests that pools are likely not a significant source of MRSA exposure. Even with high-level contamination, MRSA died quickly. Presumably, there would be little MRSA shed by a person that was only a carrier, and when you consider the dilutional effect of a small amount of MRSA in a large volume of water, plus the bactericidal effects of treated water, the risks should be extremely low. Common sense would dictate that someone with an MRSA infection shouldn't go in the water because they could shed large numbers of bacteria, but this study suggests that the risks are probably minimal and short-term even then.

Bottom line: Don't worry about pools in terms of MRSA. Pools are a greater risk for certain causes of gastrointestinal disease like norovirus and Cryptosporidium. If you or your dog has an infectious disease, stay out of pools. If not, and you are otherwise healthy, then don't worry. There's always some risk of exposure to infectious disease, but it's very low. Life is full of risks and swimming in a pool is not a big one (at least from an infectious disease standpoint.  If you can't swim, that's a different story!).

Image from: http://blog.timesunion.com

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Antibiotic resistant bacteria are a huge problem in human medicine, and they're an increasing problem in veterinary medicine. In pets, we are seeing dramatic increases in multidrug-resistant bacteria, some as a result of transmission from humans and some that are developing in animals. Regardless of the source, infections caused by resistant bacteria are a major problem. As resistance increases and we have fewer and fewer treatment options for some infections, the potential need to use certain antibiotics that are important for serious infections in humans ("big-gun" antibiotics) increases. This is a very contentious issue because concerns have been raised over the use of these drugs in animals and the potential impact on humans.

There are two extremes to the argument:

1. These are critically important drugs in human medicine and they should never be used in animals.
2. These drugs are used thousands of times a day in people and very rarely in animals, so the impact of periodic use in animals should be minimal, and failure to use them would result in animal deaths from potentially treatable infections.

I take the middle ground here. I am very concerned about antibiotic resistance (in pets and people) and I want to make sure that what I do does not have a negative impact on public health. I also realize that very rare and appropriate use of these drugs will realistically be unlikely to have any negative impact on public health, and that withholding treatment could cause animal suffering, death and prolonged infections that could be transmitted to their owners. The key, to me, is ensuring that use of these drugs is truly very rare and appropriate. At the Ontario Veterinary College, we have strict guidelines for use of "big-gun" antibiotics to try to ensure that there are used rarely and properly. For example, vancomycin can be used, but only when:

• An infection is present and it is known that the bacterium is resistant to all other options and susceptible to vancomycin.
• Local antibiotic administration or other types of alternative treatment are not options.
• It's a serious infection that needs to be treated but it is treatable (i.e. no throwing a big gun drug at a patient that clearly has a terminal disease and does not have a realistic chance of surviving).
• Approval is obtained from the Chief of Infection Control (i.e. me).

With this approach, we've only had 1 case where vancomycin was used, and that was in 2001. That's a pretty good record for a busy referral centre with a tertiary care caseload that sees "the worst of the worst." There have been a few instances when vancomycin was requested but with discussion and review of the case, better alternatives were identified. I'm certain that these guidelines have reduced the use of vancomycin and increased awareness of the problem, but have had no negative impact on patient care.

Antimicrobial resistance isn't going away. We can control it but not eradicate it. Scrutiny of antibiotic use in veterinary medicine is also not going to go away, and in some ways, that's a good thing. It should provide impetus to make sure that we improve how we use drugs, from the big guns down to our day-to-day drugs. Realistically, it's the regular use (appropriate use, overuse and misuse) of less exotic antibiotics that is having a bigger impact on antimicrobial resistance, and we need to pay attention to that as much as to the high-profile drugs.

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We've seen reasonably good evidence of the potential involvement of pets in the transmission of methicillin-resistant Staphylococcus aureus (MRSA) for a few years, and a study recently published in the Journal of Hospital Infection (Loeffler et al 2010) sheds a little more light on the subject.

In this UK study, they tested 608 veterinary staff and pet owners in contact with pets that were carrying MRSA or methicillin-susceptible S. aureus (MSSA). MRSA carriage was identified in 12.3% of veterinarians that treated MRSA-infected animals and in 7.5% of their owners (although the chicken vs egg conundrum comes up, i.e. are vets that treated MRSA -infected pets more likely to have MRSA because they got it from the pet or because they already had MRSA and infected their patient?). These numbers are relatively consistent with a small number of other studies that have looked at these groups, and are higher than the expected carriage rates in the general population. This is highlighted by the results from people that had contact with animals only carrying methicillin-susceptible S. aureus, since MRSA was only identified in 4.8% of veterinary staff and 0% of owners in this group. Veterinary personnel were significantly more likely to carry MRSA than pet owners. As expected, virtually all MRSA from people and pets in the study were the predominant strains present in human hospitals in the UK.

We shouldn't fear MRSA or our pets, but we should respect the potential for infection and act accordingly. Mainly, this involves basic practices like:

• Good hygiene: washing hands regularly after handling pets
• Avoiding contact with infected body sites in pets, and preventing pets from having contact with infected body sites in people
• Prudent antibiotic use in both veterinary and human medicine
• Proper and timely diagnostic testing to identify MRSA infections, to permit proper treatment and earlier implementation of appropriate infection control practices.

Ultimately, MRSA in pets is a human-borne disease. Most pets that have MRSA presumably acquire it from a close human contact, so efforts at controlling MRSA in pets need to be directed at both the pet and human aspects. Uncontrolled MRSA in people will lead to increased risk for pets, and for pets to be a source of subsequent human infection.

Image: Seven-month-old British Shorthair (photo credit: Tamila Aspen)

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.An article about a therapy dog demonstrates some good points of these programs and places to improve. The story is about "Taco", a Chihuahua involved in pet therapy at the Livingston Regional Hospital (Tennessee). The obvious benefit of the program is highlighted by the owner's comment "She creates smiles when there were none." There are definite social and emotional benefits of pet therapy. There are also some potential health benefits, although the research on that isn't the strongest. On the downside, there are disease transmission concerns. These can be greatly reduced through attention to some simple procedures, but this article describes a number of concerning yet common problems:

"(Taco) greets each patient (ones who are comfortable enough to have her in their lap) with kisses on the nose."

• Being allowed to lick patients has been shown to be a risk factor for visitation dogs acquiring MRSA. Being allowed to like the nose is about as good of a model of MRSA transmission as you can develop, because the nose is the number-one site where this important bacterium lives. This type of licking can also transmit various other infectious agents to this compromised hospital population. Licking is an unnecessary behaviour that should not be permitted because it can be associated with infectious agent transmission.  Not permitting licking does little to decrease the value of visitation.

"(Owner Gerry) Cotnoir has had Taco since she was 9 weeks old.  She worked at Bethesda [Health Care Center) in Cookeville then and brought Taco with her to work every day. "She got used to people at an early age,""

• Socialization of dogs is important, but a hospital is not the place to do this. Only dogs older than 1 (and ideally older than 2) years of age should be in hospitals. Young animals are more likely to bite or scratch; not necessarily from aggression but also from playful or excited behaviour. Young animals also have much higher rates of shedding of various infectious agents such as Campyobacter.
• People in hospitals should not be bringing pets to work. Animals that are in hospitals should be there for formal, structured, short-term, properly observed and properly scrutinized visitation activities. That's not the case when someone brings a pet to work. A hospital is not a doggie day-care, although some people use them as such, with the occasional visit of a patient to explain why they are there.

The hospital's infection control personnel have approved the use of Taco in the Livingston facility, but you have to wonder how much they investigated the issues. There are clear guidelines for hospital therapy programs which aren't being followed here. Hopefully other important aspects of the guidelines, especially hand hygiene, are being followed. It's likely this is a situation where people don't understand the issues and don't realize that there are both concerns and resources to help them out.  Any facility that has, or is thinking of having, a visitation program, should be aware of these guidelines, plus other information from reputable groups such as Delta Society.

(Image source: www.studentsoftheworld.info)

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At the ongoing ASM-ESCMID conference on methicillin resistant staphylococci in animals, Dr. Engeline van Duijkeren of Utrecht University (The Netherlands) presented a study on an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) in their equine hospital.

From 2006-2008, several horses that underwent surgery at their hospital developed MRSA infections.  MRSA was also isolated from some healthy horses and personnel at the clinic. Early in the process, the hospital was closed for a thorough disinfection and the outbreak stopped, however another outbreak occurred later.  Further study again found people in the clinic that were MRSA carriers. Close to 15% of people in the hospital who handled equine patients were MRSA carriers, which is really astounding when you consider that less than 0.1% of the general population in the Netherlands carries MRSA. When they started testing horses coming into the clinic, they found that 9.3% of horses were carriers when they arrived. Weekly sampling of all hospitalized horses over a five-week period determined that 43% of all horses in the hospital carried MRSA at one point or another during their stay. Additionally, 53% of environmental surface samples were positive for MRSA, which is really not surprising if that many people and horses are carriers.

If horses keep coming into a facility carrying MRSA and people keep getting colonized, MRSA is hard to control. These experiences led the equine hospital at Utrecht to implement more stringent infection control practices to try to contain the problem, but the high MRSA rate in their referral population is going to pose a continual risk.

MRSA outbreaks in horses aren’t new. They’ve been reported by a few hospitals (including ours) and occur in many, many, (many!) more without ever being published. Since MRSA is present in the horse population, equine hospitals are at continual risk of MRSA outbreaks. If a large percentage of horses in the general population are carriers, the risk of outbreaks is higher.

MRSA is clearly a problem in horses in many areas. It’s important to realize that it’s a problem in the general population, not just horses in hospitals. Equine hospitals can amplify the spread of MRSA, but ultimately a lot (if not most) MRSA-positive horses originate from farms, not clinics or hospitals. Equine hospitals need solid infection control programs to reduce  the risk of outbreaks, but the risk will never be completely eliminated. Farms need good infection control programs to reduce the risk of spread of MRSA between horses and between farms, as well as from horses to people (and back). Antibiotics need to be used prudently since antibiotic use is a risk factor for MRSA carriage and infection.

More information about MRSA in horses can be found on the equIDblog Resources page.

This Worms & Germs blog entry was originally posted on equIDblog on 26-Sep-09.

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People sometimes panic after they hear that their pet has been diagnosed with an MRSA infection. ("Dr. Google" doesn’t help because if you search "MRSA" you can come up with a lot of scary information). However, it’s very important to understand that just because MRSA is involved, it does not mean that an animal (or person) has an untreatable infection. In fact, there are typically at least a couple of different treatment options available. That’s not to say that MRSA infections are of no concern, because they certainly are, but you have to maintain some balance.

Two studies presented at the ASM-ESCMID conference on methicillin-resistant staphylococci in animals re-inforce this. Dr. Andy Hillier from The Ohio State University presented a small study looking at 11 dogs with MRSA infections, including skin infections, surgical site infections, soft tissue infections and an ear infection. One dog was euthanized before treatment was started. All of the other 10 dogs survived. Aggressive treatment was needed in some cases, including some that required surgery to remove surgical implants or severely infected tissue. Still, they survived.

Similar results were presented by Dr. Meredith Faires from the University of Guelph. As part of one study, she reported survival of 42/45 (93%) of dogs with MRSA infections. A large percentage of dogs in that study had MRSA skin infections, which would not typically be expected to cause death, so it’s important to consider what types of infections are involved. Studies of invasive infections (e.g. infections of deeper tissues, infections of the bloodstream) presumably carry a much worse prognosis.

Regardless, these two studies provide more evidence that while MRSA can be bad, it’s not automatically a death sentence. With prompt diagnosis and proper treatment, a large percentage of infected dogs (and presumably cats as well) will survive. Prompt diagnosis and proper treatment are the key.

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When it comes to methicillin-resistant staphylococci in pets, MRSA (methicillin-resistant S. aureus) gets most of the attention. That's fair since it's emerging as an important health problem, and can be transmitted between pets and people. Now another staph, MRSP (methicillin-resistant S. pseudintermedius) is getting more attention, and it's actually a more common cause of infections in dogs and cats compared to MRSA. There are also some other methicillin-resistant staph that get much less attention. One is methicillin-resistant S. scheliferi (MRSS).

There are actually two different subspecies of this bacterium, S. schleiferi subsp. coagulans and S. schleiferi subsp. schleiferi. Staphylococcus schlieferi subsp. coagulans is the coagulase-positive subspecies. (Coagulase testing is one of the main ways staph species are classified.) Sta[hylocccus schleiferi subsp. schleiferi is coagulase-negative. In general, coagulase-negative staph are considered to be minor concerns and rare causes of disease other than in sick, compromised individuals in hospitals. However, it looks like S. schleiferi subsp. schleiferi is an exception to that rule, as it is able to cause disease in otherwise healthy dogs and cats.

Both S. schleiferi subtypes predominantly cause skin and ear infections. As with other staph, methicillin-resistance is a concern and is increasing. Methicillin-resistant S. schleiferi (MRSS) rates appear to be increasing, which is a concern because methicillin-resistant staph infections are harder to treat due to their resistance to many antibiotics.

One factor that limits our knowledge of the role of MRSS (and really, S. schleiferi in general) in disease is the fact that many, if not most, diagnostic laboratories don't try to differentiate it from S. pseudintermedius because the two species are very similar. (Sometimes, labs don't even try to differentiate any of the coagulase positive staph, including S. aureus).

While MRSA in pets is a public health concern, there is probably much less to fear from MRSS. Staphylococcus schleiferi infections in people are quite rare and there is currently no indication that pets are an important source of human infection. However, given our limited knowledge of this bacterium, it's wise to take some degree of precaution around animals with MRSS infections, particularly basic measures such as avoiding direct and indirect contact with infected sites, and good handwashing habits. These are the same general recommendations for pets with MRSP, and more details about this are available on the Worms & Germs Resources page. 

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I received a flyer from Zoologix, a company that offers various (typically unvalidated and unproven) PCR tests for animals. The flyer headline was "Pets can carry MRSA - but testing can help."

Testing in certain situations is useful, but this is almost always limited to diagnosis of animals with active infections (i.e. they're sick). PCR is not a good way to make such a diagnosis, because the test doesn't tell you anything about the bacterium's susceptibility to other antibiotics. Screening of pets just to determine whether or not they carry MRSA is rarely needed, and currently there is no evidence that PCR is a reasonable test for this.

There are no validated PCR tests for MRSA in animals. We looked at using a human test in horses and it failed miserably. There are validated tests for use in people, and they are quite good: they accurately identify MRSA and differentiate it from other methicillin-resistant staphylococci and from methicillin-susceptible S. aureus. That's critical, because you have to know what a positive test really means.

I called the company and asked what the test actually detects. They said it detects the mecA gene, the gene that confers methicillin-resistance to staphylococci such as S. aureus. However, this gene can be present in other staphylococci that can be found in many  healthy dogs and cats (10-30% in some studies). It does not actually detect MRSA and a large percentage of samples that give positive results will be false positives. The tests that are used in humans are specifically designed to look at two things in combination: whether S. aureus is present and whether it has the mecA gene (methicillin-resistance). This is the right approach because it excludes all those other false positives. Detecting mecA alone is completely useless. It's interesting that the flyer states "PCR testing is fast, effective and accurately differentiates MRSA from other bacteria - even other Staph strains." Based on what the company told me over the phone, with regard to the test they're advertising, that's a blatant lie.

This is an example of a combination of bad science and bad ethics. This company has no business marketing this test. It's false advertising, because the test isn't an MRSA test. Their justification for using it is similarly weak. Anyone thinking about using this test should run away quickly! The issues with this test (and others) should also be considered when deciding whether to use this company for any tests.

More (and accurate) information about MRSA can be found on the Worms & Germs Resources page.

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There's been a lot of talk (hype) in the press about pet bites and MRSA (methicillin-resistant Staphylococcus aureus). This relates to a paper in Lancet Infectious Diseases regarding infections associated with pet bites. Some press articles are more sensational than others, but most are taking the bite infection paper and building in unrelated comments about MRSA in animals to make it seem like there's a major MRSA dog bite epidemic underway.

I realize that MRSA is a hot topic that is easy for reporters to latch onto, but the problem is that the actual research related to MRSA is being taken out of context (and blown out of proportion). MRSA was certainly mentioned in the paper, but it was not the focus of the research nor do the authors play up concerns about pets as a source of MRSA infections. Nevertheless, the impression people are getting from many news articles is that there is rampant MRSA transmission by infected pets.

Is MRSA infection a potential concern after a dog bite?

• Yes, but more because of the bite itself than the particular dog.  MRSA infections that occur after a dog bite are probably the result of contamination of the wound with MRSA from the person's own nose or from another person, for example during a visit to their physician/clinic/hospital. It's possible for MRSA to be in the mouth of the dog and for it to be transferred to the wound during the bite, but that's pretty unlikely. The person bitten or someone treating the wound is a more likely source of the bacterium. So, the bite was the ultimate "cause" of the MRSA infection, because the infection probably wouldn't have developed without that break to the body's normal defensive barriers (i.e. the skin), however the "source" of the infection was (in most cases) NOT the animal.  The same kind of infection could have happened with any similar type of trauma.

What should I do if I'm worried about MRSA and dog bites?

• Worry more about dog bites than MRSA. Bites themselves are major problems, even if MRSA is not involved. The degree of trauma can be significant, and a variety of bacteria can cause serious bite infections, not just MRSA.
• Take measures to reduce the risk of being bitten, both in terms of how you handle and train your dog and how you interact with other dogs.
• If you are bitten, immediately clean the wound as thoroughly as possible. If the bite is over a joint, tendon (e.g. wrist/ankle), prosthesis or genitals, if there is significant trauma or if you have a weakened immune system, you need to see a physician. If you have any other concerns, get examined by a physician promptly.

More information on MRSA in animals can be found on the Worms & Germs Resources page.

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There is a nice, concise commentary in the most recent issue of the Canadian Medical Association Journal about preventing infections in the home. It covers three important organisms: MRSA, Clostridium difficile and vancomycin-resistant enterococci (VRE). An excellent aspect of this particular commentary is its relatively low-key approach, with an emphasis on routine, basic practices such as hand hygiene. It also includes some comments about pets that are similarly well-balanced and go along with a lot of what we've been saying on Worms & Germs Blog. For example, in discussing MRSA, they state:

"Because domestic pets may serve as a reservoir of MRSA, hands should always be washed thoroughly with soap and water after contact with animals or their feces. In cases of outbreaks within a family of an infection caused by community-associated MRSA that cannot be arrested, a colonized pet may need to be temporarily removed from the home. However, it may be prudent to re-emphasize the importance of personal hygiene before taking such a drastic measure."

Overall, it's a commentary you might find useful. It can be downloaded by clicking here.

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Methicillin-resistant Staphylococcus aureus (MRSA) is an important  (and high profile) cause of disease in people, and an emerging problem in animals. Evaluating the types of MRSA that we find in pets can help us understand what is happening with MRSA in pets and why.

A few different studies have evaluated the types of MRSA found in pets, using different molecular typing methods. The common result from all these studies is that the MRSA types found in pets are typically the same as those found in people in the same area. Even in different countries where there are different MRSA strains, the strains most commonly found in people are the same as the ones most commonly found in pets. Also, as the types of MRSA found in people in different regions change, so do the types found in pets.  For example, USA300 (which can be a particularly nasty strain of MRSA) emerged a few years ago as a leading cause of MRSA infections in people in the general population (i.e. community-associated MRSA) in the US.  Shortly thereafter, we started to see this strain in pets too. As USA300 began to crop up in people in Ontario, we also started finding it in pets. These results strongly suggest that MRSA in pets is closely related to MRSA in humans, and that most MRSA infections in pets ultimately started off in a person. Remember, though, that pets can still transmit MRSA once they've been infected.

It's inevitable that we will see more changes in MRSA types in people in the future, and it's almost certain that these changes will then be reflected in animals. In some ways, we can use humans as sentinels for what we are going to see in pets. By monitoring what is happening with MRSA in people and how it is being addressed, we can perhaps figure out the best (and worst!) ways to address the problem in animals.

More information about MRSA in pets can be found on the Worms & Germs Resources page. Information about MRSA in horses can be found on our sister site, equIDblog.

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A study published recently in the Journal of Hospital Infection (Lefebvre & Weese, 2009) looked at contamination of the haircoat of animals used in hospital visitation programs. In the study, Dr. Lefebvre petted animals that were going into a hospital and we cultured her hands.  Then when the dogs finished their visits she petting them again and we re-cultured her hands.  We tested for MRSA and Clostridium difficile, two important causes of hospital-associated infections. The goal was to see if the dogs' coats could become contaminated, presumably by patients' hands, during regular visits. The dogs' paws were also tested before and after to see what they picked up walking around the hospital.

After being in the hospital, one dog (4%) was found to have C. difficile on its feet. The strain that was recovered (ribottype 027/NAP1) is a strain of great concern, being it has caused outbreaks of illness internationally. The fact that there was C. difficile on the dog's paws, which was presumably picked up from the floor in the hospital, isn't exactly surprising. It shows that contact with dogs' feet (e.g. shaking a paw) could be a source of exposure to people in hospitals, and at home, and that dogs could be exposed to C. difficile after hospital visits by licking their paws. We previously demonstrated in another study that visitation dogs are at high risk for picking up C. difficile during visits.

The more important aspect of the study was what ended up on Dr. Lefebvre's hands after petting the dogs - a very common type of contact with dogs in hospitals and at home. She picked up MRSA from the coat of one dog (4% of dogs overall) after it had been in the hospital. The dog was not an MRSA carrier, and it did not have contact with anyone known to be carrying MRSA during its visit. Presumably, there was someone in the hospital that was an unknown carrier. If MRSA was on the person's hands, they could have transfered the MRSA to the dog's coat. The important part is that this MRSA was then able to spread to someone else's hands (Dr. Lefebvre's, in this case). This is a potential route of transmission of MRSA to patients during hospital visitations, and to other people these dogs might encounter outside of hospitals. The same thing could presumably happen with other infectious agents, including bugs like norovirus and influenza. These can't infect dogs, but dogs could potentially be short-term vectors of these viruses and spread them around a hospital.

The good thing about all this is that some basic guidelines can greatly reduce the risk of transmission:

• Patients should wash their hands  or use an alcohol-based hand sanitizer before  (to reduce the risk of depositing something on the pet's coat) and after (to reduce the risk of picking something up from the pet's coat) touching a pet.
• Pets should be kept off beds unless a disposal/washable barrier (e.g. drape, towel) is kept between the pet and the bed sheets, to prevent dirty feet from infecting the patient's living space/clothes/sheets.
• People should not "shake-a-paw" with pets in hospitals.

All these precautions can be taken without compromising the benefits of hospital pet visitations. More details about guidelines for hospital visitation aniamls can be found in an earlier post. More information about Clostridium difficile and MRSA can be found on the Worms & Germs Resources page.

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I've had this question a lot lately. Methicillin-resistant Staphylococcus pseudintermedius (MRSP), which is sometimes misidentified as methicillin-resistant S. intermedius (MRSI), is an important and increasing cause of infections in dogs and cats. After an animal has had an MRSP/MRSI infection, a question people often ask is how long they will carry the bacterium?

MRSP can be carried in the nose, intestinal tract or on the skin of a small percentage of normal animals. The implications of this are not clear, but it is reasonable to assume that carriers are more likely to develop infections in certain situations (e.g. if they sustain a wound or need to have surgery), and can transmit it to other animals (and possibly people, but that's much less of a concern with MRSP than with MRSA).

Back to the question... To be perfectly honest, we really don't know. However, I think it's reasonable to assume that some animals could carry MRSP for a long period of time - certainly weeks or months, maybe even years. Staphylococcu pseudintermedius is a common bacterium in healthy dogs and cats, and has basically evolved to survive on these animals. The methicillin-resistant versions are likely no different in this respect, so it's reasonable to assume that some animals could be long-term carriers. This makes controlling MRSP more difficult.  In contrast, MRSA appears to be only transiently carried by dogs and cats, probably because it is better adapted to living on humans than pets.

What you should do in the meantime if your pet has MRSP:

• Treat any infection as per your vet's instructions.
• Always complete the full treatment course.
• Wash your hands after contact with your pet, healthy or not.

More information about different types of staph bacteria can be found in the previous Worms&Germs post entitled Methicillin-Resistant Staph - What's In A Name?

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An MRSA prevalence study was recently performed at the American College of Veterinary Surgeons (ACVS) conference in San Diego, CA. As per the study protocols, results are being made available through  the Worms&Germs website. Click here to download the results file. This file contains code numbers for all positive results. If your number is not there, we did not isolate MRSA from your swab.

If MRSA was isolated from your swab, please do not panic! MRSA can normally be found in a small percentage of healthy individuals. Rates of MRSA carriage are higher in some groups, such as veterinarians. Most people that are carrying MRSA do not have any problems. In most situations, people in the general population that are carrying MRSA are not treated to eliminate colonization. However, if you are concerned about your result, we recommend that you contact your physician.

We appreciate your participation in this study. Analysis of the results is ongoing to look for factors associated with MRSA colonization. Further testing of MRSA isolates to characterize them is also ongoing.  If there are any problems or questions, please contact Scott Weese at jsweese@uoguelph.ca.

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You may notice a recurring theme in many of our posts and on virtually all of the information sheets on the Worms & Germs Resources page: an emphasis on handwashing. There is increasing emphasis on hand hygiene (i.e. hand washing and use of alcohol hand sanitizers) education in hospitals because the hands of healthcare workers are a major (if not the most important) means of disease transmission between patients. Despite hand hygiene being easy, cheap and effective, people rarely wash their hands as often as they should, and they often don't do it properly.

Most of the research about hand hygiene that has been published has focused on its use and impact in human hospitals, but this area is now also being studied more with regard to animals and veterinary medicine. A study published earlier this year in Veterinary Microbiology provided more evidence that hand hygiene is a critical infection control measure when dealing with animals. The study, coordinated by Dr. Maureen Anderson (of Worms&Germs fame) looked at MRSA carriage rate in veterinarians who work with horses. In addition to finding a high rate of MRSA carriage among these veterinarians (which was consistent with other reports indicating that equine vets are at higher than average risk for exposure to MRSA), the study looked at factors associated with MRSA carriage. Vets that reported routinely washing their hands between farms and those that reported washing their hands after contact with potentially infectious cases had a significantly lower rate of MRSA carriage. That should come as absolutely no surprise, but it's one more piece of evidence that we need to pay more attention to this routine infection control measure, in human hospitals, in veterinary environments and in households.

Remember, the 10 most important sources of infection are the fingers on your hands!

Click here for instructions on how to wash your hands properly.

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If you are looking for an interesting website to play around with, you should try HealthMap. This is a website created by the Harvard-MIT Division of Health Sciences and Technology that maps infectious disease reports from various sources. You can search by region and see what disease problems have been reported recently, or select specific diseases and find out where they've been reported.   Some examples are shown below. The top image shows all disease reports worldwide (in the last 30 days), while the bottom image shows reports of Salmonella in North America during the same time period. The site relies on reports of diseases (many cases of various diseases occur but are never reported), so it focuses mainly on outbreaks or high profile cases , but it is still quite interesting.

Above: All reported disease outbreaks/cases worldwide in the last 30 days.
Below: Reported outbreaks/cases of Salmonella in North America in the last 30 days.
See the HealthMap site for more details.

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A common question from owners of pets infected with methicillin-resistant Staphylococcus aureus (MRSA) is "Where did it come from?" The answer is not completely clear, but evidence strongly suggests it probably came from humans. The MRSA strains found in pets are almost always teh same as those found in people (including people that don't have pets) in the same geographic area. This strongly suggests that the MRSA came from the same source. Considering the fact that S. aureus in general is much more common in humans than in pets, and how long MRSA has been around in people, and that MRSA can sometimes be found in both people and pets in the same household, it is very likely that MRSA can move between species and originally went from humans to animal.

Even though MRSA in pets probably originated from people, now that it is in the pet population, pets can spread it to other animals and back to people. It is unclear how frequently this occurs - most people are still more likely to encounter MRSA from another person than from an animal.

The emergence and spread of MRSA in humans was largely driven by extensive antibiotic use in people.  Once MRSA crossed over to pets, antibiotic use in these animals almost certainly played a role in helping MRSA spread in the pet population. Antibiotic treatment has been identified as a risk factor for development of MRSA infection in dogs, and for MRSA carriage in horses.

Prudent antibiotic use is likely the most important factor in reducing the risk of MRSA in individual pets.  Using antibiotics prudently means doing things like:

• Only using antibiotics when they're really necessary
• Using the most basic antibiotic possible (instead of the fanciest or most powerful antibiotic)
• Finishing every prescription completely and as directed)

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Skin reactions from spider bites are usually very mild, if they are even noticed.  However, bites from certain kinds of spiders can cause severe skin lesions that may develop into  deep open wounds.  These are sometimes called "volcano lesions". Deaths due to such bites have been reported, mainly in children. However, the relatively small brown recluse spider, Loxosceles reclusa (see picture), is the only one of approximately 20 000 different species of spiders in the Americas that can cause these severe lesions. This spider is native to the midwestern and southeastern US, and is rarely found elsewhere.

In many cases (particularly in people but also in pets), a variety of focal skin lesions, including volcano lesions, may be diagnosed as a "spider bite" without any further testing. This is even done in areas where  brown recluse spiders don't live!  Another possible cause of a volcano lesion that may be mistaken for a spider bite is methicillin-resistant Staphylococcus aureus (MRSA). It is clear that many MRSA infections in people are being misdiagnosed as spider bites, but I have also talked to various pet owners whose dogs had MRSA infections that were originally diagnosed as spider bites. Most of these were from areas where brown recluse spiders would never be found. If an MRSA infection is diagnosed initially as a spider bite, the delay in starting proper treatment can lead to more prolonged and potentially more serious disease.

In addition to MRSA, the related bacterium methicillin-resistant S. pseudintermedius (MRSP), which is more common in dogs and cats than in humans, could be involved in similar skin infections. This is just as serious for the pet, but less of a concern for people in contact with the pet.  For more information about MRSA versus MRSP, check out our blog on Methicillin-Resistant Staph: What's in a Name?

• MRSA, MRSP and other infectious agents should be considered as potential causes for focal skin lesions, particularly if they form deep open wounds or an abscess containing pus.
  
• Volcano lesions should not be assumed to be spider bites unless a bite from a brown recluse spider was observed.  Such lesions should definitely not be diagnosed as spider bites in regions where the brown recluse spider does not live.
• Wash your hands if you touch any unusual skin lesion on a person or a pet.

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There is a lot of concern and confusion about methicillin-resistant staphylococcal infections in pets. "Staphylococcus" is genus of bacteria which contains numerous different species. All these species can come in 'methicillin-resistant' forms that are resistant to many antibiotics, but some of these species are of greater concern than others. The main species of concern are discussed below.

Methicillin-resistant S. aureus (MRSA): This species is the big concern. MRSA is an important cause of disease in people and an increasing problem in pets. It can cause serious infections and be transmitted between animals and people (in both directions).

Methicillin-resistant S. intermedius (MRSI): Actually, what most laboratories still call S. intermedius appears to be a related species called S.  pseudintermedius. Regardless, MRSI (or MRSP) can cause a variety of infections in pets - usually skin and ear infections. While it can be spread from animals to people, this is likely rare and there is much less concern about MRSI compared to MRSA in terms of risk to humans from infected pets.

Methicillin-resistant S. schleiferi (MRSS): This species is closely related to (and often misidentified) as S. intermedius. It is most commonly found in skin and ear infections. There is no information about the risk of transmission to people from pets. It is probably possible but very unlikely.

Methicillin-resistant coagulase-negative staphylococci: This is a large group of staphylococcal species that are usually lumped together. They are commonly found in or on healthy dogs and cats as part of the body's normal bacterial population. They are less common causes of disease. There is currently minimal concern about transmission to humans.

MRSA is the main concern with regard to staph infections, and warrants particular attention when it causes infection in a pet. In these cases, important precautions to take include washing your hands frequently, avoiding contact with the infected part of the animal's body (plus the nose, where MRSA often hangs out), keeping the infected site(s) bandaged (if possible), keeping infected pets off the bed, and restricting contact with high risk people (e.g. young children, elderly, immunocompromised). For the other staph species, the risks to people are much lower, but it is still reasonable to implement these measures to further reduce the risks.

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Many people in the horse world have heard the hype about methicillin-resistant Staphylococcus aureus (MRSA) in horses. MRSA can cause infection in horses, just like it can in people, dogs, cats and many other animals. It’s usually what we call an “opportunistic” pathogen, meaning it usually takes advantage of a person or an animal that is already sick or injured, like someone who’s in the hospital and has just had surgery. And because MRSA is resistant to many different antibiotics, the infection can be difficult to treat. The big concern with MRSA in recent years is that infections are now sometimes occurring in people who aren’t sick, and who don’t have wounds or incisions, which is where MRSA usually likes to move in. It’s very important to find out from the start if an infection is being caused by MRSA, so that it can be prevented from spreading to other people and animals, and so that it can (if necessary) be treated with the right kind of antibiotic.

Horses are a bit of a special case when it comes to animals and MRSA. When researchers look at the DNA of MRSA from a dog or a cat, it usually turns out to be one of the common human MRSA strains (usually called a “clone”) from the same area. This means that the dog or cat probably picked up the MRSA from a person somewhere.  When researchers look at the DNA of MRSA from horses, however, they often find a different clone, which seems to be more common in horses and people who work with horses than in people in general. A very similar situation has also been discovered in pigs. The worry is that this “horse MRSA clone” can survive in and be transmitted between horses better than the human MRSA clones. That means that in order to control MRSA, just controlling it in the people won't do the trick - we need to take steps to stop the spread of MRSA in horses specifically as well.

Here are some key points to help reduce the risk of your horse (and you!) getting MRSA:

• Always wash your hands with soap and water (or use an alcohol-based hand sanitizer) after handling a horse, and before handling another horse.
  • This is especially important if you have touched a horse’s nose, or any cuts or wounds that the horse may have.
  • Don’t go down the row of stalls in the barn and pet every horse on the nose! They love the attention, but this is a great way to spread MRSA if it’s there!
• New horses coming into the barn, or animals coming back from a hospital, should be kept separate from all the other animals and only dealt with after all the other horses, for 3-4 weeks.
  • This is an important measure for controlling many infectious diseases, not just MRSA.
• If your horse has a cut that looks infected, cover it with a bandage of some kind and contact your veterinarian. Your veterinarian can culture the wound to determine if it is an MRSA infection.

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Recently, a story about a man who brought a horse into a hospital to visit his father was widely reported. The horse apparently made it to the man’s room, which included a trip in an elevator. The son, who appeared intoxicated, was eventually asked to leave (and take the horse with him). Said a hospital spokesperson “We do have a pet visitation policy, but it does not include a horse”. Strangely, the horse that was brought to the hospital apparently wasn’t even the father’s horse (which supports suspicions of the son’s lack of sobriety).

There are guidelines about which animals are appropriate for hospital visits, although it shouldn’t take an expert to figure out that a horse is not an appropriate candidate. Kicks, bites, and trauma from being crushed or run over are among the most obvious concerns. Horses can also carry a variety of bacteria that are potentially dangerous, especially to people in hospitals. These include Salmonella and methicillin-resistant Staphylococcus aureus (MRSA). There also aren’t that many house-trained horses out there.

So, while I can easily see how someone in a hospital would like to see his or her horse, there’s no way this should even be considered.

Some closing thoughts
-    Would you like to ride in an elevator with a horse?
-    Would you like to be stuck in an elevator with a horse?
-    Do you think the horse was house trained?
-    Do you think any of the healthcare personnel washed their hands after touching the horse?

This isn't the first time a horse has been in hospital, and some even get invited. The picture is from a story in Veterinary Practice News that described a program where horses were brought into hospitals!

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A Letter was just published in the New England Journal of Medicine about a woman with recurrent methicillin-resistant Staphylococcus aureus (MRSA) infections and her cat. MRSA is a hot topic because it’s a big cause of disease in people and there are indications that it can be transmitted between people and pets (in both directions). She kept getting recurrent infections and they eventually cultured MRSA from her cat. The cat was not sick and was a carrier. That’s something that we’re seeing increasingly, although we don’t know whether the pets are actually involved in transmission or whether they are innocent bystanders that are infected by their owners. The concerns that I had with this Letter revolve around the fact that the cat was treated for MRSA (in my experience, carriage of MRSA by dogs and cats is transient and antibiotics aren’t needed), they never tested the cat after treatment but they declare that the woman’s infections only ceased after the cat was treated. The problem is, the cat may have gotten rid of MRSA despite the antibiotic treatment, the owner may have handled the cat differently after finding out it was MRSA positive and therefore decreased the risk of transmission, or it may never have played a role in her infections.

Unfortunately, this Letter may lead to unnecessary treatment of pets that carry MRSA or over-assumption of the role of pets in human infections. It also meant that I was stuck doing rounds and rounds of interviews with reporters wanting comments. The key take-home messages from this are:

- Pets are part of the household and should be considered if a household disease investigation is undertaken.
- While pets may sometimes be involved in transmission of MRSA, simply finding MRSA in a pet does not mean that it has infected anyone.
- There is currently no indication that we should be using antibiotics to get rid of MRSA colonization in pets because they almost invariably get rid of it on their own.

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