National Survey of the Bone Densitometry Evaluation Process Within an Integrated Healthcare System.

BACKGROUND: To assess the current state of bone mineral density evaluation services via dual energy x-ray absorptiometry (DXA) provided to Veterans with fracture risk through the development and administration of a nationwide survey of facilities in the Veterans Health Administration. METHODOLOGY: The Bone Densitometry Survey was developed by convening a Work Group of individuals with expertise in bone densitometry and engaging the Work Group in an iterative drafting and revision process. Once completed, the survey was beta tested, administered through REDCap, and sent via e-mail to points of contact at 178 VHA facilities. RESULTS: Facility response rate was 31 % (56/178). Most DXA centers reported positively to markers of readiness for their bone densitometers: less than 10 years old (n=35; 63 %); in "excellent" or "good" condition (n=44; 78 %, 32 % and 46 %, respectively); and perform phantom calibration (n=43; 77 %). Forty-one DXA centers (73 %) use intake processes that have been shown to reduce errors. Thirty-seven DXA centers (66 %) reported their technologists receive specialized training in DXA, while 14 (25 %) indicated they receive accredited training. Seventeen DXA centers (30 %) reported performing routine precision assessment. CONCLUSIONS: Many DXA centers reported using practices that meet minimal standards for DXA reporting and preparation; however, the lack of standardization, even within an integrated healthcare system, indicates an opportunity for quality improvement to ensure consistent high quality bone mineral density evaluation of Veterans.

Attitudes toward bone health among rural-dwelling veterans identified as at risk of fracture: a qualitative analysis.

Although much is known about system-level barriers to prevention and treatment of bone health problems, little is known about patient-level barriers. The objective of this study was to identify factors limiting engagement in bone health care from the perspective of rural-dwelling patients with known untreated risk. Over 6 months, 39 patients completed a qualitative interview. Interview questions focused on the patient's experience of care, their decision to not accept care, as well as their knowledge of osteoporosis and the impact it has had on their lives. Participants were well-informed and could adequately describe osteoporosis and its deleterious effects, and their decision making around accepting or declining a dual-energy x-ray absorptiometry (DXA) scan and treatment was both cautious and intentional. Decisions about how to engage in treatment were tempered by expectations for quality of life. Our findings suggest that people hold beliefs about bone health treatment that we can build on. Work to improve care of this population needs to recognize that bone health providers are not adding a behavior of medication taking to patients, they are changing a behavior or belief. Published 2021. This article is a U.S. Government work and is in the public domain in the USA. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Longitudinal Case Series of Staphylococcus aureus Colonization and Infection in Two Cohorts of Rural Iowans.

OBJECTIVE: Examine the relationship between colonization with Staphylococcus aureus in the community and symptomatic infection in two cohorts of Iowans. DESIGN: Case series within cohort study. PARTICIPANTS: Rural Iowans selected from the Keokuk Rural Health Study, the Agricultural Health Study, and the Iowa Voter Registry. METHODS: Longitudinal study within established cohorts evaluating documented S. aureus infections with samples available for molecular typing. RESULTS: We examined this relationship in two cohorts of Iowans with a combined 11 incident cases of S. aureus SSTI, for which samples were available. Seven of the 11 individuals (63.6%) were colonized at baseline, in the nose (3/7, 42.9%), or in both the nose and throat (57.1%). All seven cases had matching sequence types between colonization and infection isolates. CONCLUSIONS: Staphylococcus aureus causes millions of skin and soft tissue infections yearly. Although colonization with S. aureus is a frequent antecedent to infection, many studies investigating the link between colonization and infection have taken place in a clinical setting, particularly in urban hospitals. Our study has shown similar results in a rural community setting to those previously seen in clinics.

Whole-Genome Analysis of Recurrent Staphylococcus aureus t571/ST398 Infection in Farmer, Iowa, USA.

Staphylococcus aureus strain sequence type (ST) 398 has emerged during the last decade, largely among persons who have contact with swine or other livestock. Although colonization with ST398 is common in livestock workers, infections are not frequently documented. We report recurrent ST398-IIa infection in an Iowa farmer in contact with swine and cattle.

A Novel Methicillin-Resistant Staphylococcus aureus t11469 and a Poultry Endemic Strain t002 (ST5) Are Present in Chicken in Ebonyi State, Nigeria.

BACKGROUND: The changing epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) from a hospital-associated pathogen to an organism commonly found in the community and in livestock reflects an organism well-equipped to survive in diverse environments and adjust to different environmental conditions including antimicrobial use. METHODS: We investigated the molecular epidemiology of S. aureus and MRSA in poultry in Ebonyi State, Nigeria. Samples were collected from 1800 birds on 9 different farms within the state. Positive isolates were tested for antibiotic susceptibility and molecular typing. RESULTS: Prevalence in birds was 13.7% (247/1800). MRSA prevalence in poultry was 0.8%. The prevalence of MRSA in broilers and layers was 1.2% and 0.4%, respectively. All tested isolates were susceptible to vancomycin. Molecular analysis of the isolates revealed 3 spa types: t002, t084, and a novel spa type, t11469. The novel spa type t11469 belonged to sequence type ST5. CONCLUSION: The detection of t002 in chicken suggests the presence of livestock-associated MRSA in poultry in Ebonyi State. The detection of the new spa type t11469 in poultry that has not been characterised to ascertain its pathogenic potential remains a cause for concern, especially as some were found to carry PVL genes, a putative virulence factor in staphylococcal infection.

Detection of Airborne Methicillin-Resistant Staphylococcus aureus Inside and Downwind of a Swine Building, and in Animal Feed: Potential Occupational, Animal Health, and Environmental Implications.

Aerosolized methicillin-resistant Staphylococcus aureus (MRSA) was sampled inside and downwind of a swine facility. Animal feed was sampled before and after entry into the swine facility. Aerosolized particles were detected using an optical particle counter for real-time measurement and with an Andersen sampler to detect viable MRSA. Molecular typing and antimicrobial susceptibility testing were performed on samples collected. Viable MRSA organisms isolated inside the swine facility were primarily associated with particles >5 µm, and those isolated downwind from the swine facility were associated with particles <5 µm. MRSA isolates included spa types t008, t034, and t5706 and were resistant to methicillin, tetracycline, clindamycin, and erythromycin. Animal feed both before and after entry into the swine facility tested positive for viable MRSA. These isolates were of similar spa types as the airborne MRSA organisms. Air samples collected after power washing with a biocide inside the swine facility resulted in no viable MRSA organisms detected. This pilot study showed that the ecology of MRSA is complex. Additional studies are warranted on the maximum distance that viable MRSA can be emitted outside the facility, and the possibility that animal feed may be a source of contamination.

Human Infections with Staphylococcus aureus CC398.

Staphylococcus aureus isolates belonging to clonal cluster 398 (CC398) have emerged over the previous decade as a risk to livestock workers. Though most of the research to date has focused on colonization with these strains, a number of infections have also been documented, ranging from mild skin infections to more serious invasive infections and even death. Here, we review existing reports of human infections with CC398 and discuss their geographic distribution, general characteristics, and implications for future research. We identified 74 publications describing CC398 infections in humans in 19 different countries, suggesting this is an emerging worldwide issue.

Epidemiology of necrotizing infection caused by Staphylococcus aureus and Streptococcus pyogenes at an Iowa hospital.

The present study was performed to characterize the epidemiology of necrotizing soft tissue infection caused by Streptococcus pyogenes (n=14) and Staphylococcus aureus (n=14) isolates collected at the University of Iowa Hospitals and Clinics. An additional 9 S. pyogenes isolates were collected from patients being treated for mild respiratory infections and served as a comparison sample in the analysis. Patient data corresponding to the isolates (n=37) were also collected in order to identify risk factors or comorbid conditions possibly correlated with necrotizing fasciitis (NF). The prevalence of methicillin-resistant S. aureus among the study isolates was 35.7% (5/14), and the prevalence of the Panton-Valentine leukocidin (PVL) gene was 57% (8/14). The S. pyogenes NF (wound) isolates (n=14) belonged to 10 different emm types, none of which appeared to be associated with more severe disease when compared to the milder infection (throat) samples (n=9). Comorbid conditions such as diabetes and cardiovascular disease were significantly associated with NF. The results indicate that there may be a high prevalence of the PVL virulence factor in NF infections and that spa type t008 may be responsible for the increasing incidence of S. aureus NF infections in Iowa.

Swine Farming Is a Risk Factor for Infection With and High Prevalence of Carriage of Multidrug-Resistant Staphylococcus aureus.

BACKGROUND: Livestock-associated Staphylococcus aureus (LA-SA) has been documented worldwide. However, much remains unknown about LA-SA colonization and infection, especially in rural environments. METHODS: We conducted a large-scale prospective study of 1342 Iowans, including individuals with livestock contact and a community-based comparison group. Nasal and throat swabs were collected to determine colonization at enrollment, and skin infection swabs over 17 months were assessed for S. aureus. Outcomes included carriage of S. aureus, methicillin-resistant S. aureus (MRSA), tetracycline-resistant S. aureus (TRSA), multidrug-resistant S. aureus (MDRSA), and LA-SA. RESULTS: Of 1342 participants, 351 (26.2%; 95% confidence interval [CI], 23.8%-28.6%) carried S. aureus. MRSA was isolated from 34 (2.5%; 95% CI, 1.8%-3.5%) and LA-SA from 131 (9.8%; 95% CI, 8.3%-11.5%) of the 1342 participants. Individuals with current swine exposure were significantly more likely to carry S. aureus (prevalence ratio [PR], 1.8; 95% CI, 1.4-2.2), TRSA (PR, 8.4; 95% CI, 5.6-12.6), MDRSA (PR, 6.1; 95% CI, 3.8-10.0), and LA-SA (PR, 5.8; 95% CI, 3.9-8.4) than those lacking exposure. Skin infections (n = 103) were reported from 67 individuals, yielding an incidence rate of 6.6 (95% CI, 4.9-8.9) per 1000 person-months. CONCLUSIONS: Current swine workers are 6 times more likely to carry MDRSA than those without current swine exposure. We observed active infections caused by LA-SA. This finding suggests that individuals with livestock contact may have a high prevalence of exposure to, and potentially infection with, antibiotic-resistant S. aureus strains, including LA-SA strains.

Methicillin-resistant Staphylococcus aureus in central Iowa wildlife.

Livestock and pets have been identified as carriers of Staphylococcus aureus; however, the role of wild animals as a reservoir of S. aureus strains has not yet been examined. We conducted a pilot study to determine the prevalence of methicillin-sensitive S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) in 37 species of wild animals rehabilitated at a university clinic. Nasal, wing, wound, and cloacal swabs were collected. Of 114 animals, seven (6.1%) were MSSA-positive and three (2.6%) were MRSA-positive. The MRSA isolates were obtained from two eastern cottontail rabbits (Sylvilagus floridanus) and a Lesser Yellowlegs (Tringa flavipes), a migratory shorebird. Antibiotic resistance testing of the MRSA isolates revealed that two were additionally resistant to tetracycline and erythromycin, and the third isolate was also resistant to erythromycin, clindamycin, and levofloxacin. All three isolates were positive for the Panton-Valentine leukocidin (PVL) gene. Sequence typing of the staphylococcal protein A (spa) region revealed one MRSA isolate to be t002, whereas the other two MRSA isolates were found to be t008. Our results suggest that S. aureus, including MRSA, is being carried by wild animals, although at a low prevalence with the limited number of animals tested. Additional studies are needed to determine how this may impact human health.

High prevalence of Panton-Valentine leukocidin among methicillin-sensitive Staphylococcus aureus colonization isolates in rural Iowa.

Recent studies have shown that livestock can carry Staphylococcus aureus and transmit it to human caretakers. We conducted a pilot study to determine the prevalence and molecular epidemiology of S. aureus among rural Iowans, including individuals with livestock contact. Nasal and throat swabs were collected and plated onto selective media to isolate methicillin-susceptible and methicillin-resistant S. aureus (MRSA), followed by antibiotic resistance testing and molecular analysis of the isolates. While no MRSA was detected, overall, 23.7% (31/131) of participants were found to harbor S. aureus in their nose, throat, or both. Fifteen isolates displayed resistance to one or more tested antibiotics, and the Panton-Valentine leukocidin (PVL) genes were present at a high level (29% [9/31] of S. aureus-positive participants). Younger age and tobacco use were associated with increased risk of S. aureus carriage. Our results suggest that carriage of PVL-positive S. aureus is common among rural Iowans, even in the absence of detectable MRSA colonization.

Molecular and epidemiologic predictors of Staphylococcus aureus colonization site in a population with limited nosocomial exposure.

BACKGROUND: The anterior naris has been considered the most consistent location of asymptomatic Staphylococcus aureus colonization. However, recent studies have shown that a substantial number of individuals, ranging from 7% to 32% of colonized individuals, are exclusive throat carriers. Most of these studies have been carried out in a health care setting, limiting their generalizability to nonhospitalized populations. METHODS: To evaluate anatomic carriage sites of S aureus in individuals outside of a health care setting, we combined the results of 2 cross-sectional studies conducted in Iowa. RESULTS: S aureus was carried by 103 of 340 individuals (30.3%), including 31 (30.1%) exclusive throat carriers, 44 (42.7%) exclusive nose carriers, and 28 (27.2%) colonized in both sites. Nonwhite race (adjusted odds ratio [OR], 4.91; 95% confidence interval [CI], 1.26-18.3) and younger age (≥30 years: OR, 0.23; 95% CI, 0.10-0.54) were associated with increased odds of exclusive throat carriage, whereas nonwhite race (OR, 5.14; 95% CI, 1.62-16.3) and spring or summer sampling season (OR, 2.62; 95% CI, 1.32-5.18) were associated with increased odds of exclusive nasal carriage. CONCLUSIONS: These findings suggest that including a throat swab in addition to a nasal swab could play an important role in the success of surveillance programs, particularly among younger adults.

MRSA in conventional and alternative retail pork products.

In order to examine the prevalence of Staphylococcus aureus on retail pork, three hundred ninety-five pork samples were collected from a total of 36 stores in Iowa, Minnesota, and New Jersey. S. aureus was isolated from 256 samples (64.8%, 95% confidence interval [CI] 59.9%-69.5%). S. aureus was isolated from 67.3% (202/300) of conventional pork samples and from 56.8% (54/95) of alternative pork samples (labeled "raised without antibiotics" or "raised without antibiotic growth promotants"). Two hundred and thirty samples (58.2%, 95% CI 53.2%-63.1%) were found to carry methicillin-sensitive S. aureus (MSSA). MSSA was isolated from 61.0% (183/300) of conventional samples and from 49.5% (47/95) of alternative samples. Twenty-six pork samples (6.6%, 95% CI 4.3%-9.5%) carried methicillin-resistant S. aureus (MRSA). No statistically significant differences were observed for the prevalence of S. aureus in general, or MSSA or MRSA specifically, when comparing pork products from conventionally raised swine and swine raised without antibiotics, a finding that contrasts with a prior study from The Netherlands examining both conventional and "biologic" meat products. In our study spa types associated with "livestock-associated" ST398 (t034, t011) were found in 26.9% of the MRSA isolates, while 46.2% were spa types t002 and t008--common human types of MRSA that also have been found in live swine. The study represents the largest sampling of raw meat products for MRSA contamination to date in the U.S. MRSA prevalence on pork products was higher than in previous U.S.-conducted studies, although similar to that in Canadian studies.

Emerging swine zoonoses.

The majority of emerging infectious diseases are zoonotic in origin. Swine represent a potential reservoir for many novel pathogens and may transmit these to humans via direct contact with live animals (such as swine farmers and large animal veterinarians), or to the general human population via contaminated meat. We review recent emerging microbes associated with swine and discuss public health implications.

Methicillin-resistant Staphylococcus aureus in pork production shower facilities.

As methicillin-resistant Staphylococcus aureus (MRSA) has been found in pigs, we sought to determine if MRSA is present in pork production shower facilities. In two production systems tested, 3% and 26% of shower samples were positive for MRSA. spa types identified included t034, t189, t753, and t1746.