This study provides evidence of an association between previous antimicrobial drug prescriptions and a diagnosis of MRSA in the community. This association appears to be dose-dependent and to vary according to antimicrobial class; it is particularly strong for previous exposure to fluoroquinolones and macrolides. A substantial proportion of case-patients, however, were not prescribed antimicrobial drugs in the year before MRSA diagnosis. Persons who had concurrent conditions and persons who were obese were at higher risk for MRSA.
The clear dose-response relationship and the differential associations across antimicrobial drug classes support an association of antimicrobial drugs and MRSA in the community. This association is consistent with nosocomial MRSA, in which the use of specific antimicrobial drugs is linked to antimicrobial resistance. Previous studies have found fluoroquinolones, macrolides, and cephalosporins to be associated with nosocomial MRSA (14
). Moreover, a dose-dependent association exists between exposure to antimicrobial drugs and nosocomial MRSA on the patient level and on the hospital level (16
In a US surveillance study, incidence of community-acquired MRSA was 25.7 case-patients per 100,000 in Atlanta and 18.0 case-patients per 100,000 in Baltimore, findings that are highly consistent with ours (12
). In that study, a considerable proportion of cases occurred in persons >65 years of age. In our study, compared with previous outbreak reports (10
), case-patients were older and had more concurrent conditions. This finding is likely because we did not include any cases in children and, in contrast to reports of outbreaks, our cases are sporadic and thus less prone to be reported.
Similarly, specific occupation-related risk factors (e.g., abrasions, crowded housing) are likely to be more prevalent in a study based on military beneficiaries compared with a study based on the general population. This could explain the higher incidence of MRSA infections found in such a study (13
) than in ours.
Our study population was a representative sample of the UK general population (17
). The use of the GPRD therefore enables the examination of a large number of MRSA infections diagnosed by general practitioners in the community. However, the GPRD has some limitations for the study of an infectious disease. We lacked information on severity and site of MRSA infection and on patient lifestyle characteristics (e.g., incarceration, intravenous drug use). We also lacked information on molecular characteristics of the MRSA strains and thus cannot exclude the possibility that MRSA was diagnosed in cases that did not result from between-patient spread within the community, but rather from secondary exposure to the hospital environment through family members, visitation, or employment. However, the importance of the lack of microbiologic information on the causative MRSA strains may be questioned because it no longer enables a distinction to be made between community and nosocomial MRSA strains (24
The clinical codes that we used for our case definition are likely to be specific, but they may lack sensitivity; some MRSA infections that would have met the Centers for Disease Control and Prevention’s case definition of infection may not be captured with the clinical codes. This lack of sensitivity may affect risk factors for MRSA that we observed in this study as well as the strength of the association between antimicrobial drugs and later MRSA diagnosis.
To our knowledge, MRSA infections in the GPRD have not been previously studied, although infectious diseases in this database have been, such as acute respiratory infections (19
), urinary tract infections (20
), C. difficile
), pneumonia (26
), and sexually transmitted infections (27
). Disease codes for clinically relevant outcomes in the GPRD have been validated (17
); however, MRSA has not been included in such studies.
In previous UK community studies, ≈0.8% of elderly participants were colonized with MRSA (9
). In a meta-analysis, the pooled MRSA colonization rate was 1.3% (8
). In persons without prior health care contacts, the rate was 0.2% (8
). We report an incidence rate of MRSA diagnosis in the community that is too low to be consistent with these prevalence figures, probably because general practitioners are unlikely to screen asymptomatic patients for colonization with MRSA.
The results of our sensitivity analysis of the 3 diagnostic codes we used to define these MRSA cases suggest that antimicrobial drugs promote both MRSA infection and colonization. The association between antimicrobial drugs and MRSA diagnosis was weaker in case-patients with a diagnosis of carrier status and stronger in those with a postoperative wound infection. The association observed in the patients who had their diagnosis recorded with the most frequently used code (4JP..00) appeared to be more similar to those coded as postoperative wound infections (SP25800) than to those coded as carriers (ZV02A00). This finding supports the hypothesis that active infections are more likely than colonization to be recorded in a general practice database. Therefore, separating risk factors for acquiring MRSA from risk factors for increased severity of infection with MRSA using the approach of this study may be difficult.
We did not consider antimicrobial drugs that were prescribed in the 30 days before MRSA diagnosis. With this exposure definition, we prevent mistaking prescriptions issued for treatment of the infection as causes of the infection (protopathic bias ). This distinction is relevant for MRSA, for which the diagnosis is likely delayed due to outstanding microbiologic test results or likely made after failure of empirical treatment with antimicrobial drugs. Therefore, we may have wrongly classified as unexposed some persons whose exposure to antimicrobial drugs in fact preceded the MRSA infection. Any bias resulting from this exposure definition will be toward the null hypothesis and thus will weaken the effect of antimicrobial drugs as promoters of MRSA infections.
To minimize the chances of overlooking any important confounders, we adjusted our analyses for age, sex, lifestyle factors, and a broad range of concurrent conditions. That antimicrobial drug prescriptions are a marker for an important unknown confounder is remotely possible. However, to substantially bias our results, such a confounder would need to be strongly related to both the prescription of antimicrobial drugs and the diagnosis of MRSA but unrelated to our study covariates.
Further support for our results comes from the ecologic association between fluoroquinolone use and nosocomial MRSA found in an intervention study (30
) and a quasi-experimental study (31
). Similar to nosocomial MRSA (16
), the use of specific antimicrobial drugs in the community may cause selection pressures that favor the acquisition of resistance in S. aureus
on the community level.
In conclusion, the role of antimicrobial drugs in MRSA diagnosed in the community appears to be similar to their role in nosocomial MRSA. Therefore, appropriate use of antimicrobial drugs, in addition to traditional infection control measures, may be a strategy to not only control nosocomial MRSA (32
), but also to limit the incidence of community-diagnosed MRSA infections.