市中型MRSA感染症

1 2. MRSA . 1 . 2 3 . 1 1 2 3 3 . 3 3 3 3 . 1 2 . 30 .. 12 20 23 .. 27 . 31 . 1 6 . 1 8 .. BMI 37 .. WBC ! 18900 L Neut 1 . Lym Mono Eos . RBC . ! ! ! 443 106 L Hb dL Plt 104 L AST 1 28 . ! ! ! 17U L ALT 16U L LDH 247U L BUN ! 110 70mmHg 78 ! !dL Cre ! ! ! dL CPK 29U L Glu 124mg min . dL CRP ! dL RPR TPLA HBs . Ag HCV HIV .. 1 WBC 1 . Staphylococcus aureus 2 Table WBC ! 17000 L. 1 . Neut Lym Mono Eos .. ! ! ! RBC 432 106 L Hb dL Plt 104 L . ! ! ! AST 17U L ALT 12U L LDH 190U L BUN. insect bite 2 ! dL Cre ! dL CRP ! dL. cefazoliu CEZ ! . 1+, WBC 1 . CEZ aureus 2 . Table 2 . MRSA . 7 cefditoren pivoxil CFPN-Pl 1 . 100mg 1 3 MRSA . 14 ! vancomycin VCM 2g fosfomycin 22 9 20 15.

2 Ta ble1 St aph ylo Ta ble2 St aph ylo coc cusa ure us coc cusa ure us . MI. C MI. C . MPIPC 2 R MPIPC 2 R. ABPC 8 R ABPC 8 R. CEZ 4 R CEZ 4 R. CTM 4 R CTM 4 R. CPR 2 R CPR 2 R. IPM/CS 1 R IPM/CS 1 R. ABK 2 S ABK 2 S. EM 4 R EM 4 R. CLDM 0. 5 S CLDM 0. 5 S. TEIC 2 S TEIC 2 S. VCM 2 S VCM 2 S. LVFX 4 R LVFX 4 R. ST 2 S ST 2 S. MPI PC: oxaci ll in,ABPC: ampic il lin,CEZ: ce- fazo lin,CTM :c efo tia m,CPR :c ef pir o me, IPM/ CS :imipenem/ ci las tati n,ABK :a rbek- aci n,EM :e rythromyc i n,CLDM :c l inda- myc i n, TEIC: t eic o pl anin,VCM : vancomyc i n, LVFX :l e vofl oxacin,ST :s ul fame thoxa z ol e- tri me thopri m Fi . ! FOM 4g VCM Fig. 2.

3 ! 15 g mL 3 MRSA . ! 4g MRSA Community- 5 Associated MRSA CA-MRSA . CA-MRSA . 10 MRSA . VCM clindamycin . ! CLDM 450mg SCCmec type V PVL . CLDM 14 CA-MRSA MRSA. 24 . 16 84 5 . Fi . 22 9 20 17.. What is CA-MRSA? . Staph and MRSA can also cause illness in per- . sons outside of hospitals and healthcare facili- . ties. MRSA infections that are acquired by per- community-associated MRSA CA-MRSA . sons who have not been recently within the CA- past year hospitalized or had a medical proce- MRSA hospital-associated dure such as dialysis, surgery, catheters are MRSA HA-MRSA . know as CA-MRSA infections. Staph or MRSA.. infections in the community are usually mani.

4 Fested as skin infections, such as pimples and boils, and occur in otherwise healthy people. 1 CA-MRSA . 1 MRSA CDC : Centers for Disease Control and Prevention MRSA methicillin-resistant Staphylococcus aureus 2 CA-MRSA. CDC Centers for Disease Control and Pre- staphylococcal cassette chro- vention CA-MRSA . mosome mec : SCCmec DNA MRSA . SCCmec mecA CA-MRSA .. CA-MRSA . MRSA . SCCmec typing . Pulsed field gel electrophoresis : PFGE . MLST. Multilocus sequence typing SCCmec mec . Fi MRSA . 18 84 5 . ccr 2 CA-MRSA . I VIII type CA-MRSA . 1 . Table 1 CA-MRSA SCCmec . IV HA-MRSA . ! New York Japan SCCmec . II PFGE 1 Panton-Valentine . Panton-Valentine fragment leukocidin : PVL.

5 PVL . CDC PFGE . MRSA 3 HA-MRSA PVL . USA300. SCCmec IVa . CA-MRSA PVL . CA-MRSA CA-MRSA . 2 MLST 7 . sequence type . 4 . PVL . ! USA300 ST8 New York Japam clone ST5 PVL CA-MRSA. Table 2 .. 2 ACME . ACME . USA300 . Ta ble1 SCCme ct ng1 . ypi MRSA . SCCme c c cr me c .. I 1. A1B1. B 5 . I. I 2. A2B2. A. 3 cytolytic peptide . I. II 3. A3B3. A. I. V 2. A2B2. B MRSA . V 5. C C2 PSMs phenol-soluble modulins . VI 4. A4B4. B CA-MRSA PSMs . VI. I 5. C C1 . VI. II 4. A4B4. A. 6 . Ta ble2 . PFTs MLST SCCme ctypi ng PVL. Ne w Yo rk/. Japa ncl one USA1. 00 ST5 II . USA3. 00 ST8 I. Va . MW2 USA4. 00 ST1 I. Va +. Ta ble3 CA- MRSA .. St aph ylo coc cusa ure us 40 88 2.

6 31/81. 8 2 8..2% 8. 4. MRSA 7/40. 4. 5/88 51. 1% 44/81. 8 5 . 4% 16/84 19% . SCCmec IV 14/81. 8 1 . 7% 7/84. 8 .3% . 1. 997 -200. 2 1. 999 6 -199. 9 9 200. 1 - 2. 002 2. 003 - 20. 04 . Ya mas akie ta8. l Ya maguc hie ta9. l Hi sat aeta l10. Ta kiz awae ta1. l1.. 22 9 20 19. CA-MRSA USA300 . 2 USA300 SCCmec IVa PVL .. 7 .. 2 CA-MRSA . CA-MRSA .. 3 CA-MRSA . MRSA 17 . 1 CA-MRSA 51 Table 1990 USA400 CA- 3 .. MRSA CA-MRSA SCCmec USA300 CA-MRSA IV 44% PVL 1 6% . CA-MRSA . 2004 PVL. 78 MLST ST89 ST91 . MRSA 12 CA-MRSA USA300 . MRSA 97 .. ST30 . SCCmec IV PVL . Ta bl MRSA 13 . e4 CA- CA- Ri skgr oups MRSA . 2 .. 4 CA-MRSA .. 1 .. S. aureus Streptococcus pyogenes.

7 CA- MRSA S. aureus MSSA . MRSA .. Ta bl MRSA 7 . e5 CA- No te CLDM 3. -24. % .. D EM . MI. NO 9. -24. % CA- MRSA . A . ST 0. -10. % CA- MRSA . A . RFP 1% . LZD 1% . CLDM: cli ndamyc in, MINO: mino cyc li ne, ST: sul fame taz ole -tr ime tho pri m,RFP: rif ampi ci n,LZD: line zol id 20 84 5 . ST1.. USA400 SCCmec IVa ST8 USA300 . SCCmec IVa . ST80 ST30 . CA-MRSA Table ST59 . 4 . USA300. 2 CA-MRSA SCCmec IVa PVL . CA-MRSA CDC CA-MRSA . MRSA CA-MRSA .. SCCmec PVL . IV CA-MRSA CA-MRSA . PVL . SCCmec IV . 2 CA-MRSA . 2009 PVL CA-MRSA. 14 . 1 4 . 5 CA-MRSA CA-MRSA . 1 CA-MRSA ST30 SCCmec IVa . HA-MRSA ST30 CA-MRSA . CA-MRSA CA-MRSA . CA-MRSA PVL CA-MRSA.

8 SCCmec V CA-MRSA . MLST ST772 16 . 2 CA-MRSA USA300 . 15 . CDC .. 13 . clindamycin MRSA . CLDM minocyclin MINO sulfametazole- CA-MRSA . trimethoprim ST . linezolid LZD . vancomycin VCM CLDM . 7 . MINO ST S. pyogenes Table 5 I CA-MRSA . II CA-MRSA . III CA-MRSA . IV CA-MRSA . CLDM erythromycin EM V PVL . D VI CA-MRSA . 6 .. 1 CA-MRSA . PVL CA-MRSA .. 22 9 20 21. impetigo and the emergence of new methicillin- 1 International Working Group on the Classifica- resistant clonal groups in Kansai district in Ja- tion of Staphylococcal Cassette Chromosome pan. J Infect Dis. 2002 ; 185 10 : 1511 6. Elements IWG-SCC . Classification of staphylo- 10 Hisata K, Kuwahara-Arai K, Yamanoto M, Ito coccal cassette chromosome mec SCCmec : T, Nakatomi Y, Cui L, et al.

9 Dissemination of guidelines for reporting novel SCCmec ele- methicillin-resistant staphy lo cocci among ments. Antimicrob Agents Chemother. 2009 ; 53 healthy Japanese children. J Clin Microbiol. 12 : 4961 7. 2005 ; 43 7 : 3364 72. 2 Moran GJ, Krishnadasan A, Gorwitz RJ, 11 Takizawa Y, Taneike I, Nakagawa S, Oishi T, Fosheim GE, McDougal LK, Carey RB, et al. Nitahara Y, Iwakura N, et al. A Panton- Methicillin-resistant S. aureus infections among Valentine leucocidin PVL -positive community- patients in the emergency department. N Engl acquired methicillin-resistant Staphylococcus J Med. 2006 ; 355 7 : 666 74. aureus MRSA strain, another such strain carry- 3 Boyle-Vavra S, Daum RS.

10 Community-acquired ing a multiple-drug resistance plasmid, and methicillin-resistant Staphylococcus aureus : the other more-typical PVL-negative MRSA strains role of Panton-Valentine leukocidin. Lab Invest. found in Japan. J Clin Microbiol. 2005 ; 43 7 : 2007 ; 87 1 : 3 9. 3356 63. 4 Genestier AL, Michallet MC, Pr vost G, Bellot 12 Tatsuo Yamamoto, Akihito Nishiyama, Tomomi G, Chalabreysse L, Peyrol S, et al. Staphylococcus Takano, Shizuka Yabe, Wataru Higuchi, Olga aureus Panton-Valentine leukocidin directly tar- RazvinaandDa Shi. Community-acquired methi- gets mitochondria and induces Bax-independent cillin-resistant Staphylococcus aureus : community apoptosis of human neutrophils.