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. Ta ble1 St aph ylo Ta ble2 St aph ylo coc cusa ure us coc cusa ure us . MI. C MI. C.

2 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 . ! 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?

3 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- . 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.

4 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 . 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.

5 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. 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.

6 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 .. 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.

7 CA-MRSA PVL CA-MRSA .. 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.

8 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. 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.

9 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. J Clin Invest. transmission, pathogenesis, and drug resistance. 2005 ; 115 11 : 3117 27. ! J Infect Chemother DOI : s10156-010- 5 Diep BA, Stone GG, Basuino L, Graber CJ, 0045-9 . Miller A, des Etages SA, et al. The arginine 13 Nathwani D, Morgan M, Masterton RG, Dryden catabolic mobile element and staphylococcal M, Cookson BD, French G, et al.

10 Guidelines for chromosomal cassette mec linkage : conver- UK practice for the diagnosis and management gence of virulence and resistance in the USA of methicillin - resistant Staphylococcus aureus 300 clone of methicillin - resistant Staphylococcus MRSA infections presenting in the commu- aureus . J Infect Dis. 2008 ; 197 11 : 1523 30 nity. J Antimicrob Chemother. 2008 ; 61 5 : 6 Wang R, Braughton KR, Kretschmer D, Bach 976 94. TH, Queck SY, Li M, et al. Identification of 14 Ito T, Iijima M, Fukushima T, Nonoyama M, novel cytolytic peptides as key virulence deter- Ishii M, Baranovich T, et al. Pediatric pneumo- minants for community-associated MRSA. Nat nia death caused by community-acquired Med. 2007 ; 13 12 : 1510 4. methicillin - resistant Staphylococcus aureus , Japan.