Review
The role of nasal carriage in Staphylococcus aureus infections

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Summary

Staphylococcus aureus is a frequent cause of infections in both the community and hospital. Worldwide, the increasing resistance of this pathogen to various antibiotics complicates treatment of S aureus infections. Effective measures to prevent S aureus infections are therefore urgently needed. It has been shown that nasal carriers of S aureus have an increased risk of acquiring an infection with this pathogen. The nose is the main ecological niche where S aureus resides in human beings, but the determinants of the carrier state are incompletely understood. Eradication of S aureus from nasal carriers prevents infection in specific patient categories—eg, haemodialysis and general surgery patients. However, recent randomised clinical trials in orthopaedic and non-surgical patients failed to show the efficacy of eliminating S aureus from the nose to prevent subsequent infection. Thus we must elucidate the mechanisms behind S aureus nasal carriage and infection to be able to develop new preventive strategies. We present an overview of the current knowledge of the determinants (both human and bacterial) and risks of S aureus nasal carriage. Studies on the population dynamics of S aureus are also summarised.

Introduction

Staphylococcus aureus is both a human commensal and a frequent cause of clinically important infections (figure 1).1 Although the prevalence of meticillin-resistant S aureus (MRSA) is still very low in northern European countries,2 there is a worldwide increase in the number of infections caused by MRSA. Vancomycin is one of the last therapeutic options available for MRSA infections. The recent isolation of vancomycin-resistant MRSA strains in the USA is a major cause for concern.3 Therefore, the prevention of staphylococcal infections and reduction of the spread and emergence of MRSA are essential.

The association between S aureus nasal carriage and staphylococcal disease was first reported by Danbolt in 1931, who studied furunculosis.4 The increasing incidence of penicillin-resistant S aureus hospital infections since 1947 emphasised the need for a better understanding of the pathogenesis of staphylococcal disease. Subsequently, numerous studies confirmed Danbolt's finding.5, 6, 7, 8, 9 A causal relation between S aureus nasal carriage and infection is supported by the fact that the nasal S aureus strain and the infecting strain share the same phage type or genotype.8, 10 Furthermore, nasal application of an antistaphylococcal drug temporarily decolonises the nose and other body sites, which prevents infection.11

Our knowledge of the mechanisms, risks, and treatment of S aureus nasal carriage has greatly expanded over the past decade. Table 1 presents an overview of major events in S aureus research. Here, we focus on the latest insights into the determinants of S aureus nasal carriage and the risks of infection associated with S aureus nasal carriage. Most studies were done in western countries, so conclusions drawn can not always be generalised.

Section snippets

S aureus nasal carriage patterns

S aureus colonises the skin and mucosae of human beings and several animal species.5 Although multiple body sites can be colonised in human beings, the anterior nares of the nose is the most frequent carriage site for S aureus.5 Extra-nasal sites that typically harbour the organism include the skin, perineum, and pharynx.5, 23, 24, 25 Other carriage sites including the gastrointestinal tract,5, 26 vagina,27 and axillae5, 25, 28 harbour S aureus less frequently (figure 2).

Most studies on S aureus

Community-acquired infections

Most studies regarding the risks of acquiring S aureus infections in the community concern skin and soft tissue infections. Several, mostly older, studies investigated the relation between S aureus nasal carriage and skin infections,121 including furunculosis,122, 123 impetigo,124 sycosis barbae,10, 122, 125 and stye.126 On average, 80% (range 42–100%) of those with skin lesions were S aureus nasal carriers, and 65% (range 29–88%) had the same phage type in the nose and lesion.

In one large

Conclusions

Many studies have been published on S aureus nasal carriage—a Pubmed search with the terms “Staphylococcus aureus” and “nasal” gives 1383 hits. Based on these studies and the results of contradicting twin studies183, 184 a simple Mendelian trait probably does not explain the different S aureus nasal carrier states.38, 48 The repeated exposure to S aureus in the (household) environment is considered to be an important determinant of S aureus nasal carriage, probably more important than the

Search strategy and selection criteria

We searched Pubmed with the following search terms: “Staphylococcus aureus”, “colonisation”, “carriage”, “nose”, “nasal”, “vestibulum nasi”, “mucosa”, “nasal”, “nosocomial”, “epidemiology”, “determinants”, “risk factor”, “treatment”, and “infection”. The following limits were used: English language, abstract, and human studies. We identified additional articles by searching the reference lists of existing articles.

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