Increasing Hospitalizations and General Practice Prescriptions for Community-onset Staphylococcal Disease, England

Rates of hospital-acquired staphylococcal infection increased throughout the 1990s; however, information is limited on trends in community-onset staphylococcal disease in the United Kingdom.We used Hospital Episode Statistics to describe trends in hospital admissions for community-onset staphylococcal disease and national general practice data to describe trends in community prescribing for staphylococcal disease.Hospital admission rates for staphyloccocal septicemia, staphylococcal pneumonia, staphylococcal scalded-skin syndrome, and impetigo increased >5-fold.Admission rates increased 3-fold for abscesses and cellulitis and 1.5-fold for bone and joint infections.In primary care settings during 1991-2006, fl oxacillin prescriptions increased 1.8-fold and fusidic acid prescriptions 2.5-fold.The increases were not matched by increases in admission rates for control conditions.We identifi ed a previously undescribed but major increase in pathogenic communityonset staphylococcal disease over the past 15 years.These trends are of concern given the international emergence of invasive community-onset staphylococcal infections.H armless colonization of the nasal membranes and skin with Staphylococcus aureus is common in the community (1), but the organism can also cause a variety of infections (2).S. aureus is the most common cause of skin and soft tissue infections, including wound infections, abscesses, furuncles, carbuncles (3), and impetigo (4) and is a major cause of cellulitis (5).It can also cause deep-seated infections such as osteomyelitis (6), endocarditis, pneumonia, and septicemia (2).Toxigenic strains can cause toxic shock, staphylococcal scalded-skin syndrome (SSSS), and staphylococcal food poisoning (2).More than 70 different potential virulence factors have been identifi ed in S. aureus, including adhesins, exoenzymes, and exotoxins (7).Exfoliative toxins are associated with impetigo and SSSS (8), and production of Panton-Valentine leukocidin (PVL) toxin has been associated with invasive strains that cause abscesses, bone and joint infection, and pneumonia (9,10).In the 1950s, PVL production was associated with particularly invasive infections caused by the penicillin-resistant phage-type 80/81 strain (11,12).More recently, in 2006, a review of data on isolates referred to the Health Protection Agency's Staphylococcal Reference Unit identifi ed 27 deaths in 27 months from infections with invasive PVL-positive S. aureus.These deaths were in previously healthy people with community-onset pneumonia, bacteremia, or severe skin and soft tissue infection (13).Most were caused by methicillin-sensitive S. aureus (MSSA) strains.In view of these data and the wider concern about emerging community-onset methicillinresistant S. aureus (MRSA) (14-16), we sought to determine whether there had been a generalized increase in 1) community-onset staphylococcal disease severe enough to merit hospitalization and 2) general practice (GP) antimicrobial drug prescribing for skin and soft tissue infections putatively caused by staphylococci. MethodsWe analyzed Hospital Episode Statistics (HES) to identify trends in admissions for community-onset disease that were likely to be caused by pathogenic staphylococci.