Battan, R. (Ruggero)

Boyle, J.F. (John)

Cort, S. (Susannah)

Raviglione, M.C. (Mario)

Taranta, A. (Angelo)

Wallace, J. (Joyce)

Erasmus University Digital Repository

S. aureus nasal carriage among hemosexuel men with and without HIV infection To the Editor: Staphylococcus aureus bacteremias have been rec- ognized as a frequent complication of acquired im- munodeficiency syndrome (AIDS).’ ’ Several factors are thought to play a role in predisposing AIDS pa- tients to clinical infections with this pathogen.“h We and others have reported a high rate of S. aureus nasal carriage rate in hospitalized patients with AIDS?-” Nasal carriage correlates with widespread skin colonization,” which is considered in turn to be a risk factor for S. atlreus infections, as it has been shown in patients undergoing long-term dialysis”, ‘* and in intravenous drug users.” It is not readily apparent why patients with AIDS who are not intravenous drug abusers have an in- creased rate of S. aweus skin carriage. Our study population with AIDS consisted of hospitalized ho- mosexual men, as we excluded all patients belonging to categories known to have an increased S. auretds carriage rate, particularly intravenous drug abu- sers.‘4-‘x Persistent skin carriage of S. aureus is thought to result from frequent skin breaks through which the organism can penetrate and then spread throughout the skin, with the nose acting as a natural reservoir for skin colonization.1° We conducted a con- trolled study to evaluate the influence of anal sex, with its attendant risk of mucosal and skin break- ings,‘” on carriage rate of S. aureus and to assess the prevalence of S. aureus nasal carriage in an outpa- tient population of homosexual men in various stages of HIV (human immunodeficiency virus) disease. Consecutive outpatients referred for HIV testing, and for follow-up of HIV infection or other sexually transmitted diseases were given a self-administered anonymous questionnaire on current sexual habits. This included specific questions on anal intercourse (receptive versus insertive or both). For each person, cultures were obtained once from the anterior nares by means of sterile swabs (Culturette, Marion Sci- entific Co., Kansas City, MO.). Specimens were cul- tured aerobically on blood agar, and S. aureus was identified by standard methods as previously de- scribed.‘The study was approved by the Institutional Review Board of the Foundation for Research on Sex- ually Transmitted Diseases. Informed consent was obtained from each participating subject. Manifestations of HIV disease (classified according to the Centers for Disease Control [CDC] criteria),?” medical history, and use of antibiotics were re- viewed. Patients with recent intravenous drug use (within I week),” patients with insulin-requiring di- 98 Table 1. Nasal carriage of Staphyiococcus aureus in gay men according to stage of HIV infection and sexual habits (N) .- S. aureus Stage Total carriers AlDSiARC 65 :?I/65 (32%) Receptive anal sex 46 '6:46 135%) HIV (+ ) asymptomatic 25 6; 25 i3%%j Receptive anal sex !7 d., 17 (24%) HIV (--) 39 ?:39 iiwo) Receptive anal sex 20 4:20 (20%) Total 129 3W ' 29 (2H%j Receptive anal sex 83!126' 24,'83 i29%) --.-- - __--__ *Three subjects did not answer the questlonnal!e abetes mellitus, and patients with chronic renal fail- ure who were undergoing dialysis were excluded. Statistical analysis was performed by means of the x2 test with Yates’ continuity correction and with 95% confidence intervals to assess differences bc- tween groups. All of the eligible persons consented to the study. Of 129 homosexual men, 65 had full-blown AIDS or other manifestations of advanced HIV infec- tion (CDC class IV), 25 were symptom-free HIV- seropositive (CDC classes II and III), and 39 were HIV-seronegative. S. aweus nasal carriage was detected in 21 (32%), 8 (32%), and 7 (19%) pa- tients, respectively, from these groups. The rate ot S. aureus carriage in the overall population was 28%. The rate of S. aweus carriage among all the HIV- seropositive patients, including those with AIDS (29/90 or 32%), was increased as compared with the HIV-seronegative ones (7/39 or 19%) and was close to statistical significance (0.05 c: p *:’ 0.1, 95% con- fidence interval for the difference = - 0.01 to 0.291. Of 126 homosexual men who completed the ques- tionnaire on sex habits, 98 reported that they practiced either type of anal sex: 27% of them were S. uureus carriers as compared to 28%’ of 28 who reported that they did not currently practice anal intercourse. When they were subdivided into those practicing receptive anal intercourse versus those practicing only insertivc anal intercourse (thought to be less traumatic), the rate of S. az{rez,t.r carriage remained 28% in both groups, which was the overall rate of carriage in the study group. Distribution of receptive anal sex was not skewed in favor of any specific category of HIV infection (Table 1). None of the persons in any group had been ho+ Volume 19 Number 2 April 1991 pitalized within the previous month. Twelve patients with AIDS or AIDS-related complex had been hos- pitalized more than 1 month before entry into the study; 25% of them were nasal carriers of S. aureus, as compared with 28% of the remaining subjects. S. aureus nasal carriage was present in 3 (18%) of 17 subjects who were taking antibiotics active against staphylococci and in 32 (28%) of 112 who were not (p = NS, 95% confidence interval for the difference = -0.30 to 0.09). Twelve (27%) of 44 subjects who were taking zidovudine (known to have activity against gram-negative organisms)” were found to be nasal carriers of S. aureus, as compared with 24 (28%) of 85 who were not taking it. A small group of heterosexuals, not including ac- tive intravenous drug users, was also tested: S. aureus nasal carriage was found in 5 of 22 persons with AIDS or AIDS-related complex (23%) and in 2 of 12 symptom-free HIV-seropositive persons (17%). We did not find any evidence to suggest that anal sex predisposes to S. aureus carriage among homo- sexual men, and our epidemiologic survey shows that receptive anal sex is not per se a risk factor for per- sistent skin colonization with S. aureus. These data must be taken with caution, as they were not based on objective observation but, rather, on anonymous self-reporting. On the other hand, we noted a difference in na- sal carriage rate of S. aureus in relation to HIV infection, although not of the magnitude previ- ously reported.6’” The difference in carriage rate between subjects with HIV infection and the HIV- seronegative subjects was not large and could not reach statistical significance, probably because of the small number of HIV-seronegative subjects (only 39). Still, close to one third of our HIV-infected subjects were carriers of S. aureus in the nares. This rate was comparable to that of other patients previously re- ported to be frequent carriers of S. aureus, such as intravenous drug usersI and diabetic patients taking insulin.‘” However, in our previous series on hospi- talized AIDS patients, we found a carriage rate of 55%,7 and others have reported a similar rate.8 In that study we used the same technique for nasal cul- ture and investigated patients within 24 hours of ad- mission. Those patients were likely to be sicker and to experience more complications related to their underlying disease than the present outpatient pop- ulation. Some of them had long-term indwelling ve- nous catheters, which have been reported to be as- sociated with S. aureus infections.‘,’ The patients may have also been contaminated with S. aureus from the hospital environment during the first 24 hours of admission. A similar phenomenon was de- scribed in patients admitted to the medical intensive care unit (22% respiratory tract colonization rate with gram-negative bacilli within 24 hours from ad- Letters to the editor 99 mission).Z’ In our opinion, these factors may have created more favorable conditions for the acquisition of S. aureus skin carriage and may explain the dif- ferent carriage rate observed in the two studies. We did not find that the use of zidovudine had any influence on nasal carriage of S. aureus, but a trend toward decreased carriage rate in antibiotic users was noted. The influence of recent hospitalization could not be reliably analyzed; only a few patients had been hospitalized previously, and all these ad- missions had occurred more than 1 month before nasal culture . Overall, it seems that HIV infection is capable of increasing the carriage rate of S. aureus, although it is not clear through which mechanism this phenom- enon occurs. HIV-infected persons have been found to have impaired neutrophil and monocyte func- tions,4~b and decreased mucosal IgA secretion.Z3 Whether these factors could play a role in mucosal or cutaneous carriage of S. aureus is not known at present. If they are proved to be significant, one may suspect that more advanced stages of HIV disease could produce even more sustained defects of mu- cocutaneous immunity and a higher carriage rate of S. aureus. Skin carriage of S. aureus is known to be a risk factor for subsequent development of S. aureus infections in certain categories of patients.“-I3 How- ever, the magnitude of this risk has never been for- mally assessed in HIV-infected persons. We think it should be properly tested and, if found to be signif- icant, measures to eradicate S. aureus carriage should be studied. Ruggero Battan, MD Mario C. Raviglione, MD Joyce Wallace, MD’ Susannah Coti, MD* John F. Boyle, PhD Angelo Taranta, MD Cabrini Medical Center, New York, NY, and *Foundation for Research on Sexually Trans- mitted Diseases, New York, NY. Reprint requests: Dr. Ruggero Battan. Division of Endocrinology and Diabetes, University of Massachusetts Medical Center, Worcester, MA 01605. References Jacobson MA, Gellermann H, Chambers H. Staphylo- coccus aureus bacteremia and recurrent staphylococcal infection in patients with acquired immunodeticiency syndrome and AIDS-related complex. Am J Med 1988; 85:172-6. 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S. aureus nasal carriage among homosexual men with and without HIV infection

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S. aureus nasal carriage among homosexual men with and without HIV infection

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