Nasal colonization with Staphylococcus aureus in individuals with HIV / AIDS attended in a Brazilian Teaching Hospital 1

Copyright © 2013 Revista Latino-Americana de Enfermagem This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC). This license lets others distribute, remix, tweak, and build upon your work non-commercially, and although their new works must also acknowledge you and be non-commercial, they don’t have to license their derivative works on the same terms. Corresponding Author: Elucir Gir Universidade de São Paulo. Escola de Enfermagem de Ribeirão Preto Departamento de Enfermagem Geral e Especializada Av. Bandeirantes, 3900 Bairro: Monte Alegre CEP: 14040-902, Ribeirão Preto, SP, Brasil E-mail: egir@eerp.usp.br Lilian Andreia Fleck Reinato2 Daiana Patrícia Marchetti Pio3 Letícia Pimenta Lopes4 Fernanda Maria Vieira Pereira3 Ana Elisa Ricci Lopes2 Elucir Gir5


Introduction
Staphylococcus aureus is a gram-positive bacteria which colonizes the skin and has a preference for the anterior nares, with this colonization's prevalence varying, depending on the population studied.It has a mean of 37.2% in the general population, and a rate of up to 35.5% in the nasal sites of patients with Human Immunodeficiency Virus (HIV) (1)(2) .Staphylococcus aureus's resistance to methicillin (MRSA) was first described in Europe in 1961, as a nosocomial pathogenic agent (3) .
For researching Staphylococcus aureus and, principally, MRSA, the sites of the greatest interest are the nasal mucosa and the skin, due to their characteristic of being naturally colonized.
The colonization of individuals with HIV/AIDS by pathogenic micro-organisms has been associated with higher risk of morbidity and mortality, principally when related to Staphylococcus aureus.Researchers found a rate of 76.7% of colonization with this bacteria in this population, indicating prolonged hospitalization (over 10 days) as a risk factor for resistance to methicillin (4) .

The prevalence of nasal colonization with
Staphylococcus aureus varies depending on the population studied.The recent use of antibiotics and inpatient treatment in the last year have been found as independent predictors for nasal MRSA colonization in HIV-positive patients treated as outpatients (5) .

Method
The present study is quantitative and crosssectional and was undertaken in two units which are The inclusion criteria established were: to be aged over 18 years old; to be aware of the diagnosis of infection with HIV/AIDS; to be clinically well enough to understand the guidance and to take the decision to participate or not.Individuals with HIV/AIDS using any ventilatory equipment which would make consenting or data collection impossible were excluded, as were those who were inpatients before the data collection period.
On the first day of inpatient treatment, (the first

Results
Of the 229 individuals approached in the period, 169 (73.8%) participated in the research; these were individuals with HIV/AIDS receiving inpatient treatment during the data collection period, who met the inclusion criteria; 57.4% were male, their ages varied between 19 and 72 years, with a mean of 42 years, and 39.6% of them were in the age range between 40 and 49 years were identified as MSSA and 10 (21.7%), as MRSA.
The male sex was more frequent in the population studied, both in those individuals who were colonized and among those who were not.The predominant age range was from 30 to 39 years of age among those colonized with Staphylococcus aureus.The predominant level of schooling was completed primary school.
A similar, retrospective, study, with individuals with HIV/AIDS, undertaken to identify risk factors for colonization or infection with MRSA, obtained results showing that 63.0% of the participants were male and that the mean age was 41 years old (22 to 60 years old).
Nasal colonization in individuals with HIV/AIDS was identified more in those who had a low viral load (≤100 copies/ml), CD4+ T lymphocytes count <200 cells/mm 3 , those with a history of at least one episode of inpatient treatment in the previous six months, and who were using antimicrobials.Only MRSA was identified with greater frequency among the individuals who were not using antiretroviral drugs, as, in the MSSA evidence, the majority of the participants were using antiretroviral drugs.
Previous research had identified a rate of 34% of nasal colonization with Staphylococcus aureus in individuals with HIV, emphasizing being a nasal carrier, having a vascular catheter, a low CD4+ T lymphocyte count and neutropenia as important risk factors for infections related to this pathogen (7) .
Research conducted among individuals with HIV found that 83.3% of the nasal carriers of Staphylococcus aureus were patients with CD4 T lymphocytes <200 cells/ mm 3 , while among those who had a CD4 T cell count above 300 cells/mm 3 , MRSA was not isolated (4) .
Inpatient treatment, the previous use of antimicrobials, skin/soft tissue infection or being HIVpositive may all be considered as risk factors for patients who presented colonization with MRSA (8) .behaviors, such as high-risk sexual practices and the use of illicit drugs (9) .
The use of antimicrobials has also been documented as a risk factor for colonization with Staphylococcus aureus in individuals with HIV (10) .
The use of antiretroviral drugs and the prophylactic use of Trimethoprim/sulfamethoxazole (TMP/SMX) are included among probable protective factors against colonization with Staphylococcus aureus among individuals with HIV (6,(10)(11) .
Some measures for the prevention and control of MRSA can be instituted, such as the investigation of patients who are suspected of being colonized or infected with MRSA, as well as this patient's restriction in the hospital environment (private room and bathroom); the investigation of body sites with swabs (nasal site, the genital region), and the use of personal protective equipment for the health professionals when in direct contact with the suspected cases, followed by the treatment and decolonization of patients and health professionals identified as colonized (12) .
One study undertaken with health professionals emphasizes the need to implement strategies which cover public policies directed at programs for the control of this pathogen in the hospital setting, promoting broad discussions on this topic (13) .

Conclusion
The concern with identifying colonization with Staphylococcus aureus in the population which lives with HIV/AIDS is growing, in view of the need for interventions for controlling the spread of this pathogen, minimizing correlated future infections.
In spite of being a bacteria first isolated in human beings over four decades ago, Staphylococcus aureus commonly causes the infection of skin and soft tissues, among others, both in people receiving inpatient treatment and those living in the community.
It is necessary for there to be joint action from professionals and government bodies linked to health, so as to improve policies of control related to antimicrobial resistance and to multi-drug-resistant micro-organisms.
colonization with multiresistant bacteria and the occurrence of infections.This manuscript's relevance is explained by the fact that publications on the issue of Staphylococcus aureus in people living with HIV/AIDS were not found in Nursing periodicals in Brazil.Objective To evaluate the prevalence of nasal colonization with Staphylococcus aureus in individuals with HIV/AIDS receiving inpatient treatment in a teaching hospital in the state of São Paulo (Brazil).
24 hours) the individual was invited to participate and received information referent to the study objective and the research's ethical precepts; once the individual had understood and accepted to participate, he or she signed the Terms of Free and Informed Consent.Socio-demographic and clinical data was collected through individual interviews and by accessing the medical records; the biological material was collected respecting the recommended bio-security measures, in the period August 2011 -July 2012.The nasal secretion was obtained using Stuart swabs, these being rubbed lightly in the left and right anterior nares.The material collected was seeded and the isolation and the phenotypic identification of Staphylococcus aureus were carried out by an automatized method, using Vitek ® system cards (BioMérieux™).Susceptibility to antimicrobials was tested using the AST-P585 card (BioMérieux™).The data was organized in Microsoft Office and Mac Excel 2011 spreadsheets and then exported to the Statistical Package for the Social Science program, version 17.0.The distribution of the frequencies (mean and median) and the subsequent descriptive statistics of the data were undertaken.
specialized in attending individuals with HIV/AIDS in a large* teaching hospital in the state of São Paulo.This research project was considered and approved by the Research Ethics Committee of the Ribeirão Preto School of Nursing (Protocol n° 1304/2011 EERP-USP).

Table 1 -
Distribution of the individuals with HIV/AIDS receiving inpatient treatment in two units of a teaching hospital (N=169) by socio-demographic variables and nasal colonization with Staphylococcus aureus, sensitive to (MSSA), *In the Brazilian context, a 'large' hospital is one with between 150 and 500 beds.Translator's note.www.eerp.usp.br/rlaeReinatoLAF, Pio DPM, Lopes LP, Pereira FMV, Lopes AER, Gir E. Regarding the number of episodes of inpatient treatment in the previous six months, it was observed that 44.4% of the individuals with HIV/AIDS colonized with MSSA, and 30.0% of the individuals with HIV/ AIDS colonized with MRSA, had not received inpatient The use of antiretroviral drugs was identified in 43.5% of the individuals colonized with MSSA, not being observed in 60.0% of those individuals colonized with MRSA.Table 2 brings together the characterization of those subjects classified as colonized or not, with MSSA 1238 www.eerp.usp.br/rlae

Table 2 -
Distribution of the individuals with HIV/AIDS receiving inpatient treatment in two units of a teaching hospital (N=169) by the variables of the disease, treatment, hospitalization and colonization with Staphylococcus aureus, sensitive to oxacillin (MSSA) and resistant to oxacillin (MRSA).Ribeirão Preto, SP, Brazil, 2011-2012 previous six months, use of antimicrobials, and use of antiretroviral drugs.