Methicillin-Resistant Staphylococcus aureus ST398 in Swine Farm Personnel, Belgium

We assessed methicillin-resistant Staphylococcus aureus (MRSA) in persons on 49 swine farms in Belgium. Surveys showed that 48 (37.8%) persons carried MRSA ST398 and 1 (0.8%) had concurrent skin infection. Risk factors for carriage were MRSA carriage by pigs, regular contact with pigs and companion animals, and use of protective clothing.


The Study
We randomly selected 50 farms from the 7,500 farms in the pig farm national database of the Belgian Federal Agency for Food Safety. Sample size was based on an estimated 20% prevalence of MRSA colonization among farm workers and residents (1). The sample size was calculated to test the null hypothesis of prevalence <10% with a power of 80%. Participation was offered to all persons on the farm at the time of the visit, including farmers, co-workers, and household members. After giving written consent, participants were screened for MRSA carriage and interviewed.
Simultaneously, on the same farms, a study of MRSA carriage in 30 randomly selected pigs per farm was conducted by veterinarians (3).
Samples from anterior nares and skin lesions on hands or face of human participants were placed into Stuart transport medium (Copan, Italy), inoculated within 24 h into 7.5% NaCl brain-heart infusion enrichment broth, and subcultured after 24 h onto Chromagar MRSA (bioMérieux, Marcy l'Etoile, France) and mannitol salt agar (Becton Dickinson, Heidelberg, Germany). S. aureus isolates were identified by coagulase test and PCR for 16S rRNA, mecA, and nuc genes (4).
Data were analyzed by using Stata 9.2 (Statacorp, College Station, TX, USA). We calculated prevalence of MRSA carriage in humans and 95% confidence intervals (CIs) by using cluster survey analysis. We performed risk factor analysis by using multiple logistic regression for cluster surveys, adjusting for clustering within farms. p values <0.05 were considered significant.
Univariate analysis showed MRSA carriage to be associated with being a farmer or farm co-worker, being male, having regular contact with animals (including goats, sheep, dogs, or cats) and, paradoxically, wearing gloves and apron and reporting occasional or regular hand disinfection with an antimicrobial product. Multivariate analysis showed MRSA carriage to be independently associated with MRSA prevalence among pigs at the farm, being a farmer with regular pig contact, reporting regular contact with dogs and horses, and reporting use of protective clothing (apron, gloves, or mask) ( Table 1).
than that for hospitalized patients or nursing home residents in Belgium (www.nsih.be/surv_mrsa/download_fr.asp). MRSA isolates from farmers belonged to closely related spa types corresponding to ST398, which are unrelated to hospital-and community-acquired strains but identical to strains from humans in contact with pigs in other European countries (1,2,10). Despite the high prevalence of nasal MRSA, active MRSA skin infection was detected infrequently (<1%), within the range described in recent US-based studies (11). In a hospital in the Netherlands, a lower attack rate was found for MRSA ST398 than for other MRSA strains (12). However, invasive infections caused by MRSA ST398 have been reported, suggesting that this genotype is patho-genic for humans (2). In our study, MRSA strains did not harbor exotoxin.
Two MRSA genotypes were predominant. For 70% of farms with multiple MRSA carriers, all strains belonged to the same genotype, suggesting transmission within the farm. Although these strains have been shown to not spread easily in hospitals (12), outbreaks of MRSA ST398 in a residential care facility and a hospital probably originated from healthcare workers living on pig farms (13,14). In contrast with MRSA strains, MSSA isolates in our study showed diverse genotypes that frequently colonize human populations (4). MSSA isolates from 3 farmers belonged to the ST398 genotype, which is infrequently reported in humans except in pig farmers with contact with pigs (4).
Risk factors for MRSA ST398 carriage included regular contact with pigs but also with horses and dogs (10), suggesting that different animals could be MRSA ST398 reservoirs or vectors, at least on pig farms. Protective measures did not seem to reduce the risk of becoming colonized with MRSA; this lack of effectiveness has previously been observed for veterinarians (15). This apparent lack of protection should be further investigated to determine routes of transmission other than direct contact with pigs, including airborne transmission and contact with contaminated surfaces and companion animals.  Herman Claeys for logistic support; and Lucie Seyler for reviewing the manuscript.
This study was supported by the Belgian Antibiotic Policy Coordination Committee, the Federal Public Health Service, and the Sanitary Fund against Porcine Diseases. The study protocol was based on the protocol of a similar survey by the Dutch Working Party on Surveillance and Research of MRSA, kindly provided by Edine Tiemersma and Jan Kluytmans.
Dr Denis is a clinical microbiologist in the Belgian National Reference Laboratory for MRSA, Université Libre de Bruxelles Hôpital Erasme. His primary research interest is the epidemiology of MRSA.