A GIS Approach toStaphylococcus Associated Mortality

in Texas in 2005By

Samuel F. Barker, MTSchool of Rural Public Health

Texas A&M Health Science Center

Refer all questions to: Marilyn.Felkner@dshs.state.tx.us

Updates and Assumptions

• Oxacillin, Nafcillin, and Methicillin were treated equally to establish methicillin resistance.

• By definition, MRSA is genetically resistant to:• Betalactams• Cephalosporins• Carbapenems

• Intermediate resistance was treated as resistant based on clinical treatment protocols.

Texas Death Cohort 2005

• 155,924 deaths on record

• 439 records listed Staphylococcus sp. as a contributing cause

• 223 records listed Staphylococcus sp. as the underlying cause

• 210 records requested

• 114 complete records received

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# Staph Death Cases

Texas Counties

Texas Staphylococcal Death Cases in 2005

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Houston

Dallas

Austin

El Paso

San Antonio

Fort Worth

Waco

Abilene

LubbockPlano

Corpus Christi

Beaumont

Amarillo

Laredo

# Staph Death Cases

Texas Counties

Texas Staphylococcal Death Cases in 2005

Response rates to requests for laboratory records by facilities in which staphylococcal

deaths occurred in Texas, 2004-2005

Response

20041 20052

Adequate information 77 (68.2) 114 (51.2)No culture reports 12 (10.6) 40 (17.9)No response 24 (21.2) 69 (30.9)Total 113 (100) 223 (100)

2 Medical records requested on 210 deaths

Number ( %)

1 Medical records requested on sample of 197 total deaths

2004

Race MRSA# (%)

MSSA# (%)

White † 39 (67.2) 19 (37.8)

Black 5 (71.4) 2 (28.6)

Other 8 (66.7) 4 (33.3)

Race/Ethnicity

† Reference group

Culture sources of staphylococcal infectionsresulting in death in Texas, 2004-2005

Culture Source 20041 20052

Blood 53 (68.8) 51 (44.7)Sputum 11 (14.3) 36 (31.6)Bronchial Wash 3 (3.9) 7 (6.1)Respiratory 3 (3.9) 5 (4.4)Catheter Tip 2 (2.6) 0 (0.0)Skin 1 (1.3) 0 (0.0)Spinal fluid 2 (2.6) 0 (0.0)Wound 1 (1.3) 10 (8.8) Urine 0 (0.0) 4 (3.5)Arterial Line 0 (0.0) 1 (0.9)Not Listed 1 (1.3) 0 (0.0)

Total 77 (100) 114 (100)

2 Medical records requested on 210 deaths

Number ( %)

1 Medical records requested on sample from 197 deaths

Contributing Cause of Death 2000 2001 2002 2003 2004 2005

Staphylococcal septicemia 220 261 250 215 236 247 (ICD10: A41.0, A41.1, A41.2, P36.2, P36.3)

Staphylococcus aureus septicemia 83 (38%) 121 (46%) 143 (57%) 109 (51%) 121 (51%) 132 (53%)

(ICD 10: A41.0,P36.2)

Staphylococcal pneumonia 88 91 107 120 100 103 (ICD10: J15.2, P23.2)

Staphylococcal infection, unspecified 31 56 47 80 110 87 (ICD10: A49.0)

Staphylococcal meningitis 4 2 2 1 2 1 (ICD10: G00.3)

Staphylococcal arthritis/polyarthritis 0 1 0 0 0 1 (ICD10: M00.0)

Total 343 411 406 416 448 439

Number of deaths per year reporting staphylococcus as a contributing COD

Underlying Cause of Death 2000 2001 2002 2003 2004 2005

Staphylococcal septicemia 94 80 94 88 107 105 (ICD10: A41.0, A41.1, A41.2, P36.2, P36.3) Staphylococcus aureus septicemia 37 (39%) 40 (50%) 46 (49%) 45 (51%) 49 (46%) 62 (59%)

(ICD 10: A41.0,P36.2)

Staphylococcal pneumonia 54 66 72 72 67 97 (ICD10: J15.2, P23.2)

Staphylococcal infection, unspecified 7 14 11 14 17 17 (ICD10: A49.0)

Staphylococcal meningitis 0 1 2 0 5 3 (ICD10: G00.3)

Staphylococcal arthritis/polyarthritis 1 0 0 0 1 1 (ICD10: M00.0)

Total 156 161 179 174 197 223

Number of deaths per year reporting staphylococcus as the underlying COD

Staphylococcal species responsible for infections resulting in death in Texas, 2004-2005

Species

20041 20052

Coagulase Positive, S. aureus 68 (88.3) 108 (94.7)Coagulase Negative 9 (11.7) 6 (5.3)

S. epidermidus 5 (6.5) 3 (2.6)S. haemolyticus 1 (1.3) 1 (0.9)Unspecified 3 (3.9) 2 (1.8)

Total 77 (100.0) 114 (100)1 Medical records requested on sample of 197 total deaths 2 Medical records requested on 210 deaths

Number (%)

Demographic variables associated with deaths due to MRSA compared with deaths due to MSSA

2004 2005

Sex MRSA# (%)

MSSA# (%)

MRSA# (%)

MSSA# (%)

Male † 33 (64.7) 18 (35.3) 50 (80.6) 12 (19.4)

Female 19 (73.9) 7 33 (73.3) 12 (26.7)

† Reference group

Demographic variables associated with deaths due to MRSA compared with deaths due to MSSA

2004 2005

Age MRSA# (%)

MSSA# (%)

MRSA# (%)

MSSA# (%)

Mean Age 61 59 69 75

≥ 30 † 5 (55.6) 4 (44.4) 6 (85.7) 1 (14.3)

31 - 60 16 (69.6) 7 (30.4) 18 (85.7) 3 (14.3)

> 60 31 (68.9) 14 (31.1) 59 (74.7) 20 (25.3)

† Reference Group

Cause of Death (ICD-10 Codes) MRSA MSSA OR (95% CI) MRSA MSSA OR (95% CI)Staphylococal septicemia† 22 (55.0) 18 (45.0) 1.0† 39 (47.0) 14 (58.3) 1.0†

(A41.0, A41.1, A41.2, P36.2, P36.3)

Staphylococal pneumonia 26 (92.9) 2 (7.1) 10.6 (2.1, 101.4) 41 (49.4) 9 (37.5) 1.6 (0.6, 4.8) (J15.2, P23.2)

Staphylococal infection, unspecified 2 (40.0) 3 (60.0) 0.6 (0.4, 5.38) 3 (3.6) 1 (4.2) 1.1 (0.1, 60.5) (A49.0)

Staphylococal meningitis 2 (50.0) 2 (50.0) 0.8 (0.1, 12.4) 0.0 0.0 0.0 (G00.3)

Total 52 25 83 24† Reference Group

2004 2005

Association of site of staphylococcal infection with MRSA compared with MSSA

Percent antibiotic resistance of staphylococcal species as reported on susceptibility tests for persons dying of

staphylococcal infections in Texas, 2004-2005 Antibiotic Resistant/Total (%)

2004 2005 Penicillin

61/65 (93.8) 106/112 (94.6) Oxacillin 59/76 (77.6) 87/111 (78.4) Ampicillin 44/50 (88.0) 106/112 (94.6) Amoxicillin 25/32 (78.1) 106/112 (94.6) Clindamycin 26/62 (41.9) 53/98 (54.1) Cefazolin 45/57 (78.9) 87/110 (79.1) Ceftriaxone 21/27 (77.8) 88/110 (80.0) Cefotaxime 8/11 (72.7) 87/108 (80.6) Cefepime 2/2 (100.0) 87/109 (79.8) Cephalothin 3/5 (60.0) 86/108 (79.6) Erythromycin 54/66 (81.8) 81/99 (81.8) Azithromycin 7/10 (70.0) 11/14 (78.6) Clarithromycin 3/4 (75.0) 5/5 (100.0) Gentamicin 7/52 (13.5) 5/89 (5.6) Trim/Sulfa 6/71 (8.5) 3/101 (3.0) Tetracycline 8/57 (14.0) 6/87 (6.9) Vancomycin 1*/69 (1.4) 2*/106 (1.9) Levofloxacin 34/51 (66.7) 58/79 (73.4) Ciprofloxacin 20/28 (71.4) 35/49 (71.4) Rifampin 3/40 (7.5) 2/76 (2.6) Imipenem

Lin

10/14 (71.4) 85/102 (83.3) Linezolid 0/7 (0.0) 0/37 (0.0) Synercid 0/0 (0.0) 0/16 (0.0)

*Data are based on hospital laboratory reports. No vancomycin resistant staphylococcus have been confirmed in Texas.

Antibiotic Classification

PenicillinsCephalosporins/Cephamycins Macrolides Aminoglycosides Quinolones Sulfonamides Tetracyclines Glycopeptides

Amoxicillin Cefaclor Azithromycin Amikacin Ciprofloxacin Doxycycline VancomycinAmoxicillin/Clavulinate Cefazolin Erythromycin Gentamicin Gatifloxacin TetracyclineAmpicillin Cefepime Clarithromycin LevofloxacinAmpicillin/Sulbactam Cefotaxime MoxifloxacinMethicillin Ceftriaxone NorfloxacinNafcillin Cefuroxime OfloxacinOxacillin Cephalothin SparfloxacinPenicillin GPiperacillinPiperacillin/TazobactamTicarcillin/Clavulinate

Rifampins Carbapenems Lincosamides Streptogramins Oxazolidinone Amphenicols NitrofuransRifampin Imipenem Clindamycin Synercid Linezolid Chloramphenicol Nitrofurantoin

Meropenem

Trimethoprim/Sulfamethoxazole

Percent antibiotic class resistance of staphylococcal species as reported on susceptibility tests for persons dying of

staphylococcal infections in Texas, 2004-2005

Antibiotic Class Resistant/Total (%)

(%)

Resistant/Total (%) 2004 2005 Cephalosporins & CCephamy

50/61 (82.0) 88/110 (80.0) Cephamycins Macrolides 54/67 (80.6) 82/99 (82.8) Aminoglycosides 7/52 (13.5) 6/89 (6.7) Sulfonamides 6/71 (8.5) 3/101 (3.0) Tetracyclines 8/57 (14.0) 6/87 (6.9) Glycopeptides 1/69 (1.4) 2/106 (1.9) Quinolones 39/58 (67.2) 67/89 (75.3) Rifampins 3/40 (7.5) 2/76 (2.6) Carbapenems 10/14 (71.4) 85/102 (83.3) Lincosamides 0/7 (0.0) 53/98 (54.1)

Texas Pop. 200554 - 5000

5001 - 12500

12501 - 25000

25001 - 50000

50001 - 3735075

Staph Death Count1

2

3

4 - 5

6 - 36

2005 Texas Population and Staph Death

Count

Texas Pop. 200554 - 5000

5001 - 12500

12501 - 25000

25001 - 50000

50001 - 3735075

Staph Death Rate0.18 - 1.00

1.01 - 2.00

2.01 - 4.00

4.01 - 10.00

10.01 - 25.00

2005 Texas Population and Staph Death Rate

(per 100,000)

Houston

Dallas

Austin

El Paso

San Antonio

Fort Worth

Abilene

Port Arthur

Corpus Christi

Tyler

Amarillo

Midland

Laredo

San Angelo

Wichita Falls

McAllen

Killeen

Galveston

Brownsville

Texas Pop. 200554 - 5000

5001 - 12500

12501 - 25000

25001 - 50000

50001 - 3735075

Staph Deaths

Death Count

Death Rate

2005 Texas Population and Staphylococcal Death

(Per 100,000)

Staph Death Rate0.18 - 1.00

1.01 - 2.00

2.01 - 4.00

4.01 - 10.00

10.01 - 25.00

No Deaths

Staph Death Count1

2

3

4 - 5

6 - 36

Staphylococcal Death Count and Rate (per

100,000)

Rural Urban Cont. Code

Metro 250,000+

Metro <250.000

Urban 20,000+

Urban 2,500-20,000

Rural <2,500

Staph Death Count

1

2

3

4 - 5

6 - 36

Rural Urban Continuum Code by Staph Death Count

Rural Urban Cont. Code

Metro 250,000+

Metro <250.000

Urban 20,000+

Urban 2,500-20,000

Rural <2,500

Staph Death Rate

0.18 - 1.00

1.01 - 2.00

2.01 - 4.00

4.01 - 9.00

9.01 - 25.00

RUC Code and Staph Death Rate (per 100,000)

Houston

Dallas

Austin

El Paso

San Antonio

Fort Worth

Waco

Abilene

Port Arthur

Corpus Christi

Tyler

Amarillo

Midland

Laredo

San Angelo

Wichita Falls

McAllen

Killeen

Galveston

Brownsville

Rural Urban Cont. CodeMetro 250,000+

Metro <250.000

Urban 20,000+

Urban 2,500-20,000

Rural <2,500

Staph Deaths

Death Count

Death Rate

Staphylococcal Death by Rural-Urban Continuum Code

(Per 100,000)

Special Thanks to

J. Charles Huber Jr, PhDAsst. Professor of BiostatisticsDept. of Epidemiology and BiostatisticsTexas A&M Health Science Center School of Public Health