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A cryptic triptych (final) 120429


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A cryptic triptych (final) 120429

  1. 1. A Cryptic TriptychThree seemingly unrelated cases of PVL-associatedStaphylococcus aureus infection, their investigationand managementDominic MellonSpecialty Registrar – Public HealthSouth West (North) Health Protection Unit
  2. 2. Objectives• Review a series of three sporadic cases of PVL-SA• Discuss nature of the information available• Consider the role of HPZone in the investigation• Comment on issues arising from the investigation• Share learning and recommendations arising fromthis incident
  3. 3. Panton-Valentin Leukocidin (PVL)associated Staphylococcus aureusSource: Health Protection Agency (2011) ‘PVL-Staphylococcus aureus infections: an update’, Health Protection Report, 5(7),[online] Available from: (Accessed 24 April 2012).
  4. 4. Case 1• Female student• 21 years old• Bath address/postcode, student rentedaccommodation• PVL-SA lab result reported to HPU on 8thFebruaryfollowing admission with abscess• Reporting clinician concerned that this is the thirdhousemate to be admitted, concerns around housingquality• No linked cases on HPZone
  5. 5. Initial investigation• No geographically/temporally linked cases of PVL-SA• Case 3 shares a postcode with a previous enquiryabout damp, mold and health effects• Environmental Health Service had been involvedpreviously• Hospital visit and interview with Case 1 and parents• Began timeline of events• Queried HPZone for housemates
  6. 6. Case 2 (probable index case)• Female student and food handler• 20 years old• Registered at GP practice in Hertfordshire,• Parent’s home address recorded• Recurrent boils and abscesses• Initially managed by Hertfordshire HPU• Transferred to South West (North) HPU 9thJanuary asterm time address is in Bath• No linked cases on HPZone
  7. 7. Case 3• Male food handler• 21 years old• South Gloucestershire postcode, lives with parents• GP reported PVL-SA positive lab result 27thJanuaryfollowing swab at hospital the previous week• Treated in hospital for abscess on buttock• Girlfriend has had similar• HPU unable to contact case• No linked cases on HPZone
  8. 8. Response• Visited student house to consider possible routes ofinfection• Arranged decolonisation for household contacts ofCases 1 and 2 (Case 3 already decolonised)• Provided public health/infection control advice• Did not consider further action required on the basisof housing quality
  9. 9. Review• Conducted a tabletop review of the investigation andresponse to identify and share learning points
  10. 10. Results• Over-reliance on HPZone to link cases together• Identifying linked cases may not be a straightfowardprocess and requires more than a cursoryassessment• Students may not be registered with local primarycare services or list term time addresses• Indirect transmission of the infectious agent mayhave played a significant role
  11. 11. Conclusions• HPZone is a powerful tool, but it is only one toolavailable to the public health professional• HPZone has significant limitations in querying data• Sometimes it is important to get out from behind thedesk and leave the office to understand the situation
  12. 12. ReferencesCavanagh, J., Quinn, M. and Wong, V. (2011) ‘Challenge of responding to PVL positive Staphylococcus aureus skininfection’, BMJ, 343(oct12 1), p. d6477-d6477, [online] Available from: (Accessed 13 February 2012).Gillet, Yves, Issartel, Bertrand, Vanhems, Philippe, Fournet, Jean-christophe, et al. (2002) ‘Mechanisms of DiseaseSeries: Association between Staphylococcus aureus strains carrying gene for Panton-Valentine leukocidin andhighly lethal necrotising pneumonia in young immunocompetent patients’, Lancet, 359, pp. 753-759, [online]Available from: Protection Agency (2009) ‘Boils and Skin Infections: Information for the public’, London, Health ProtectionAgency, [online] Available from: Protection Agency (2008) Guidance on the diagnosis and management of PVL-associated Staphylococcusaureus infections (PVL-SA) in England, London, [online] Available from: Protection Agency (2012) Management of PVL-Staphylococcus aureus: Recommendations for Practice, London,[online] Available from: Protection Agency (2011) ‘PVL-Staphylococcus aureus infections: an update’, Health Protection Report, 5(7),[online] Available from: (Accessed 24 April 2012).Knott, Lawrence (2010) ‘PVL-positive Staphylococcus Aureus’,, [online] Available from: (Accessed 24 April2012).Millership, S, Cummins, A, Irwin, D, Kearns, A and English, P (2011) ‘Follow up of cases of PVL-positive Staphylococcusaureus is not worthwhile.’, The Journal of Infection, The British Infection Association, 62(3), pp. 234-5, [online]Available from: (Accessed 13 February 2012).Panton, P N and Valentine, F C O (1932) ‘Staphyloccocal Toxin’, The Lancet, 219(5662), pp. 506-508, [online] Availablefrom:
  13. 13. Any questions?