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Romanian JouRnal of infectious Diseases – Vol. XXIV, No. 4, YeaR 2021
181
ABSTRACT
The overall risk of methicillin-resistant Staphylococcus aureus (MRSA) in obstetric populations is unknown. MRSA infec-
tion incidence has increased in pregnant women and neonates even if prevention techniques of MRSA have improved.
MRSA infections affect both mothers and their infants. MRSA is the most common pathogen responsible for postpartum
mastitis. There are also other postpartum infections with MRSA such as cellulitis, pelvic thrombophlebitis, pneumonia,
septicemia, cesarean wound infections, episiotomy infections and urinary tract infections.
The objectives of this review were to identify the most frequent risk factors for postpartum MRSA infection and to deter-
mine the frequency of antibiotic-resistant Staphylococcus aureus infections after delivery.
A literature review was conducted using PubMed and we used the following key words “MRSA infection in postpartum”,
“risk factors for postpartum MRSA infection”. We are included in our review 27 articles from the last 20 years which
presented rare cases of MRSA infection in postpartum and those which identified the risk factors of this infection after
delivery.
Infections with MRSA appear to be more frequent among pregnant women colonized with MRSA. Early identification of
MRSA, early diagnosis and appropriate treatment of infection is mandatory for a good prognosis. By now, vigilance and
effective MRSA prevention strategies are considered essential to limit the spread and infection.
Keywords: methicillin-resistant Staphylococcus aureus, postpartum infection, risk factors
Corresponding author:
Nicolae Gica
E-mail: gica.nicolae@umfcd.ro
GENERAL PAPERS
Ref: Ro J Infect Dis. 2021;24(4)
DOI: 10.37897/RJID.2021.4.3
Article History:
Received: 25 November 2021
Accepted: 2 December 2021
Methicillin-resistant
Staphylococcus aureus
infections in postpartum period
Ruxandra Gabriela Cigaran1, Nicolae Gica1,2, Radu Botezatu1,2, Anca Marina Ciobanu1,2,
Brindusa Ana Cimpoca-Raptis1,2, Mihaela Demetrian1, Corina Gica1,
Gheorghe Peltecu1,2, Anca Maria Panaitescu1,2
1Filantropia Clinical Hospital, Bucharest, Romania
2“Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
INTRODUCTION
Antimicrobial resistance is a major global health
concern and Staphylococcus aureus (SA) is a danger-
ous pathogen, responsible for multiple human in-
fections involving the skin, soft tissue, bone, joints
or infections associated with indwelling medical
devices [1-4]. Bacteremia with methicillin-resistant
Staphylococcus aureus (MRSA) can cause secondary
infections such as infective endocarditis, septic ar-
thritis, and osteomyelitis and complications such as
sepsis and septic shock that may be life-threatening
[4].
Methicillin-resistant Staphylococcus aureus of-
ten colonize asymptomatically skin, skin glands or
mucous tissues of healthy individuals [5]. MRSA is
one of the major causes of hospital and community-
acquired infection [1-2]. Studies have shown that
about 20% of individuals are persistent nasal carri-
ers of Staphylococcus aureus and around 30% are
intermittent carriers [6]. In the hospital, contami-
nated medical devices may play a role as intermedi-
ate sources of MRSA infection, but ultimately these
originate from patients or healthcare workers that
carry MRSA [6]. This colonization represents a res-
ervoir of the pathogen, and it significantly increases
the chances of infections. In most cases, the affected
individuals are infected by the Staphylococcus au-
reus with which they usually are colonized [7]. Re-
Romanian JouRnal of infectious Diseases – Vol. XXIV, No. 4, YeaR 2021
182
sistance to the entire class of β-lactam antibiotics,
such as methicillin and penicillin, makes MRSA in-
fections difficult to treat and with poorer clinical
outcomes [8].
Hospital-acquired MRSA infections generally
arise from persistent carriers undergoing antibiotic
therapy or from intermittent carriers [9].
The overall risk of MRSA in obstetric populations
is unknown. The objectives of this review were to
identify the most frequent risk factors for postpar-
tum MRSA infection and to determine the frequen-
cy of antibiotic-resistant Staphylococcus aureus in-
fections in pregnant and postpartum women.
METHODS
A literature review was conducted using Pub-
Med and we used the following key words “MRSA
infection in postpartum”, “risk factors for postpar-
tum Staphylococcus aureus infection”. We are in-
cluded in our review 27 articles from the last 20
years which presented rare cases of MRSA infection
in postpartum and those which identified the risk
factors of this infection after delivery. Publications
were selected based on accessibility to full paper ar-
ticle, publication year, attempting to select recent
studies. The publications used are mentioned in the
References section.
RISK FACTORS FOR MRSA INFECTION IN POSTPARTUM
PERIOD
Over the years, MRSA infection has increased in
pregnant women and neonates, even in developed
countries [10,11]. Infections with MRSA appear to be
more frequent among patients colonized with MRSA
in the anterior nares and other sites [9]. Moreover,
the exposure to antibiotics of pregnant women is fre-
quent and this is a known risk factor for MRSA infec-
tion [12]. MRSA infections affect both mothers and
their infants. It is the most common pathogen re-
sponsible for postpartum mastitis [13]. There are
also other postpartum infections with MRSA such as
cellulitis, pelvic thrombophlebitis, pneumonia, sep-
ticemia, cesarean wound infections, episiotomy in-
fections and urinary tract infections [14].
There are some studies that showed an increas-
ing neonatal MRSA colonization and, sometimes,
infection because of horizontal transmission from
MRSA colonized mothers to their neonates [15].
Other studies investigated that the high volume
of deliveries at the hospital, provider level and ce-
sarean section rates may predispose to postpartum
MRSA infection, but clear data were not found, and
additional studies are needed [16]. Overall, postpar-
tum MRSA is associated with worse health and eco-
nomic outcomes for women and their infants [17].
However, the asymptomatic colonization with
MRSA in pregnancy is considered the major risk
factor for infection after delivery, including serious
systemic infections. Stumpf et al. reported a serious
postpartum infection (wound abscess, septicemia,
septic thrombophlebitis and septic pulmonary em-
boli) due to MRSA in an asymptomatic carrier who
had screened positive for MRSA in nares, vagina,
and rectum at the time of her prior admission in
labor, as part of a research study [18].
THE WAY OF MANIFESTATION OF THE MRSA INFECTION
AFTER DELIVERY
The most frequent way of manifestation of the
MRSA infection was postpartum breast abscesses.
Other postpartum infections with MRSA such as ce-
sarean wound infections, episiotomy infections, en-
dometritis and urinary tract infections may appear.
There were also reported serious and potentially
life-threatening infection such as septic thrombo-
phlebitis, septic pulmonary emboli and septicemia.
Toxic shock syndrome in postpartum period due
to MRSA may be, frequently, caused by endometritis
or mastitis. A case of postpartum MRSA-toxic shock
syndrome was reported from a perineal laceration
[19]. Ovarian vein thrombophlebitis and deep sep-
tic pelvic thrombophlebitis have been described as
rare forms of MRSA-infection after delivery [20]. An
isolated native pulmonary valve infection endocar-
ditis complicated by a pelvic abscess, clavicular os-
teomyelitis and polyarticular septic arthritis, was
presented as a rare occurrence after vaginal deliv-
ery in a patient with intravenous drug use [21].
Cases of osteomyelitis involving femoral head
[22], pubic symphysis [23,24], and tibia [25] or the
sacroiliac joint destruction (sacroiliitis) [26-28]
were also described as rare MRSA infection in post-
partum.
DISCUSSION
MRSA infections can be divided into hospital-as-
sociated infections and community-associated in-
fections. The most important risk factor considered
that influence the MRSA infection is colonization
with MRSA. Frequently, Staphylococcus aureus (SA),
including MRSA colonizes the anterior nares [9], but
it may also be present in the throat, axilla, rectum,
groin area, perineum, or vagina and most often it
colonizes more than one site [8].
The vagina is colonized by SA in 4-22% of preg-
nant women and the prevalence of MRSA rectovagi-
nal colonization has been reported to range 0.5-10%
[29,30]. There are reports that vaginal carriage dur-
ing pregnancy represents a major risk factor for
MRSA infections in pregnant and postpartum wom-
Romanian JouRnal of infectious Diseases – Vol. XXIV, No. 4, YeaR 2021
183
en as well as for the transmission of MRSA to the
newborn [30].
Deng et al utilized in vitro and in vivo models of
MRSA vaginal colonization to identify determinants
of persistence within the female reproductive tract
and demonstrated that both hospital-associated and
community-associated MRSA isolates can colonize
the murine vaginal tract. These results revealed
that fibrinogen binding and the host nutritional
limitation are important determinants of MRSA
vaginal colonization [30].
Top et al. conducted a retrospective cohort study
and demonstrated that rectovaginal colonization
with SA was associated with an increased risk of in-
fections in women but not in their infants and the
frequency of MRSA infections was low. For these
reasons the routine MRSA screening of pregnant
women may not be indicated [29].
Hospitalization is another important risk factor
for methicillin resistant Staphylococcus aureus in-
fection [31-36]. Hospital associated MRSA infections
usually are associated with invasive procedures or
devices, such as surgeries or intravenous catheteri-
zation [31,35-36]. It is considered, also, that a high
patient volume and a high rate of cesarean section
have been correlated with both general nosocomial
infections and MRSA infection in early postpartum
period and colonization of the hospital departments
[16,31-34,37]. Possible way of transmission may be
via health care workers hands touching people with
unclean hands or contaminated medical devices
[31-36]. Moreover, in a hospital with a high volume
of deliveries and an exposure to more patients, the
transmission has more opportunity to be via carrier
patients to other patients, possible by hands, cloth-
ing or touching unclean surfaces [16,35-37].
On the other hand, Janakiraman et al. found that
individual providers with a low volume of deliver-
ies have a higher incidence of maternal complica-
tions (including infections) compared with provid-
ers with a high volume [37]. High volume of work is
associated with better experience and better re-
sults. More studies should be conducted for a relia-
ble conclusion.
Another risk of MRSA infection at women under-
going cesarean sections is associated with the pro-
phylactic antibiotics, which may increase the num-
ber of drug resistant organisms [38-40].
Prevention of MRSA infection is the solution of
this health concern. Over the years, guidelines have
been established and most hospitals have an expert
team who perform surveillance and monitor for
outbreaks of MRSA. All MRSA cases need to be re-
ported when they are discovered, and preventive
measures are mandatory to be applied to limit the
spread. An effectively prevention of MRSA infection
and transmission includes active surveillance, iso-
lation precautions, increased hand hygiene compli-
ance, environmental cleaning, and decontamina-
tion [41]. There are controversies regarding
universal screening and decolonization. In UK me-
thicillin-resistant Staphylococcus aureus screening
of ‘high risk’ cases and women undergoing elective
cesarean sections is taken into consideration [42].
The recent data from the USA do not support pre-
cesarean section universal screening for SA and de-
colonization of carriers to be beneficial for mothers
or babies because it is unlikely to be cost-effective
under the known epidemiological conditions [43-
46].
CONCLUSIONS
Infections with MRSA appear to be more fre-
quent among patients colonized with MRSA. Even if
identification and prevention techniques of MRSA
have improved, these infections remain a major
healthcare problem in obstetrics, associated with
poor clinical outcomes and a worse economic ef-
fect. Early identification of MRSA, early diagnosis
and appropriate treatment of infection is mandato-
ry for a good prognosis. By now, vigilance and effec-
tive MRSA prevention strategies are considered es-
sential to limit the spread and infection.
Universal screening for MRSA before cesarean
section and decolonization of carriers are not cost-
effective and are not recommended.
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Conflict of interest: none declared
Financial support: none declared
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