Community-Acquired MRSA Outbreaks Tied to Fly-by-Night Tattooists

ATLANTA, June 23 ? Six unrelated clusters of community-acquired methicillin-resistant Staphylococcus aureus infection involving 44 people in three states have been linked to 13 unlicensed street-corner tattoo artists.

Some of the tattoos were performed with needles made of old guitar strings, using inks intended for an ink-jet printer, according to researchers from several local health departments, led by Teresa Long, M.D., commissioner of the Columbus (Ohio) Health Department.

The first four clusters-in June and November 2004 and two in April 2005-were reported in Ohio. A fifth cluster was seen in May 2005 in Kentucky and a sixth in Vermont in August 2005. Dr. Long and colleagues reported in the June 23 issue of the CDC's Morbidity and Mortality Weekly Report.

Thirty-four of the patients were identified as primary cases, those who got the disease directly from the tattoo, probably because of "nonsterile equipment and suboptimal infection-control practices," Dr. Long and colleagues said. Another 10 patients were considered secondary cases. They were infected through close contact with one of the primary patients.

Many of the infections were limited to cellulitis and small pustules, but 20 larger abscesses required surgical incision and drainage. Drainage and/or oral antimicrobials-including trimethoprim-sulfamethoxazole, Levaquin (levofloxacin), and clindamycin-resolved most infections. However, four patients had bacteremia and were hospitalized for IV vancomycin.

Interviews with the primary patients and seven of the 13 tattooists who could be located showed that gloves were usually used by tattooists, but other infection-control measures-changing gloves between clients, hand hygiene, skin antisepsis, and disinfection of equipment and surfaces-were not taken.

Three of the tattooists in Ohio had recently been in prison, which the investigators said is a "potential site for exposure to MRSA infection," but that was not so for the tattooists in Kentucky or Vermont. Also, none of the 34 primary cases was in jail when tattooed.

Five of the patients said they saw lesions on the hands of tattooists that looked like MRSA infection, and one tattooist reported a pustule on his finger. Skin cultures were not taken from any of the tattoo artists.

Tattoos are becoming a fashion accessory of the decade. One American in eight has a tattoo, including nearly 40% of people aged 20 to 25.

A primary concern has been the transmission of blood-borne diseases, such as hepatitis C or HIV, but the CDC said last year there is little evidence that tattooing has transmitted such infections, except among selected populations.

On the other hand, infectious disease authorities note, tattooing is essentially a wound, with the potential for infection, and licensed tattooists are trained in measures needed to minimize infection.

The problem in the current report, the researchers noted, is that none of the tattooists was licensed and many of the operations took place in public places, such as parks and private residences, where infection-control measures were not used.

The message for clinicians, Dr. Long and colleagues said, is that they "should consider community-acquired methicillin-resistant S. aureus in their differential diagnosis for staphylococcus diseases, including skin infections." In some cases, community-acquired methicillin-resistant S. aureus is reportable, depending on local regulations, and doctors should contact local health departments to find out.