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Volume 22, Number 7—July 2016

Increased Mortality Rates Associated with Staphylococcus aureus and Influenza Co-infection, Maryland and Iowa, USA1

Jennifer S. McDanelComments to Author , Eli N. Perencevich, Jeremy Storm2, Daniel J. Diekema, Loreen Herwaldt, J. Kristie Johnson, Patricia L. Winokur, and Marin L. Schweizer
Author affiliations: University of Iowa, Iowa City, Iowa, USA (J.S. McDanel, E.N. Perencevich, J. Storm, D.J. Diekema, L. Herwaldt, P.L. Winokur, M.L. Schweizer); Iowa City Veterans Affairs Health Care System, Iowa City (J.S. McDanel E.N. Perencevich, P.L. Winokur, M.L. Schweizer); University of Iowa Hospitals and Clinics, Iowa City (D.J. Diekema, L. Herwaldt); University of Maryland School of Medicine, Baltimore, Maryland, USA (J.K. Johnson)

Cite This Article


We retrospectively analyzed data for 195 respiratory infection patients who had positive Staphyloccocus aureus cultures and who were hospitalized in 2 hospitals in Iowa and Maryland, USA, during 2003–2009. Odds for death for patients who also had influenza-positive test results were >4 times higher than for those who had negative influenza test results.

Staphylococcus aureus is a common cause of respiratory infections, including pneumonia (1), and can lead to necrotizing pneumonia and death (24). Influenza complicated by S. aureus co-infection can progress rapidly to death within a week of symptom onset (3,4). However, few studies have evaluated whether patients who are co-infected with influenza and S. aureus are more likely to experience poor outcomes compared with patients who are infected with S. aureus alone. We compared patient characteristics and outcomes of patients who had a respiratory culture that grew S. aureus and who tested positive for influenza with those who had negative influenza test results.

The Study

This retrospective cohort study included pediatric and adult patients admitted to the University of Iowa Hospitals and Clinics (Iowa City, IA, USA) or to the University of Maryland Medical Center (Baltimore, Maryland, USA) during 2003–2009. First, we used codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), to identify patients with influenza-like illness (ILI) (5). This criterion was part of an initial study investigating influenza-like illness and S. aureus pneumonia (J.S. McDanel, unpub. data). Patients were included in the study if they had respiratory cultures (sputum, bronchial specimen, or tracheal aspirate) that grew S. aureus and were tested for influenza before or during their admissions. If a patient was admitted >1 time, only the admission with the first S. aureus positive respiratory culture was included. The University of Iowa institutional review board approved this study.

The primary outcome of interest, 30-day in-hospital mortality, was defined as death occurring in the hospital within 30 days of the first culture that grew S. aureus. The adapted Charlson Comorbidity Index served as an aggregate score for co-occurring conditions (6). The year of each patient’s first positive S. aureus culture was dichotomized: 2003–2007 and 2008–2009.

We conducted bivariable analyses using either the χ2 test or the Fisher exact test for categorical variables and the Student t-test or Wilcoxon rank-sum test for continuous variables. We used logistic regression to identify associations between potential predictor variables and 30-day mortality rates. We included variables in the multivariable model using a manual stepwise method. Variables associated with death (p<0.25) in the bivariable regression analysis were examined for fit within the multivariable model and were retained if statistically significant (p<0.05). The year of each patient’s first positive S. aureus culture was forced into the model. We analyzed data using SAS software version 9.3 (SAS Institute, Cary, NC, USA).

A total of 195 patients had >1 respiratory culture that grew S. aureus and were also tested for influenza. Sputum samples (115, 59%) and bronchial washes (50, 26%) were the most common respiratory specimens. Blood cultures of 17 (9%) patients grew S. aureus. Respiratory or blood samples of 109 (56%) patients grew methicillin-resistant S. aureus (MRSA). Most patients (166, 85%) were admitted to the University of Maryland Medical Center; 116 (59%) were male, and median age was 42 (interquartile range 5–59) years.

Of the 195 patients, 32 (16%) had positive influenza test results. Patients who had a positive influenza test were more likely to receive quinolones (odds ratio [OR] 3.30, 95% CI 1.51–7.21) than were patients whose influenza tests were negative (Table 1). Patients who had a positive influenza test were significantly more likely to have the positive S. aureus respiratory culture collected <2 days after hospital admission than were the patients whose influenza tests were negative (OR 3.27, 95% CI 1.39–7.70).

Of the 32 influenza-positive patients, 9 (28%) died; of the 163 influenza-negative patients, 18 (11%) died (OR 3.15, 95% CI 1.27–7.86; p = 0.021) (Table 2). Of the 9 influenza-positive patients who died, 5 had MRSA. Among the 27 patients who died, those with a positive influenza test were more likely to have diabetes than those who had a negative influenza test (33% vs. 0%; p = 0.029). The multivariable logistic regression model found that, after statistically adjusting for year and time from admission to collection of S. aureus culture samples, patients whose influenza tests were positive had >4-fold increased odds of death compared with patients whose influenza tests were negative (OR 4.31, 95% CI 1.57–11.83; p<0.005) (Table 2).


Our results are consistent with the results of other studies. Other investigators reported poor outcomes among patients who were co-infected with influenza viruses and S. aureus (3,4,7). Kallen et al. found a statistically significant increased risk for death among patients who had positive influenza test results and community-acquired S. aureus pneumonia, compared with patients who had negative influenza test results and community-acquired S. aureus pneumonia (7). The Kallen et al. study included patients who had either MRSA or methicillin–susceptible S. aureus pneumonia (7) but evaluated only 47 patients. The sample size for our study was much larger than previously performed studies, and we were able to examine mortality rates among patients who had a respiratory culture that grew either MRSA or methicillin-susceptible S. aureus.

Additionally, co-infection with influenza and S. aureus has been examined in animal models to identify mechanisms that cause poor outcomes (812). Severity of illness related to co-infection has been associated with a dysfunctional cell repair system and an altered immunologic response such as suppression of macrophage function, inhibition in phagocytic bacterial clearance, and cell damage to the airway system (812). Investigators have hypothesized that influenza damages epithelial cells in the respiratory system, providing opportunity for enhanced bacterial attachment (8,11). Once bacteria invade, cell destruction and fluid cause dysfunction of the airway system (8,11).

This study had limitations. First, the investigation might have excluded patients who were tested for influenza at other facilities or who did not have laboratory-confirmed influenza. Second, we could not determine whether the respiratory cultures that grew S. aureus represented infections or colonization. However, the information we describe remains clinically relevant because often clinicians do not know whether patients with positive S. aureus cultures are infected or colonized. Diagnosing S. aureus pneumonia is challenging, and acquiring a lower respiratory culture such as a bronchial specimen or tracheal aspirate can be invasive and difficult to collect. Therefore, if S. aureus pneumonia is suspected (e.g., symptoms and positive sputum culture), patients may be treated without a confirmed positive lower respiratory culture. Third, our dataset did not include information about variables such as influenza vaccination status, mechanical ventilation, co-infection with organisms other than influenza and S. aureus, and whether the pneumonia was necrotizing. Fourth, misclassification bias may exist based on our definition of influenza infection. Patients with a negative influenza test may be misclassified since we were unable to determine the time interval between the onset of ILI symptoms and the collection of the influenza sample. Therefore, patients may have recovered from influenza before receiving an influenza test. Last, influenza-like illness ICD-9-CM codes were used to identify the cohort because the patients initially were included in a study of influenza-like illness and S. aureus pneumonia (J.S. McDanel, unpub. data). Therefore, patients may have been missed if they had a respiratory infection with S. aureus and the condition or symptoms were not captured through an ICD-9-CM code.

In conclusion, among patients whose respiratory cultures grew S. aureus, patients with influenza were significantly more likely to die than were patients whose influenza tests were negative. Interventions that increase influenza vaccination rates among patients at high risk for S. aureus respiratory infections may prevent both co-infection and death.

Dr. McDanel is a postdoctoral fellow and adjunct lecturer at the University of Iowa in Iowa City. Her research interests include the treatment and prevention of hospital-associated infections.



This study was funded in part by an ASPIRE Young Investigator Award from Pfizer (#WS79560E); Pfizer had no role in the design or conduct of the study or the writing of the manuscript. M.L.S. was funded by a Veterans Health Administration Health Services Research and Development Career Development Award (CDA 11-215). E.N.P. was funded through a VA HSR&D grant (IIR 09-099). J.S.M. received research funding from Cubist Pharmaceuticals.

J.S.M. has received speaker honorarium from bioMerieux. D.J.D. has received research funding from Cerexa, a subsidiary of Forest Laboratories.



  1. Kollef  MH, Shorr  A, Tabak  YP, Gupta  V, Liu  LZ, Johannes  RS. Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia. Chest. 2005;128:385462 .DOIPubMedGoogle Scholar
  2. Centers for Disease Control and Prevention (CDC). Four pediatric deaths from community-acquired methicillin-resistant Staphylococcus aureus—Minnesota and North Dakota, 1997–1999. MMWR Morb Mortal Wkly Rep. 1999;48:70710.PubMedGoogle Scholar
  3. Centers for Disease Control and Prevention (CDC). Severe methicillin-resistant Staphylococcus aureus community-acquired pneumonia associated with influenza–––Louisiana and Georgia, December 2006-January 2007. MMWR Morb Mortal Wkly Rep. 2007;56:3259.PubMedGoogle Scholar
  4. Hageman  JC, Uyeki  TM, Francis  JS, Jernigan  DB, Wheeler  JG, Bridges  CB, Severe community-acquired pneumonia due to Staphylococcus aureus, 2003–04 influenza season. Emerg Infect Dis. 2006;12:8949 .DOIPubMedGoogle Scholar
  5. Marsden-Haug  N, Foster  VB, Gould  PL, Elbert  E, Wang  H, Pavlin  JA. Code-based syndromic surveillance for influenza like illness by International Classification of Diseases, Ninth Revision. Emerg Infect Dis. 2007;13:20716 .DOIPubMedGoogle Scholar
  6. Deyo  RA, Cherkin  DC, Ciol  MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol. 1992;45:6139 .DOIPubMedGoogle Scholar
  7. Kallen  AJ, Brunkard  J, Moore  Z, Budge  P, Arnold  KE, Fosheim  G, Staphylococcus aureus community-acquired pneumonia during the 2006 to 2007 influenza season. Ann Emerg Med. 2009;53:35865 .DOIPubMedGoogle Scholar
  8. Kash  JC, Taubenberger  JK. The role of viral, host and secondary bacterial factors in influenza pathogenesis. Am J Pathol. 2015;185:152836 .DOIPubMedGoogle Scholar
  9. Robinson  KM, McHugh  KJ, Mandalapu  S, Clay  ME, Lee  B, Scheller  EV, Influenza A virus exacerbates Staphylococcus aureus pneumonia in mice by attenuating antimicrobial peptide production. J Infect Dis. 2014;209:86575 .DOIPubMedGoogle Scholar
  10. Sun  K, Metzger  DW. Influenza infection suppresses NADPH oxidase-dependent phagocytic bacterial clearance and enhances susceptibility to secondary methicillin-resistant Staphylococcus aureus infection. J Immunol. 2014;192:33017 .DOIPubMedGoogle Scholar
  11. Kash  JC, Walters  KA, Davis  AS, Sandouk  A, Schwartzman  LM, Jagger  BW, Lethal synergism of 2009 pandemic H1N1 influenza virus and Streptococcus pneumoniae coinfection is associated with loss of murine lung repair responses. MBiol 2011; 2:e00172e11. DOIPubMedGoogle Scholar
  12. Kostrzewska  K, Massalski  W, Narbutowicz  B, Zielinski  W. Pulmonary staphylococcal complications in patients during the influenza epidemic in 1971–1972. Mater Med Pol. 1974;6:20712.PubMedGoogle Scholar




Cite This Article

DOI: 10.3201/eid2207.151319

1Presented in part at ID Week, October 17-21, 2012, San Diego, CA, USA. Abstract 36846.

2Current affiliation: Infectious Disease Specialists, P.C., Sioux Falls, South Dakota, USA.

Table of Contents – Volume 22, Number 7—July 2016

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Jennifer S. McDanel, CADRE Building 152, 601 Highway 6 West, Iowa City, IA 52246, USA

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Page created: June 14, 2016
Page updated: June 14, 2016
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