ABSTRACT Tampons recovered from a cohort of 737 healthy women (median age,
32 years) were analyzed for the presence of Staphylococcus aureus. A total of 198
tampons (27%) were colonized by S. aureus, 28 (4%) by a strain producing toxic
shock syndrome toxin 1 (TSST-1). S. aureus was detected more frequently in tampons
that did not require an applicator for their insertion (74/233 [32%] versus 90/
381 [24%]; odds ratio [OR]=1.51 [95% confidence interval, 1.04 to 2.17]) and in
women who used an intrauterine device for contraception (53/155 [34%] versus 145/
572 [27%]; OR = 1.53 [95% confidence interval, 1.05 to 2.24]). The S. aureus strains
isolated from tampons belonged to 22 different clonal complexes (CCs). The most
prevalent CC was CC398 agr1 (n=57 [27%]), a clone that does not produce superantigenic
toxins, followed by CC30 agr3 (n=27, 13%), producing TSST-1 (24/27
[89%]), the principal clone of S. aureus involved in menstrual toxic shock syndrome
(MTSS).

IMPORTANCE Menstrual toxic shock syndrome (MTSS) is an uncommon severe
acute disease that occurs in healthy menstruating women colonized by TSST-1-
producing S. aureus who use intravaginal protection, such as tampons and menstrual
cups. The catamenial product collected by the protection serves as a growth
medium for S. aureus and allows TSST-1 production. Previous studies evaluated the
prevalence of genital colonization by S. aureus by vaginal swabbing, but they did
not examine tampon colonization. This study demonstrated a high prevalence of
tampon colonization by S. aureus and the presence of the CC30 TSST-1 S. aureus
clone responsible for MTSS in tampons from healthy women. The results support the
vaginal carriage of this lineage in healthy women. In addition, the higher prevalence
of S. aureus within tampons that do not require an applicator indicates a crucial role
for handwashing before tampon handling to decrease the risk of tampon contamination.

KEYWORDS Staphylococcus aureus, colonization, healthy women, menstruation,
vagina