Intermittent nasal carriage with Staphylococcus aureus within a menstrual cycle: Results from a prospective cohort of healthy carriers

Female sex hormones have been related to nasal Staphylococcus aureus carriage in healthy individuals; however, whether nasal staphylococcal carriage varies by menstrual cycle phase remains unknown. We sampled anterior nares of female healthcare workers twice per week for 6 consecutive menstrual cycles. We used mixed-effects Poisson regression models to determine whether intermittent carriage was associated with cycle phases in a given individual. We also performed recurrent event survival analysis to identify host factors linked to incident carriage status. Overall, we collected 754 nasal swabs over 89 consecutive person-cycles from 14 intermittent carriers. In 84 ovulation-defined menstrual cycles (715 swabs), the period prevalence of staphylococcal carriage was 58.7%, 63.1%, and 64.9% in the follicular, periovulatory, and luteal phases, respectively; these differences were not statistically significant after multivariable adjustment and correction for within-person correlation (adjusted relative risk [RR]—periovulatory 0.92, P: 0.30; luteal 1.00, P: 0.98). Using survival analysis, we identified several host factors that were associated with incident loss, gain of colonization, or both. For example, as compared to women aged 20 to 30 years, those aged 30 to 40 years were less likely to losing carriage (hazard ratio [HR]: 0.26, 95% confidence interval [CI]: 0.09, 0.80) but were as likely to regaining carriage (HR: 0.53, 95% CI: 0.21, 1.34). In comparison, being underweight (body mass index [BMI] <18.5) was significantly associated with a higher risk for regaining (HR: 1.95, 95% CI: 1.34, 1.51) and losing (HR: 1.57, 95% CI: 1.16, 2.12) colonization, indicating the alternating tendency for status changes. Personal hygiene behaviors, such as nostril cleansing habit and methods, differentially affected carriers’ risk for losing or regaining staphylococcal colonization. Using an intensive sampling scheme, we found that nasal staphylococcal carriage could vary substantially over time in healthy carriers. Yet, such dynamic intraperson changes in carriage status did not depend on menstrual cycle phases but were associated with host age, BMI, and personal hygiene behavior.