Significance of methicillin–teicoplanin resistant Staphylococcus haemolyticus in bloodstream infections in patients of the Semmelweis University hospitals in Hungary

Prevalence and Molecular Determinants of Antimicrobial Resistance in Clinical Isolates of Staphylococcus haemolyticus from India

Aims: Although Staphylococcus haemolyticus is considered as a part of normal skin flora, infections associated with them are increasing. Irrespective of the low virulence profile it poses a severe threat to patients with indwelling devices due to its multidrug-resistant nature. The aim of this study was to determine antibiotic resistance patterns and to detect the genes responsible in clinical isolates of S. haemolyticus. Results: All the 356 S. haemolyticus isolates were susceptible to glycopeptides. 91.3% were resistant to cefoxitin, 85.4% to erythromycin, 57.3% to co-trimoxazole, 52.8% to clindamycin, whereas only 3.7% of isolates were resistant to linezolid. Tetracycline resistance was found in 16.6% of isolates with tetK as the major genetic determinant. Most of the cefoxitin-resistant isolates carried mecA gene (99.4%), whereas dfrG gene was found only in 57.3% of co-trimoxazole-resistant isolates. Macrolides resistance was seen in 85.4% of isolates with cMLS_B (constitutive macrolide, lincosamide, and streptogramin B) (42.5%) as the major phenotype with ermC and msrAB genes as the predominant genetic determinants. Among linezolid-resistant isolates all except one showed higher minimum inhibitory concentration (MIC) (>256 μg/mL) with chloramphenicol-florfenicol resistance (cfr) gene as the genetic determinant, whereas one isolate had a lower MIC (16 μg/mL) and was negative for cfr gene. Conclusion: Emerging resistance to linezolid is a cause for concern. Strategies to prevent the spread of antibiotic resistance require continuous surveillance of these multidrug-resistant strains.

Teicoplanin resistance in Staphylococcus haemolyticus is associated with mutations in histidine kinases VraS and WalK

We investigated the genetic basis of glycopeptide resistance in laboratory-derived strains of S. haemolyticus with emphasis on differences between vancomycin and teicoplanin. The genomes of two stable teicoplanin-resistant laboratory mutants selected on vancomycin or teicoplanin were sequenced and compared to parental S. haemolyticus strain W2/124. Only the two non-synonymous mutations, VraS Q289K and WalK V550L were identified. No other mutations or genome rearrangements were detected. Increased cell wall thickness, resistance to lysostaphin-induced lysis and adaptation of cell growth rates specifically to teicoplanin were phenotypes observed in a sequenced strain with the VraS Q289K mutation. Neither of the VraS Q289K and WalK V550L mutations was present in the genomes of 121S. haemolyticus clinical isolates. However, all but two of the teicoplanin resistant strains carried non-synonymous SNPs in vraSRTU and walKR-YycHIJ operons pointing to their importance for the glycopeptide resistance.

Diversity of staphylococcal cassette chromosome mec elements in nosocomial multiresistant Staphylococcus haemolyticus isolates

Staphylococcus haemolyticus is the second, most frequently isolated coagulase-negative staphyloccus (CoNS) from patients with hospital-acquired infections, and it is usually resistant to methicillin and other semisynthetic penicillins. The purpose of this study was to characterize staphylococcal cassette chromosome mec (SCCmec) elements and assess the in-vitro activity of antibiotics against 60 S. haemolyticus strains recovered from hospitalized patients. All these strains expressed methicillin resistance and carried a mecA gene. Moreover, all strains possessed a multiresistant phenotype, i.e., exhibited resistance to more than three classes of antibiotics. Eleven strains (18 %) harbored the SCCmec type V, containing ccrC and mec complex C. Three isolates harboring the ccrC gene did not contain a known mec complex. One strain positive for mec complex C was not typeable for ccr. This suggests that ccrC and mec complex C may exist autonomously. Only four strains carried mec complex B, whereas none of the S. haemolyticus harboured mec complex A. A new combination, which is mec complex B-ccrAB ship, was found in S. haemolitycus. The ccrAB ship was also identified in two strains of S. haemolitycus in which the mec gene complex was not identified. The results of the present study indicate that in S. haemolyticus the mec gene complex and the ccr genes are highly divergent. However, ccr sequence analysis does not allow the identification of a new allotype, based on a cut-off value of 85 % identity. The ccr genes in the S. haemolitycus strain showed ≥96 % sequence identity to the ccrAB2 genes.

Impact of Insertion Sequences and Recombination on the Population Structure of Staphylococcus haemolyticus

Staphylococcus haemolyticus is one of the most common pathogens associated with medical-device related infections, but its molecular epidemiology is poorly explored. In the current study, we aimed to better understand the genetic mechanisms contributing to S. haemolyticus diversity in the hospital environment and their impact on the population structure and clinical relevant phenotypic traits. The analysis of a representative S. haemolyticus collection by multilocus sequence typing (MLST) has identified a single highly prevalent and diverse genetic lineage of nosocomial S. haemolyticus clonal complex (CC) 29 accounting for 91% of the collection of isolates disseminated worldwide. The examination of the sequence changes at MLST loci during clonal diversification showed that recombination had a higher impact than mutation in shaping the S. haemolyticus population. Also, we ascertained that another mechanism contributing significantly to clonal diversification and adaptation was mediated by insertion sequence (IS) elements. We found that all nosocomial S. haemolyticus, belonging to different STs, were rich in IS1272 copies, as determined by Southern hybridization of macrorestriction patterns. In particular, we observed that the chromosome of a S. haemolyticus strain within CC29 was highly unstable during serial growth in vitro which paralleled with IS1272 transposition events and changes in clinically relevant phenotypic traits namely, mannitol fermentation, susceptibility to beta-lactams, biofilm formation and hemolysis. Our results suggest that recombination and IS transposition might be a strategy of adaptation, evolution and pathogenicity of the major S. haemolyticus prevalent lineage in the hospital environment.

Comparative Genotypes, Staphylococcal Cassette Chromosome mec (SCCmec) Genes and Antimicrobial Resistance amongst Staphylococcus epidermidis and Staphylococcus haemolyticus Isolates from Infections in Humans and Companion Animals

This study compares the characteristics of Staphylococcus epidermidis (SE) and Staphylococcus haemolyticus (SH) isolates from epidemiologically unrelated infections in humans (Hu) (28 SE-Hu; 8 SH-Hu) and companion animals (CpA) (12 SE-CpA; 13 SH-CpA). All isolates underwent antimicrobial susceptibility testing, multilocus sequence typing and DNA microarray profiling to detect antimicrobial resistance and SCCmec-associated genes. All methicillin-resistant (MR) isolates (33/40 SE, 20/21 SH) underwent dru and mecA allele typing. Isolates were predominantly assigned to sequence types (STs) within a single clonal complex (CC2, SE, 84.8%; CC1, SH, 95.2%). SCCmec IV predominated among MRSE with ST2-MRSE-IVc common to both Hu (40.9%) and CpA (54.5%). Identical mecA alleles and nontypeable dru types (dts) were identified in one ST2-MRSE-IVc Hu and CpA isolate, however, all mecA alleles and 2/4 dts detected among 18 ST2-MRSE-IVc isolates were closely related, sharing >96.5% DNA sequence homology. Although only one ST-SCCmec type combination (ST1 with a non-typeable [NT] SCCmec NT9 [class C mec and ccrB4]) was common to four MRSH-Hu and one MRSH-CpA, all MRSH isolates were closely related based on similar STs, SCCmec genes (V/V_T or components thereof), mecA alleles and dts. Overall, 39.6% of MR isolates harbored NT SCCmec elements, and ACME was more common amongst MRSE and CpA isolates. Multidrug resistance (MDR) was detected among 96.7% of isolates but they differed in the prevalence of specific macrolide, aminoglycoside and trimethoprim resistance genes amongst SE and SH isolates. Ciprofloxacin, rifampicin, chloramphenicol [fexA, cat-pC221], tetracycline [tet(K)], aminoglycosides [aadD, aphA3] and fusidic acid [fusB] resistance was significantly more common amongst CpA isolates. SE and SH isolates causing infections in Hu and CpA hosts belong predominantly to STs within a single lineage, harboring similar but variable SCCmec genes, mecA alleles and dts. Host and staphylococcal species-specific characteristics were identified in relation to antimicrobial resistance genes and phenotypes, SCCmec and ACME.

Staphylococcus haemolyticus - an emerging threat in the twilight of the antibiotics age

Staphylococcus haemolyticus is one of the most frequent aetiological factors of staphylococcal infections. This species seems to lack the important virulence attributes described in other staphylococci. However, studies have shown that the presence of various enzymes, cytolysins and surface substances affects the virulence of S. haemolyticus. Nevertheless, none of them has been identified as crucial and determinative. Despite this, S. haemolyticus is, after Staphylococcus epidermidis, the second most frequently isolated coagulase-negative staphylococcus from clinical cases, notably from blood infections, including sepsis. This raises the question of what is the reason for the increasing clinical significance of S. haemolyticus? The most important factor might be the ability to acquire multiresistance against available antimicrobial agents, even glycopeptides. The unusual genome plasticity of S. haemolyticus strains manifested by a large number of insertion sequences and identified SNPs might contribute to its acquisition of antibiotic resistance. Interspecies transfer of SCCmec cassettes suggests that S. haemolyticus might also be the reservoir of resistance genes for other staphylococci, including Staphylococcus aureus. Taking into consideration the great adaptability and the ability to survive in the hospital environment, especially on medical devices, S. haemolyticus becomes a crucial factor in nosocomial infections caused by multiresistant staphylococci.

In Vitro Activity of Rifampicin Combined with Daptomycin or Tigecycline on Staphylococcus haemolyticus Biofilms

Staphylococcus haemolyticus is of increasing concern as a cause of several biofilm-associated infections, and today, it represents the second most common organism among clinical isolates of coagulase-negative staphylococci. However, little is known regarding the treatment of infections caused by these bacteria. In this study, we characterize the biofilm formed by S.haemolyticus strains isolated from bloodstream infections and assess in vitro the activity of rifampicin combined with daptomycin or tigecycline against bacteria growing in a biofilm. The results of our studies indicated that the majority (78 %) of methicillin-resistant Staphylococcushaemolyticus strains have the ability to form a biofilm in vitro. None of these strains carried icaADBC genes indicating that they form biofilm via ica-independent mechanisms. The molecular characterization of the biofilm showed that proteins are the predominant matrix component and play a major role in biofilm structure. Extracellular DNA and polysaccharides, other than polysaccharide intercellular adhesin, are also present in the biofilm matrix, but they play a minor role. The images obtained by confocal laser scanning microscopy showed that most S. haemolyticus strains formed a dense biofilm with a low number of dead cells. In vitro study demonstrated excellent activity of tigecycline in combination with rifampicin against cell growth in the proteinous biofilm. The BIC (biofilm inhibitory concentration) value for tigecycline/rifampicin ranged from 0.062 to 1 µg/ml, whereas for daptomycin/rifampicin from 0.125 to 2 µg/ml. These results indicated that the tigecycline/rifampicin combination was more effective against ica-independent biofilm, formed by S. haemolyticus strains, than the daptomycin/rifampicin combination.

Synthesis and antibacterial evaluation of some teicoplanin pseudoaglycon derivatives containing alkyl- and arylthiosubstituted maleimides

Bis-alkylthio maleimido derivatives have been prepared from teicoplanin pseudoaglycon by reaction of its primary amino group with N-ethoxycarbonyl bis-alkylthiomaleimides. Some of the new derivatives displayed excellent antibacterial activity against resistant bacteria.

Influence of papain in biofilm formed by methicillin-resistant Staphylococcus epidermidis and methicillin-resistant Staphylococcus haemolyticus isolates

Methicillin-resistant Staphylococcus epidermidis (MRSE) and methicillin-resistant Staphylococcus haemolyticus (MRSHa) are important coagulase-negative staphylococci. They are often isolated from bacteremia in humans mainly due to their ability to form biofilm on the surfaces of medical devices. Papain is a complex mixture of proteolytic enzymes and peroxidases extracted from the latex of Carica papaya and it is recognized by accelerating the healing process of wounds. This study aimed to evaluate the ability of the MRSE and MRSHa isolates to produce biofilms. Besides this, the ability of papain to inhibit the formation of biofilms or to disrupt the ones already formed by those bacteria was analyzed. Thirty MRSHa and 30 MRSE were isolated from bacteremia and used in this study. It was observed that papain has ability to reduce biofilms formed by MRSE (p < 0.06) and by MRSHa (p = 0.0005). In addition, papain was able to disrupt mature biofilms made by MRSE (p = 0.014). No antibacterial activity of papain was observed for any isolates of MRSE and MRSHa tested. Papain has been demonstrated as a potential product for reducing biofilm.

Prevalence of antibiotic resistance in multi-drug resistant coagulase-negative staphylococci isolated from invasive infection in very low birth weight neonates in two Polish NICUs

BACKGROUND

Multi-drug resistant coagulaso-negative staphylococci (CNS) have become an increasing problem in nosocomial infections connected with the presence of medical devices. The paper aimed to analyze the prevalence of antibiotic resistance in CNS isolated from invasive infection in very low birth weight (VLBW) neonates.

METHODS

Continuous prospective target surveillance of infections was conducted in 2009 at two Polish NICUs that participated in the Polish Neonatology Surveillance Network (PNSN). The study covered 386 neonates with VLBW (≤1500 g), among which 262 cases of invasive infection were detected with predominance of CNS (123; 47%). Altogether, 100 CNS strains were analyzed. The resistance phenotypes were determined according to EUCAST. Resistance genes: mecA, ermA, ermB, ermC, msrA, aac(6')/aph(2''), ant(4')-Ia and aph(3')-IIIa were detected using multiplex PCR.

RESULTS

The most common species was S. epidermidis (63%), then S. haemolyticus (28%) and other CNS (9%). Among S. epidermidis, 98% of isolates were resistant to methicillin, 90% to erythromycin, 39% to clindamycin, 95% to gentamicin, 60% to amikacin, 36% to ofloxacin, 2% to tigecycline, 3% to linezolid and 13% to teicoplanin. Among S. haemolyticus isolates, 100% were resistant to methicillin, erythromycin and gentamicin, 18% to clindamycin, 50% to amikacin, 86% to ofloxacin, 14% to tigecycline and 4% to teicoplanin. No resistance to linezolid was detected for S. haemolyticus isolates. Moreover, all isolates of S. epidermidis and S. haemolyticus were susceptible to vancomycin. The mecA gene was detected in 98% of S. epidermidis isolates and all of S. haemolyticus ones. Among macrolide resistance isolates, the ermC was most common in S. epidermidis (60%) while msrA was prevalent in S. haemolyticus (93%). The ermC gene was indicated in all isolates with cMLSB, whereas mrsA was found in isolates with MSB phenotype. Of the aminoglycoside resistance genes, aac(6')/aph(2'') were present alone in 83% of S. epidermidis, whereas aac(6')/aph(2'') with aph(3')-IIIa were predominant in 84% of S. haemolyticus.

CONCLUSIONS

Knowing the epidemiology and antibiotic resistance of CNS isolated from invasive infection in VLBW neonates is a key step in developing targeted prevention strategies and reducing antibiotic consumption.

Antimicrobial resistance and persistence of Staphylococcus epidermidis clones in a Brazilian university hospital

Oxacillin is an alternative for the treatment of Staphylococcus spp. infections; however, resistance to this drug has become a major problem over recent decades. The main objective of this study was to epidemiologically characterize coagulase-negative staphylococci (CoNS) strains recovered from blood of patients hospitalized in a Brazilian teaching hospital. Oxacillin resistance was analyzed in 160 strains isolated from blood culture samples by phenotypic methods, detection of the mecA gene, and determination of intermediate sensitivity to vancomycin on brain heart infusion agar supplemented with 4 and 6 μg/mL vancomycin. In addition, characterization of the epidemiological profile by staphylococcal cassette chromosome mec (SCCmec) typing and clonal analysis by pulsed-field gel electrophoresis (PFGE) were performed. The mecA gene was detected in 72.5% of the isolates. Methicillin-resistant CoNS isolates exhibited the highest minimum inhibitory concentrations and multiresistance when compared to methicillin-susceptible CoNS strains. Typing classified 32.8% of the isolates as SCCmec I and 50% as SCCmec III. PFGE typing of the SCCmec III Staphylococcus epidermidis isolates identified 6 clones disseminated in different wards that persisted from 2002 to 2009. The high oxacillin resistance rates found in this study and clonal dissemination in different wards highlight the importance of good practices in nosocomial infection control and of the rational use of antibiotic therapy in order to prevent the dissemination of these clones.

Synthesis of fluorescent ristocetin aglycon derivatives with remarkable antibacterial and antiviral activities

Isoindole and benzoisoindole derivatives of ristocetin aglycon have been prepared by reaction with o-phthalaldehyde or naphthalene-2,3-dialdehyde and various thiols. The new compounds exhibited potent antibacterial and anti-influenza virus activity. The cluster forming and fluorescent properties of the aglycon derivatives were also studied.

Synthesis of isoindole and benzoisoindole derivatives of teicoplanin pseudoaglycon with remarkable antibacterial and antiviral activities

The primary amino function of teicoplanin pseudoaglycon has been transformed into arylthioisoindole or benzoisoindole and glycosylthioisoindole derivatives, in a reaction with o-phthalaldehyde or naphtalene-2,3-dicarbaldehyde and various thiols. All of the obtained semisynthetic antibiotics exhibited potent antibacterial activities against Gram-positive bacteria in the ng per ml concentration range. A few of them showed antiviral activity, in particular against influenza virus.

Misidentification of vancomycin-resistant Staphylococcus aureus as coagulase-negative Staphylococcus

Reduced vancomycin susceptibility in Staphylococcus aureus in many cases appears to be associated with changes in biological characteristics, including reduced coagulase activity, cell wall thickening, slow growth, smaller colonies, decreased pigment formation and less or no haemolysis. Whether these changes affect identification by routine methods has not been reported. In this study, 24 vancomycin-susceptibility-reduced coagulase-negative staphylococci (CoNS) strains (including 22 Staphylococcus haemolyticus strains and two Staphylococcus epidermidis strains) were retested by PCR-based detection of Staphylococcus aureus-specific genes (nuc, coa and 16S rRNA). The results showed that six isolates identified by conventional biochemical tests as S. haemolyticus contained nuc, coa and 16S rRNA genes. These six strains were serial-passaged daily on nutrient agar without vancomycin supplementation, and vancomycin-susceptible revertants were obtained after 15 continuous passages. Revertant isolates were coagulase-positive and were identified as S. aureus by automated testing methods. This suggests that biochemical changes in S. aureus strains with reduced vancomycin susceptibility should be highlighted and that the detection of these strains requires more attention and improved techniques.