Antibiotic resistance plasmids of Staphylococcus aureus and their clinical importance

The Plasmidome of Firmicutes: Impact on the Emergence and the Spread of Resistance to Antimicrobials

The phylum Firmicutes is one of the most abundant groups of prokaryotes in the microbiota of humans and animals and includes genera of outstanding relevance in biomedicine, health care, and industry. Antimicrobial drug resistance is now considered a global health security challenge of the 21st century, and this heterogeneous group of microorganisms represents a significant part of this public health issue.The presence of the same resistant genes in unrelated bacterial genera indicates a complex history of genetic interactions. Plasmids have largely contributed to the spread of resistance genes among Staphylococcus, Enterococcus, and Streptococcus species, also influencing the selection and ecological variation of specific populations. However, this information is fragmented and often omits species outside these genera. To date, the antimicrobial resistance problem has been analyzed under a "single centric" perspective ("gene tracking" or "vehicle centric" in "single host-single pathogen" systems) that has greatly delayed the understanding of gene and plasmid dynamics and their role in the evolution of bacterial communities.This work analyzes the dynamics of antimicrobial resistance genes using gene exchange networks; the role of plasmids in the emergence, dissemination, and maintenance of genes encoding resistance to antimicrobials (antibiotics, heavy metals, and biocides); and their influence on the genomic diversity of the main Gram-positive opportunistic pathogens under the light of evolutionary ecology. A revision of the approaches to categorize plasmids in this group of microorganisms is given using the 1,326 fully sequenced plasmids of Gram-positive bacteria available in the GenBank database at the time the article was written.

Mechanism of staphylococcal multiresistance plasmid replication origin assembly by the RepA protein

The staphylococcal multiresistance plasmids are key contributors to the alarming rise in bacterial multidrug resistance. A conserved replication initiator, RepA, encoded on these plasmids is essential for their propagation. RepA proteins consist of flexibly linked N-terminal (NTD) and C-terminal (CTD) domains. Despite their essential role in replication, the molecular basis for RepA function is unknown. Here we describe a complete structural and functional dissection of RepA proteins. Unexpectedly, both the RepA NTD and CTD show similarity to the corresponding domains of the bacterial primosome protein, DnaD. Although the RepA and DnaD NTD both contain winged helix-turn-helices, the DnaD NTD self-assembles into large scaffolds whereas the tetrameric RepA NTD binds DNA iterons using a newly described DNA binding mode. Strikingly, structural and atomic force microscopy data reveal that the NTD tetramer mediates DNA bridging, suggesting a molecular mechanism for origin handcuffing. Finally, data show that the RepA CTD interacts with the host DnaG primase, which binds the replicative helicase. Thus, these combined data reveal the molecular mechanism by which RepA mediates the specific replicon assembly of staphylococcal multiresistant plasmids.

Identification and control of a gentamicin resistant, meticillin susceptible Staphylococcus aureus outbreak on a neonatal unit

We describe the identification and control of an outbreak of gentamicin resistant, meticillin susceptible Staphylococcus aureus (GR-MSSA) on a 36-bed neonatal unit (NNU) in London. Control measures included admission and weekly screening for GR-MSSA, cohorting affected babies, environmental and staff screening, hydrogen peroxide vapour (HPV) for terminal disinfection of cohort rooms, and reinforcement of hand hygiene. Seventeen babies were affected by the outbreak strain over ten months; seven were infected and ten were asymptomatic carriers. The outbreak strain was gentamicin resistant and all isolates were indistinguishable by pulsed-field gel electrophoresis. The outbreak strains spread rapidly and were associated with a high rate of bacteraemia (35% of 17 affected patients had bacteraemia vs. 10% of 284 patients with MSSA prior to the outbreak, p=0.007). None of 113 staff members tested were colonised with GR-MSSA. GR-MSSA was recovered from 11.5% of 87 environmental surfaces in cohort rooms, 7.1% of 28 communal surfaces and 4.1% of 74 surfaces after conventional terminal disinfection. None of 64 surfaces sampled after HPV decontamination yielded GR-MSSA. Recovery of GR-MSSA from two high level sites suggested that the organism could have been transmitted via air. Occasional breakdown in hand hygiene compliance and contaminated environmental surfaces probably contributed to transmission.

Molecular epidemiology of clinically significant antibiotic resistance genes

Antimicrobials were first introduced into medical practice a little over 60 years ago and since that time resistant strains of bacteria have arisen in response to the selective pressure of their use. This review uses the paradigm of the evolution and spread of beta-lactamases and in particular beta-lactamases active against antimicrobials used to treat Gram-negative infections. The emergence and evolution particularly of CTX-M extended-spectrum beta-lactamases (ESBLs) is described together with the molecular mechanisms responsible for both primary mutation and horizontal gene transfer. Reference is also made to other significant antibiotic resistance genes, resistance mechanisms in Gram-negative bacteria, such as carbepenamases, and plasmid-mediated fluoroquinolone resistance. The pathogen Staphylococcus aureus is reviewed in detail as an example of a highly successful Gram-positive bacterial pathogen that has acquired and developed resistance to a wide range of antimicrobials. The role of selective pressures in the environment as well as the medical use of antimicrobials together with the interplay of various genetic mechanisms for horizontal gene transfer are considered in the concluding part of this review.

Transfer of erythromycin resistance from poultry to human clinical strains of Staphylococcus aureus

The transfer of ermA and ermC genes, the two most common resistance determinants of erythromycin resistance, was studied with Luria-Bertani broth in the absence of additional Ca(2+) or Mg(2+) ions. Fifteen human and five poultry isolates of Staphylococcus aureus, which were resistant to erythromycin but carried different genetic markers for erythromycin resistance, were used for conjugation. Since both the donors (Amp(s)-Tet(r)) and recipients (Amp(r)-Tet(s)) were resistant to erythromycin, the transconjugants were initially picked up as ampicillin- and tetracycline-resistant colonies. The resistance transfer mechanisms of the chromosomally located erythromycin rRNA methylase gene ermA and the plasmid-borne ermC gene were monitored by a multiplex PCR and gene-specific internal probing assay. Four groups of transconjugants, based upon the transfer of the ermA and/or ermC gene, were distinguished from each other by the use of this method. Selective antibiotic screening revealed only one type of transconjugant that was resistant to ampicillin and tetracycline. A high frequency of transfer (4.5 x 10(-3)) was observed in all of the 23 transconjugants obtained, and the direction of tetracycline and erythromycin resistance marker transfer was determined to be from poultry to clinical isolates. The transfers of the ermA and ermC genes were via transposition and transformation, respectively.

Effect of biocides commonly used in the hospital environment on the transfer of antibiotic-resistance genes in Staphylococcus aureus

The effect of sub-minimal inhibitory concentrations of biocides, commonly used in the hospital environment, on the conjugation and transduction of plasmid pWG613 was investigated in three strains of Staphylococcus aureus. The highest transfer frequency was obtained in the conjugation experiments. A low concentration of povidone-iodine was found to significantly reduce transfer frequency by 10-fold in S. aureus SAU3/13136 mating, while other biocides had no effect at low concentrations. Cetrimide (0.0001%) was found to increase significantly transduction efficiency in S. aureus RF2 when the biocide was included in the recovery media. A low concentration of chlorhexidine or povidone-iodine reduced transduction efficiency in the same recipient. This study showed that reduction in transduction efficiency was caused by the direct effect of biocides on the recipient strains rather than on the phage 80 alpha particles.

Detection of an integrated tetracycline-resistance plasmid in Staphylococcus aureus from a Nigerian hospital

The genetics of tetracycline-resistance determinants was studied in eight methicillin-resistant and two methicillin-sensitive Staphylococcus aureus isolated from a Nigerian hospital. Curing and transfer experiments demonstrated that one methicillin-sensitive S. aureus isolate WBG4762, had a 4.4 kb extrachromosomal plasmid- as well as a chromosomally-mediated tetracycline resistance. All others had chromosomal tetracycline resistance and were resistant to either tetracycline and minocycline or tetracycline only. The two methicillin-susceptible isolates were resistant to both tetracycline and minocycline. Chromosomal DNA from all the resistant isolates hybridized with a digoxigenin-11-dUTP labeled 4.4 kb tetracycline-resistance plasmid probe indicating that they contained tetracycline-resistance plasmids similar to the probe integrated into their chromosomes. The results demonstrated the presence of integrated tetracycline-resistance plasmid in both methicillin-resistant and methicillin-susceptible S. aureus resistant to tetracycline and minocycline as well as those resistant only to tetracycline. This is the first demonstration of an integrated tetracycline-resistance plasmid in methicillin-sensitive S. aureus and suggests that the integrated tetracycline-resistance plasmid may be widespread in S. aureus.

Epidemiology of drug resistance: implications for a post-antimicrobial era

In the last several years, the frequency and spectrum of antimicrobial-resistant infections have increased in both the hospital and the community. Certain infections that are essentially untreatable have begun to occur as epidemics both in the developing world and in institutional settings in the United States. The increasing frequency of drug resistance has been attributed to combinations of microbial characteristics, selective pressures of antimicrobial use, and societal and technologic changes that enhance the transmission of drug-resistant organisms. Antimicrobial resistance is resulting in increased morbidity, mortality, and health-care costs. Prevention and control of these infections will require new antimicrobial agents, prudent use of existing agents, new vaccines, and enhanced public health efforts to reduce transmission.

Common antibiotic resistance plasmids in Staphylococcus aureus and Staphylococcus epidermidis from human and canine infections

The plasmids of a multiresistant "canine" Staphylococcus epidermidis-culture were investigated. Two small plasmids, the 4.55 kB chloramphenicol resistance (CmR-) plasmid pSC4 and the 4.45 kB tetracycline resistance (TetR-) plasmid pST 3 could be isolated. Detailed restriction maps of pSC 4 and pST 3 were constructed by double restriction endonuclease digests. The restriction maps revealed extensive structural homologies between pSC 4 from "canine" S. epidermidis and the CmR-plasmid pC 221 from "human" S. aureus as well as between pST 3 from "canine" S. epidermidis and the TetR-plasmid pT 181 from "human" S. aureus. These data suggested that an exchange of small plasmids between S. epidermidis and S. aureus might be possible.

The changing pattern of severe neonatal staphylococcal infection: a 10-year study

Forty-two cases of severe staphylococcal infection occurring over a 10-year period in the neonatal unit at Queen Mary Hospital are described. There was a 4.5-fold increase in incidence in the latter half of the study period, when methicillin-resistant Staphylococcus aureus (MRSA) emerged. The isolated MRSA were also resistant to gentamicin, but sensitive to vancomycin, fusidic acid, co-trimoxazole and amikacin. Comparison between MRSA and methicillin-sensitive cases showed that the former was associated with a longer hospital stay after diagnosis. Overall mortality was 9.5%. Two cases with meningitis died. MRSA is at least as virulent as its methicillin-sensitive counterparts. The treatment implications of severe neonatal staphylococcal infection are discussed.

Transduction of Escherichia coli by bacteriophage P1 in soil

Transduction of Escherichia coli W3110(R702) and J53(RP4) (10(4) to 10(5) CFU/g of soil) by lysates of temperature-sensitive specialized transducing derivatives of bacteriophage P1 (10(4) to 10(5) PFU/g of soil) (P1 Cm cts, containing the resistance gene for chloramphenicol, or P1 Cm cts::Tn501, containing the resistance genes for chloramphenicol and mercury [Hg]) occurred in soil amended with montmorillonite or kaolinite and adjusted to a -33-kPa water tension. In nonsterile soil, survival of introduced E. coli and the numbers of E. coli transductants resistant to chloramphenicol or Hg were independent of the clay amendment. The numbers of added E. coli increased more when bacteria were added in Luria broth amended with Ca and Mg (LCB) than when they were added in saline, and E. coli transductants were approximately 1 order of magnitude higher in LCB; however, the same proportion of E. coli was transduced with both types of inoculum. In sterile soil, total and transduced E. coli and P1 increased by 3 to 4 logs, which was followed by a plateau when they were inoculated in LCB and a gradual decrease when they were inoculated in saline. Transduction appeared to occur primarily in the first few days after addition of P1 to soil. The transfer of Hg or chloramphenicol resistance from lysogenic to nonlysogenic E. coli by phage P1 occurred in both sterile and nonsterile soils. On the basis of heat-induced lysis and phenotype, as well as hybridization with a DNA probe in some studies, the transductants appeared to be the E. coli that was added. Transduction of indigenous soil bacteria was not unequivocally demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of plasmids and genetic change on the numerical classification of staphylococci

Newly isolated bacterial strains often contain extrachromosomal DNA as plasmid DNA. These accessory components of the DNA gene pool confer additional phenotypic properties on their host but, despite this, little attention has been paid to the impact of plasmid-mediated characters on bacterial classification. In the present study, the effect of antibiotic resistance plasmids on the classification of representative staphylococci was determined using numerical phenetic techniques. Over sixty percent of the eighty-one test strains contained one or more plasmids which varied in molecular weight from 1.4 to 36 Mdal. Antibiotic resistance phenotypes were eliminated from strains of S. aureus, S. chromogenes, S. cohnii, S. hyicus and S. xylosus, and from a laboratory isolate, to give sixteen derivative strains. Fourteen had lost one or more plasmids and two had deleted plasmids. In addition three further derivative strains were isolated which showed no plasmid loss but exhibited gross phenotypic changes. The test and derivative strains were the subject of numerical phenetic analyses based on seventy-eight unit characters. Data were examined using the simple matching, Jaccard and pattern coefficients and clustering achieved using the unweighted pair group method with arithmetic averages algorithm. Cluster composition was not markedly affected by the statistics used or by test error, estimated at 1.02%. Numerically circumscribed clusters and subclusters were equated with the established species S. aureus, S. chromogenes, S. cohnii, S. hyicus, S. lentus, S. intermedius, S. sciuri and S. xylosus. The sixteen derivative strains with either lost or delected plasmids were recovered in the same cluster or subcluster as their corresponding parent indicating that the removal of plasmid-expressed characters had little effect on the structure of the numerical classification. In contrast, two of the three strains of S. xylosus with genomically-derived phenotypic variation formed a cluster that separated from their parent strain at the 70% similarity level in the SSM, UPGMA analysis.

Antimicrobial resistance of Staphylococcus aureus: genetic basis

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Epidemiologic study of Staphylococcus strains isolated from clinical material in 24 Italian hospitals

A nationwide epidemiologic study of clinical Staphylococcus isolates was performed in Italy by 24 operative units distributed throughout the country. A total of 7,017 Staphylococcus strains were examined according to a standard protocol. Three species of acknowledged importance in human infections (namely S. aureus, S. epidermidis, and S. saprophyticus) were identified singly, whereas the other staphylococci were considered as a whole and designated Staphylococcus spp. S. aureus totalled 55% of total isolates and was reported by most operative units as the predominant species among isolates both from various inpatient departments and from outpatients. S. saprophyticus was twofold more frequent among isolates from out- than from inpatients. Susceptibility to methicillin varied considerably from hospital to hospital, but a general tendency toward an increasing spread of resistance was noted. The overall incidence of methicillin resistance (29%) resulted from a wide range of values generally higher in isolates from inpatients (35%) than from outpatients (21%). Particularly high percentages of resistance (45%) were recorded in isolates from intensive care departments. Susceptibility testing to four additional beta-lactams (cefoxitin, cefuroxime, cefotaxime, and piperacillin) and to four aminoglycosides (gentamicin, tobramycin, amikacin, and netilmicin) indicated that antibiotic resistance was widespread and in all species more frequent among methicillin-resistant than among methicillin-sensitive staphylococci. Netilmicin proved more active than the other antibiotics tested; its greater activity was most evident against methicillin-resistant strains. Coagulase-negative staphylococci were more resistant than S. aureus to methicillin and most of the other antibiotics, suggesting their increasing involvement in human infections.

The role of beta-lactamase in staphylococcal resistance to penicillinase-resistant penicillins and cephalosporins

We showed that most Staphylococcus aureus strains that have borderline or intermediate susceptibility to the penicillinase-resistant penicillins (PRPs) react this way because of the activity of their beta-lactamase on these antimicrobial agents. These strains produced large amounts of staphylococcal beta-lactamase that rapidly hydrolyzed penicillin and partially hydrolyzed the PRPs. Susceptibility to hydrolysis was penicillin greater than oxacillin greater than cephalothin greater than methicillin. The borderline results and the hydrolysis could be prevented by the beta-lactamase inhibitors clavulanic acid and sulbactam. For intrinsically methicillin-resistant (heteroresistant) S. aureus, the inhibitors reduced the penicillin MICs, but the strains remained resistant to all the beta-lactam antimicrobial agents, including penicillin. We conclude that the borderline in vitro susceptibility or resistance to PRPs in most of these S. aureus strains is mediated by beta-lactamase and they are not heteroresistant or intrinsically resistant. We do not know whether this in vitro resistance is expressed clinically.

Staphylococcus aureus: biology, mechanisms of virulence, epidemiology

The prominence of Staphylococcus aureus as a cause of serious human infection has prompted extensive studies of the microbiology, pathogenesis, and epidemiology of staphylococci and staphylococcal infections. Staphylococci are of the family Micrococcaceae, although there are diverse genetic and phenotypic differences between them and other members of this family. Of the more than 20 species of staphylococci, only three are clinically significant: S. aureus, S. epidermidis, and S. saprophyticus. These species can be distinguished by coagulase production and novobiocin resistance. Staphylococci produce a variety of structural, enzymatic, and toxic products, which are associated with adherence, invasion, toxicity, and avoidance of host defense mechanisms. In addition, a variety of host characteristics increase susceptibility to staphylococcal infection. Staphylococci are an important cause of infection in hospitals and the community. Following the introduction of antimicrobials, staphylococci rapidly developed resistance. A penicillin-resistant specific phage type, designated 80/81, caused severe outbreaks of nosocomial disease in the 1950s and 1960s. Staphylococci recently acquired resistance to methicillin and other antimicrobials, and persist as important nosocomial pathogens. Although S. aureus is one of the earliest recognized and most studied human pathogens, it is a perplexing, ever-changing, recurring public health problem.

Comparison of the activities of coumermycin, ciprofloxacin, teicoplanin, and other non-beta-lactam antibiotics against clinical isolates of methicillin-resistant Staphylococcus aureus from various geographical locations

One hundred clinical isolates of methicillin-resistant (Metr) Staphylococcus aureus from five different geographical origins were tested for their susceptibility to 12 non-beta-lactam antibiotics by the broth microdilution technique recommended by the National Committee for Clinical Laboratory Standards. Coumermycin and rifampin showed the highest activity with of MIC90s of 0.032 micrograms/ml for each compound. No resistance was found to coumermycin, whereas a single Metr S. aureus strain was found to be resistant to rifampin. Ciprofloxacin, vancomycin, and teicoplanin were the next most active compounds with MIC90s of 0.25, 0.5, and 0.5 micrograms/ml, respectively. Norfloxacin was less active, with an MIC90 of 1.0 micrograms/ml. Amikacin was the most active aminoglycoside tested, whereas high levels of resistance were found to tobramycin and gentamicin. Doxycycline and chloramphenicol showed variable results. Geographical variations in results were seen with doxycycline, chloramphenicol, and aminoglycosides. Kill-curve studies showed that coumermycin, ciprofloxacin, teicoplanin, vancomycin, and rifampin were highly bactericidal; more than 90% of the inoculum was killed within 8 h.

Genetics and epidemiology of methicillin-resistant Staphylococcus aureus isolated in a Western Australian hospital

Strains of methicillin-resistant Staphylococcus aureus (MRSA) isolated in the Royal Perth Hospital (RPH) in Western Australia have been analysed genetically and three main types were characterized: (i) strains similar to those isolated in Europe before 1973. These strains caused small outbreaks in the RPH during the period 1966-1974, but have not been isolated in recent years, except from one patient with reactivation of osteomyelitis after 16 years; (ii) strains of the type prevalent in eastern and northern Australia, one of which caused a difficult-to-control outbreak in the RPH in 1982. Strains of this type have previously been isolated only from patients who had been in hospitals in eastern and northern Australia, but recently were isolated also from other patients--which indicates that this type of MRSA is now present in the Western Australian community; and (iii) strains, which are genetically different from either of the above two types, were isolated from patients who had been in hospitals in Southeast Asia, but have not yet caused an outbreak in the RPH.

Interspecific co-transfer of antibiotic resistance plasmids in staphylococci in vivo

The co-transfer of plasmid-borne genes governing resistance to gentamicin, tetracycline, erythromycin and chloramphenicol has been demonstrated on human and mouse skin. Two different gentamicin resistance plasmids have been studied in detail; both appear to have the ability to mobilize in vivo otherwise non-transferable resistance plasmids from coagulase-negative to coagulase-positive staphylococci. This emphasis the role of the skin in maintaining a pool of resistance genes available to pathogenic staphylococci.

Occurrence of a nonplasmid-located determinant for gentamicin resistance in strains of Staphylococcus aureus

The occurrence of resistance to gentamicin in strains of Staphylococcus aureus with different phage patterns in two hospitals is described. The data suggest transfer of gentamicin resistance between different strains. In the strains investigated the determinant for resistance to gentamicin (parallel resistance to kanamycin and tobramycin) is located on the chromosome. The transfer of this resistance determinant in a mixed culture of donor and recipient cells in vitro is mediated by transduction because it is dependent upon lysogenicity of the donor for a serogroup-B phage and because it can be inhibited by gamma-globulin. The transfer is always associated with lysogenization of the recipient cells by this phage.

Stability of a plasmid F Trim in populations of a recombination-deficient strain of Escherichia coli in continuous culture

Populations of a recA derivative of Escherichia coli AB1157 containing the plasmid F Trim were grown in carbon-limited continuous culture at dilution rates of 0.1 h-1 to 0.4 h-1. The plasmid was lost after a lag, except in fermenter-experienced populations when it was retained. These results can be explained in terms of non-specific competition.

Transduction analysis of transposon Tn551 insertions in the trp-thy region of the Staphylococcus aureus chromosome

Previous studies have shown that Tn551, a 5.2-kilobase-pair transposon that determines constitutive resistance to erythromycin, can occupy a variety of chromosomal sites between thy-101 and trp-103 in Staphylococcus aureus 8325. Although many of these insertions were "silent," many others, including lys, thr, met, tyr, and trp, resulted in auxotrophic mutations. The close proximity and erythromycin-resistant phenotypes of the insertions in this region have made their mapping by transformation difficult. Analysis of these sites and similar chemically induced mutations by generalized transduction with phage 80 alpha have defined the order and relationship of these insertion sites and provided a detailed map of this region of the chromosome, including the orientation of the trp operon. The results of this study and a limited phenotypic characterization of the mutants have shown that the divergent pathway from aspartate to lysine, threonine, and methionine, several reactions in tyrosine biosynthesis, and the entire tryptophan operon are determined by this region of the chromosome. The linkage results obtained by transduction have been compared with similar data obtained previously by transformation; this comparison suggests the existence, between thy and lys, of a preferred headful cutting site for transducing phage DNA morphogenesis from the host chromosome.

Gentamicin-resistant staphylococci: genetics of an outbreak in a dermatology department

The genetics of gentamicin resistance in Staphylococcus aureus strains isolated during an outbreak of infection in dermatology department have been studied. The predominant strain of S. aureus did not appear to possess a plasmid mediating gentamicin resistance though one isolate yielded a plasmid coding for penicillin and gentamicin. Three distinct plasmids were isolated from other phage types of S. aureus which appeared towards the end of the epidemic. There appeared to be a stepwise loss of gentamicin resistance in the predominant strain.

Self-transmissible plasmids in staphylococci that encode resistance to aminoglycosides

High-level resistance to gentamicin, tobramycin, and kanamycin was transferred between staphylococci of the same and different species by filter mating. Resistance and transfer proficiency were mediated by plasmids ranging from 38 to 54 kilobases in size. All of the plasmids encoded intermediate resistance to amikacin and netilmicin and resistance to ethidium bromide; some encoded beta-lactamase production. None of these plasmids carried resistance to other antibiotics or heavy metals. Transfer of antibiotic resistance occurred by a mechanism similar to that of conjugation, because it was DNase resistant, required cell-to-cell contact, and did not appear to involve phage. The participation of phage in transfer appeared to be unlikely because mijtomicin C-induced lysates of donor isolates did not mediate transfer, filter mating transfer proceeded at high frequency between nonlysogenic donor and recipient cells, and transfer of the aminoglycoside resistance plasmid mobilized the transfer of as many as five additional plasmids. All 17 gentamicin-resistant Staphylococcus aureus and all 6 Staphylococcus epidermidis isolates obtained from an outbreak of staphylococcal infections in a newborn nursery contained conjugative plasmids, as did all 6 gentamicin-resistant S. aureus isolates from bacteremic adults. However, only 3 of 10 gentamicin-resistant S. epidermidis isolates from colonized cardiac surgery patients and 1 of 2 S. epidermidis isolates from patients with prosthetic valve endocarditis transferred gentamicin resistance by filter mating. The recent increase in nosocomial infections caused by gentamicin-resistant staphylococci may be partially explained by the evolution of self-transmissible plasmids in these isolates.

Analysis of plasmids in nosocomial strains of multiple-antibiotic-resistant Staphylococcus aureus

Nosocomial infections caused by Staphylococcus aureus strains resistant to methicillin and multiple antibiotics have reached epidemic proportions in Melbourne, Australia, over the past 5 years. Plasmid analysis of representative clinical isolates demonstrated the presence of three classes of plasmid DNA in most strains. Resistance to gentamicin, kanamycin, and tobramycin was usually mediated by an 18-megadalton plasmid but could also be encoded by a related 22-megadalton plasmid. Two distinguishable plasmids of 3 megadaltons each endowed resistance to chloramphenicol, and the third class consisted of small plasmids, each approximately 1 megadalton in size, with no attributable function. An extensive array of resistance determinants, including some which have usually been associated with a plasmid locus, were found to exist on the chromosome. Evidence that resistance to gentamicin, kanamycin, and tobramycin is chromosomally encoded in some clinical isolates suggests that this determinant may have undergone genetic translocation onto the staphylococcal chromosome.

Transfer of resistance plasmids from Staphylococcus epidermidis to Staphylococcus aureus: evidence for conjugative exchange of resistance

The ability of Staphylococcus epidermidis to transfer antimicrobial resistance to Staphylococcus aureus was tested by mixed culture on filter membranes. Two of six clinical isolates examined were able to transfer resistance to S. aureus strains 879R4RF, RN450RF, and UM1385RF. Subsequent S.aureus transconjugants resulting from matings with S. epidermidis donors were able to serve as donors to other S. aureus strains at similar frequencies. Cell-free and mitomycin C-induced filtrates of donors and transconjugants showed no plaque-forming ability. Addition of DNase I, citrate, EDTA, calcium chloride, and human sera to mating mixes and agar showed no effect on transfer. Nonviable donor cells were unable to transfer resistance and transfer did not occur at 4 degrees C. Cell-to-cell contact was required since transfer did not occur in broth or when filters of donor and recipient, respectively, were placed back-to-back so cells were not in direct contact. Analysis of DNA from S. epidermidis isolate UM899, its subsequent S. aureus transconjugants, and cured derivatives demonstrated that all resistance markers which transferred resided on plasmids. Mating experiments suggested a central role for the gentamicin plasmid pAM899-1 in the transfer process. It is concluded that our results are consistent with a conjugative transfer of resistance from S. epidermidis to S. aureus analogous to plasmid transfer demonstrated in streptococcal species for plasmids such as pAM beta 1. This represents a novel mechanism for gene exchange among staphylococci.

Conjugational transfer of gentamicin resistance plasmids intra- and interspecifically in Staphylococcus aureus and Staphylococcus epidermidis

We have previously reported the transfer of gentamicin resistance (Gmr) plasmids in a mixed culture inter- and intraspecifically between strains of Staphylococcus aureus and Staphylococcus epidermidis isolated at Michael Reese Hospital (Jaffe et al., Antimicrob. Agents Chemother. 21:773-779, 1982). We have now shown that representatives of these plasmids were transferred between apparently nonlysogenic strains of S. aureus either in mixed culture in broth or by filter-mating on agar medium. The mechanism of transfer appeared to be conjugation. A transferable Gmr plasmid (pSH8) mobilized or cotransferred a tetracycline R-plasmid and a chloramphenicol R-plasmid that were not independently transferable. The transfer of Gmr plasmids was accompanied by a high incidence of deletion mutations with varied loss of plasmid resistance determinants and, with some mutants, loss of the ability to effect self-transfer. Restriction endonuclease digestion of pSH8 and its deletion mutants made it possible to assign the property of self-transfer to a specific segment of the pSH8 genome and provided the basis for a physical and genetic map of that plasmid. Similar Gmr plasmids from S. aureus strains isolated in locations remote from Michael Reese Hospital had resistance determinants and transfer properties comparable to those of pSH8. Our observations provide evidence for the conjugal transfer of some staphylococcal plasmids, apparently independent of the presence of phage. This mechanism may be of significance in the intra- and interspecific dissemination of resistance to aminoglycosides and other antibiotics in Staphylococcus spp.

The importance of incubation temperature for detecting beta-lactam-resistant Staphylococcus aureus strains

Sixty-six isolates of methicillin-resistant Staphylococcus aureus strains originating from Austria, Egypt, the Federal Republic of Germany and Switzerland were tested for their sensitivity to 12 beta-lactam antibiotics at both 30 degrees and 37 degrees C using the agar disk diffusion test. The MICs for six of the beta-lactam antibiotics were determined by the microdilution technique. Resistance to methicillin was always accompanied by resistance to several beta-lactam antibiotics. Resistance to all semi-synthetic penicillins and cephalosporins, including cefotaxime, was higher at 30 degrees C than at 37 degrees C. Cephalothin and cefamandole proved to be the most effective cephalosporin antibiotics against methicillin-resistant S. aureus strains. Newer cephalosporins, i.e. cefotaxime, cefoxitin and cefuroxime, exhibited only a low rate of activity against these strains. The occurrence of phage-type "85" in S. aureus strains from Austria, Egypt and Germany indicates that certain lysotypes are widespread.

In vitro activity of teichomycin A 2 in comparison with penicillin and vancomycin against gram-positive cocci

Teichomycin A2, a glycopeptide antibiotic from Actinoplanes teichomyceticus, was tested for its in vitro activity against 190 gram-positive cocci under variable test conditions. Minimum inhibitory concentrations were fairly insensitive to both changes of inoculum size and pH, but were higher on agar than in broth. Teichomycin was about as active as vancomycin against Staphylococcus aureus (both methicillin resistant and sensitive strains), slightly inferior to vancomycin against Staphylococcus epidermidis, and distinctly more active against Streptococcus faecalis.

Methicillin-resistant-Staphylococcus aureus colonization and infection in a rehabilitation facility

Methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in a rehabilitation hospital (Rancho Los Amigos Hospital [RLAH]) were studied from October 1977 to May 1980. Eighty-four episodes of MRSA colonization or infection were observed in 81 patients (attack rate, 0.44 per 100 admissions). The MRSA was considered to have been acquired at RLAH in 65% of the episodes and from transferring hospitals in 34%. The infection rate was 35% among MRSA-colonized patients, and only one death was attributed to MRSA infection. Colonization for more than 100 days occurred most frequently in wounds and anterior nares. All but two of the MRSA isolates were resistant to aminoglycosides, and 80% of those typed belonged to phage type 83A. The patients were allowed to continue participation in rehabilitation programs. Spread of the MRSA occurred in wards where intensive medical and nursing care was being practiced. There was no evidence of MRSA spread in the services with less intense medical and nursing care and where physical and occupational therapy was continued. Patients in a rehabilitation hospital with MRSA colonization may receive intensive physical and occupational therapy as long as special precautions are observed to prevent MRSA spread.

Common R-plasmids in Staphylococcus aureus and Staphylococcus epidermidis during a nosocomial Staphylococcus aureus outbreak

During a 7-month period in 1978 to 1979, 31 patients and personnel at a Kentucky hospital were colonized or infected with a Staphylococcus aureus strain resistant to clindamycin, erythromycin, gentamicin, methicillin, penicillin, and tetracycline. S. epidermidis with similar antibiotic resistance patterns had been isolated in this hospital in the year before the S. aureus outbreak. A 32-megadalton R-plasmid, pUW3626, mediating resistance to penicillin and gentamicin, was present in these isolates and in coisolated S. epidermidis from the same outbreak. By colony hybridization, pUW3626 was homologous to gentamicin R-plasmids from staphylococci isolated in other geographic areas. Our studies suggest that the emergency of antibiotic resistance in S. Aureus may result from genetic transfer from S. epidermidis as well as from the interhospital spread of resistant staphylococci.

Penicillin and tetracycline resistance plasmids in Staphylococcus epidermidis

The genetic nature of penicillin (Pc) and tetracycline (Tc) resistance plasmids in Staphylococcus epidermidis were studied and compared with those in S. aureus. Of 10 S. epidermidis strains transduced for penicillin resistance, we could isolate Pc plasmids from only 3. One of these plasmids also encoded for cadmium resistance and another encoded for resistance to ethidium bromide, traits also associated with S. aureus Pc plasmids. Endonuclease fingerprinting of the Pc plasmids from the two species revealed extensive heterogeneity. Two S. epidermidis strains were also transduced for tetracycline resistance. Both harbored plasmids indistinguishable from S. aureus Tc plasmids as judged by endonuclease fingerprinting. These data suggest that genetic exchange between S. aureus and S. epidermidis occurs in vivo.

Factors influencing the establishment and spread of R-plasmids in an experimental model of urinary tract infection

An experimental model simulating infection of the urinary tract was used to investigate factors influencing the transfer of plasmid-mediated drug resistance in the human bladder in the absence of antibiotic therapy. When a small number of cells carrying plasmid-mediated drug resistance was added to an established population of sensitive cells, it was found that varying the physical conditions of the bladder model had no significant effect on the spread of the plasmid and, under all conditions used, exponential spread of the plasmid through the originally sensitive population occurred. When the initial donor cells were killed shortly after addition to the model, exponential transfer of resistance amongst the established sensitive population still occurred. Thus, even in the absence of antibiotic therapy, only a small number of initial transfer events was required for a fully resistant population to be developed. This was true of both actively multiplying and early stationary phase cultures. An initially greater proportion of resistant cells, or the use of an antimicrobial agent to which some of the cells are resistant, would ensure that this process occurred more rapidly.

Emergence of gentamicin- and methicillin-resistant Staphylococcus aureus strains in New York City hospitals

Gentamicin- and methicillin-resistant strains of Staphylococcus aureus have been isolated from Spring 1979 to the present from many hospitals in New York City. A large proportion of the strains were resistant to the majority of antistaphylococcal antibiotics. The ratio of multiply resistant strains was highest among tetracycline-resistant strains. There were significant differences in phage susceptibility patterns and the resistance spectrum of strains isolated at different hospitals, whereas strains isolated at the same hospital often showed a marked degree of similarity. This suggests multiple origins of gentamicin- and methicillin-resistant strains isolated in New York City.

Epidemic neonatal gentamicin-methicillin--resistant Staphylococcus aureus infection associated with nonspecific topical use of gentamicin

One hundred sixteen infants in an intensive care nursery acquired Staphylococcus aureus resistant to gentamicin and methicillin; 54 patients acquired S. aureus sensitive to gentamicin and methicillin. Topical application of gentamicin ointment was significantly associated with acquisition of GMRS. Of 78 infants who acquired GMRS, 38 had received GmO before GMRS was first cultured, whereas only one of 49 infants with GMSS had previously received GmO (P = 8.6 X 10(-8)). Infants with GMRS were also more likely than patients with GMSS to have had a lower mean birth weight, Apgar score, and gestational age; systemic antibiotic therapy and incubator care were significantly prolonged for patients with GMRS, but these factors did not explain susceptibility to GMRS infection. Multivariate logistic regression analysis showed that use of GmO was the single most important risk factor.

Classification and characteristics of coagulase-negative, methicillin-resistant staphylococci

Sixty-five clinical isolates of coagulase-negative, methicillin-resistant staphylococci have been classified as Staphylococcus epidermidis (63.0%), "phosphatase-negative S. epidermidis" (12.3%), coagulase-negative Staphylococcus aureus (6.2%), Staphylococcus hemolyticus (6.2%), Staphylococcus hominis (3.1%), and Staphylococcus warneri (1.5%). Five of the organisms (7.7%) could not be classified with certainty as currently recognized species. Novobiocin resistance was encountered in eight of the strains, but these were not classified as the accepted novobiocin-resistant staphylococcal species. Some differences in antibiotic resistance patterns to those typical of methicillin-resistant S. aureus were noted in that, although 29 strains were resistant to methicillin, penicillin, sulfamethizole, streptomycin, and tetracycline, the remainder of the strains were sensitive to streptomycin or tetracycline or both. In a majority of the strains (42 of 65), methicillin susceptibility testing by the disk method at 30 or at 37 degrees C in the presence of NaCl did not appear to enhance resistance expression. Most of the strains produced beta-lactamase (EC 3.5.2.6), but none of the 21 strains tested produced enterotoxin B.

Transferability of macrolide, lincomycin, and streptogramin resistances between group A, B, and D streptococci, Streptococcus pneumoniae, and Staphylococcus aureus

The transferability of plasmid pRI405 between various streptococci of groups A, B, and D, Streptococcus pneumoniae, and Staphylococcus aureus is described. pRI405 originated from Streptococcus faecalis and encodes for resistance to macrolides, lincomycin, and streptogramin B (MLS resistance). The host range of the well-documented streptococcal plasmid pAM beta 1 was found to be similar to that of pRI405. Cleavage with restriction enzymes suggests that pRI405 belongs to a related family of MLS resistance plasmids.

Erythromycin and clindamycin resistance in Corynebacterium diphtheriae from skin lesions

Erythromycin- and clindamycin-resistant Corynebacterium diphtheriae isolates were recovered from skin lesions. Resistance to erythromycin and clindamycin was induced by a subinhibitory concentration (0.03 microgram/ml) of erythromycin. Clindamycin (0.07 microgram/ml) was a more effective inducer of its own resistance than of erythromycin resistance. Erythromycin-inducible cross-resistance to vernamycin B alpha was demonstrated in disk diffusion tests.

Genetics of staphylococcal enterotoxin B in methicillin-resistant isolates of Staphylococcus aureus

Biophysical and genetic analysis of staphylococcal enterotoxin B (SEB) synthesis in 16 methicillin-resistant (Mecr) Staphylococcus aureus isolates demonstrated that the toxin gene (entB) can occupy either a plasmid or chromosomal locus. Biophysical analysis of the plasmid deoxyribonucleic acid content of these strains by agarose gel electrophoresis revealed the presence of a 1.15-megadalton plasmid in six isolates that appears to contain the entB gene. Genetic manipulation of SEB synthesis by transduction and elimination procedures demonstrated that this plasmid is critical for enterotoxigenesis. Nevertheless, the majority of the Mecr SEB+ isolates (62.5%) analyzed in this investigation were found to lack the 1.15-megadalton plasmid. In at least two of these strains (COL and 57-dk), transduction and elimination procedures showed that entB was chromosomal. Genetic studies involving strains harboring either a plasmid or chromosomal entB gene demonstrated that toxin synthesis was coeliminated with mec. However, analysis of the entB and mec loci by transformation or transduction showed that the genes are not closely linked. On the other hand, transduction of entB, regardless of the donor, was observed when both mec and the Tcr plasmid were jointly cotransduced. This finding suggests that, during transduction, a transient association between entB, mec, and the Tcr plasmid may exist.

Changing phage typing patterns of epidemic gentamicin-resistant Staphylococcus aureus. Evidence for transmission of gentamicin resistance

In a 10-week period, infection with gentamicin resistant Staphylococcus aureus appeared in 24 adults and infants in one hospital. Medical staff were affected first, and subsequently 16 infants in the neonatal intensive-care unit. The gentamicin-resistant staphyloccal isolates showed three distinct phage susceptibility patterns in two distinct phage groups during the early, middle, and late phases of the outbreak. Although not confirmed with in-vitro or in-vivo laboratory data, this outbreak suggests that gentamicin resistance may be transferred between different strains of Staph. aureus in vivo.

Investigations of the occurrence of gentamicin-resistant Staphylococcus aureus

During the 19-month period from June 1976 to December 1977, 90 patients became colonized or infected with gentamicin-resistant Staphylococcus aureus (GRS). Of 63 adults, 56 had hospital-acquired GRS, whereas only 9 of 27 children had hospital-acquired GRS (P < 0.001). The other 7 adults and 18 children had GRS present on admission. More than half of those who acquired GRS in the hospital had received prior aminoglycoside therapy. Attack rates were higher in adults than in children and significantly higher on the plastic surgery service than on any other adult service. Phage typing revealed a single-strain outbreak on the plastic surgery ward involving 11 patients, whereas other isolates were of several phage types. Community-acquired GRS occurred more frequently in rural native communities (P < 0.02) and may be related to the use of topical gentamicin. Of 17 native children, 10 were from the same area but there was no common phage type. Agar dilution minimal inhibitory concentration (MIC) testing confirmed that all isolates were gentamicin resistant (MIC >/= 8 mug/ml) and almost all were tobramycin resistant (MIC >/= 8 mug/ml). Although the MIC distribution between gentamicin disk-susceptible and -resistant strains was significantly different, MIC's for 90% of gentamicin disk-resistant strains were </=8 mug of amikacin per ml, and MIC's for 92% of the strains were </=4 mug of netilmicin per ml.

The effect of a plasmid on growth and survival of E. coli

We studied the growth characteristics of a pair of Escherichia coli strains, isogenic apart from the possession of a nonconjugative plasmid. There was no difference between the two strains when they were grown separately. In mixed culture, a second slow phase of growth that normally occurred following the end of rapid exponential growth, was absent from the plasmid-carrying strain. This resulted in a considerable decrease in the proportion of the cells that carried the plasmid after overnight incubation. The effect of different conditions of growth is reported. The plasmid-carrying strain survived extended incubation (150 days at 37 degrees C) as well as did the plasmid free strain separately. In a mixture, the proportion of plasmid-carrying cells declined rapidly, and none was detected after 100 days.