Diversity among community isolates of methicillin-resistant Staphylococcus aureus in Australia

Escalation of antimicrobial resistance among MRSA part 1: focus on global spread

INTRODUCTION

Staphylococcus aureus produce numerous virulence factors that influence tissue invasion, cytotoxicity, membrane damage, and intracellular persistence allowing them to be very common human pathogens. S. aureus isolates exhibit considerable diversity though specific genotypes have been associated with antimicrobial resistance (AMR) and toxin gene profiles. MRSA is an important pathogen causing both community-acquired (CA) and healthcare-acquired (HCA) infections. Importantly, over the past several decades, both HCA-MRSA and CA-MRSA have spread all over the globe. Even more concerning is that CA-MRSA clones have disseminated into hospitals and HCA-MRSA have entered the community. Factors that enhance spread of MRSA include: poor antimicrobial stewardship and inadequate infection control. The emergence and spread of multidrug resistant (MDR) MRSA has limited therapeutic options.

AREAS COVERED

The authors discuss the escalation of MRSA, both HCA-MRSA and CA-MRSA across the globe. A literature search of MRSA was performed via PubMed (up to September 2022), using the key words: antimicrobial resistance; β-lactams; community-associated MRSA; epidemiology; infection; multidrug resistance; Staphylococcus aureus.

EXPERT OPINION

Over the past several decades, MRSA has spread all over the globe. We encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection control measures to minimize the spread of MRSA.

Diversity and Dissemination of Methicillin-Resistant Staphylococcus aureus (MRSA) Genotypes in Southeast Asia

Methicillin-resistant Staphylococcus aureus (MRSA) is a successful pathogen that has achieved global dissemination, with high prevalence rates in Southeast Asia. A huge diversity of clones has been reported in this region, with MRSA ST239 being the most successful lineage. Nonetheless, description of MRSA genotypes circulating in the Southeast Asia region has, until now, remained poorly compiled. In this review, we aim to provide a better understanding of the molecular epidemiology and distribution of MRSA clones in 11 Southeast Asian countries: Singapore, Malaysia, Thailand, Vietnam, Cambodia, Lao People's Democratic Republic (PDR), Myanmar, Philippines, Indonesia, Brunei Darussalam, and Timor-Leste. Notably, while archaic multidrug-resistant hospital-associated (HA) MRSAs, such as the ST239-III and ST241-III, were prominent in the region during earlier observations, these were then largely replaced by the more antibiotic-susceptible community-acquired (CA) MRSAs, such as ST22-IV and PVL-positive ST30-IV, in recent years after the turn of the century. Nonetheless, reports of livestock-associated (LA) MRSAs remain few in the region.

Prospective Application of Aptamer-based Assays and Therapeutics in Bloodstream Infections

Sepsis is still a severe health problem worldwide with high morbidity and mortality. Blood bacterial culture remains the gold standard for the detection of pathogenic bacteria in bloodstream infections, but it is time-consuming, and both the sophisticated equipment and well-trained personnel are required. Immunoassays and genetic diagnosis are expensive and limited to specificity and sensitivity. Aptamers are single-stranded deoxyribonucleic acid (ssDNA) and ribonucleic acid (RNA) oligonucleotide or peptide sequence generated in vitro based on the binding affinity of aptamer-target by a process known as Systematic Evolution of Ligands by Exponential Enrichment (SELEX). By taking several advantages over monoclonal antibodies and other conventional small-molecule therapeutics, such as high specificity and affinity, negligible batch-to-batch variation, flexible modification and production, thermal stability, low immunogenicity and lack of toxicity, aptamers are presently becoming promising novel diagnostic and therapeutic agents. This review describes the prospective application of aptamerbased laboratory diagnostic assays and therapeutics for pathogenic bacteria and toxins in bloodstream infections.

Vancomycin intermediate resistant Staphylococcus aureus in the nasal cavity of asymptomatic individuals: a potential public health challenge

Background

The potential of transmitting multidrug resistant Staphylococcus aureus from asymptomatic individuals to healthy individuals could constitute a great challenge to antimicrobial therapy.

Methods

The antibiograms of the S. aureus from asymptomatic individuals were determined by disk diffusion and agar dilution assay techniques with different antibiotics and vancomycin.

Results

Of the 152 S. aureus isolated, (59)38.8% isolates were multi-drug resistant strains. Streptomycin was the most effective and inhibited (135)88.82% of the isolates while ceftazidime inhibited (24)15.8% of the isolates. While (82)54.0% of the isolates inhibited by cefuroxime had resistant colonies within their inhibition zones (Rc) and ofloxacin inhibited (100)65.8% of the isolates without having resistant colonies within the inhibition zones, ceftazidime inhibited (7)4.6% of the isolates with resistant colonies within the inhibition zones. Subjecting the isolates to vancomycin showed that (27)17.8% were resistant to 2 µg/ml, (43)28.3% were resistant to 4 µg/ml and (27)17.8% of the isolates were simultaneously resistant to both concentrations of vancomycin. Although (100)65.8% of the isolates had MAR_index ≥0.2, (52)34.2% of the isolates had MAR_index ≤ 0.2 and (65)428% of the isolates were considered multidrug resistant strains.

Conclusion

The isolation of multi-drug and vancomycin intermediate resistant strains of S. aureus in high percentage, in this study, presents a great threat to clinicians and general populace. The vancomycin intermediate resistant S. aureus (VISA) in asymptomatic individuals could be a critical concern to the therapeutic dilemma to be added to the presence of multi-drug resistance. A more sustainable therapy must be in place to prevent its dissemination or the outbreak of its infection.

Staphylococcus argenteus isolated from retail foods in China: Incidence, antibiotic resistance, biofilm formation and toxin gene profile

Staphylococcus argenteus is a novel species of coagulase-positive staphylococci which was separated from Staphylococcus aureus in 2014. It can threaten human health like S. aureus but can not identify with conventional biochemical or other phenotypic testing. From 2011 to 2016, 1581 S. aureus strains were isolated from 4300 samples from retail foods covering most provincial capitals in China. According to multilocus sequence typing (MLST) and PCR confirmation, 7.2% of isolates (114/1581) were confirmed as S. argenteus. The pathogen was distributed in 22 of 39 sampled cities and all food types. Interestingly, most S. argenteus positive samples were collected from coastal cities in South China. MLST detected 8 different sequence types (STs), including five new STs. CC2250 was the predominant lineage of S. argenteus, followed by CC1223. To further characterize the isolates, their antibiotic resistance, virulence genes, biofilm formation and biofilm-related genes were examined. The pvl gene was not detected in S. argenteus, and only 1 isolate (0.9%) was positive for the tsst-1 gene. For 18 enterotoxin genes, 16.7% (19/114) of isolates harboured more than three genes, whereas 70.2% (80/114) of isolates had none of the investigated genes. Penicillin and ampicillin were the major antibiotics to which the S. argenteus isolates were resistant, followed by tetracycline, kanamycin and fusidic acid. A total of 94.7% of isolates had the ability to produce biofilms and all isolates harboured icaA, fnbA, and fib genes. Other biofilm-related genes, such as eno, clfB, fnbB, and icaC, were also found in 99.1%, 92.1%, 88.6%, and 74.6% of isolates, respectively. This study is the first systematic investigation of the prevalence of S. argenteus in retail foods in China and shows their ubiquity in food. We also provide comprehensive surveillance of the incidence of S. argenteus in retail foods and information to enable more accurate and effective treatment of infections of this new species.

Diversity of bacteriophages encoding Panton-Valentine leukocidin in temporally and geographically related Staphylococcus aureus

Production of the Panton-Valentine leukocidin (PVL) by Staphylococcus aureus is mediated via the genes lukS-PV and lukF-PV which are carried on bacteriophage ϕSa2. PVL is associated with S. aureus strains that cause serious infections and clones of community-associated methicillin-resistant S. aureus (CA-MRSA) that have additionally disseminated widely. In Western Australia (WA) the original CA-MRSA were PVL negative however, between 2005 and 2008, following the introduction of eight international PVL-positive CA-MRSA, PVL-positive WA CA-MRSA were found. There was concern that PVL bacteriophages from the international clones were transferring into the local clones, therefore a comparative study of PVL-carrying ϕSa2 prophage genomes from historic WA PVL-positive S. aureus and representatives of all PVL-positive CA-MRSA isolated in WA between 2005 and 2008 was performed. The prophages were classified into two genera and three PVL bacteriophage groups and had undergone many recombination events during their evolution. Comparative analysis of mosaic regions of selected bacteriophages using the Alignments of bacteriophage genomes (Alpha) aligner revealed novel recombinations and modules. There was heterogeneity in the chromosomal integration sites, the lysogeny regulation regions, the defence and DNA processing modules, the structural and packaging modules and the lukSF-PV genes. One WA CA-MRSA (WA5₁₈₇₅₁) and one international clone (Korean Clone) have probably acquired PVL-carrying ϕSa2 in WA, however these clones did not disseminate in the community. Genetic heterogeneity made it impossible to trace the source of the PVL prophages in the other WA clones. Against this background of PVL prophage diversity, the sequence of one group, the ϕSa2USA/ϕSa2wa-st93 group, was remarkably stable over at least 20 years and associated with the highly virulent USA300 and ST93-IVa CA-MRSA lineages that have disseminated globally.

Methicillin-Resistant Staphylococcus aureus Infection and Treatment Options

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of infection worldwide, including a wide array of both hospital- and community-acquired infections-most commonly bacteremia, upper and lower respiratory tract infection, skin and soft-tissue infection, osteomyelitis, and septic arthritis. This chapter describes the epidemiology of MRSA infection, its ability to confer antibiotic resistance and produce a wide array of virulence factors, and its pivotal role in human infection, especially cystic fibrosis. It also provides an introduction to the strategies for treatment of both chronic and acute MRSA infections.

Prevalence and predictors of MRSA carriage among employees in a non-outbreak setting: a cross-sectional study in an acute care hospital

Background

Health care workers have an increased risk of being infected with Methicillin-resistant Staphylococcus aureus (MRSA), though little information is available about how prevalent (dormant) MRSA colonization is among health care workers. The aim of this study was to estimate the prevalence and predictors of MRSA carriage in a non-outbreak setting in a university hospital in Germany.

Methods

The entire staff of a university hospital heart center for cardiologic maximum medical care and cardiac surgery were invited to participate in a cross-sectional study (N = 575). The sampled population included health care workers as well as employees with no close patient contact.

A questionnaire concerning personal and occupational risk factors as well as lifestyle and demographic factors was applied and nasal swabs were taken. In total 180 persons (31.3%) participated in the study.

Results

The majority of study participants had close contact to patients at work (n = 149, 82.8%). Thereof, about one-third had contact to MRSA-patients (n = 53, 35.6%), and most reported wearing protective clothing (n = 44, 83.0%). None of the administrative staff tested positive for MRSA and only one in 149 persons (0.7%, CI 0.00–0.02) with close patient contact carried MRSA (strain CC1-MRSA-IV). This person had close contact to patients with MRSA, less than 1 year of work experience, and had been treated with antibiotics within the last 12 months.

Conclusion

The results of our study suggest low point prevalence rates of MRSA colonization in health care workers in a non-outbreak setting.

Characterization of Biofilms Formed by Foodborne Methicillin-Resistant Staphylococcus aureus

The objective of this study was to evaluate the capacity of 49 methicillin resistant Staphylococcus aureus (MRSA) from foods of animal origin (42 from dairy products and 7 from meat and meat products) to form biofilms. Overall, a higher biofilm biomass was observed for those MRSA strains harboring SCCmec type IV, while 8 MRSA strains (5 from dairy products and 3 from meat and meat products) were classified as strong biofilm formers in standard Tryptic Soy Broth medium. When a prolonged incubation period (48 h) was applied for those 8 MRSA strains, an increased biofilm biomass accumulation was observed during the time course, whereas the number of viable cells within the biofilms decreased as the biomass increased. The capacity of biofilm production correlated pretty well between the experiments using polystyrene microtiter plates and stainless steel micro-well plates, and significant higher values were observed in stainless steel when glucose was added to TSB during the enrichment. Biofilms were further characterized by confocal laser scanning microscope (CLSM), confirming that proteins and α-polysaccharides were the predominant components inside the extracellular polymeric matrix of biofilms formed by MRSA strains. In conclusion, our results confirm that MRSA isolates from foods of animal origin have significant capacity for forming biofilms with a high protein content, which can play a key role for the successful dissemination of MRSA lineages via food. Knowledge of the capacity of MRSA strains to produce biofilms, as well as characterization of the main MRSA biofilms matrix components, can help both to counteract the mechanisms involved in biofilm formation and resistance and to define more rational control strategies by using tailor-made cleaning agents.

Methicillin-Resistant Staphylococcus aureus: Molecular Characterization, Evolution, and Epidemiology

Staphylococcus aureus, a major human pathogen, has a collection of virulence factors and the ability to acquire resistance to most antibiotics. This ability is further augmented by constant emergence of new clones, making S. aureus a "superbug." Clinical use of methicillin has led to the appearance of methicillin-resistant S. aureus (MRSA). The past few decades have witnessed the existence of new MRSA clones. Unlike traditional MRSA residing in hospitals, the new clones can invade community settings and infect people without predisposing risk factors. This evolution continues with the buildup of the MRSA reservoir in companion and food animals. This review focuses on imparting a better understanding of MRSA evolution and its molecular characterization and epidemiology. We first describe the origin of MRSA, with emphasis on the diverse nature of staphylococcal cassette chromosome mec (SCCmec). mecA and its new homologues (mecB, mecC, and mecD), SCCmec types (13 SCCmec types have been discovered to date), and their classification criteria are discussed. The review then describes various typing methods applied to study the molecular epidemiology and evolutionary nature of MRSA. Starting with the historical methods and continuing to the advanced whole-genome approaches, typing of collections of MRSA has shed light on the origin, spread, and evolutionary pathways of MRSA clones.

The rise of methicillin resistant Staphylococcus aureus: now the dominant cause of skin and soft tissue infection in Central Australia

This study aimed to examine the epidemiology and treatment outcomes of community-onset purulent staphylococcal skin and soft tissue infections (SSTI) in Central Australia. We performed a prospective observational study of patients hospitalised with community-onset purulent staphylococcal SSTI (n = 160). Indigenous patients accounted for 78% of cases. Patients were predominantly young adults; however, there were high rates of co-morbid disease. Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) was the dominant phenotype, accounting for 60% of cases. Hospitalisation during the preceding 6 months, and haemodialysis dependence were significant predictors of CA-MRSA infection on univariate analysis. Clinical presentation and treatment outcomes were found to be comparable for methicillin-susceptible S. aureus (MSSA) and methicillin-resistant cases. All MRSA isolates were characterised as non-multi-resistant, with this term used interchangeably with CA-MRSA in this analysis. We did not find an association between receipt of an active antimicrobial agent within the first 48 h, and progression of infection; need for further surgical debridement; unplanned General Practitioner or hospital re-presentation; or need for further antibiotics. At least one adverse outcome was experienced by 39% of patients. Clindamycin resistance was common, while rates of trimethoprim-sulfamethoxazole resistance were low. This study suggested the possibility of healthcare-associated transmission of CA-MRSA. This is the first Australian report of CA-MRSA superseding MSSA as the cause of community onset staphylococcal SSTI.

Diversity of methicillin-resistant Staphylococcus aureus CC22-MRSA-IV from Saudi Arabia and the Gulf region

OBJECTIVES

CC22-MRSA-IV, UK-EMRSA-15/Barnim EMRSA, is a common and pandemic strain of methicillin-resistant Staphylococcus aureus (MRSA) that has been found mainly in Western Europe, but also in other parts of the world including some Gulf countries. One suspected case of an infection with this strain in a patient who was admitted to the surgical unit in Riyadh, Kingdom of Saudi Arabia (KSA) was investigated in order to check whether this strain has reached KSA.

METHODS

Besides the index isolate, 46 additional isolates of CC22-MRSA-IV from patients from KSA, Abu Dhabi, Kuwait, and Germany (patients with a history of travel in the Middle East), were characterized by microarray hybridization.

RESULTS

The study revealed a regional presence of as many as six distinct 'strains' of CC22-MRSA-IV that could be distinguished based on carriage of SCCmec IV subtypes and virulence factors. No true UK-EMRSA-15/Barnim EMRSA was identified in Riyadh; all suspected isolates from Riyadh were assigned to other, albeit related strains. However, this strain was identified in Abu Dhabi and Kuwait.

CONCLUSIONS

CC22-MRSA-IV from KSA could be linked to other epidemic strains from the Middle East and possibly India, rather than to the Western European UK-EMRSA-15/Barnim EMRSA. High-resolution typing methods, including SCCmec subtyping, might help to differentiate related epidemic strains and to monitor routes of transmission.

Identification of Staphylococcus argenteus in Eastern China based on a nonribosomal peptide synthetase (NRPS) gene

AIM

To investigate whether the Staphylococcus argenteus is present in Eastern China and to verify the utility of a new screening process.

MATERIALS & METHODS

Phenotype observation, PCR assay targeting a hypothetical nonribosomal peptide synthetase (NRPS) gene, phylogenetic analysis of rpoB and multilocus sequence typing were used to screen and identify strains of S. argenteus from 839 presumptive S. aureus isolates.

RESULTS

Eighty-nine (89/839, 10.6%) of the presumptive S. aureus isolates produced white colonies on tryptone soya agar plates. Of the white-colony isolates, six (6/89, 7%) were S. argenteus, 75 (75/89, 84%) were S. aureus and eight (8/89, 9%) were other bacteria.

CONCLUSION

The PCR-based method targeting the NRPS gene can simultaneously identify and distinguish S. argenteus and S. aureus. All representative sequences of rpoB generated in this study were deposited in GenBank under accession numbers SJTU F20002, KT767581; SJTU F20269, KT767582; SJTU F20419, KT767583; SJTU F20420, KT767584; SJTU F20124, KT767585; SJTU F21164, KT767586; SJTU F21285, KT767587; SJTU F21224, KT767588; SJTU F21155, KT767589; SJTU F21294, KT767590; SJTU F20030, KT767591; SJTU F20044, KT767592; SJTU F20135, KT767593; SJTU F20123, KT767594; SJTU F21319, KT767595, respectively. All the new sequence types (STs) were submitted to a multilocus sequence typing database and the assigned ST numbers are ST3261 (151-469-20-101-145-150-131), ST3262 (12-3-1-1-4-4-410) and ST3267 (2-471-2-2-6-3-2).

Plasmid-Borne Antimicrobial Resistance of Staphylococcus aureus Isolated in a Hospital in Lisbon, Portugal

Plasmids play a key role in the genetic plasticity and survival of Staphylococcus aureus in challenging environments. Although many S. aureus plasmids have been described, still few studies portray the plasmid content of a given S. aureus population. The aim of this work was to characterize the plasmids carried by a collection of 53 S. aureus isolates collected in a large hospital in Lisbon, Portugal, and investigate their role in conferring resistance to several antimicrobial agents. Plasmids were present in 44 out of the 53 isolates and were grouped into eleven AccI restriction profiles. Plasmid curing of representative strains and comparison of antimicrobial susceptibility profiles between pairs of isogenic strains proved to be a valuable guidance tool in the identification of plasmid-located resistance genes. The plasmids harbored several resistance genes, namely blaZ (resistance to β-lactams), erm(C) (resistance to macrolides, lincosamides, and streptogramin B), cadA (resistance to cadmium and zinc), cadD (resistance to cadmium), and qacA and smr (resistance to biocides and dyes). This study demonstrates the impact of plasmids on the resistance properties of S. aureus, highlighting their role in the dissemination of antibiotic, heavy metal, and biocide resistance genes, and survival of this major pathogen in the hospital environment.

Oral Antimicrobial Therapy: Efficacy and Safety for Methicillin-Resistant Staphylococcus aureus Infections and Its Impact on the Length of Hospital Stay

Background

Carefully switching from intravenous to oral antibiotic therapy has shown to reduce treatment costs and lengths of hospital stay as well as increase safety and comfort in patients with infections. The aim of this study was to compare the clinical efficacy and safety between the patients treated with glycopeptides (case group), and the patients given oral antibiotics, as the initial or step-down therapy (control group), in the treatment of patients with methicillin-resistant Staphylococcus aureus (MRSA) infection.

Materials and Methods

A multicenter observational study was retrospectively performed in 7 teaching hospitals in Korea from January to December 2012. The study included adult patients (≥ 18 years) with infection caused by MRSA isolates, susceptible to clindamycin, erythromycin, and ciprofloxacin. The primary end point was treatment outcome, including all-cause mortality and switching of antibiotics. Drug-related adverse events and the lengths of hospital stay were also compared between the two treatment groups.

Results

During the study period, 107 patients (43 cases and 64 controls) with MRSA infections were enrolled from the participating hospitals. The most common sites of MRSA infection were skin and soft tissue (n = 28) and bone and joint (n = 26). The median Charlson comorbidity index (P = 0. 560), the frequency of severe sepsis (P = 0.682) or thrombocytopenia (P = 1.000), and median level of serum C-reactive protein (P = 0.157) at the onset of MRSA infections were not significantly different between the case and control groups. The oral antibiotics most frequently prescribed in the case group, were fluoroquinolones (n = 29) and clindamycin (n = 8). The median duration of antibiotic treatment (P = 0.090) and the occurrence of drug-related adverse events (P = 0.460) did not reach statistically significant difference between the two groups, whereas the total length of hospital stay after the onset of MRSA infection was significantly shorter in the case group than the control group [median (interquartile range), 23 days (8-41) vs. 32 days (15-54), P = 0.017]. In multivariate analyses, the type of antibiotic used was not an independent risk factor for treatment failure. The statistically significant factors associated with treatment failure included underlying hepatic diseases, prior receipt of antibiotics, and foreign body retention.

Conclusions

This study indicates that oral antibiotic therapy with active agents against MRSA isolates can be considered as the initial or step-down therapy for the treatment of MRSA infections and also reduce the length of hospital stay.

Community-associated methicillin-resistant Staphylococcus aureus case studies

Over the past decade, the emergence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has changed the landscape of S. aureus infections around the globe. Initially recognized for its ability to cause disease in young and healthy individuals without healthcare exposures as well as for its distinct genotype and phenotype, this original description no longer fully encompasses the diversity of CA-MRSA as it continues to expand its niche. Using four case studies, we highlight a wide range of the clinical presentations and challenges of CA-MRSA. Based on these cases we further explore the globally polygenetic background of CA-MRSA with a special emphasis on generally less characterized populations.

Molecular recognition of live methicillin-resistant staphylococcus aureus cells using DNA aptamers

AIM: To generate DNA-aptamers binding to Methicillin-resistant Staphylococcus aureus (MRSA).

METHODS: The Cell-Systematic Evolution of Ligands by Exponential Enrichment (SELEX) technology was used to run the selection against MRSA bacteria and develop target-specific aptamers. MRSA bacteria were targeted while Enterococcus faecalis bacteria were used for counter selection during that process. Binding assays to determine the right aptamer candidates as well as binding assays on clinical samples were performed through flow cytometry and analyzed using the FlowJo software. The characterization of the aptamers was done by determination of their K_d values and determined by analysis of flow data at different aptamer concentration using SigmaPlot. Finally, the recognition of the complex Gold-nanoparticle-aptamer to the bacteria cells was observed using transmission electron microscopy (TEM).

RESULTS: During the cell-SELEX selection process, 17 rounds were necessary to generate enrichment of the pool. While the selection was run using fixed cells, it was shown that the binding of the pools with live cells was giving similar results. After sequencing and analysis of the two last pools, four sequences were identified to be aptamer candidates. The characterization of those aptamers showed that based on their K_d values, DTMRSA4 presented the best binding with a K_d value of 94.61 ± 18.82 nmol/L. A total of ten clinical samples of MRSA, S. aureus and Enterococcus faecalis were obtained to test those aptamers and determine their binding on a panel of samples. DTMRSA1 and DTMRSA3 showed the best results regarding their specificity to MRSA, DTMRSA1 being the most specific of all. Finally, those aptamers were coupled with gold-nanoparticle and their binding to MRSA cells was visualized through TEM showing that adduction of nanoparticles on the aptamers did not change their binding property.

CONCLUSION: A total of four aptamers that bind to MRSA were obtained with K_d values ranking from 94 to 200 nmol/L.

Spread of Community-Acquired Methicillin-ResistantStaphylococcus aureus(MRSA) in Hospitals in Taipei, Taiwan in 2005, and Comparison of Its Drug Resistance with Previous Hospital-Acquired MRSA

Panton-Valentine leucocidin (PVL)-positive methicillin-resistant Staphylococcus aureus (PVL+ MRSA) is an emerging pathogen in the community worldwide. The incidence of PVL+ MRSA in Taipei, Taiwan was 23.3% for hospital MRSA. PVL+ MRSA was isolated from both outpatients and inpatients. Some PVL+ (mecA+) strains (36.8%) showed low MIC values (<or=2 microg/ml) to oxacillin. A major PVL+ MRSA resistance pattern was oxacillin and clindamycin resistance (81%). There was no multidrug resistance over three drugs, in contrast to patient PVL- MRSA with resistance to five drugs as a major resistance pattern. The majority of PVL+ MRSA belonged to multilocus sequence (ST) type 59, while PVL+ MRSA belonged to ST239, ST59 and ST5. The data suggests that although PVL+ CA-MRSA is isolated at a high incidence from hospitals in Taipei, the drug resistance is mostly selected in the community and less prominent compared with previous PVL- hospital-acquired MRSA.

Prospective Surveillance of Community-Onset and Healthcare-Associated Methicillin-ResistantStaphylococcus aureusIsolated from a University-Affiliated Hospital in Japan

We conducted a prospective comparative study of community-onset (CO) and healthcare-associated (HA) methicillin-resistant Staphylococcus aureus(MRSA) strains between 2000 and 2001 at Tokyo Women's Medical University Hospital (1,500 beds) in Japan. Of the 172 consecutive MRSA isolates analyzed, 13 (8%) were categorized as CO-MRSA. The mean age of patients with CO-MRSA was significantly younger than that of patients with HA-MRSA. Most CO-MRSA strains were isolated from skin and more likely to be susceptible to erythromycin, clindamycin, tetracycline, levofloxacin, and spectinomycin compared to HA-MRSA isolates. Pulsed-field gel electrophoresis (PFGE) analysis, staphylococcal cassette chromosome mec(SCCmec) typing, and multi-locus sequence typing (MLST) revealed that CO-MRSA strains were divided into the following multi-clones: 3 clone A: II: ST5 (PFGE type: SCCmec type: MLST sequence type); 1 L: II: ST5; 1 H: IV: ST1; 1 I: IV: ST81; 2 D: IV: ST8; 1 B: IV: ST89; 1 B: IV: ST379; and 3 B: IV: ST91. Of the 159 HAMRSA strains, 124 (78%) belonged to a single clone (PFGE clone A: SCCmec type II: tst and sec positive: coagulase type II: multi-drug resistance). Four CO-MRSA strains belonging to PFGE clone B: SCCmec type IV: MLST clonal complex 509 (ST89, 91, 379) had the exfoliative toxin B (etb) genes, but all CO-MRSA and HA-MRSA strains did not possess the Panton-Valentine leukocidin (pvl) genes. These results demonstrate that multiple lineages of CO-MRSA have the potential for dissemination in the community in Japan.

Multicenter prospective observational study of the comparative efficacy and safety of vancomycin versus teicoplanin in patients with health care-associated methicillin-resistant Staphylococcus aureus bacteremia

The purpose of this study was to compare the clinical efficacy and safety of vancomycin to those of teicoplanin for the treatment of adult patients with health care-associated methicillin-resistant Staphylococcus aureus (HA-MRSA) bacteremia. A multicenter observational study was prospectively conducted in 15 teaching hospitals in Korea between February 2010 and July 2011. Adult patients (≥18 years old) with HA-MRSA bacteremia who were initially treated with vancomycin (VAN) (n = 134) or teicoplanin (TEC) (n = 56) were enrolled. Clinical and microbiological responses and drug-related adverse events were compared between the two treatment groups using univariate and multivariate logistic regression analyses. The vancomycin and teicoplanin MICs were determined by Etest. The MRSA-related mortality, duration of fever, and duration of MRSA bacteremia in the treatment groups were not significantly different. There was no significant difference in the occurrence of drug-related adverse events. Among the 190 MRSA isolates, the VAN MICs ranged from 0.5 to 2 μg/ml (MIC50 and MIC90, 1.5 μg/ml), and the TEC MIC ranged from 0.5 to 8 μg/ml (MIC50, 3 μg/ml; MIC90, 6 μg/ml). In multivariate analyses, the antibiotic type (vancomycin or teicoplanin) was not associated with treatment outcomes. This study indicates that teicoplanin is an effective and safe alternative to vancomycin for the treatment of HA-MRSA bacteremia.

Inducible resistance to clindamycin in Staphylococcus aureus: validation of Vitek-2 against CLSI D-test

AIMS

Inducible resistance to clindamycin in Staphylococcus aureus is common but not easily identified by routine testing, and can result in treatment failure if not detected. The gold standard method is the D-test described by the Clinical and Laboratory Standards Institute (CLSI). The Vitek-2 AST-P612 card contains an 'inducible clindamycin resistance' (ICR) test. We aimed to determine the accuracy of the Vitek-2 ICR test compared to the D-test.

METHODS

Isolates of erythromycin non-susceptible, clindamycin susceptible Staphylococcus aureus were identified. Routine antimicrobial susceptibility testing was performed using the Vitek-2 AST-P612 card, including the ICR test, and compared against the D-test.

RESULTS

217 isolates were obtained. All of the 191 isolates that were ICR positive were D-test positive. Of the 27 ICR negative isolates, 10 (37%) were D-test positive [9 methicillin-sensitive S. aureus (MSSA), 1 methicillin-resistant S. aureus (MRSA)]. This correlates with a specificity of 100%, sensitivity of 95%, positive predictive value of 100%, and negative predictive value of 72%.

CONCLUSIONS

The ICR test is reliable in the presence of a positive result; however there is a false negative rate of approximately one in four. This will lead to susceptibility reporting errors, with potentially serious clinical implications. A negative ICR should be confirmed by CLSI D-test before reporting clindamycin as susceptible where the organism is not susceptible to erythromycin.

Molecular characterization of the first community-acquired methicillin-resistant Staphylococcus aureus strains from Central Iran

BACKGROUND

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has spread throughout the world with varying regional incidences and different staphylococcal cassette chromosome mec (SCCmec) elements in different genetic backgrounds. No information is available on CA-MRSA in Iran. A cross-sectional study was carried out among healthy students to investigate: (1) the prevalence of CA-MRSA in Central Iran, (2) the molecular epidemiology of such CA-MRSA strains, (3) the antimicrobial resistance patterns of the strains, and (4) the distribution of virulence genes in these CA-MRSA strains.

METHODS

A total of 700 nasal swabs were collected and subjected to S. aureus and MRSA-specific isolation procedures. Antimicrobial resistance patterns were determined using the disk diffusion method, and molecular typing was carried out by multi-locus sequence typing (MLST), SCCmec typing, and Staphylococcus protein A (spa) typing for all CA-MRSA isolates. PCR was used to detect various virulence genes.

RESULTS

One hundred fifty-four S. aureus strains were isolated from the anterior nares of 700 healthy students. According to the US Centers for Disease Control and Prevention definitions for CA-MRSA, seven (4.5%) isolates were confirmed as CA-MRSA. CA-MRSA isolates belonged to SCCmec types IV (n = 6) and V (n = 1). The predominant spa-type among the CA-MRSA isolates was t790 (n = 3), with single t660, t084, and t325 isolates; one isolate was not typeable. The predominant sequence type was ST22, t790, SCCmec IV in three isolates, and the four other sequence types were ST25, ST859, ST14, and ST15.

CONCLUSIONS

Iranian CA-MRSA strains are genetically diverse with an elevated prevalence of t790/ST22 SCCmec IV isolates. These findings support the need for more effective infection control measures to reduce nasal carriage and prevent dissemination of CA-MRSA in Iran.

Meticillin-resistant Staphylococcus aureus in elderly residents of care homes: colonization rates and molecular epidemiology

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) is a significant cause of mortality and morbidity in healthcare and community settings; however, there is a paucity of large-scale, longitudinal studies monitoring the occurrence of MRSA in the care home setting.

AIM

To determine the molecular epidemiology of MRSA colonizing elderly residents of care homes.

METHODS

Residents in 65 care homes in Leeds, UK, were screened for MRSA nasal colonization in four consecutive years (2006-2009). Isolates were characterized using antibiotic susceptibility testing, detection of the Panton-Valentine leucocidin (PVL) locus, accessory gene regulator allotyping, characterization of the staphylococcal cassette chromosome mec element, spa-typing and pulsed-field gel electrophoresis.

FINDINGS

MRSA was recovered from 888 nasal swabs of 2492 residents and prevalence was similar (19-22%) throughout the study. Resistance to ≥3 antibiotic classes was common (34%), but resistance to only β-lactam agents was rare (3%); no PVL-positive isolates were identified. Most isolates were related to healthcare-associated epidemic-MRSA type 15 (EMRSA-15, ST22-IV); such isolates decreased in prevalence during the study (86-72%; P < 0.0001, χ(2)-test). The remainder belonged to five different multi-locus sequence type clonal complexes (CC). Most notably, CC59 strains increased in prevalence (10-25%; P < 0.0001, χ(2)-test) and were associated with high-level mupirocin resistance.

CONCLUSIONS

The molecular epidemiology of MRSA in care homes is complex and dynamic. There was a high, consistent prevalence of MRSA nasal colonization, dominated by healthcare-associated strains. Vigilance is recommended; however, as high-level mupirocin resistance was associated with a single clonal group (CC59) that significantly increased in prevalence during the study.

The role of the Panton-Valentine leucocidin toxin in staphylococcal disease: a systematic review and meta-analysis

BACKGROUND

Invasive community-onset staphylococcal disease has emerged worldwide associated with Panton-Valentine leucocidin (PVL) toxin. Whether PVL is pathogenic or an epidemiological marker is unclear. We investigate the role of PVL in disease, colonisation, and clinical outcome.

METHODS

We searched Medline and Embase for original research reporting the prevalence of PVL genes among Staphylococcus aureus pneumonia, bacteraemia, musculoskeletal infection, skin and soft-tissue infection, or colonisation published before Oct 1, 2011. We calculated odds ratios (ORs) to compare patients with PVL-positive colonisation and each infection relative to the odds of PVL-positive skin and soft-tissue infection. We did meta-analyses to estimate odds of infection or colonisation with a PVL-positive strain with fixed-effects or random-effects models, depending on the results of tests for heterogeneity.

RESULTS

Of 509 articles identified by our search strategy, 76 studies from 31 countries met our inclusion criteria. PVL strains are strongly associated with skin and soft-tissue infections, but are comparatively rare in pneumonia (OR 0·37, 95% CI 0·22-0·63), musculoskeletal infections (0·44, 0·19-0·99), bacteraemias (0·10, 0·06-0·18), and colonising strains (0·07, 0·01-0·31). PVL-positive skin and soft-tissue infections are more likely to be treated surgically than are PVL-negative infections, and children with PVL-positive musculoskeletal disease might have increased morbidity. For other forms of disease we identified no evidence that PVL affects outcome.

INTERPRETATION

PVL genes are consistently associated with skin and soft-tissue infections and are comparatively rare in invasive disease. This finding challenges the view that PVL mainly causes invasive disease with poor prognosis. Population-based studies are needed to define the role of PVL in mild, moderate, and severe disease and to inform control strategies.

FUNDING

None.

Strategies of adaptation of Staphylococcus epidermidis to hospital and community: amplification and diversification of SCCmec

OBJECTIVES

Staphylococcus epidermidis is a harmless commensal, but it can become a human pathogen, mainly in the hospital environment. In order to clarify strategies used by these bacteria to adapt to the hospital environment, we compared the population structure and staphylococcal cassette chromosome mec (SCCmec) content of S. epidermidis from the community and hospital.

METHODS

S. epidermidis were collected from nasal swabs of both healthy military draftees (192 isolates) and patients (94 isolates) recovered in the same time period and geographical region. S. epidermidis were characterized by PFGE, multilocus sequence typing and SCCmec typing.

RESULTS

Clonal complex 5 was predominant in the hospital (100%) and the community (58%), but some clonal types were specific to each environment and others were found in both (C/H clones). The methicillin-resistant S. epidermidis (MRSE) colonization rate in the community was very low (7%) when compared with the hospital (30%; P < 0.05). Community-associated MRSE carried mostly SCCmec IV and V [Simpson's index of diversity (SID) = 57.52%; 95% CI 38.35-76.69], whereas hospital-associated MRSE carried 17 SCCmec structures (SID = 82.67%; 95% CI 77.38-87.96). Isolates of the same PFGE type had a much higher number of different SCCmec types when collected in the hospital than in the community.

CONCLUSIONS

Our data suggest that the S. epidermidis population is composed of hospital-associated clonal types, community-associated clonal types and types that are able to survive in both environments. Moreover, adaptation to the hospital environment in S. epidermidis appears to promote an increase in the frequency and diversification of SCCmec.

Colonization, pathogenicity, host susceptibility, and therapeutics for Staphylococcus aureus: what is the clinical relevance?

Staphylococcus aureus is a human commensal that can also cause a broad spectrum of clinical disease. Factors associated with clinical disease are myriad and dynamic and include pathogen virulence, antimicrobial resistance, and host susceptibility. Additionally, infection control measures aimed at the environmental niches of S. aureus and therapeutic advances continue to impact upon the incidence and outcomes of staphylococcal infections. This review article focuses on the clinical relevance of advances in our understanding of staphylococcal colonization, virulence, host susceptibility, and therapeutics. Over the past decade key developments have arisen. First, rates of nosocomial methicillin-resistant S. aureus (MRSA) infections have significantly declined in many countries. Second, we have made great strides in our understanding of the molecular pathogenesis of S. aureus in general and community-associated MRSA in particular. Third, host risk factors for invasive staphylococcal infections, such as advancing age, increasing numbers of invasive medical interventions, and a growing proportion of patients with healthcare contact, remain dynamic. Finally, several new antimicrobial agents active against MRSA have become available for clinical use. Humans and S. aureus co-exist, and the dynamic interface between host, pathogen, and our attempts to influence these interactions will continue to rapidly change. Although progress has been made in the past decade, we are likely to face further surprises such as the recent waves of community-associated MRSA.

Evolution and diversity of community-associated methicillin-resistant Staphylococcus aureus in a geographical region

BACKGROUND

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) was first reported in remote regions of Western Australia and is now the predominant MRSA isolated in the state. The objective of this study is to determine the genetic relatedness of Western Australian CA-MRSA clones within different multilocus sequence type (MLST) clonal clusters providing an insight into the frequency of S. aureus SCCmec acquisition within a region.

RESULTS

The CA-MRSA population in Western Australia is genetically diverse consisting of 83 unique pulsed-field gel electrophoresis strains from which 46 MLSTs have been characterised. Forty five of these sequence types are from 18 MLST clonal clusters and two singletons. While SCCmec IV and V are the predominant SCCmec elements, SCCmec VIII and several novel and composite SCCmec elements are present. The emergence of MRSA in diverse S. aureus clonal clusters suggests horizontal transmission of the SCCmec element has occurred on multiple occasions. Furthermore DNA microarray and spa typing suggests horizontal transfer of SCCmec elements has also occurred within the same CC. For many single and double locus variant CA-MRSA clones only a few isolates have been detected.

CONCLUSIONS

Although multiple CA-MRSA clones have evolved in the Western Australian community only three clones have successfully adapted to the Western Australian community environment. These data suggest the successful evolution of a CA-MRSA clone may not only depend on the mobility of the SCCmec element but also on other genetic determinants.

Molecular characterization of methicillin-resistant Staphylococcus aureus obtained from the anterior nares of healthy Korean children attending daycare centers

OBJECTIVES

This study was performed to investigate the molecular characterization of methicillin-resistant Staphylococcus aureus (MRSA) isolated from the anterior nares of Korean children attending daycare centers.

METHODS

During September and October 2008, a survey of nasal carriage of MRSA was conducted among healthy children who were attending daycare centers in Seoul, Korea. Nasal swab samples were cultured to isolate S. aureus, and antimicrobial susceptibility was assessed using a disk diffusion test. All MRSA isolates were archived for subsequent molecular tests, including multilocus sequence typing, Panton-Valentine leukocidin (PVL) genes polymerase chain reaction (PCR), and staphylococcal cassette chromosome mec (SCCmec) typing.

RESULTS

Among 428 preschool-aged children enrolled, 9.3% (40/428) were colonized with MRSA. Among the 40 MRSA isolates, antibiotic susceptibilities to clindamycin and erythromycin were 97.5% (39/40) and 45% (18/40), respectively. All of the 21 strains susceptible to clindamycin and resistant to erythromycin had MLS(B)-inducible phenotypes. Sequence type (ST) 72-SCCmec type IV was the predominant clone (n=23; 57.5%), followed by ST72-SCCmec type II (n=6; 15%), ST1765-SCCmec type IV (n=4; 10%), ST1765-SCCmec type II (n=2; 5%), and ST1-SCCmec type IV (n=2; 5%). No clone was positive for PVL genes.

CONCLUSIONS

ST72 strains, which were previously found in hospital-associated MRSA, are now widely distributed in healthy Korean children. In addition, the prevalence of inducible resistance of clindamycin should be considered when selecting empirical antibiotics for community-associated MRSA infections in Korea.

Detection of staphylococcal cassette chromosome mec type XI carrying highly divergent mecA, mecI, mecR1, blaZ, and ccr genes in human clinical isolates of clonal complex 130 methicillin-resistant Staphylococcus aureus

Methicillin resistance in staphylococci is mediated by penicillin binding protein 2a (PBP 2a), encoded by mecA on mobile staphylococcal cassette chromosome mec (SCCmec) elements. In this study, two clonal complex 130 (CC130) methicillin-resistant Staphylococcus aureus (MRSA) isolates from patients in Irish hospitals were identified that were phenotypically PBP 2a positive but lacked mecA by conventional PCR and by DNA microarray screening. The isolates were identified as methicillin-susceptible S. aureus using the GeneXpert real-time PCR assay. Whole-genome sequencing of one isolate (M10/0061) revealed a 30-kb SCCmec element encoding a class E mec complex with highly divergent blaZ-mecA-mecR1-mecI, a type 8 cassette chromosome recombinase (ccr) complex consisting of ccrA1-ccrB3, an arsenic resistance operon, and flanking direct repeats (DRs). The SCCmec element was almost identical to that of SCCmec type XI (SCCmec XI) identified by the Sanger Institute in sequence type 425 bovine MRSA strain LGA251 listed on the website of the International Working Group on the Classification of Staphylococcal Cassette Chromosome Elements. The open reading frames (ORFs) identified within SCCmec XI of M10/0061 exhibited 21 to 93% amino acid identity to ORFs in GenBank. A third DR was identified ca. 3 kb downstream of SCCmec XI, indicating the presence of a possible SCC remnant. SCCmec XI was also identified in the second CC130 MRSA isolate by PCR and sequencing. The CC130 MRSA isolates may be of animal origin as previously reported CC130 S. aureus strains were predominantly from bovine sources. The highly divergent nature of SCCmec XI relative to other SCCmec elements indicates that it may have originated in another taxon.

High prevalence of EMRSA-15 in Portuguese public buses: a worrisome finding

BACKGROUND

The nosocomial prevalence of methicillin resistant Staphylococcus aureus (MRSA) in Portugal remains one of the highest in Europe and is currently around 50%. Transmission of S. aureus, including MRSA, occurs principally by direct human-to-human skin contact. However, S. aureus can survive for long periods on inanimate objects, which may represent an important reservoir for dissemination as well.

METHODOLOGY/PRINCIPAL FINDINGS

Between May 2009 and February 2010, handrails of 85 public urban buses circulating in Oporto, Portugal, were screened for the occurrence of MRSA. Twenty-two (26%) buses showed MRSA contamination. The molecular characterization of a total of 55 MRSA, by pulsed-field gel electrophoresis (PFGE), staphylococcal cassette chromosome (SCC) mec typing, spa typing, and multilocus sequence typing (MLST), clustered the isolates into three clonal types. However, the overwhelming majority (n = 50; 91%) of the isolates belonged to a single clone (PFGE A, spa types t747, t032, t025 or t020, ST22, SCCmec type IVh) that exhibits the characteristics of the pandemic EMRSA-15, currently the major lineage circulating in Portuguese hospitals, namely in the Oporto region. Two additional clones were found but in much lower numbers: (i) PFGE B, ST5, spa type t002, SCCmec IVa (n = 3), and (ii) PFGE C, spa type t008, ST8, SCCmec IVa (n = 2). None of the 55 isolates was PVL positive.

CONCLUSIONS/SIGNIFICANCE

Public buses in Oporto seem to be an important reservoir of MRSA of nosocomial origin, providing evidence that the major hospital-associated MRSA clone in Portugal is escaping from the primary ecological niche of hospitals to the community environment. Infection control measures are urgently warranted to limit the spread of EMRSA-15 to the general population and future studies are required to assess the eventual increase of MRSA in the Portuguese community, which so far remains low.

Molecular detection and characterization of methicillin-resistant Staphylococcus aureus (MRSA) isolates from dogs in Portugal

Fifty-four healthy dogs were screened in Portugal for the presence of nasal methicillin-resistant Staphylococcus aureus (MRSA) carriage. Sixteen MRSA isolates (one/sample) were recovered from nasal samples of dogs, and they were typed by molecular methods (S. aureus protein A [spa]-, multilocus sequence typing-, staphylococcal cassette chromosome mec-typing). MRSA isolates were investigated for their susceptibility to antimicrobial agents by disk-diffusion test. The presence of resistance genes and of the Panton-Valentine leukocidin gene (lukF-lukS) was analyzed by PCR. Four different spa-types were identified among our MRSA isolates (t032, t432, t747, and t4726), with t032 as the most frequently detected. The sequence-type ST22 was identified in four tested MRSA isolates with different spa-types. All 16 isolates presented the staphylococcal cassette chromosome mec type IV. Most of MRSA isolates were resistant to ciprofloxacin, erythromycin, and clindamycin (94%-100%), and no resistance was identified to chloramphenicol, mupirocin, and trimethoprim-sulfametoxazole. The ermC and tetM resistance genes were detected in all MRSA isolates. The amino acid changes Ser84Leu in GyrA protein and Ser80Phe in GrlA protein were the most prevalent ones in our MRSA isolates. None of the MRSA strains carried the lukF-lukS genes. The results presented in this study indicate that healthy dogs may be a reservoir of MRSA that could be transmitted to humans by direct contact.

Community-Associated Methicillin-Resistant Staphylococcus Aureus Skin and Soft Tissue Infections

The prevalence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections is increasing globally and in Singapore. Skin and soft tissue infections (SSTIs) are the most common manifestations, ranging from common furuncles to the rare but life-threatening necrotizing fasciitis. Surgical drainage and debridement where feasible are the mainstay of therapy, whereas MRSA-active antibiotics are essential when surgery is not possible or as adjunctive therapy for severe and/or complicated SSTIs. In itself, the continued inexorable rise in CA-MRSA rates poses difficult challenges for primary healthcare and hospital infection control. Innovative approaches are required to mitigate its impact in both the community and hospital settings.

Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic

Staphylococcus aureus is an important cause of skin and soft-tissue infections (SSTIs), endovascular infections, pneumonia, septic arthritis, endocarditis, osteomyelitis, foreign-body infections, and sepsis. Methicillin-resistant S. aureus (MRSA) isolates were once confined largely to hospitals, other health care environments, and patients frequenting these facilities. Since the mid-1990s, however, there has been an explosion in the number of MRSA infections reported in populations lacking risk factors for exposure to the health care system. This increase in the incidence of MRSA infection has been associated with the recognition of new MRSA clones known as community-associated MRSA (CA-MRSA). CA-MRSA strains differ from the older, health care-associated MRSA strains; they infect a different group of patients, they cause different clinical syndromes, they differ in antimicrobial susceptibility patterns, they spread rapidly among healthy people in the community, and they frequently cause infections in health care environments as well. This review details what is known about the epidemiology of CA-MRSA strains and the clinical spectrum of infectious syndromes associated with them that ranges from a commensal state to severe, overwhelming infection. It also addresses the therapy of these infections and strategies for their prevention.

First outbreak of PVL-positive nonmultiresistant MRSA in a neonatal ICU in Australia: comparison of MALDI-TOF and SNP-plus-binary gene typing

The purpose of this brief report is to describe the first outbreak of a community-associated nonmultiresistant and PVL-positive MRSA strain (CC30) in a neonatal intensive care unit in Australia. The utility of matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF-MS) for microbial typing is compared with single nucleotide polymorphism (SNP) plus binary gene analysis. The composite correlation index analysis of the MALDI-TOF-MS data demonstrated the similar inter-strain relatedness found with the SNP-plus-binary gene typing used to confirm the outbreak. The evolving spread of MRSA emphasizes the importance of surveillance, infection control vigilance and the ongoing investigation of rapid typing methods for MRSA.

Methicillin-resistant Staphylococcus aureus: from the hospital to the community

Infections due to community-associated methicillin---resistant Staphylococcus aureus (CA-MRSA) are becoming more prevalent. CA-MRSA infections have unique epidemiologic features and virulence factors. Compared with health care-associated MRSA (HA-MRSA), most CA-MRSA is clonal type USA300 or 400 and has the Staphylococcal cassette chromosome mec type IV, which carries the mecA gene that encodes for resistance to methicillin and other beta-lactam antibiotics but generally not for other antibiotics. CA-MRSA often contains various virulence factors that may result in tissue necrosis. CA-MRSA clinical presentation includes mostly skin and soft tissue infections and less frequently pneumonia. In many of the small soft tissue abscesses due to CA-MRSA, primary treatment with surgical drainage may result in improvement without antibiotic therapy. Optimal treatment and prevention of CA-MRSA infections are unclear. However, distinction between CA-MRSA and HA-MRSA may be less relevant in the future, as CA-MRSA strains are now diagnosed in the hospital setting.

Community-associated meticillin-resistant Staphylococcus aureus

Meticillin-resistant Staphylococcus aureus (MRSA) is endemic in hospitals worldwide, and causes substantial morbidity and mortality. Health-care-associated MRSA infections arise in individuals with predisposing risk factors, such as surgery or presence of an indwelling medical device. By contrast, many community-associated MRSA (CA-MRSA) infections arise in otherwise healthy individuals who do not have such risk factors. Additionally, CA-MRSA infections are epidemic in some countries. These features suggest that CA-MRSA strains are more virulent and transmissible than are traditional hospital-associated MRSA strains. The restricted treatment options for CA-MRSA infections compound the effect of enhanced virulence and transmission. Although progress has been made towards understanding emergence of CA-MRSA, virulence, and treatment of infections, our knowledge remains incomplete. Here we review the most up-to-date knowledge and provide a perspective for the future prophylaxis or new treatments for CA-MRSA infections.

Prevalence and clonality of methicillin-resistant Staphylococcus aureus (MRSA) in the Atlantic Azores islands: predominance of SCCmec types IV, V and VI

In order to obtain insights into the methicillin-resistant Staphylococcus aureus (MRSA) population structure in the Azores archipelago, 106 MRSA isolates were collected from patients attending an Azorean central hospital between January 2007 and February 2008. Antimicrobial resistance was determined for all isolates. Molecular typing was performed by pulsed-field gel electrophoresis (PFGE), spa typing, multilocus sequence typing (MLST), staphylococcal chromosome cassette mec (SCCmec) typing and the presence of Panton–Valentine leukocidin (PVL). The majority of the isolates (87%, n = 92) belonged to the EMRSA-15 clone (ST22, SCCmec-IVh), followed by the Pediatric clone (ST5-VI/IVc) (11%, n = 12). The Berlin clone (ST45-IVa) and a new clone (spa type t1839, ST1339 and SCCmec V variant) were represented by single isolates. All of the isolates carried SCCmec types IV, V or VI and a non-multiresistant antibiotic profile, resembling the currently emerging community MRSA. Moreover, PVL was described for the first time to be associated with the Pediatric clone carrying SCCmec type VI. We provided the first description of the population structure of MRSA in the Azores islands, which seems to be shaped by genetic events occurring locally, as well as by the regular population exchange between the islands, continental Portugal, the United Kingdom and the United States.

Community-associated methicillin-resistant Staphylococcus aureus immune evasion and virulence

Staphylococcus aureus is a significant cause of human infections globally. Methicillin-resistant S. aureus (MRSA) emerged in the early 1960s and is now endemic in most healthcare facilities. Although healthcare-associated MRSA infections remain a major problem in most industrialized countries, those caused by community-associated MRSA (CA-MRSA) are now the most abundant cause of bacterial infections in the community in some parts of the world, such as the United States. The basis for the emergence and subsequent success of CA-MRSA is incompletely defined. However, the ability of the pathogen to cause disease in otherwise healthy individuals is likely attributed, in part, to its ability to circumvent killing by the innate immune system, which includes survival after phagocytosis by neutrophils. In this review, we discuss the role of neutrophils in host defense against S. aureus and highlight progress made toward understanding mechanisms of CA-MRSA virulence and pathogenesis.

Reemergence of antibiotic-resistant Staphylococcus aureus in the genomics era

Staphylococcus aureus is the leading cause of bacterial infections in developed countries and produces a wide spectrum of diseases, ranging from minor skin infections to fatal necrotizing pneumonia. Although S. aureus infections were historically treatable with common antibiotics, emergence of drug-resistant organisms is now a major concern. Methicillin-resistant S. aureus (MRSA) was endemic in hospitals by the late 1960s, but it appeared rapidly and unexpectedly in communities in the 1990s and is now prevalent worldwide. This Review focuses on progress made toward understanding the success of community-associated MRSA as a human pathogen, with an emphasis on genome-wide approaches and virulence determinants.