Clinical significance of coagulase-negative staphylococci isolates from nosocomial bloodstream infections

Bacteremia in the Gulf Cooperation Council Region: A Review of the Literature 2013-2023

Bloodstream infections (BSIs) are amongst the leading healthcare-associated infections (HCAIs), and their comprehensive evaluation and management are of global and regional importance. This narrative review examines and reports data on BSIs from the Gulf Cooperation Council (GCC) region covering the period between 2013 and 2023. The reviewed literature demonstrated that BSIs were frequently associated with critical care settings such as the Intensive Care Unit (ICU) and were often associated with invasive lines and devices [such as central-line associated BSI (CLABSI)]. Fever was the main presenting symptom, while diabetes mellitus and hypertension were the common associated comorbidities. High mortality rates were reported for BSIs, particularly when caused by multidrug-resistant (MDR) Gram-negative pathogens. There was a wide range of antimicrobial resistance rates reported across the region; however, carbapenem-resistance rates exceeding 30% were reported for Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae. Few publications included molecular mechanisms of carbapenem resistance; however, when mechanisms were reported they were dominated by OXA-48. In conclusion, the lack of structured surveillance programs and networks to monitor microbiological phenotypic and genotypic patterns as well as clinical outcomes across the region means there is paucity of uniform data on BSIs across the GCC region. To bridge this gap, we recommend timely surveillance programs for the monitoring of resistance and outcomes.

Global prevalence of macrolide-resistant Staphylococcus spp.: a comprehensive systematic review and meta-analysis

Background

Staphylococcus is a genus of bacteria responsible for various infections ranging from mild skin to severe systemic diseases. Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS) are significant challenges owing to their resistance to multiple antibiotics, including macrolides, such as erythromycin, clarithromycin, and azithromycin.

Objective

This study aimed to systematically review and synthesize data on the prevalence of macrolide resistance in Staphylococcus spp., identify trends and changes in resistance patterns over time, and assess how testing methods and guidelines affect reported resistance rates.

Methods

The study conducted a systematic search of the Scopus, PubMed, Web of Science, and EMBASE databases. Studies have reported the proportion of macrolide-resistant Staphylococcus spp. Two authors independently extracted and analyzed the data using a random-effects model. Heterogeneity was assessed, and subgroup analyses were performed based on country, continent, species, AST guidelines, methods, and period.

Results

In total, 223 studies from 76 countries were included. The pooled prevalence of resistance to erythromycin, clarithromycin, and azithromycin were 57.3, 52.6, and 57.9%, respectively. Significant heterogeneity was observed across studies (I2 > 95%, p < 0.001). Oceania (72%) had the highest erythromycin resistance, whereas Europe had the lowest (40.7%). Subgroup analyses revealed variations in resistance based on the species, with higher resistance in MRSA than in MSSA and CoNS than in other species. Over time, a slight decrease in erythromycin resistance has been observed (59.6% from 2015-2019 to 55% from 2020-2023).

Conclusion

This study emphasizes the high prevalence of macrolide resistance in Staphylococcus spp. and its notable regional variation. These findings highlight the necessity for standardized methodologies and global surveillance to manage macrolide resistance effectively. Controlling antibiotic resistance should prioritize enhancing public health measures and updating treatment guidelines.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=557756, CRD42024557756.

Detection and genetic characterization of multidrug-resistant staphylococci isolated from public areas in an international airport

The environmental realm has been acknowledged as a pivotal arena for the emergence and propagation of antimicrobial resistance. To further explore insight into antimicrobial resistance dynamics beyond clinical and veterinary settings, we embarked on an environmental surveillance initiative targeting the prevalence of antibiotic-resistant bacteria within the bustling confines of an international airport in Japan. Our findings illuminate a high prevalence of methicillin-resistant staphylococci (46.3%) on frequently contacted surfaces in the public domain. Notably, Staphylococcus haemolyticus and S. epidermidis emerged as the preeminent carriers of the mecA gene. Intriguingly, we encountered a virulent strain of livestock-associated MRSA harboring a PVL-positive ST1232 clone, CC398 lineage. Further scrutiny unveiled a repertoire of resistance mechanisms, the methicillin-resistant isolates exhibited two or more resistance genes conferring resistance against different types of antibiotics, including beta-lactams, macrolides, lincosamides, aminoglycosides, chloramphenicol, and fosfomycin. Revealing multidrug-resistant CoNS and a LA-MRSA across various surfaces in urban public areas unearths a looming public health hazard. Thus, implementation of molecular surveillance is imperative, augmenting our capacity for early detection and mitigation of the insidious spread and potential transfer of antibiotic resistance genes and virulence factors amidst urban settings, notably within pivotal nodes such as airports.

Staphylococcus aureus and Coagulase-Negative Staphylococci from Bloodstream Infections: Frequency of Occurrence and Antimicrobial Resistance, 2018-2021

BACKGROUND

The abuse of antibiotics during the SARS-CoV-2 pandemic might have disrupted efforts to curb the further development and spread of the antimicrobial resistance of Staphylococcus aureus infection and Staphylococcus spp. coagulase-negative (CoNS) agents of nosocomial bloodstream infections (NBSIs). The purpose of our work was to study the resistance patterns of Staphylococcus aureus and CoNS through the analysis of blood cultures in hospitalized SARS-CoV-2-positive and SARS-CoV-2-negative patients (pts.).

MATERIALS AND METHODS

During the period January 2018-June 2021, a retrospective case-control study was performed on blood cultures positive for Staphylococcus spp. detected in 177 adult pts. (≥18 years old) hospitalized for >48 hours at Sant'Elia Hospital, Caltanissetta.

RESULTS

Staphylococcus aureus was isolated in 33.9% of blood culture samples, and among CoNS, the most frequent strains were Staphylococcus capitis (18.6%) and Staphylococcus hominis (18.1%). Patients aged ≥ 65 years, with a greater number of males, comprised the SARS-CoV-2-negative pts. (71.8% vs. 52.2%, p = 0.0154). Among the SARS-CoV-2-positive patients, the significant resistance of Staphylococcus aureus was only observed for erythromycin (57.1%). The oxacillin resistance of Staphylococcus capitis was higher in SARS-CoV-2-positive than in negative pts. (90% and 78.3%, respectively). Comparing the two groups, we found an increase in resistance in SARS-CoV-2-negative patients for the following antibiotics: gentamicin for Staphylococcus aureus (p = 0.007), clindamycin and erythromycin (p = 0.012) for Staphylococcus hominis and oxacillin and rifampicin for Staphylococcus haemoliticus (p = 0.012).

CONCLUSIONS

Our study confirms the relevance of oxacillin-resistant Staphylococcus aureus in being responsible for bloodstream infection and draws attention to highly oxacillin-resistant CoNS such as Staphylococcus capitis. The presence of resistant strains of CoNS in hospitals can be worrying, as it limits treatment options and worsens outcomes. The Infection Control Committee (ICC) recommends new treatment strategies to decrease colonization and infections. As part of the implementation of a bloodstream infection prevention program, the authors encourage the introduction of a report on the antimicrobial resistance of hospital bacteremia due to CoNS.

Vancomycin heteroresistance among methicillin-resistant clinical isolates S. haemolyticus, S. hominis, S. simulans, and S. warneri

Besides being an essential part of the skin microbiome, coagulase-negative staphylococci are the etiological factors of serious infections. The aim of the study was to evaluate the heteroresistance to vancomycin and the potential antimicrobial efficacy of teicoplanin and daptomycin against the multiresistant strains of S. haemolyticus, S. hominis, S. warneri, and S. simulans. The study covered 80 clinical coagulase-negative staphylococci. Teicoplanin, vancomycin, and daptomycin MICs for the tested strains were determined according to EUCAST recommendation. The vanA and vanB genes were searched. The brain heart infusion screen agar method detected vancomycin heteroresistance. The population analysis profile method and analysis of autolytic activity were applied for the strains growing on BHI containing 4 mg/L vancomycin. Seven S. haemolyticus, two S. hominis, and two S. warneri strains presented a heterogeneous resistance to vancomycin. Their subpopulations were able to grow on a medium containing 4-12 mg/L of vancomycin. Monitoring heteroresistance to peptide antibiotics, which are often the last resort in staphylococcal infections, is essential due to the severe crisis in antibiotic therapy and the lack of alternatives to treat infections with multiresistant strains. Our work highlights the selection of resistant strains and the need for more careful use of peptide antibiotics.

Mucoid Staphylococcus haemolyticus: an unheeded multidrug-resistant pathogen

Coagulase-negative Staphylococci (CoNS) are among the most abundant members of human skin microbiome. CoNS have lately been recognized as substantial agents in plethora of infections, especially nosocomial infections in preterm infants and immunocompromised patients. Staphylococcus haemolyticus is the second most common species isolated from blood, and identification is further hindered when there is a deviation in morphology from the classical one. Here, we report an uncommon case of multidrug resistant mucoid S. hemolyticus isolated from blood in a patient of polytrauma. The patient was managed with ceftriaxone-sulbactam, gentamicin, and meropenem as empirical therapy, which was subsequently changed to intravenous vancomycin. The patient showed favorable response to treatment. Mucoid isolates are known to be more virulent and multi-drug resistant than the classical morphotypes. We also conducted systematic review to decipher the prevalence of mucoid S. hemolyticus and linezolid (LZD) resistance in the same. This case highlights the significance of awareness of mucoid phenotypes of Gram-positive cocci for clinical microbiologists to reach accurate identification. Resistance to LZD further underscores the need of restriction policies in hospitals and to roll out antimicrobial stewardship program stringently, so that the growing resistance could be contained.

Knowledge, Attitude and Practice Regarding Staphylococcus pettenkoferi

Staphylococcus pettenkoferi is a coagulase-negative staphylococcus, first described in 2002. Using medical databases, i.e., Scopus, Web of Science, Pubmed, and Embase, we identified and analysed research, reports, and opinions dealing with S. pettenkoferi. Published data allow us to conclude that S. pettenkoferi is a human commensal, opportunistic bacterium and may be isolated from the environment and animals. The involvement of S. pettenkoferi in bloodstream infection and osteomyelitis has been described, but its clinical relevance is not fully understood, so far. This work summarizes knowledge about S. pettenkoferi and reveals the difficulties and rules for interpreting the results of microbiological tests, when S. pettenkoferi has been identified in the blood sample. Clinical and laboratory criteria, recommended by Centers for Disease Control and Prevention (CDC) and the third international consensus definitions of sepsis and septic shock (Sepsis-3), are important to determine whether the presence of bacteria in the sample is a consequence of an infection, contamination from the environment, or translocation of the bacteria outside the place of its natural existence. The precise identification of bacteria from the blood sample and recognizing the true bacteraemia are critical to implement the appropriate procedures and make decisions concerning the patient’s medical care.

Antimicrobial Resistance Profiles of Coagulase-Negative Staphylococci in Community-Based Healthy Individuals in Germany

Coagulase-negative staphylococci (CoNS) are common opportunistic pathogens, but also ubiquitous human and animal commensals. Infection-associated CoNS from healthcare environments are typically characterized by pronounced antimicrobial resistance (AMR) including both methicillin- and multidrug-resistant isolates. Less is known about AMR patterns of CoNS colonizing the general population. Here we report on AMR in commensal CoNS recovered from 117 non-hospitalized volunteers in a region of Germany with a high livestock density. Among the 69 individuals colonized with CoNS, 29 had reported contacts to either companion or farm animals. CoNS were selectively cultivated from nasal swabs, followed by species definition by 16S rDNA sequencing and routine antibiotic susceptibility testing. Isolates displaying phenotypic AMR were further tested by PCR for presence of selected AMR genes. A total of 127 CoNS were isolated and Staphylococcus epidermidis (75%) was the most common CoNS species identified. Nine isolates (7%) were methicillin-resistant (MR) and carried the mecA gene, with seven individuals (10%) being colonized with at least one MR-CoNS isolate. While resistance against gentamicin, phenicols and spectinomycin was rare, high resistance rates were found against tetracycline (39%), erythromycin (33%) and fusidic acid (24%). In the majority of isolates, phenotypic resistance could be associated with corresponding AMR gene detection. Multidrug-resistance (MDR) was observed in 23% (29/127) of the isolates, with 33% (23/69) of the individuals being colonized with MDR-CoNS. The combined data suggest that MR- and MDR-CoNS are present in the community, with previous animal contact not significantly influencing the risk of becoming colonized with such isolates.

Investigation of Antimicrobial Susceptibilities Among Bacteria Isolated from Blood Cultures in Hospitalized Patients, Tehran, Iran

Background: Bacteremia is the status, which is detected via a positive blood culture test with no contamination. Centers for Disease Control and Prevention (CDC) indicates that direct medical procedures and total costs are significantly high. Antibiotic resistance can play a major role in the costs, which are related to the long duration of treatment. Objectives: The aim of this study was to investigate the rate and profiles of antimicrobial susceptibility of blood culture isolates from Tehran, Iran. Methods: In the current cross-sectional study, a total of 5,000 blood culture samples were collected from patients hospitalized in the Loghman General Hospital, Tehran, Iran, with positive blood culture results from 2012 to 2013. Susceptibility to antimicrobial agents was analyzed using National Committee for Clinical Laboratory Standards guidelines. Results: Coagulase-negative staphylococci (38.8%), Staphylococcus aureus (20.5%), Acinetobacter (11.9%), and Escherichia coli (11.7%) were the most frequent bacteria isolated from the blood cultures, collectively accounting for > 80% of the isolates. Of isolated microorganisms, 63.75% and 36.24% belonged to Gram-positive and Gram-negative bacteria, respectively. Moreover, 88% of the isolates were MRSA (oxacillin-/methicillin-resistant), and 7% were VRE (vancomycin-resistant). Conclusions: The most frequent isolated organisms were Gram-positive bacteria, and the rate of MDR (multi-drug resistance) was high. The results of the current study obviously indicate the misuse of antibiotic in society. National surveillance studies in Iran will be useful for clinicians to choose the right empirical treatment and will help control and prevent infections caused by resistant organisms.

Improved diagnostic prediction of the pathogenicity of bloodstream isolates of Staphylococcus epidermidis

With an estimated 440,000 active cases occurring each year, medical device associated infections pose a significant burden on the US healthcare system, costing about $9.8 billion in 2013. Staphylococcus epidermidis is the most common cause of these device-associated infections, which typically involve isolates that are multi-drug resistant and possess multiple virulence factors. S. epidermidis is also frequently a benign contaminant of otherwise sterile blood cultures. Therefore, tests that distinguish pathogenic from non-pathogenic isolates would improve the accuracy of diagnosis and prevent overuse/misuse of antibiotics. Attempts to use multi-locus sequence typing (MLST) with machine learning for this purpose had poor accuracy (~73%). In this study we sought to improve the diagnostic accuracy of predicting pathogenicity by focusing on phenotypic markers (i.e., antibiotic resistance, growth fitness in human plasma, and biofilm forming capacity) and the presence of specific virulence genes (i.e., mecA, ses1, and sdrF). Commensal isolates from healthy individuals (n = 23), blood culture contaminants (n = 21), and pathogenic isolates considered true bacteremia (n = 54) were used. Multiple machine learning approaches were applied to characterize strains as pathogenic vs non-pathogenic. The combination of phenotypic markers and virulence genes improved the diagnostic accuracy to 82.4% (sensitivity: 84.9% and specificity: 80.9%). Oxacillin resistance was the most important variable followed by growth rate in plasma. This work shows promise for the addition of phenotypic testing in clinical diagnostic applications.

Comparative Genomics Analysis Demonstrated a Link Between Staphylococci Isolated From Different Sources: A Possible Public Health Risk

Coagulase-negative staphylococci (CoNS) have been recovered from different ecological niches, however, little is known about the genetic relatedness of these isolates. In this study, we used whole genome sequencing to compare mecA positive (mecA ⁺) Staphylococcus epidermidis, Staphylococcus haemolyticus and Staphylococcus hominis isolates recovered from hand-touched surfaces from general public settings in East and West London with data of isolates deposited to European Nucleotide Archive (ENA) by other research groups. These included isolates associated with hospital settings (including those recovered from patients), healthy humans, livestock, pets, plants and natural, and other public environments. Using core and accessory phylogenetic analyses we were able to identify that the mecA⁺ S. epidermidis and S. haemolyticus isolates recovered from general public settings were genetically related to isolates recovered from the bloodstream, urinary tract and eye infections. S. epidermidis isolates recovered in our study were also shown to be genetically related to isolates previously recovered from livestock/livestock housing, whereas S. haemolyticus isolates were genetically related to isolates recovered from a dog and kefir (fermented cow milk drink). MecA ⁺ S. hominis isolates were not genetically related to any isolates recovered from clinical samples but were genetically related to isolates recovered from mosquitoes, air samples (residential areas) and kefir. All three species showed to have genetic relatedness to isolates recovered from healthy humans. These results show that CoNS isolates in this study share genetic similarities with those of different lineages and that mecA⁺ S. epidermidis and S. haemolyticus isolates found in general public settings in this study may pose a risk to public health.

Healthcare-Associated Laboratory-Confirmed Bloodstream Infections-Species Diversity and Resistance Mechanisms, a Four-Year Retrospective Laboratory-Based Study in the South of Poland

INTRODUCTION

Regardless of the country, advancements in medical care and infection prevention and control of bloodstream infections (BSIs) are an enormous burden of modern medicine.

OBJECTIVES

The aim of our study was to describe the epidemiology and drug-resistance of laboratory-confirmed BSI (LC-BSIs) among adult patients of 16 hospitals in the south of Poland.

PATIENTS AND METHODS

Data on 4218 LC-BSIs were collected between 2016-2019. The identification of the strains was performed using MALDI-TOF. Resistance mechanisms were investigated according to European Committee on Antimicrobial Susceptibility Testing, EUCAST recommendations.

RESULTS

Blood cultures were collected from 8899 patients, and LC-BSIs were confirmed in 47.4%. The prevalence of Gram-positive bacteria was 70.9%, Gram-negative 27.8% and yeast 1.4%. The most frequently isolated genus was Staphylococcus (50% of all LC-BSIs), with a domination of coagulase-negative staphylococci, while Escherichia coli (13.7%) was the most frequent Gram-negative bacterium. Over 4 years, 108 (2.6%) bacteria were isolated only once, including species from the human microbiota as well as environmental and zoonotic microorganisms. The highest methicillin resistant Staphylococcus aureus (MRSA) prevalence was in intensive care units (ICUs) (55.6%) but S. aureus with resistance to macrolides, lincosamides and streptogramins B (MLSB) in surgery was 66.7%. The highest prevalence of E. faecalis with a high-level aminoglycoside resistance (HLAR) mechanism was in ICUs, (84.6%), while E. faecium-HLAR in surgery was 83.3%. All cocci were fully glycopeptide-sensitive. Carbapenem-resistant Gram-negative bacilli were detected only in non-fermentative bacilli group, with prevalence 70% and more.

CONCLUSIONS

The BSI microbiology in Polish hospitals was similar to those reported in other studies, but the prevalence of MRSA and enterococci-HLAR was higher than expected, as was the prevalence of carbapenem-resistant non-fermentative bacilli. Modern diagnostic techniques, such as MALDI-TOF, guarantee reliable diagnosis.

Ca-Zn-Ag Alginate Aerogels for Wound Healing Applications: Swelling Behavior in Simulated Human Body Fluids and Effect on Macrophages

Chronic non-healing wounds represent a substantial economic burden to healthcare systems and cause a considerable reduction in quality of life for those affected. Approximately 0.5-2% of the population in developed countries are projected to experience a chronic wound in their lifetime, necessitating further developments in the area of wound care materials. The use of aerogels for wound healing applications has increased due to their high exudate absorbency and ability to incorporate therapeutic substances, amongst them trace metals, to promote wound-healing. This study evaluates the swelling behavior of Ca-Zn-Ag-loaded alginate aerogels and their metal release upon incubation in human sweat or wound fluid substitutes. All aerogels show excellent liquid uptake from any of the formulas and high liquid holding capacities. Calcium is only marginally released into the swelling solvents, thus remaining as alginate bridging component aiding the absorption and fast transfer of liquids into the aerogel network. The zinc transfer quota is similar to those observed for common wound dressings in human and animal injury models. With respect to the immune regulatory function of zinc, cell culture studies show a high availability and anti-inflammatory activity of aerogel released Zn-species in RAW 264.7 macrophages. For silver, the balance between antibacterial effectiveness versus cytotoxicity remains a significant challenge for which the alginate aerogels need to be improved in the future. An increased knowledge of the transformations that alginate aerogels undergo in the course of the fabrication as well as during wound fluid exposure is necessary when aiming to create advanced, tissue-compatible aerogel products.

Antimicrobial Resistance Profiling of Coagulase-Negative Staphylococci in a Referral Center in South Italy: A Surveillance Study

Background:

CoNS are part of the normal flora of the skin, upper respiratory tract and human intestine. CoNS are able to colonize host tissues or inert materials such as prosthetics, heart valves, pacemakers, and urinary and venous catheters. They can also internalize in host cells, thus eluding immune defenses and attack by antibiotics.

Objective:

In this study, we collected the epidemiological data and determined the antibiotic susceptibility of 828 CoNS, collected in Garibaldi Hospital (Catania, Italy) between January 2016 and October 2018.

Methods:

Strains were evaluated by determining the Minimum Inhibitory Concentration (MIC) using the broth microdilution method, according to the guidelines of the Clinical and Laboratory Standards Institute. The antibiotic sensitivity pattern of CoNS against eighteen antibiotics was determined.

Results:

For all the 828 clinical isolates, varying resistance rates were observed: ampicillin (87%), penicillin (86%), amoxicillin-clavulanate (71%), oxacillin (70%), erythromycin (69%), azithromycin (68%), levofloxacin (55%), ciprofloxacin (54%), gentamycin (47%), moxifloxacin (42%), trimethoprim-sulfamethoxazole (30%), clindamycin (28%), tetracycline (24%), rifampicin (20%), quinupristin-dalfopristin (synercid) (4%). No strains investigated demonstrated resistance to teicoplanin, vancomycin and linezolid.

Conclusion:

Our results highlight the importance of monitoring the evolution of CoNS resistance in order to implement control measures and reduce the risk of spread in the population.

Linezolid resistant coagulase negative staphylococci (LRCoNS) with novel mutations causing blood stream infections (BSI) in India

Background

Coagulase-negative Staphylococci (CoNS) have emerged as a major causative agent of blood-stream infections (BSI). Linezolid (LZD) is currently used for treating glycopeptide and methicillin-resistant staphylococci. It is important to understand the resistance mechanism and probable transmission of LZD resistant (LR) CoNS within the hospital.

Methods

Clinically significant LRCoNS from patients with BSI were characterized using MALDI-TOF and 16S rRNA gene sequence analysis. Antimicrobial susceptibility and MIC of vancomycin and LZD were determined. LZD resistance mechanisms using PCR for the cfr gene and mutation in the V domain of the 23S rRNA gene were studied.

Results

The MIC of LZD ranged from 8 to 32 μg/ml. LR was observed in three different CoNS species from diverse locations within the hospital. The cfr gene was identified in all the isolates. Sequence analysis of V domain region of 23S rRNA gene confirmed mutation in single copy among 12/15 isolates with novel mutations: G2614 T and C2384T. All infections were nosocomially acquired and LZD resistance was emerging in the absence of prior LZD use. Horizontal spread of resistant isolates and cfr gene among diverse species were the probable mechanisms of transmission.

Conclusion

The study highlights the novel mutations associated with LRCoNS and the importance of surveillance & transmission pathway within the hospital. It also systematically discusses the published information on LRCoNS.

The species distribution, antimicrobial resistance and risk factors for poor outcome of coagulase-negative staphylococci bacteraemia in China

Objective

Coagulase-negative staphylococci (CoNS) are one of the major opportunistic pathogens and the incidence of CoNS bacteraemia is increasing. However, most of the CoNS-positive blood cultures are contaminants rather than true CoNS bacteraemia. In order to minimize contamination, we defined true CoNS bacteraemia as the patient that has two or more identical CoNS-positive blood cultures drawn within 48 h in this study and the objective of this study was to analyse the species distribution and antibiotic resistance and to identify risk factors for 30-day mortality of the true CoNS-bacteraemia.

Method

By reviewing the electronic medical database, this study retrospectively analysed patients diagnosed as CoNS bacteraemia by blood cultures in a comprehensive tertiary care hospital in China from January 1, 2014, to December 31, 2017.

Result

A total of 1241 patients with 1562 episodes of CoNS-positive blood cultures were recorded in the database but only 157 patients were finally diagnosed as true CoNS bacteraemia after contaminants were excluded. All these 157 patients (12.7%, 157/1241) had bacteraemia-related clinical symptoms. Among the 157 patients, the most common species were Staphylococcus hominis (40.8%), Staphylococcus epidermidis (36.3%) and Staphylococcus capitis (11.5%). The antimicrobial susceptibility tests showed that all CoNS had a high rate of resistance to penicillin (94.9%), oxacillin (93.6%) and erythromycin (92.4%). Resistance to gentamicin (22.3%) and rifampicin (10.8%) was low, and none of the bacteria were resistant to vancomycin or linezolid. The 30-day mortality of patients with CoNS bacteraemia was up to 12.7% (20/157), and the multivariate logistics regression analysis showed that chronic renal failure (OR 5.9, 95% CI 1.6–21.5, p = 0.007) and chronic liver failure (OR 4.0, 95% CI 1.2–13.1, p = 0.024) were both the significant independent risk factors for the 30-day mortality of CoNS bacteraemia.

Conclusion

Staphylococcus hominis and Staphylococcus epidermidis were the most common species in CoNS bacteraemia. All CoNS had high multi-drug resistance, but gentamicin and rifampicin had a relatively lower resistance and could be considered as alternative antibiotics for anti-CoNS bacteraemia in addition to vancomycin and linezolid. Additionally, patients with chronic renal failure or chronic liver failure have a higher 30-day mortality after the onset of CoNS bacteraemia.

A Comprehensive Multilocus Sequence Typing Scheme for Identification and Genotyping of Staphylococcus Strains

Increasing clinical significance of coagulase-negative staphylococci requires effective methods for species identification and genotyping. In this study, six housekeeping genes (femA, ftsZ, gap, pyrH, rpoB, and tuf) with extensive allelic polymorphisms were identified and evaluated to develop a comprehensive multilocus sequence typing (MLST) scheme. Selected primers were capable of amplification of the six loci from all of the 180 Staphylococcus strains belonging to 18 different species. Sequence analysis of each locus (44-63 alleles) revealed higher nucleotide diversity than 16S rRNA (28 alleles). Phylogenetic analysis of the concatenated sequences (3054 bp) of the six loci provided accurate species identification and highly discriminatory typing for all the strains. Multilocus allelic analysis of the 180 Staphylococcus strains generated 103 different sequence profiles, suggesting high genetic diversity of the strains. For example, 30 S. aureus, 37 S. epidermidis, 32 S. haemolyticus, and 14 S. hominis strains were typed into 15, 21, 11, and 10 sequence profiles, respectively. Compared with published MLST schemes that restrict on a few particular species, this new scheme both achieved similar discrimination for typing S. aureus, S. epidermidis, S. haemolyticus, and S. hominis and provided sufficient discriminatory power for typing additional opportunistic species, such as S. cohnii, S. capitis, and S. warneri. Importantly, the comprehensive MLST scheme for Staphylococcus strains provides a better genotyping tool for understanding the phylogeny of coagulase-positive Staphylococcus aureus strains.

Multidrug-Resistant Bacteria Associated with Cell Phones of Healthcare Professionals in Selected Hospitals in Saudi Arabia

Cell phones may be an ideal habitat for colonization by bacterial pathogens, especially in hot climates, and may be a reservoir or vehicle in transmitting nosocomial infections. We investigated bacterial contamination on cell phones of healthcare workers in three hospitals in Saudi Arabia and determined antibacterial resistance of selected bacteria. A questionnaire was submitted to 285 healthcare workers in three hospitals, and information was collected on cell phone usage at the work area and in the toilet, cell phone cleaning and sharing, and awareness of cell phones being a source of infection. Screening on the Vitek 2 Compact system (bioMérieux Inc., USA) was done to characterize bacterial isolates. Of the 60 samples collected from three hospitals, 38 (63.3%) were positive with 38 bacterial isolates (4 Gram-negative and 34 Gram-positive bacteria). We found 38.3% of cell phones were contaminated with coagulase-negative staphylococci, particularly Staphylococcus epidermidis (10 isolates). Other bacterial agents identified were S. aureus, S. hominis, Alloiococcus otitis, Vibrio fluvialis, and Pseudomonas stutzeri. Antimicrobial susceptibility testing showed that most coagulase-negative staphylococci were resistant to benzylpenicillin, erythromycin, and rifampicin. Eight isolates were resistant to oxacillin, specifically S. epidermidis (3), S. hominis (2), and S. warneri (2). A. otitis, a cause of acute otitis media showed multidrug resistance. One isolate, a confirmed hetero-vancomycin intermediate-resistant S. aureus, was resistant to antibiotics, commonly used to treat skin infection. There was a significant correlation between the level of contamination and usage of cell phone at toilet and sharing. Our findings emphasize the importance of hygiene practices in cell phone usage among healthcare workers in preventing the transmission of multidrug-resistant microbes.

Staphylococcus haemolyticus epididymo-orchitis and bacteraemia: a case report

Introduction

Although more often recognized as a culprit in female urinary tract infection, coagulase-negative staphylococci (CoNS) can cause severe genitourinary infections in men. While positive blood cultures with CoNS are usually thought to be contaminants, in the setting of a severe genito-urinary infection they can represent true infection.

Case presentation

We present the case of a 70-year-old male without a central venous catheter or urinary catheter who developed Staphylococcus haemolyticus bloodstream infection secondary to epididymo-orchitis.

Conclusion

This case highlights the importance of prompt recognition of serious CoNS infections, including bacteraemia, in the setting of CoNS genitourinary tract infections.

Clinical features, outcomes, and molecular characteristics of an outbreak of Staphylococcus haemolyticus infection, among a mass-burn casualty patient group, in a tertiary center in northern Taiwan

BACKGROUND/PURPOSE

We reported an outbreak of Staphylococcus haemolyticus (SH) infection in a group of young patients (mean age 21.6) simultaneously hospitalized due to a mass-burn incident. This study analyzed the clinical features of these patients and the microbiological characteristics of the outbreak.

METHODS

All 50 patients hospitalized for burns were enrolled, and their clinical differences were analyzed based on culture results. A drug sensitivity test and pulsed-field gel electrophoresis (PFGE) were conducted to analyze the microbiological difference between SH isolates from the mass-burn casualty patients (the study group) and SH isolates from other patients hospitalized during the same period (the control group) with the intention of identifying the strain of SH outbreak.

RESULTS

Patients with isolated SH (N = 36) had a significantly higher disease severity (higher revised Baux score, APACHE II score, and concurrent bacteremia rate), and a significantly poorer clinical outcome (longer ICU and hospital stay, and longer MV usage). Significant differences in the phenotype (antibiotics drug sensitivity test) and genotype (PFGE typing) were observed between the study and control groups. The dominant PFGE type C identified among the study group was related to poorer outcomes in a subgroup analysis.

CONCLUSION

A dominant PFGE type of SH infection was found in these mass-burn casualty patients. Pathogenesis or virulence factors may have contributed to our results. Further study of isolated SH should be conducted.

Coagulase-negative staphylococcal bacteraemia in cancer patients. Time to positive culture can distinguish bacteraemia from contamination

BACKGROUND

Coagulase-negative staphylococci (CoNS) are the most common contaminants of blood cultures, however, we sometimes have difficulties in determining their clinical significance. It is still controversial that there is a significant difference between the contamination group and the true bacteraemia group in the time to positivity (TTP) of blood cultures. We validated the relationship between a TTP and the presence of CoNS bacteraemia in cancer patients by using an objective, non-judgmental definition for CoNS contamination.

METHODS

We retrospectively reviewed 175 sets of blood cultures drawn from 95 patients that yielded CoNS from October 2011 to March 2013. We considered as contamination if an isolate of CoNS was identified in one out of multiple sets of blood cultures. We investigated the TTP, the threshold values and corresponding likelihood ratios to distinguish CoNS bacteraemia from contamination.

RESULTS

The median TTP in CoNS bacteraemia group was significantly shorter than that in contamination group (14 h 45 min and 20 h 31 min, respectively, p = .0157). A TTP of ≤16 h had a specificity of 83% for predicting CoNS bacteraemia, and that of >20 h had a sensitivity of 86% for predicting CoNS contamination.

CONCLUSIONS

We validated that the median TTP in CoNS bacteraemia group was significantly shorter than that in their contamination group, and that a TTP of ≤16 h was associated with CoNS bacteraemia, while that of >20 h was associated with CoNS contamination, if evaluated with an objective, non-judgmental definition for CoNS contamination.

CRISPR-Cas Systems Features and the Gene-Reservoir Role of Coagulase-Negative Staphylococci

The claimed role of gene reservoir of coagulase-negative staphylococci (CoNS) could be contradicted by estimates that CRISPR/Cas systems are found in the genomes of 40–50% of bacteria, as these systems interfere with plasmid uptake in staphylococci. To further correlate this role with presence of CRISPR, we analyzed, by computational methods, 122 genomes from 15 species of CoNS. Only 15% of them harbored CRISPR/Cas systems, and this proportion was much lower for S. epidermidis and S. haemolyticus, the CoNS most frequently associated with opportunistic infections in humans. These systems are of type II or III, and at least two of them are located within SCCmec, a mobile genetic element of Staphylococcus bacterial species. An analysis of the spacers of these CRISPRs, which come from exogenous origin, allowed us to track the transference of the SCCmec, which was exchanged between different strains, species and hosts. Some of the spacers are derived from plasmids described in Staphylococcus species that are different from those in which the CRISPR are found, evidencing the attempt (and failure) of plasmid transference between them. Based on the polymorphisms of the cas1 gene in CRISPRs of types II and III, we developed a multiplex polymerase chain reaction (PCR) suitable to screen and type CRISPR systems in CoNS. The PCR was tested in 59 S. haemolyticus strains, of which only two contained a type III cas1. This gene was shown to be expressed in the exponential growth, stationary phase and during biofilm formation. The low abundance of CRISPRs in CoNS is in accordance with their role as gene reservoirs, but when present, their spacers sequence evidence and give an insight on the dynamics of horizontal genetic transfer among staphylococci.

Should first-line empiric treatment strategies cover coagulase-negative staphylococcal infections in severely malnourished or HIV-infected children in Kenya?

Background

Bloodstream infection is a common cause of morbidity in children aged <5 years in developing countries. In studies reporting bacteremia in Africa, coagulase-negative Staphylococci (CoNS) are commonly isolated. However, it is currently unclear whether children who are highly susceptible to infection because of severe acute malnutrition (SAM) or HIV should be treated with antimicrobials specifically to cover CoNS. We aimed to determine the clinical significance of CoNS amongst children admitted to a rural hospital in Kenya in relation to nutritional and HIV status.

Methods

Systematically collected clinical and microbiological surveillance data from children aged 6–59 months admitted to Kilifi County Hospital (2007–2013) were analysed. Multivariable regression was used to test associations between CoNS isolation from blood cultures and SAM (MUAC <11.5cm or nutritional oedema (kwashiorkor)), and HIV serostatus; and among children with SAM or HIV, associations between CoNS isolation and mortality, duration of hospitalization and clinical features.

Results

CoNS were isolated from blood culture in 906/13,315 (6.8%) children, of whom 135/906 (14.9%) had SAM and 54/906 (6.0%) were HIV antibody positive. CoNS isolation was not associated with SAM (MUAC<11.5cm (aOR 1.11, 95% CI 0.88–1.40) or kwashiorkor (aOR 0.84, 95% CI 0.48–1.49)), or a positive HIV antibody test (aOR 1.25, 95% CI 0.92–1.71). Among children with SAM or a positive HIV antibody test, CoNS isolation was not associated with mortality or prolonged hospitalization.

Conclusion

In a large, systematic study, there was no evidence that antimicrobial therapy should specifically target CoNS amongst children with SAM or HIV-infection or exposure.

Expression of the stress-response regulators CtsR and HrcA in the uropathogen Staphylococcus saprophyticus during heat shock

The uropathogen Staphylococcus saprophyticus is an ubiquitous bacterium but little is known about mechanisms that allow its persistence in diverse environments. Here we evaluated S. saprophyticus growth and survival during heat shock, the expression of stress response regulators ctsR and hrcA through qRT-PCR and heat shock protein synthesis through ³⁵S-Met metabolic labeling. S. saprophyticus does not tolerate temperatures much higher than the optimal 37 °C, as its growth is greatly affected at 42 °C, though viability is maintained up to 48 °C. At 42 °C, the expression of ctsR and hrcA repressor genes approximately triple when compared to 37 °C and continue to increase together with temperature till 48 °C. Expression of hrcA peaks after 20 min of heat shock and decreases significantly after 30 min, indicating that heat stress response regulated by this gene may last 20-30 min. An increase in temperature is accompanied by the synthesis of at least eight proteins, three of which are likely the chaperones DnaK, GroEL and ClpB. In silico analysis indicate that the groEL gene may be regulated by HrcA, clpB by CtsR and dnaK by both repressors. This is the first work to discuss heat stress response in S. saprophyticus and a step forward in the understanding of mechanisms that make this a widespread and emergent pathogen.