Molecular Typing and Resistance Profiles of Vancomycin-IntermediateStaphylococcus aureusin Korea: Results from a National Surveillance Study, 2007-2013

Lessons Learned from an Experience with Vancomycin-Intermediate Staphylococcus aureus Outbreak in a Newly Built Secondary Hospital in Korea

A vancomycin-intermediate Staphylococcus aureus (VISA) outbreak occurred in an intensive care unit (ICU) in South Korea. We aimed to investigate the condition that led to the VISA outbreak and seek measures to prevent further spread of the multidrug-resistant organism. A total of three VISA isolates were obtained from two patients and a health care worker (HCW) in a newly built 450-bed secondary hospital. Extensive screening of close contacts for VISA in terms of space sharing and physical contact, irrespective of contact time, was performed. Furthermore, multilocus sequence type, staphylococcal cassette chromosome mec type, and spa type profiles were determined for all VISA isolates. The relationship between vancomycin use and the minimum inhibitory concentration (MIC) of S. aureus was also investigated. Molecular typing showed that the strains of the three VISA isolates were identical, indicating horizontal hospital transmission. We assumed that VISA colonised in the HCW could have transmitted to the two patients, which resulted in one infection and one colonisation. The affected HCW was excused from work and was decolonised with mupirocin. Five weeks after the interventions, no additional VISA isolates were identified. No relationship between vancomycin use and MIC of S. aureus was identified. Extensive screening of contacts in addition to decolonisation is crucial in preventing the further spread of VISA.

Genomic Analysis of Heterogeneous Vancomycin-Intermediate Staphylococcus aureus Strains from Different Clonal Lineages in South Korea

Recent genomic studies of methicillin-resistant Staphylococcus aureus (MRSA) have revealed genetic diversity in the various clonal lineages. Along with clinical concerns of MRSA infection, infection with heterogeneous vancomycin-intermediate S. aureus (hVISA) is closely associated with treatment failure. In this study, we investigated the magnitude of genetic variation and features at the genomic level of hVISA strains isolated in South Korea. Four hVISA strains were analyzed by molecular epidemiology, antimicrobial susceptibility, and whole-genome sequencing methods, and they were compared with the reference VISA and vancomycin-susceptible S. aureus strains in the same clonal lineage. The epidemiologic features of hVISA strains were closely related to the ST5 and ST239 clones. Comparative analysis of the whole genome showed genetic mutations, particularly in two-component systems (TCSs) and transcriptional regulators. Genetic mutations in walK were commonly found in both ST5- (F545L, E378K, T500K) and ST239-related (E424D, T492R) hVISA strains. hVISA strains in the ST5 clonal lineage contained mutations in TCS genes, including the walK, vraR, and agr loci, whereas ST239-related strains harbored different genetic variations in walK, lytR, and saeR. This study suggests that the diverse genetic variation of TCSs and transcriptional regulators are involved in reduced vancomycin susceptibility through different mechanisms in each clonal lineage.

Molecular Characterization of Methicillin and Vancomycin Resistant Staphylococcus aureus Strains Isolated from Hospitalized Patients

Objectives: Nosocomial infections caused by methicillin resistant Staphylococcus aureus (MRSA) and emergence of vancomycin resistant S. aureus (VRSA) have led to great concern in healthcare settings worldwide. Methods: A total of 100 S. aureus clinical isolates from hospitalized patients were investigated for antimicrobial susceptibility, the presence of resistance (mecA, vanA, and vanB) and virulence (hlaA, fnbpA, cna, clfA, tsst-1, eta, and spa) encoding genes, and molecular typing based on polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) of spa gene. Results: All isolates were resistant to one or more antibiotics, with the most frequent resistance found against amoxicillin (69%). A total of 46 isolates were MRSA, and 40% of isolates were multidrug resistant (MDR). Of all S. aureus isolates, two isolates were confirmed as VRSA and four isolates confirmed as vancomycin intermediate S. aureus (VISA). The frequency of clfA, cna, tsst-1, and eta genes among MRSA isolates was significantly higher than methicillin sensitive S. aureus (MSSA). The significant correlation between MDR isolates and the carriage of multiple virulence genes was seen. All MDR isolates carried at least four virulence genes. Furthermore, biofilm formation in MRSA isolates was significantly higher than MSSA. The spa gene PCR products generated 4 major and 10 minor types. After digestion of spa amplicons with HindIII restriction enzyme, 10 different patterns ranging 174-938 bp were detected. S2b and S2a subtypes were detected frequently in MRSA isolates. Conclusions: It seems that the appropriate surveillance and control measures are essential to prevent the emergence and transmission of MRSA and VRSA strains in our country.