Methicillin and Vancomycin Resistant S. aureus in Hospitalized Patients

Antimicrobial resistance in India: A review

Antimicrobial resistance is an important concern for the public health authorities at global level. However, in developing countries like India, recent hospital and some community based data showed increase in burden of antimicrobial resistance. Research related to antimicrobial use, determinants and development of antimicrobial resistance, regional variation and interventional strategies according to the existing health care situation in each country is a big challenge. This paper discusses the situational analysis of antimicrobial resistance with respect to its problem, determinants and challenges ahead with strategies required in future to reduce the burden in India. Recent data from Google search, Medline and other sources were collected which was reviewed and analyzed by the authors. Hospital based studies showed higher and varied spectrum of resistance in different regions while there are limited number of community based studies at country level. There exists lacunae in the structure and functioning of public health care delivery system with regard to quantification of the problem and various determining factors related to antimicrobial resistance. There is an urgent need to develop and strengthen antimicrobial policy, standard treatment guidelines, national plan for containment of AMR and research related to public health aspects of AMR at community and hospital level in India.

Recurrent Challenges for Clinicians: Emergence of Methicillin-Resistant Staphylococcus aureus, Vancomycin Resistance, and Current Treatment Options

Gram-positive pathogens mainly, Staphylococcus aureus, Enterococcus and coagulase-negative Staphylococcus, are developing increasing resistance to glycopeptides that pose a problem in treating infections caused by these pathogens. Vancomycin is the treatment of choice in treating methicillin-resistant S. aureus (MRSA). Community-acquired MRSA is associated with infections in patients without recent history of hospital admission and without the classical risk factors for MRSA carriage (including healthcare personnel). MRSA poses new threats and challenges beyond the hospital with the emergence of community-acquired MRSA. Indiscriminate use of vancomycin leads to the emergence and spread of vancomycin resistance in multidrug resistant strains is of growing concern in the recent years. Minimum Inhibitory concentration (MIC) remains an important determinant in choosing the right antibiotics. Infections caused by MRSA strains with vancomycin MIC > 4 μg/mL leads to the vancomycin treatment failure. The Clinical Laboratory Standards Institute had also lowered the cut-off susceptibility and resistance breakpoints for vancomycin. Despite the availability of newer antimicrobial agents (Linezolid, Daptomycin, Tigecycline) for drug-resistant Gram-positive pathogens, clinicians and patients still need options for treatment of MRSA infection. There is a need to reduce the global burden of infections caused by Gram-positive pathogens and its resistant strains (mainly MRSA). Continuous efforts should be made to prevent the spread and the emergence of glycopeptide resistance by early detection of the resistant strains and using the proper infection control measures in the hospital setting.

Unexpected Multidrug Resistance of Methicillin-Resistant Staphylococcus aureus in Urine Samples: A Single-Center Study

PURPOSE

Infections of methicillin-resistant Staphylococcus aureus (MRSA) are becoming an increasingly concerning clinical problem. The aim of this study was to assess the development of MRSA in urine cultures in a major public university-affiliated hospital and the therapeutical and hygiene-related possibilities for reducing resistance.

MATERIALS AND METHODS

This study included 243 samples from patients diagnosed with MRSA infection over a period of 6 years. An agar diffusion test measured the effects of antimicrobial agents against bacteria grown in culture. The analyses were based on the guidelines of the Clinical and Laboratory Standards Institute.

RESULTS

A regression analysis was performed, which showed 100% resistance to the following antibiotics throughout the entire testing period: carbapenem, cephalosporin (1st-4th generation), penicillin G, aminopenicillin, β-lactamase, and isoxazolyl penicillin. However, a significant decrease in resistance was found for amikacin, gentamicin, clindamycin, levofloxacin, erythromycin, and mupirocin.

CONCLUSIONS

MRSA showed a decreasing trend of antimicrobial resistance, except against carbapenem, cephalosporin (1st-4th generation), penicillin G, aminopenicillin, β-lactamase, and isoxazolyl penicillin, for which complete resistance was observed.

Comparison of In-vitro Activities of Linezolid and Vancomycin against Staphylococcus aureus Isolated from A Tertiary Care Hospital

BACKGROUND

Methicillin resistant Staphylococcus aureus (MRSA) has emerged as one of the commonest cause of hospital acquired infections worldwide. Vancomycin is the antibiotic of choice for treatment of MRSA, but due to slow increase in vancomycin minimum inhibitory concentration (MIC) (vancomycin creep),Vancomycin has become a suboptimal therapeutic option in critically ill patients. Linezolid has emerged as an alternative drug in the treatment of such cases.

AIM

To compare in vitro activities of linezolid and vancomycin against Staphylococcus aureus, in order to help in formulating a better treatment.

METHOD

200 strains of Staphylococcus aureus were isolated from different clinical specimens between April 2010 to March 2011. Antibiotic sensitivity testing was performed by Kirby Bauer disc diffusion method and MICs of vancomycin and linezolid were determined for all 200 strains by agar dilution method by following CLSI guidelines.

RESULTS

Among 200 strains, MIC for linezolid was 4 μg/ml for 3 strains, MIC was 2 μg/ml for 71 strains, and MIC was 1 μg/ml for 126 strains, while for the same 200 strains of Staphylococcus aureus, MIC of vancomycin was 4 μg/ml for 8 strains, it was 2 μg/ml for 103 strains and it was 1 μg/ml for 89 strains.

CONCLUSION

Linezolid and vancomycin had similar in-vitro efficacies for Staphylococcus aureus in disc diffusion method, but the number of strains with higher ranges of MICs of vancomycin (1-4 μg/ml) were more as compared to those which had higher ranges of MICs for linezolid. So, we suggest that linezolid can be a good alternative for the treatment of multidrug resistant Staphylococcus aureus as compared to vancomycin.

A systematic review of animal models for Staphylococcus aureus osteomyelitis

Staphylococcus aureus (S. aureus) osteomyelitis is a significant complication for orthopaedic patients undergoing surgery, particularly with fracture fixation and arthroplasty. Given the difficulty in studying S. aureus infections in human subjects, animal models serve an integral role in exploring the pathogenesis of osteomyelitis, and aid in determining the efficacy of prophylactic and therapeutic treatments. Animal models should mimic the clinical scenarios seen in patients as closely as possible to permit the experimental results to be translated to the corresponding clinical care. To help understand existing animal models of S. aureus, we conducted a systematic search of PubMed and Ovid MEDLINE to identify in vivo animal experiments that have investigated the management of S. aureus osteomyelitis in the context of fractures and metallic implants. In this review, experimental studies are categorised by animal species and are further classified by the setting of the infection. Study methods are summarised and the relevant advantages and disadvantages of each species and model are discussed. While no ideal animal model exists, the understanding of a model's strengths and limitations should assist clinicians and researchers to appropriately select an animal model to translate the conclusions to the clinical setting.

The essentiality of staphylococcal Gcp is independent of its repression of branched-chain amino acids biosynthesis

Our previous studies revealed that the staphylococcal protein Gcp is essential for bacterial growth; however, the essential function of Gcp remains undefined. In this study, we demonstrated that Gcp plays an important role in the modulation of the branched-chain amino acids biosynthesis pathway. Specifically, we identified that the depletion of Gcp dramatically elevated the production of key enzymes that are encoded in the ilv-leu operon and responsible for the biosynthesis of the branched-chain amino acids isoleucine, leucine, and valine (ILV) using proteomic approaches. Using qPCR and promoter-lux reporter fusions, we established that Gcp negatively modulates the transcription of the ilv-leu operon. Gel-shift assays revealed that Gcp lacks the capacity to bind the promoter region of ilv. Moreover, we found that the depletion of Gcp did not influence the transcription level of CodY, a known repressor of the ilv-leu operon, while induced the transcription of CcpA, a known positive regulator of the ilv-leu operon. In addition, the depletion of Gcp decreased the biosynthesis of N⁶-threonylcarbamoyladenosine (t6A). To elucidate whether the essentiality of Gcp is attributable to its negative modulation of ILV biosynthesis, we determined the impact of the ilv-leu operon on the requirement of Gcp for growth, and revealed that the deletion of the ilv-leu operon did not affect the essentiality of Gcp. Taken together, our results indicate that the essentiality of Gcp isn’t attributable to its negative regulation of ILV biosynthesis in S. aureus. These findings provide new insights into the biological function of the staphylococcal Gcp.

Antimicrobial susceptibility and molecular subtypes of Staphylococcus aureus isolated from pig tonsils and cow's milk in China

This study investigated and compared the antimicrobial resistance patterns and ribotypes of Staphylococcus aureus isolated from pig tonsils and cow's milk in China. A total of 90 isolates of S. aureus was included: 42 strains were isolated from tonsils of pigs and 48 from half-udder milk. The broth microdilution method and the double-disc diffusion test (D test) were used for antimicrobial susceptibility testing. The mecA gene for methicillin-resistant S. aureus (MRSA) and the ermA, ermB, ermC, and msrA genes for erythromycin-resistant strains were detected by polymerase chain reaction (PCR). The isolates were ribotyped with the Riboprinter system. The highest frequency of resistance was observed with clindamycin (91.1%), followed by penicillin (90.0%), and erythromycin (85.6%). All strains were susceptible to vancomycin and trimethoprim-sulfamethoxazole. The D test showed that 54.5% (42/77) of erythromycin-resistant isolates had the constitutive resistance phenotype and 45.5% (35/77) had the inducible resistance phenotype to clindamycin. A higher proportion of resistance to cephalosporins, macrolides, fluoroquinolones, and pleuromutilins was observed in pig isolates than in milk isolates (P < 0.05). The mecA gene was detected in all MRSA isolates; 89.6% of erythromycin-resistant strains harbored the ermC gene and 16.9% harbored the ermB gene. A total of 35 different ribogroups was found among the isolates investigated; 83.3% of pig strains belonged to 1 cluster with a similarity coefficient of 0.84. In contrast, 3 main clusters were observed among 68.8% of milk strains, which indicates a high degree of host specificity.

Antimicrobial activity of geranium oil against clinical strains of Staphylococcus aureus

The aim of this work was to investigate the antibacterial properties of geranium oil obtained from Pelargonium graveolens Ait. (family Geraniaceae), against one standard S. aureus strain ATCC 433000 and seventy clinical S. aureus strains. The agar dilution method was used for assessment of bacterial growth inhibition at various concentrations of geranium oil. Susceptibility testing of the clinical strains to antibiotics was carried out using the disk-diffusion and E-test methods. The results of our experiment showed that the oil from P. graveolens has strong activity against all of the clinical S. aureus isolates—including multidrug resistant strains, MRSA strains and MLS_B-positive strains—exhibiting MIC values of 0.25–2.50 μL/mL.

ε/ζ systems: their role in resistance, virulence, and their potential for antibiotic development

Cell death in bacteria can be triggered by activation of self-inflicted molecular mechanisms. Pathogenic bacteria often make use of suicide mechanisms in which the death of individual cells benefits survival of the population. Important elements for programmed cell death in bacteria are proteinaceous toxin-antitoxin systems. While the toxin generally resides dormant in the bacterial cytosol in complex with its antitoxin, conditions such as impaired de novo synthesis of the antitoxin or nutritional stress lead to antitoxin degradation and toxin activation. A widespread toxin-antitoxin family consists of the ε/ζ systems, which are distributed over plasmids and chromosomes of various pathogenic bacteria. In its inactive state, the bacteriotoxic ζ toxin protein is inhibited by its cognate antitoxin ε. Upon degradation of ε, the ζ toxin is released allowing this enzyme to poison bacterial cell wall synthesis, which eventually triggers autolysis. ε/ζ systems ensure stable plasmid inheritance by inducing death in plasmid-deprived offspring cells. In contrast, chromosomally encoded ε/ζ systems were reported to contribute to virulence of pathogenic bacteria, possibly by inducing autolysis in individual cells under stressful conditions. The capability of toxin-antitoxin systems to kill bacteria has made them potential targets for new therapeutic compounds. Toxin activation could be hijacked to induce suicide of bacteria. Likewise, the unique mechanism of ζ toxins could serve as template for new drugs. Contrarily, inhibition of virulence-associated ζ toxins might attenuate infections. Here we provide an overview of ε/ζ toxin-antitoxin family and its potential role in the development of new therapeutic approaches in microbial defense.

The C-terminal domain of the novel essential protein Gcp is critical for interaction with another essential protein YeaZ of Staphylococcus aureus

Previous studies have demonstrated that the novel protein Gcp is essential for the viability of various bacterial species including Staphylococcus aureus; however, the reason why it is required for bacterial growth remains unclear. In order to explore the potential mechanisms of this essentiality, we performed RT-PCR analysis and revealed that the gcp gene (sa1854) was co-transcribed with sa1855, yeaZ (sa1856) and sa1857 genes, indicating these genes are located in the same operon. Furthermore, we demonstrated that Gcp interacts with YeaZ using a yeast two-hybrid (Y2H) system and in vitro pull down assays. To characterize the Gcp-YeaZ interaction, we performed alanine scanning mutagenesis on the residues of C-terminal segment of Gcp. We found that the mutations of the C-terminal Y317-F322 region abolished the interaction of Gcp and YeaZ, and the mutations of the D324-N329 and S332-Y336 regions alleviated Gcp binding to YeaZ. More importantly, we demonstrated that these key regions of Gcp are also necessary for the bacterial survival since these mutated Gcp could not complement the depletion of endogenous Gcp. Taken together, our data suggest that the interaction of Gcp and YeaZ may contribute to the essentiality of Gcp for S. aureus survival. Our findings provide new insights into the potential mechanisms and biological functions of this novel essential protein.

Anti-Glucosaminidase Monoclonal Antibodies as a Passive Immunization for Methicillin-Resistant Staphylococcus aureus (MRSA) Orthopaedic Infections

Recently, methicillin-resistant Staphylococcus aureus (MRSA) has surpassed HIV as the most deadly pathogen in the United States, accounting for over 100,000 deaths per year. In orthopedics, MRSA osteomyelitis has become the greatest concern in patient care, despite the fact that improvements in surgical technique and aggressive antibiotic prophylaxis have decreased the infection rate for most procedures to less than 5%. This great concern is largely due to the very poor outcomes associated with MRSA osteomyelitis, which includes 30-50% failure rates for revision surgery. Thus, there is a need to develop additional therapeutic interventions such as passive immunization, particularly for immunocompromised patients and the elderly who are typically poor responders to active vaccines. Using a novel murine model of implant-associated osteomyelitis in which a stainless steel pin is coated with bioluminescent S. aureus and implanted transcortically through the tibial metaphysis, we discovered that mice protect themselves from this infection by mounting a specific IgG2b response against the peptidoglycan hydrolase, glucosaminidase (Gmd), an enzyme involved in cell wall digestion during binary fission. Since this subunit of S. aureus autolysin is essential for bacterial growth, and no genetic variation has been identified among clinical strains, we propose that monoclonal antibodies against this enzyme would have multiple mechanisms of action, including promotion of opsonophagocytosis and direct inhibition of enzyme function. Here we review the field of MRSA osteomyelitis and our research to date on the development of an anti-Gmd passive immunotherapy.

A type IV modification-dependent restriction enzyme SauUSI from Staphylococcus aureus subsp. aureus USA300

A gene encoding a putative DNA helicase from Staphylococcus aureus USA300 was cloned and expressed in Escherichia coli. The protein was purified to over 90% purity by chromatography. The purified enzyme, SauUSI, predominantly cleaves modified DNA containing 5mC and 5-hydroxymethylcytosine. Cleavage of 5mC-modified plasmids indicated that the sites S5mCNGS (S = C or G) are preferentially digested. The endonuclease activity requires the presence of adenosine triphosphate (ATP) or dATP whereas the non-hydrolyzable γ-S-ATP does not support activity. SauUSI activity was inhibited by ethylenediaminetetraacetic acid. It is most active in Mg⁺⁺ buffers. No companion methylase gene was found near the SauUSI restriction gene. The absence of a cognate methylase and cleavage of modified DNA indicate that SauUSI belongs to type IV restriction endonucleases, a group that includes EcoK McrBC and Mrr. SauUSI belongs to a family of highly similar homologs found in other sequenced S. aureus, S. epidermidis and S. carnosus genomes. More distant SauUSI orthologs can be found in over 150 sequenced bacterial/archaea genomes. Finally, we demonstrated the biological function of the type IV REase in restricting 5mC-modified plasmid DNA by transformation into clinical S. aureus strain SA564, and in restricting phage λ infection when the endonuclease is expressed in E. coli.