Incidence, prevalence, and management of MRSA bacteremia across patient populations-a review of recent developments in MRSA management and treatment

Mobile genetic elements responsible for discordant Staphylococcus aureus phenotypes and genotypes in the same blood culture bottle

Approximately 15-20% of the S. aureus genome contains mobile genetic elements that can cause discrepancies between phenotypic and genotypic identification methods. Three blood culture bottles (each from a different patient) that showed discordant results, were shown to contain 2 S. aureus isolates after additional subcultures. One bottle had MRSA and MSSA that by DNA sequence analysis differed only by 31 kb; however, the deletions encompassed parts of SCCmec including mecA and SCC_M1. The second bottle contained MRSA and MSSA that differed by 124 kb; the MSSA was missing the entire SCCmec and spa regions. The last bottle contained 2 MRSA, one with ACME II disrupting SCCmec and a 24 bp spa deletion. The deletions in SCCmec and the other elements gave rise to the discrepancies between molecular and the original culture results. Such discrepancies should prompt a search for additional strains in the blood culture bottle.

Eight years of sales surveillance of antimicrobials for veterinary use in Germany-What are the perceptions?

A surveillance system for sales volumes of antimicrobial agents for veterinary use was established in Germany in 2011. Since then, pharmaceutical companies and wholesalers have been legally obliged to report annual volumes of veterinary antimicrobial products sold to veterinary practices or clinics located in Germany. The evaluation of sales volumes for eight consecutive years resulted in a considerable total decrease by 58% from 1706 tons to 722 tons. During the investigation period, two legally binding measures to control the risk of antimicrobial resistance resulting from the veterinary use of antimicrobials were introduced, a) the German treatment frequencies benchmarking in 2014 and b) the obligation to conduct susceptibility testing for the use of cephalosporins of the 3^rd and 4^th generation and of fluoroquinolones in 2018. Both had a marked impact on sales volumes. Nonetheless, the category of Critically Important Antimicrobials as defined by the World Health Organization kept accounting for the highest share on sales volumes in Germany in 2018 with 403 tons, despite an overall reduction by 53%. Sales surveillance is considered essential for data retrieval on a global scale and inter-country comparison. However, the usability of a surveillance system based on sales data for risk management of antimicrobial resistance has limitations. The German system does not include off-label use of antimicrobial products authorized for human medicine and does not allow for identification of areas of high risk according to animal species, farm and production types and indications for treatment. For further reduction and enhanced promotion of a prudent use of antimicrobials, targeted measures would be required that could only be deducted from use data collected at farm or veterinary practice level. A surveillance system based on use data is currently lacking in Germany but will be established according to Regulation (EU) 2019/6 on veterinary medicinal products.

Characterization of Clinical MRSA Isolates from Northern Spain and Assessment of Their Susceptibility to Phage-Derived Antimicrobials

Methicillin-resistant Staphylococcus aureus (MRSA) is a prevalent nosocomial pathogen, causing a wide range of diseases. The increased frequency of MRSA isolates in hospitals and the emergence of vancomycin resistance have sparked the search for new control strategies. This study aimed to characterize sixty-seven MRSA isolates collected from both infected patients and asymptomatic carriers in a Spanish hospital. RAPD-PCR allowed the identification of six genetic patterns. We also investigated the presence of genes involved in producing adhesins, toxins and the capsule; the biofilm; and antimicrobial resistance. A notable percentage of the isolates carried virulence genes and showed medium-high ability to form biofilms. Next, we assessed the strains' susceptibility to two phages (phiIPLA-C1C and phiIPLA-RODI) and one endolysin (LysRODI). All strains were resistant to phiIPLA-C1C, and most (70.2%) were susceptible to phiIPLA-RODI. Regarding LysRODI, all strains displayed susceptibility, although to varying degrees. There was a correlation between endolysin susceptibility and the random amplification of polymorphic DNA (RAPD) profile or the presence of some virulence genes (fnbA, eta, etb, PVL and czr), but that was not observed with biofilm-forming ability, strain origin or phage sensitivity. Taken together, these findings can help to explain the factors influencing endolysin effectiveness, which will contribute to the development of efficient therapies targeting MRSA infections.

The rapid and visual detection of methicillin-susceptible and methicillin-resistant Staphylococcus aureus using multiplex loop-mediated isothermal amplification linked to a nanoparticle-based lateral flow biosensor

Background

Staphylococcus aureus (S. aureus), including methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA), is an eminent human pathogen that can colonize the human host and cause severe life-threatening infections. The development of a reliable, simple and rapid assay for detecting S. aureus and identifying MRSA is important for diagnosis and follow-up treatment.

Methods

A novel molecular diagnosis technique, named multiplex loop-mediated isothermal amplification linked to a nanoparticle-based lateral flow biosensor (m-LAMP-LFB), was applied to detect all S. aureus species and identify MRSA. Two sets of primers were designed based on the femA gene (S. aureus-specific gene) and the mecA gene (encoding penicillin-binding protein 2a), and the multiple-LAMP products were analyzed using LFB. The m-LAMP-LFB amplification conditions, including the target DNA concentration, reaction temperature and time, were optimized. The sensitivity and specificity of the m-LAMP-LFB method were tested in the current study, and the multiple-LAMP-LFB technology was applied to detect the MSSA and MRSA strains from clinical samples.

Results

The S. aureus- and MRSA-specific primers based on the femA and mecA genes allowed the multiple-LAMP technology to detect S. aureus and MRSA, respectively. The multiple-LAMP conditions were optimized at 63 °C for 40 min. The full process, including genomic DNA template preparation, LAMP, and product identification, could be achieved in 80 min. The limit of detection (LoD) of the multiple-LAMP assay for femA and mecA detection was 100 fg of genomic DNA template per reaction. The specificity of m-LAMP-LFB detection was 100 %, and no cross-reactions to non-S. aureus strains were observed.

Conclusion

The multiple-LAMP-LFB technique developed in the current study is a reliable, simple, rapid, specific and sensitive method to identify MSSA and MRSA infections for appropriate antibiotic therapy.

Design, synthesis and in vivo evaluation of 3-arylcoumarin derivatives of rhenium(I) tricarbonyl complexes as potent antibacterial agents against methicillin-resistant Staphylococcus aureus (MRSA)

We have prepared a series of ten 3-arylcoumarin molecules, their respective fac-[Re(CO)₃(bpy)L]⁺ and fac-[Re(CO)₃(L⁀L)Br] complexes and tested all compounds for their antimicrobial efficacy. Whereas the 3-arylcoumarin ligands are virtually inactive against the human-associated pathogens with minimum inhibitory concentrations (MICs) > 150 μM, when coordinated to the fac-[Re(CO)₃]⁺ core, most of the resulting complexes showed remarkable antibacterial potency. Several rhenium complexes exhibit activity in nanomolar concentrations against Gram-positive pathogens such as Staphylococcus aureus strains, including methicillin-resistant S. aureus (MRSA) and Enterococcus faecium. The molecules do not affect bacterial cell membrane potential, but some of the most potent complexes strongly interact with DNA, indicating it as a possible target for their mode of action. In vivo studies in the zebrafish model showed that the complexes with anti-staphylococcal/MRSA activity were non-toxic to the organism even at much higher doses of the corresponding MICs. In the zebrafish-MRSA infection model, the complexes increased the survival rate of infected fish up to 100% and markedly reduced bacterial burden. Moreover, all rescued fish developed normally following the treatments with the metallic compounds.

Genetic Characterization of Methicillin-Resistant Staphylococcus aureus Isolates from Human Bloodstream Infections: Detection of MLSB Resistance

In this study we aimed to characterize antimicrobial resistance in methicillin-resistant Staphylococcus aureus (MRSA) isolated from bloodstream infections as well as the associated genetic lineages of the isolates. Sixteen MRSA isolates were recovered from bacteremia samples from inpatients between 2016 and 2019. The antimicrobial susceptibility of these isolates was tested by the Kirby–Bauer disk diffusion method against 14 antimicrobial agents. To determine the macrolide–lincosamide–streptogramin B (MLS_B) resistance phenotype of the isolates, erythromycin-resistant isolates were assessed by double-disk diffusion (D-test). The resistance and virulence genes were screened by polymerase chain reaction (PCR). All isolates were characterized by multilocus sequence typing (MLST), spa typing, staphylococcal chromosomal cassette mec (SCCmec) typing, and accessory gene regulator (agr) typing. Isolates showed resistance to cefoxitin, penicillin, ciprofloxacin, erythromycin, fusidic acid, clindamycin, and aminoglycosides, confirmed by the presence of the blaZ, ermA, ermC, mphC, msrA/B, aac(6’)-Ie-aph(2’’)-Ia, and ant(4’)-Ia genes. Three isolates were Panton–Valentine-leukocidin-positive. Most strains (n = 12) presented an inducible MLS_B phenotype. The isolates were ascribed to eight spa-types (t747, t002, t020, t1084, t008, t10682, t18526, and t1370) and four MLSTs (ST22, ST5, ST105, and ST8). Overall, most (n = 12) MRSA isolates had a multidrug-resistance profile with inducible MLS_B phenotypes and belonged to epidemic MRSA clones.

Simulation models for transmission of health care-associated infection: A systematic review

BACKGROUND

Health care-associated infections (HAIs) are a global health burden because of their significant impact on patient health and health care systems. Mechanistic simulation modeling that captures the dynamics between patients, pathogens, and the environment is increasingly being used to improve understanding of epidemiological patterns of HAIs and to facilitate decisions on infection prevention and control (IPC). The purpose of this review is to present a systematic review to establish (1) how simulation models have been used to investigate HAIs and their mitigation and (2) how these models have evolved over time, as well as identify (3) gaps in their adoption and (4) useful directions for their future development.

METHODS

The review involved a systematic search and identification of studies using system dynamics, discrete event simulation, and agent-based model to study HAIs.

RESULTS

The complexity of simulation models developed for HAIs significantly increased but heavily concentrated on transmission dynamics of methicillin-resistant Staphylococcus aureus in the hospitals of high-income countries. Neither HAIs in other health care settings, the influence of contact networks within a health care facility, nor patient sharing and referring networks across health care settings were sufficiently understood.

CONCLUSIONS

This systematic review provides a broader overview of existing simulation models in HAIs to identify the gaps and to direct and facilitate further development of appropriate models in this emerging field.

Microbial Distribution and Antibiotic Susceptibility of Lower Respiratory Tract Infections Patients From Pediatric Ward, Adult Respiratory Ward, and Respiratory Intensive Care Unit

Introduction

Lower respiratory tract infections (LRTIs) account for significant morbidity and mortality in patients admitted to hospitals worldwide, especially in children and elderly. The prevalent microorganisms and antibiotic susceptibility were investigated among LRTI patients from the pediatric ward, adult respiratory ward, and respiratory intensive care unit (RICU) in order to achieve more efficient treatment protocols and better recovery.

Methods

In this retrospective cross-sectional study (January 2016 to December 2019), 4,161 positive culture samples out of 18,798 different specimens (9,645 respiratory tract samples and 9,153 blood samples) from LRTI patients were analyzed for pathogen incidence and antibiotic sensitivity.

Results

Among the respiratory tract cultures, the frequency of Gram-negative bacterial strains was higher than Gram-positive bacterial strains. Pseudomonas aeruginosa was the dominant pathogen in both the adult respiratory ward (n = 156, 21.49%) and RICU (n = 975, 35.67%), whereas Staphylococcus aureus (n = 66, 19.19%) was the most common bacterium in the pediatric ward. Among the blood cultures, Gram-positive bacteria remained the major microorganisms involved in LRTIs, and the most frequent pathogen was Staphylococcus epidermidis (n = 59, 47.20%) in the pediatric ward and Staphylococcus aureus (n = 10, 21.8%) in adult respiratory ward. However, Gram-negative bacteria were the main pathogens in the RICU, of which Klebsiella pneumoniae (n = 51, 27.57%) is the most prevalent. Pseudomonas aeruginosa of LRTI patients remained highly susceptible (>70%) to routine antibiotics in pediatric ward. However, it only had high susceptibility to amikacin, tobramycin, gentamicin in both the adult respiratory ward and RICU and its antibiotic sensitivity to meropenem and imipenem was moderate in the adult respiratory ward and mild (<30%) in the RICU. Staphylococcus aureus isolated from LRTI patients was highly susceptible to linezolid, daptomycin, teicoplanin, vancomycin, tigecycline, rifampicin, and trimethoprim/sulfamethoxazole in all three wards, moderately susceptible to gentamicin in both the adult respiratory ward and RICU and to clindamycin, oxacillin, moxifloxacin only in the adult respiratory ward.

Conclusions

Microbial distribution and their patterns of antibiotic susceptibility revealed a high divergence among LRTI patients admitted to different wards in this hospital. Thus, different antibiotic therapies should be considered for distinct age groups.

Pathogens of peritoneal dialysis peritonitis: Trends from a single-center experience over 15 years

Background

Concerns are increasing about the emergence of pathogens with antibiotic resistance in peritoneal dialysis (PD) peritonitis. We investigated the current pathogen trends and risk factors in PD peritonitis.

Methods

We conducted a retrospective study analyzing data from 643 patients who maintained PD over 3 months between January 2001 and December 2015. The isolated pathogens from PD peritonitis were compared between period A (2001-2008) and period B (2009-2015).

Results

Among 643 PD patients, 252 patients experienced one or more episodes of PD peritonitis (total 308 episodes) during the median follow-up of 66 months. In both periods, gram-positive bacteria were the dominant pathogens (22.2% vs. 53.8%, P < 0.01). Gram-negative bacteria showed an increasing tendency in period B, but without statistical significance (17.0% vs. 23.7%, P = 0.15). The culture-negative rate was improved from 57% in period A to 18% in period B (P < 0.01). There was no increase in the prevalence of resistant pathogens such as methicillin-resistant Staphylococcus epidermidis (MRSE), Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli between periods A and B. Preserved residual renal function was associated with a lower risk of PD peritonitis (odds ratio, 0.53; 95% confidence interval, 0.31-0.88; P = 0.01).

Conclusion

Over the past two decades, the pathogens of PD peritonitis have not significantly changed in Korea. Gram-positive organisms remained dominant, with S. epidermidis being the most common pathogen. Resistant bacteria such as MRSE, MRSA, ESBL-producing Gram-negative bacilli did not increase, but should be monitored.

Understanding the Fight Against Resistance: Hospital-Acquired Methicillin-Resistant Staphylococcus Aureus vs. Community-Acquired Methicillin-Resistant Staphylococcus Aureus

Since the identification of Staphylococcus (S.) aureus, penicillin was exclusively used to combat its disastrous toxic effects. Shortly thereafter, resistant strains arose, which were no longer susceptible to penicillin or methicillin treatments. These strands were later identified as methicillin-resistant Staphylococcus aureus (MRSA). Two particular MRSA strands that are discussed below are the hospital-acquired methicillin-resistant Staphylococcus aureus (HA-MRSA) strands and the community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) strands. Despite arising from a single bacterium, S. aureus, each of these two strands possesses quite different resistance and virulence factors. These differences contribute to the type of population in which they affect, their ability to resist traditional treatment approaches, and their overall morbidity and mortality rates. We explore these differences by reviewing several review articles published on various reputable scientific online databases. Findings include sources from studies conducted in the United States, China, Nepal, and Uganda, ranging from 2006 to 2019. These resistance and virulence factors, the Staphylococcal cassette cartridge mecA resistance gene (SCCmec) and the Panton-Valentine Leukocidin toxin gene (PVL), were identified and isolated in each of these studies in order to appreciate similarities and differences in how they impact human beings.

Effect of the Lysin Exebacase on Cardiac Vegetation Progression in a Rabbit Model of Methicillin-Resistant Staphylococcus aureus Endocarditis as Determined by Echocardiography

Methicillin-resistant Staphylococcus aureus (MRSA) poses significant therapeutic challenges related to its frequency in clinical infections, innate virulence properties, and propensity for multiantibiotic resistance. MRSA is among the most common causes of endovascular infections, including infective endocarditis (IE). Our objective was to employ transthoracic echocardiography (TTE) to evaluate the effect of exebacase, a novel direct lytic agent, in experimental aortic valve MRSA IE. TTE was utilized to evaluate the in vivo effect of exebacase on MRSA-infected vegetation progression when combined with daptomycin (versus daptomycin alone). Primary intravegetation outcomes were maximum size, weights at sacrifice, and MRSA counts at infection baseline versus after 4 days of daptomycin treatment (alone or in addition to exebacase administered once on treatment day 1). A single dose of exebacase in addition to daptomycin cleared significantly more intravegetation MRSA than daptomycin alone. This was associated with a statistical trend toward reduced maximum vegetation size in the exebacase plus daptomycin versus the daptomycin alone therapy groups (P = 0.07). Also, mean vegetation weights in the exebacase-treated group were significantly lower than those of the daptomycin alone group (P < 0.0001). Maximum vegetation size by TTE correlated with vegetation weight (P = 0.005). In addition, intravegetation MRSA counts in the combination group were significantly lower than those of untreated controls (P < 0.0001) and the daptomycin alone group (P < 0.0001). This study suggests that exebacase has a salutary impact on MRSA-infected vegetation progression when combined with daptomycin, especially in terms of vegetation MRSA burden, size, and weight. Moreover, TTE appears to be an efficient noninvasive tool to assess therapeutic efficacies in experimental MRSA IE.

A case study on Staphylococcus aureus bacteraemia: available treatment options, antibiotic R&D and responsible antibiotic-use strategies

Objectives

This case study addresses: (i) antibiotic treatment options for Staphylococcus aureus bacteraemia (SAB), for both empirical and targeted therapy; (ii) the current status of and priorities for the antibiotic pipeline to ensure access of effective antibiotics for SAB; and (iii) strategies for responsible antibiotic use relevant to the clinical management of SAB.

Methods

Evidence to address the aims was extracted from the following information sources: (i) EUCAST and CLSI recommendations, summaries of product characteristics (SPCs), antibiotic treatment guidelines and the textbook Kucers’ The Use of Antibiotics; (ii) the www.clinicaltrial.gov database; and (iii) quality indicators for responsible antibiotic use.

Results

Current monotherapy treatment options for SAB include only three drug classes (β-lactams, glycopeptides and lipopeptides), of which two also cover MRSA bacteraemia (glycopeptides and lipopeptides). The analysis of the antibiotic pipeline and ongoing clinical trials revealed that several new antibiotics with S. aureus (including MRSA) coverage were developed in the past decade (2009–19). However, none belonged to a new antibiotic class or had superior effectiveness and their added clinical value for SAB remains to be proven. Responsible antibiotic use for the treatment of SAB was illustrated using 11 quality indicators.

Conclusions

Awareness of the problem of a limited antibiotic arsenal, together with incentives (e.g. push incentives), is needed to steer the R&D landscape towards the development of novel and effective antibiotics for treating SAB. In the meantime, responsible antibiotic use guided by quality indicators should preserve the effectiveness of currently available antibiotics for treating SAB.

Evaluation of anti-biofilm activity of acidic amino acids and synergy with ciprofloxacin on Staphylococcus aureus biofilms

Acidic amino acids, aspartic acid (Asp) and glutamic acid (Glu) can enhance the solubility of many poorly soluble drugs including ciprofloxacin (Cip). One of the mechanisms of resistance within a biofilm is retardation of drug diffusion due to poor penetration across the matrix. To overcome this challenge, this work set to investigate novel counter ion approach with acidic amino acids, which we hypothesised will disrupt the biofilm matrix as well as simultaneously improve drug effectiveness. The anti-biofilm activity of D-Asp and D-Glu was studied on Staphylococcus aureus biofilms. Synergistic effect of combining D-amino acids with Cip was also investigated as a strategy to overcome anti-microbial resistance in these biofilms. Interestingly at equimolar combinations, D-Asp and D-Glu were able to significantly disperse (at 20 mM and 40 mM) established biofilms and inhibit (at 10 mM, 20 mM and 40 mM) new biofilm formation in the absence of an antibiotic. Moreover, our study confirmed L-amino acids also exhibit anti-biofilm activity. The synergistic effect of acidic amino acids with Cip was observed at lower concentration ranges (<40 mM amino acids and <90.54 µM, respectively), which resulted in 96.89% (inhibition) and 97.60% (dispersal) reduction in CFU with exposure to 40 mM amino acids. Confocal imaging indicated that the amino acids disrupt the honeycomb-like extracellular DNA (eDNA) meshwork whilst also preventing its formation.

Rapid Approach for Detection of Antibiotic Resistance in Bacteria Using Vibrational Spectroscopy

Here, we applied vibrational spectroscopy to investigate the drug response following incubation of S. aureus with oxacillin. The main focus of this work was to identify the chemical changes caused by oxacillin over time and to determine the feasibility of the spectroscopic approach to detect antimicrobial resistance. The oxacillin-induced changes in the chemical composition of susceptible bacteria, preceding (and leading to) the inhibition of growth, included an increase in the relative content of nucleic acids, alteration in the α-helical/β-sheet protein ratio, structural changes in carbohydrates (observed via changes in the band at 1035 cm^-1), and significant thickening of the cell wall. These observations enabled a dose-dependent discrimination between susceptible bacteria incubated with and without oxacillin after 120 min. In methicillin resistant strains, no spectral differences were observed between cells, regardless of drug exposure. These results pave the way for a new, rapid spectroscopic approach to detect drug resistance in pathogens, based on their early positive/negative drug response.

Antimicrobial resistance three ways: healthcare crisis, major concepts and the relevance of biofilms

Worldwide, infections are resuming their role as highly effective killing diseases, as current treatments are failing to respond to the growing problem of antimicrobial resistance (AMR). The social and economic burden of AMR seems ever rising, with health- and research-related organizations rushing to collaborate on a worldwide scale to find effective solutions. Resistant bacteria are spreading even in first-world nations, being found not only in healthcare-related settings, but also in food and in the environment. In this minireview, the impact of AMR in healthcare systems and the major bacteria behind it are highlighted. Ecological aspects of AMR evolution and the complexity of its molecular mechanisms are explained. Major concepts, such as intrinsic, acquired and adaptive resistance, as well as tolerance and heteroresistance, are also clarified. More importantly, the problematic of biofilms and their role in AMR, namely their main resistance and tolerance mechanisms, are elucidated. Finally, some of the most promising anti-biofilm strategies being investigated are reviewed. Much is still to be done regarding the study of AMR and the discovery of new anti-biofilm strategies. Gladly, considerable research on this topic is generated every day and increasingly concerted actions are being engaged globally to try and tackle this problem.

Effect of extracellular vesicles from S. aureus-challenged human neutrophils on macrophages

Staphylococcus aureus enhances neutrophil extracellular vesicle (EV) production. To investigate whether S. aureus viability influences EV biogenesis, EVs were isolated from human neutrophils incubated with viable bacteria (bEVs) or heat-killed bacteria (heat-killed EVs). Protein analysis, nanoparticle tracking and transmission electron microscopy showed comparable EV production between subsets, and both viable and nonviable bacteria were also detected in respective EV subsets. As anticipated, S. aureus, as well as bEVs with viable bacteria, were proinflammatory, and killing bacteria with gentamicin reduced cytokine production to baseline levels. Although heat-killed bacteria induced macrophage IL-6 production, heat-killed EVs did not. Additionally, we found that human and bacterial DNA associated with bEVs, but not heat-killed EVs, and that the DNA association could be partially decreased by disrupting electrostatic interactions. We investigated the potential for DNA isolated from EVs (EV-DNA) or EVs to cause inflammation. Although liposomal encapsulation of EV-DNA increased IL-6 production from baseline by 7.5-fold, treatment of bEVs with DNase I had no effect on IL-6 and IL-1β production, suggesting that the DNA did not contribute to the inflammatory response. Filtered EVs, which lacked DNA and associated bacteria, exhibited less proinflammatory activity relative to bEVs, and enhanced macrophage expression of CD86 and HLA-DR. Ultimately, we show that bEVs isolated by differential centrifugation co-purify with bacteria and DNA, and studying their concerted activity and relative contribution to immune response is important to the study of host-pathogen interactions.

Multi-Drug-Resistant Organisms in Burn Infections

Background: Infection is the most frequent complication after severe burns and remains the predominant cause of death. Burn patients may require multiple courses of antibiotics, lengthy hospitalizations, and invasive procedures that place burn patients at especially high risk for infections with multi-drug-resistant organisms (MDROs). Methods: The published literature on MDROs in burn patients was reviewed to develop a strategy for managing these infections. Results: Within a burn unit meticulous infection prevention and control measures and effective antimicrobial stewardship can limit MDRO propagation and decrease the antibiotic pressure driving the selection of MDROs from less resistant strains. Several new antimicrobial agents have been developed offering potential therapeutic options, but familiarity with their benefits and limitations is required for safe utilization. Successful management of MDRO burn infections is supported by a multifactorial approach. Novel non-antibiotic therapeutics may help combat MDRO infections and outbreaks. Conclusions: Multi-drug-resistant organisms are being identified with increasing frequency in burn patients. Effective sensitivity testing is essential to identify MDROs and to direct appropriate antibiotic choices for patient treatment.

Dynamic Changes of Staphylococcus aureus Susceptibility to Vancomycin, Teicoplanin, and Linezolid in a Central Teaching Hospital in Shanghai, China, 2008-2018

Vancomycin, teicoplanin, and linezolid are the major treatment options for methicillin-resistant Staphylococcus aureus (MRSA). The phenomenon of progressive increase in the value of vancomycin minimum inhibitory concentration (MIC) for S. aureus (i.e., vancomycin MIC “creep”), has been reported; however, it is still a controversial concept because the results of research remain inconclusive. In this study, we conducted a retrospective epidemiologic investigation for more than 10 years to elucidate the dynamic changes of the MICs of vancomycin, teicoplanin, and linezolid in S. aureus in a central teaching hospital in Shanghai, China. A total of 2911 S. aureus isolates was recovered from 2008 to 2018, to which the MICs of three antimicrobials were tested by the E-test method and subsequently correlated with the characteristics of oxacillin susceptibility, clonotypes, and antimicrobial consumption during the study period. The proportion of MRSA dramatically decreased from 2008 to 2018 (from 84 to 49%, p < 0.001). Vancomycin MIC decline was identified both in MRSA and methicillin-sensitive S. aureus (MSSA) (both with p < 0.001), and both the dominating MRSA clone ST5 and pre-dominating MRSA clone ST239 displayed vancomycin MIC decline (p < 0.001, p = 0.040), while teicoplanin MIC decline was only identified in MRSA (p = 0.037). Linezolid MIC creep was identified in total S. aureus (p < 0.001), but linezolid in MRSA as well as teicoplanin and linezolid in MSSA displayed no statistically distinct trends of MIC creep or decline. Clinical consumption of linezolid increased significantly from 2012 to 2018 (p = 0.003), which correlated with vancomycin MIC decline in S. aureus (p = 0.005). The results of this study clearly demonstrate the dynamic changes of the MICs of these three primary antimicrobials in S. aureus, and suggest that changes in clinical antibiotic use may affect bacterial resistance.

Complete Genome Sequence of Community-Acquired Methicillin-Resistant Staphylococcus aureus Strain RJ1267, Isolated in Shanghai, China

Staphylococcal pathogens, especially multidrug-resistant Staphylococcus aureus, are responsible for various clinical infections. Multilocus sequence type 630 (ST630) methicillin-resistant Staphylococcus aureus has been shown to have augmented pathogenicity in humans. In this announcement, we report the complete genome sequence of community-acquired methicillin-resistant strain RJ1267 of Staphylococcus aureus ST630.

Staphylococcal pathogens, especially multidrug-resistant Staphylococcus aureus, are responsible for various clinical infections. Multilocus sequence type 630 (ST630) methicillin-resistant Staphylococcus aureus has been shown to have augmented pathogenicity in humans. In this announcement, we report the complete genome sequence of community-acquired methicillin-resistant strain RJ1267 of Staphylococcus aureus ST630.

Platinum ions mediate the interactions between DNA and carbon quantum dots: diagnosis of MRSA infections

In this study, we have developed a rapid and cost-effective method employing platinum ion (Pt4+)-capped fluorescent carbon quantum dots (CQDs) coupled with loop-mediated isothermal amplification (LAMP) to detect dual MRSA genes. We synthesized nitrogen- and chlorine-co-doped fluorescent CQDs (CQDSPDs) from spermidine trihydrochloride via a simple one-step pyrolysis. The CQDSPDs capped with Pt4+ ions through the cooperative coordination of the amine and chlorine groups on the surface of CQDs facilitated the double-stranded DNA (dsDNA)-induced fluorescence quenching of CQDs, and enabled the construction of the CQDSPDs/Pt4+ probe for the detection of as few as 10 copies of the MRSA gene (mecA and femA). The sensitivity and specificity of the CQDSPDs/Pt4+ probe for MRSA detection in clinical specimens (n = 24) were 94% and 86%, respectively. Our results reveal that the CQDSPDs/Pt4+ probe has great potential for the diagnosis of antibiotic-resistant superbugs with high sensitivity, specificity, and agreement.

Antibacterial and ATP Synthesis Modulating Compounds from Salvia tingitana

A surface extract of the aerial parts of Salvia tingitana afforded a nor-sesterterpenoid (1) and eight new sesterterpenoids (2-̵9), along with five known sesterterpenoids, five labdane and one abietane diterpenoid, one sesquiterpenoid, and four flavonoids. The structures of the new compounds were established by 1D and 2D NMR spectroscopy, HRESIMS, and VCD data and Mosher's esters analysis. The antimicrobial activity of compounds was evaluated against 30 human pathogens including 27 clinical strains and three isolates of marine origin for their possible implications on human health. The methyl ester of salvileucolide (10), salvileucolide-6,23-lactone (11), sclareol (15), and manool (17) were the most active against Gram-positive bacteria. The compounds were also tested for the inhibition of ATP production in purified mammalian rod outer segments. Terpenoids 10, 11, 15, and 17 inhibited ATP production, while only 17 inhibited also ATP hydrolysis. Molecular modeling studies confirmed the capacity of 17 to interact with mammalian ATP synthase. A significant reduction of ATP production in the presence of 17 was observed in Enterococcus faecalis and E. faecium isolates.

Levonadifloxacin, a Novel Benzoquinolizine Fluoroquinolone, Modulates Lipopolysaccharide-Induced Inflammatory Responses in Human Whole-Blood Assay and Murine Acute Lung Injury Model

Fluoroquinolones are reported to possess immunomodulatory activity; hence, a novel benzoquinolizine fluoroquinolone, levonadifloxacin, was evaluated in lipopolysaccharide-stimulated human whole-blood (HWB) and mouse acute lung injury (ALI) models. Levonadifloxacin significantly mitigated the inflammatory responses in an HWB assay through inhibition of proinflammatory cytokines and in the ALI model by lowering lung total white blood cell count, myeloperoxidase, and cytokine levels. The immunomodulatory effect of levonadifloxacin, along with promising antibacterial activity, is expected to provide clinical benefits in the treatment of infections.

Biophysical differentiation of susceptibility and chemical differences in Staphylococcus aureus

Differentiating bacteria strains using biophysical forces has been the focus of recent studies using dielectrophoresis (DEP). The refinement of these studies has created high-resolution separations such that very subtle properties of the cells are enough to induce significant differences in measurable biophysical properties. These high-resolution capabilities build upon the advantages of DEP which include small sample sizes and fast analysis times. Studies focusing on differentiating antimicrobial resistant and susceptible bacteria potentially have significant impact on human health and medical care. A prime example is Staphylococcus aureus, which commonly colonizes adults without ill effects. However, the pathogen is an important cause of infections, including surgical site infections. Treatment of S. aureus infections is generally possible with antimicrobials, but antimicrobial resistance has emerged. Of special importance is resistance to methicillin, an antimicrobial created in response to resistance to penicillin. Here, dielectrophoresis is used to study methicillin-resistant (MRSA) and -susceptible S. aureus (MSSA) strains, both with and without the addition of a fluorescent label. The capture onset potential of fluorescently-labeled MRSA (865 ± 71 V) and thus the ratio of electrokinetic to dielectrophoretic mobility, was found to be higher than that of fluorescently-labeled MSSA (685 ± 61 V). This may be attributable to the PBP2a enzyme present in the MRSA strain and not in the MSSA bacteria. Further, unlabeled MRSA was found to have a capture onset potential of 732 ± 44 V, while unlabeled MSSA was found to have a capture onset potential of 562 ± 59 V. This shows that the fluorescently-labeled bacteria require a higher applied potential, and thus ratio of mobilities, to capture than the unlabeled bacteria.

Prenatal exposure of staphylococcal enterotoxin B attenuates the development and function of blood regulatory T cells to repeated staphylococcal enterotoxin B exposure in adult offspring rats

Introduction. Staphylococcal enterotoxin B (SEB) is an extensively studied super-antigen. A previous study by us suggested that SEB exposure during pregnancy could alter the percentage of CD4+ and CD8+ T cells in the peripheral blood of neonatal offspring rats.Aim. It is unknown whether SEB exposure during pregnancy can influence the development of regulatory T cells (Tregs) in the peripheral blood of neonatal offspring rats.Methodology. Pregnant rats at gestational day 16 were intravenously injected with 15 µg SEB. Peripheral blood was acquired from neonatal offspring rats on days 1, 3 and 5 after delivery and from adult offspring rats for determination of Treg number by cytometry, cytokines by ELISA, and FoxP3 expression by real-time PCR and western blot.Results. SEB given to pregnant rats significantly increased the absolute number of Tregs and the expression levels of FoxP3, IL-10 and TGF-β (P<0.05, P<0.01) in the peripheral blood of not only neonatal but also adult offspring rats. Furthermore, repeated SEB exposure in adult offspring rats significantly decreased the absolute number of Tregs (P<0.01), and the expression levels of FoxP3, IL-10 and TGF-β (P<0.05, P<0.01) in their peripheral blood.Conclusion. Prenatal SEB exposure attenuates the development and function of Tregs to repeated SEB exposure in the peripheral blood of adult offspring rats.

Characterization of an ST5-SCCmec II-t311 methicillin-resistant Staphylococcus aureus strain with a widespread cfr-positive plasmid

PURPOSE

To determine the genetic characteristics of the Chinese epidemic ST5-SCCmec II-t311 methicillin-resistant Staphylococcus aureus (MRSA) clone and to investigate the transmission characteristics of the cfr-positive plasmid.

METHODS

The complete genome of SR153 was sequenced. Genomic comparison with MRSA strains of other lineages was performed. The cfr-positive plasmid was investigated and compared with other cfr-positive plasmids from different origins and different areas.

RESULTS

The cfr-positive MRSA strain SR153 was a Chinese epidemic ST5-SCCmec II-t311 strain. It clustered much closer to the Japanese ST5-SCCmec II clone than to the European and American ST5-SCCmec II clones. The genome of SR153 contains one circular chromosome and three plasmids. It harbors the genomic islands νSaα, νSaβ, νSaγ, ΦSa1 and ΦSa3, the pathogenicity island νSa4, and genes encoding virulence factors such as tst and many enterotoxins. The SR153 genome also contains several resistance genes and mutations, such as ermA, aadD, spc, aacA-aphD, lnuA, tetK, blaZ and mutations in grlA and gyrA. SR153 harbors a cfr-positive plasmid, pSR01, which is highly similar to pSX01 from a Staphylococcus xylosus of pig origin from Henan Province. pSR01 was also highly similar to pXWZ from a Staphylococcus capitis and pLRSA417 from S. aureus. Both were obtained from geographically separated hospitals in Zhejiang Province.

CONCLUSIONS

SR153, which clustered closely to the Japanese ST5-SCCmec II clone, is more resistant than N315. A pSR01-like cfr-positive plasmid was widespread among different Staphylococcus species of both human and animal origin in different hospitals and areas.

Synthesis, In Vitro and In Silico Studies of Indolequinone Derivatives against Clinically Relevant Bacterial Pathogens

Background:

According to the World Health Organization, antimicrobial resistance is one of the most important public health threats of the 21st century. Therefore, there is an urgent need for the development of antimicrobial agents with new mechanism of action, especially those capable of evading known resistance mechanisms.

Objective:

We described the synthesis, in vitro antimicrobial evaluation, and in silico analysis of a series of 1H-indole-4,7-dione derivatives.

Methods:

The new series of 1H-indole-4,7-diones was prepared with good yield by using a copper(II)- mediated reaction between bromoquinone and β-enamino ketones bearing alkyl or phenyl groups attached to the nitrogen atom. The antimicrobial potential of indole derivatives was assessed. Molecular docking studies were also performed using AutoDock 4.2 for Windows. Characterization of all compounds was confirmed by one- and two-dimensional NMR techniques 1H and 13C NMR spectra [1H, 13C – APT, 1H x 1H – COSY, HSQC and HMBC], IR and mass spectrometry analysis.

Results:

Several indolequinone compounds showed effective antimicrobial profile against Grampositive (MIC = 16 µg.mL-1) and Gram-negative bacteria (MIC = 8 µg.mL-1) similar to antimicrobials current on the market. The 3-acetyl-1-(2,5-dimethylphenyl)-1H-indole-4,7-dione derivative exhibited an important effect against different biofilm stages formed by a serious hospital life-threatening resistant strain of Methicillin-Resistant Staphylococcus aureus (MRSA). A hemocompatibility profile analysis based on in vitro hemolysis assays revealed the low toxicity effects of this new series. Indeed, in silico studies showed a good pharmacokinetics and toxicological profiles for all indolequinone derivatives, reinforcing their feasibility to display a promising oral bioavailability. An elucidation of the promising indolequinone derivatives binding mode was achieved, showing interactions with important sites to biological activity of S. aureus DNA gyrase. These results highlighted 3-acetyl-1-(2-hydroxyethyl)-1Hindole- 4,7-dione derivative as broad-spectrum antimicrobial prototype to be further explored for treating bacterial infections.

Conclusion:

The highly substituted indolequinones were obtained in moderate to good yields. The pharmacological study indicated that these compounds should be exploited in the search for a leading substance in a project aimed at obtaining new antimicrobials effective against Gram-negative bacteria.

Prevalence and Therapies of Antibiotic-Resistance in Staphylococcus aureus

Infectious diseases are the second most important cause of human death worldwide; Staphylococcus aureus (S. aureus) is a very common human pathogenic microorganism that can trigger a variety of infectious diseases, such as skin and soft tissue infections, endocarditis, osteomyelitis, bacteremia, and lethal pneumonia. Moreover, according to the sensitivity to antibiotic drugs, S. aureus can be divided into methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA). In recent decades, due to the evolution of bacteria and the abuse of antibiotics, the drug resistance of S. aureus has gradually increased, the infection rate of MRSA has increased worldwide, and the clinical anti-infective treatment for MRSA has become more difficult. Accumulating evidence has demonstrated that the resistance mechanisms of S. aureus are very complex, especially for MRSA, which is resistant to many kinds of antibiotics. Therefore, understanding the drug resistance of MRSA in a timely manner and elucidating its drug resistance mechanism at the molecular level are of great significance for the treatment of S. aureus infection. A large number of researchers believe that analyzing the molecular characteristics of S. aureus can help provide a basis for designing effective prevention and treatment measures against hospital infections caused by S. aureus and further monitor the evolution of S. aureus. This paper reviews the research status of MSSA and MRSA, the detailed mechanisms of the intrinsic antibiotic resistance and the acquired antibiotic resistance, the advanced research on anti-MRSA antibiotics and novel therapeutic strategies for MRSA treatment.

Pulmonary Pathogens Adapt to Immune Signaling Metabolites in the Airway

A limited number of pulmonary pathogens are able to evade normal mucosal defenses to establish acute infection and then adapt to cause chronic pneumonias. Pathogens, such as Pseudomonas aeruginosa or Staphylococcus aureus, are typically associated with infection in patients with underlying pulmonary disease or damage, such as cystic fibrosis (CF) or chronic obstructive pulmonary disease (COPD). To establish infection, bacteria express a well-defined set of so-called virulence factors that facilitate colonization and activate an immune response, gene products that have been identified in murine models. Less well-understood are the adaptive changes that occur over time in vivo, enabling the organisms to evade innate and adaptive immune clearance mechanisms. These colonizers proliferate, generating a population sufficient to provide selection for mutants, such as small colony variants and mucoid variants, that are optimized for long term infection. Such host-adapted strains have evolved in response to selective pressure such as antibiotics and the recruitment of phagocytes at sites of infection and their release of signaling metabolites (e.g., succinate). These metabolites can potentially function as substrates for bacterial growth and but also generate oxidant stress. Whole genome sequencing and quantified expression of selected genes have helped to explain how P. aeruginosa and S. aureus adapt to the presence of these metabolites over the course of in vivo infection. The serial isolation of clonally related strains from patients with cystic fibrosis has provided the opportunity to identify bacterial metabolic pathways that are altered under this immune pressure, such as the anti-oxidant glyoxylate and pentose phosphate pathways, routes contributing to the generation of biofilms. These metabolic pathways and biofilm itself enable the organisms to dissipate oxidant stress, while providing protection from phagocytosis. Stimulation of host immune signaling metabolites by these pathogens drives bacterial adaptation and promotes their persistence in the airways. The inherent metabolic flexibility of P. aeruginosa and S. aureus is a major factor in their success as pulmonary pathogens.

Correlation Between Biofilm Formation and Antibiotic Resistance in MRSA and MSSA Isolated from Clinical Samples in Iran: A Systematic Review and Meta-Analysis

Objectives: This study aimed at reviewing the correlation between biofilm formation and antibiotic resistance in methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) isolates. Materials and Methods: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. The literature search was conducted in PubMed, Web of Science (ISI), and Scopus databases. Combinations of Mesh terms such as "biofilms" OR "biofilm formation," AND "Drug Resistance" OR "Antimicrobial Drug Resistance" OR "Antibiotic Resistance" AND "Staphylococcus aureus" OR "Methicillin-resistant Staphylococcus aureus" or "MRSA" AND "Methicillin-sensitive Staphylococcus aureus" OR "MSSA" AND "biofilm-related genes" AND "Prevalence" AND "Iran" were searched. Two reviewers independently searched the databases. Analyses were performed in Comprehensive Meta-Analysis software. The random-effects model was used to obtain the combined prevalence with a 95% confidence interval (CI). Results: The combined prevalence of MRSA retrieved from Iranian clinical samples was 48.3% (95% CI: 40.8-55.9). The pooled rate of biofilm formation in MRSA strains was reported as 80.9% (95% CI: 67.8-89.4). Overall, 52.9%, 45.3%, and 22.5% of MRSA isolates were strong, moderate, and weak biofilm producers, respectively. The highest frequency of biofilm-related genes was observed for icaD gene (67.7%) followed by clfA gene with a frequency of 64.7%. Among seven studies that addressed the relationship between biofilm formation and antibiotic resistance, six reported positive associations. Conclusions: Regarding the MRSA strains, they had a significantly higher ability of biofilm formation than MSSA strains; therefore, preventive measures against infections caused by them are required.

Impact of colonization pressure on acquisition of extended-spectrum β-lactamase-producing Enterobacterales and meticillin-resistant Staphylococcus aureus in two intensive care units: a 19-year retrospective surveillance

BACKGROUND

Colonization pressure is a risk factor for intensive care unit (ICU)-acquired multi-drug-resistant organisms (MDROs).

AIM

To measure the long-term respective impact of colonization pressure on ICU-acquired extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE) and meticillin-resistant Staphylococcus aureus (MRSA).

METHODS

All patients admitted to two ICUs (medical and surgical) between January 1997 and December 2015 were included in this retrospective observational study. Rectal and nasal surveillance cultures were obtained at admission and weekly thereafter. Contact precautions were applied for colonized or infected patients. Colonization pressure was defined as the ratio of the number of MDRO-positive patient-days (PDs) of each MDRO to the total number of PDs. Single-level negative binomial regression models were used to evaluate the incidence of weekly MDRO acquisition.

FINDINGS

Among the 23,423 patients included, 2327 (10.0%) and 1422 (6.1%) were colonized with ESBL-PE and MRSA, respectively, including 660 (2.8%) and 351 (1.5%) acquisitions. ESBL-PE acquisition increased from 0.51/1000 patient-exposed days (PEDs) in 1997 to 6.06/1000 PEDs in 2015 (P<0.001). In contrast, MRSA acquisition decreased steadily from 3.75 to 0.08/1000 PEDs (P<0.001). Controlling for period-level covariates, colonization pressure in the previous week was associated with MDRO acquisition for ESBL-PE (P<0.001 and P=0.04 for medical and surgical ICU, respectively), but not for MRSA (P=0.34 and P=0.37 for medical and surgical ICU, respectively). The increase in colonization pressure was significant above 100/1000 PDs for ESBL-PE.

CONCLUSION

Colonization pressure contributed to the increasing incidence of ESBL-PE but not MRSA. This study suggests that preventive control measures should be customized to MDROs.

Xuebijing Injection Alleviates Pam3CSK4-Induced Inflammatory Response and Protects Mice From Sepsis Caused by Methicillin-Resistant Staphylococcus aureus

A leading cause of death worldwide is sepsis that develops as a dysregulated immune response to infection. Serious infection caused by methicillin-resistant Staphylococcus aureus (MRSA) increases the difficulty of treatment in septic patients. Host-directed therapy (HDT) is an emerging approach to bacterial infections. Xuebijing injection (XBJ), a commercialized injectable prescription from traditional Chinese medicine, has been used as adjuvant therapy for sepsis with a history of 15 years. Whether it plays a protective role in severe infection caused by antibiotic-resistant bacteria is still unknown. In this study, XBJ significantly improved the survival of MRSA-induced sepsis mice. In MRSA-infected mouse model, XBJ down-regulated the expression of inflammatory cytokines interleukin (IL)-6, tumor necrosis factor (TNF)-α, MCP-1, MIP-2, and IL-10 in sera. Besides that, it decreased the bacterial load in spleens, livers, and alleviated tissue damage of lung, liver, and kidney. The combination of XBJ with vancomycin or dexamethasone exhibited a better down-regulatory role of the inflammatory response. Then, the protective mechanism of XBJ was further investigated. XBJ inhibited heat-killed MRSA-induced IL-6 and TNF-α production in mouse macrophages. XBJ also decreased Pam3CSK4 (a synthetic tripalmitoylated lipopeptide mimicking bacterial lipoproteins)-stimulated expression of IL-6, TNF-α, IL-1β, IL-12, etc. in mouse macrophages. Furthermore, XBJ down-regulated the activation of NF-κB, MAPK, and PI3K/Akt pathways in Pam3CSK4-stimulated mouse macrophages. In conclusion, our findings demonstrated that XBJ played a protective role in MRSA-challenged mice and down-regulated the inflammatory response and the activation of signaling pathways initiated by Pam3CSK4. It enlarged the clinical application of XBJ in the treatment of severe bacterial infection, e.g. caused by MRSA.

Immunization with a Bacterial Lipoprotein Establishes an Immuno-Protective Response with Upregulation of Effector CD4+ T Cells and Neutrophils Against Methicillin-Resistant Staphylococcus aureus Infection

Staphylococcus aureus (S. aureus) is a commensal bacterium in the human body; however, the bacterium frequently generates serious inflammation and infectious diseases. Some strains of S. aureus, such as methicillin-resistant Staphylococcus aureus (MRSA), are still a serious problem in public health facilities. Thus, an effective protection strategy is eagerly expected for the prevention and cure of MRSA infection. Here, we report that a specific fraction of an S. aureus lipoprotein (SA-LP) established a protective response against MRSA infection. The fractionated S. aureus lipoprotein SA-LP-F2, which is contained in 30–50 kDa of crude S. aureus lipoprotein (SA-LP-C), effectively activated dendritic cells (DCs) and the SA-LP-F2-pulsed DCs generated IFN-γ+CD4+ T (Th1) and IL-17A+CD4+ T (Th17) cells by in vitro antigen presentation. The SA-LP-F2 immunization upregulated the Th1 and Th17 populations so that MRSA colonization on the skin was suppressed during the challenge phase with MRSA. By following the effector T cell upregulation, the neutrophil function, which was a substantial effector cell against MRSA, was also enhanced in the SA-LP-F2-immunized mice. Finally, we found that the protective effect of SA-LP-F2 immunization was maintained for at least 90 days because the immunized mice continued to show a protective response during the MRSA challenge period. In the MRSA challenge, reactivated Th1 and Th17 populations were maintained in the SA-LP-F2-immunized mice as compared to naive mice. In addition, the neutrophil population was also upregulated in the mice. The memory CD4+ T cell (central memory T; T_CM and effector memory T; T_EM) population was established by SA-LP-F2 immunization and was maintained at higher levels than usual. Taken together, our findings may provide a breakthrough in the establishment of an immunization strategy against MRSA infection.

Antibacterial Efficacy of Two Commercially Available Bacteriophage Formulations, Staphylococcal Bacteriophage and PYO Bacteriophage, Against Methicillin-Resistant Staphylococcus aureus: Prevention and Eradication of Biofilm Formation and Control of a Systemic Infection of Galleria mellonella Larvae

Sessile bacteria growing on surfaces are more resistant to standard antibiotics than their planktonic counterpart. Due to their antimicrobial properties, bacteriophages have re-emerged as a promising approach to treat bacterial biofilm-associated infections. Here, we evaluated the ability of two commercially available phage formulations, Staphylococcal bacteriophage (containing the monophage Sb-1) and PYO bacteriophage (a polyphage), in preventing and eradicating an in vitro biofilm of methicillin-resistant Staphylococcus aureus (MRSA) by isothermal microcalorimetry and high-resolution confocal laser scanning microscopy (CLSM). Moreover, to assess the potential in vivo efficacy of both phage preparations, a Galleria mellonella model of MRSA systemic infection was used. Microcalorimetry measurement showed that 10⁷ PFU/ml (the highest tested titer) of both phage formulations were able to inhibit planktonic growth in a concentration-dependent manner. However, MRSA biofilm was eradicated only by co-incubation of 5–7 days with the highest phage titers, respectively. In the experiments of biofilm prevention, isothermal microcalorimetry revealed that the heat production was completely abolished in the presence of sub-inhibitory titers (10⁴ PFU/ml) of phages. These data were also confirmed by confocal laser scanning microscopy. Both phage formulations increased the survival of G. mellonella larvae preventing or treating MRSA infection compared to untreated control. In conclusion, tested phage formulations are promising for preventing device colonization and killing biofilm bacteria attached on a surface. Novel strategies for direct coating and release of phages from material should be investigated.

Activity of Actinomycetes Isolated from Mangrove Segara Anakan Cilacap toward Methicillin-resistant Staphylococcus aureus (MRSA)

Methicillin-resistant Staphylococcus aureus (MRSA) is a major health concern because it causes numerous infections in both healthcare facilities and communities. The development of multiresistant against topical antibiotics has caused substantial difficulty in the management of Staphylococcus infection. Thus, this research was aimed to explore indigenous marine Actinomycetes isolated from Segara Anakan Cilacap for anti-MRSA activity. The methods used were screening anti-MRSA activity using agar-block method, production of anti-MRSA extract, extraction of the anti-MRSA extract with ethyl acetate, MIC determination of the ethyl-acetate extract, and species identification based on morphology and 16S rRNA genes. The results indicated that 14 out of 16 Actinomycetes have anti-MRSA activity. Three isolates, which were W-5B, W-5A, and P-7D, showed the highest anti-MRSA activity with the inhibition zone of 2.40 mm, 1.20 mm, and 0.80 mm, respectively. The minimum inhibitory concentration (MIC) of ethyl acetate extract from isolates W-5B, W-5A, and P-7D against MRSA were 2 mg/mL, 4 mg/mL, and 8 mg/mL, respectively. The species identification based on 16S rRNA genes indicated that Actinomycetes W-5B isolate has 92.51% similarity with Streptomyces sp. 2011. The W-5A has 94.69% similarity with Arthrobacter sp. HZ11. The P-7D has 94.79% similarity with Streptomyces clavuligerus strain A-ZN-05. The present study concludes that marine Actinomycetes from sediment mangrove in Segara Anakan Cilacap, Indonesia, has potency as anti-MRSA.

Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures

OBJECTIVE

To assess potential transmission of antibiotic-resistant organisms (AROs) using surrogate markers and bacterial cultures.

DESIGN

Pilot study.

SETTING

A 1,260-bed tertiary-care academic medical center.

PARTICIPANTS

The study included 25 patients (17 of whom were on contact precautions for AROs) and 77 healthcare personnel (HCP).

METHODS

Fluorescent powder (FP) and MS2 bacteriophage were applied in patient rooms. HCP visits to each room were observed for 2-4 hours; hand hygiene (HH) compliance was recorded. Surfaces inside and outside the room and HCP skin and clothing were assessed for fluorescence, and swabs were collected for MS2 detection by polymerase chain reaction (PCR) and selective bacterial cultures.

RESULTS

Transfer of FP was observed for 20 rooms (80%) and 26 HCP (34%). Transfer of MS2 was detected for 10 rooms (40%) and 15 HCP (19%). Bacterial cultures were positive for 1 room and 8 HCP (10%). Interactions with patients on contact precautions resulted in fewer FP detections than interactions with patients not on precautions (P < .001); MS2 detections did not differ by patient isolation status. Fluorescent powder detections did not differ by HCP type, but MS2 was recovered more frequently from physicians than from nurses (P = .03). Overall, HH compliance was better among HCP caring for patients on contact precautions than among HCP caring for patients not on precautions (P = .003), among nurses than among other nonphysician HCP at room entry (P = .002), and among nurses than among physicians at room exit (P = .03). Moreover, HCP who performed HH prior to assessment had fewer fluorescence detections (P = .008).

CONCLUSIONS

Contact precautions were associated with greater HCP HH compliance and reduced detection of FP and MS2.

Linezolid and Rifampicin Combination to Combat cfr-Positive Multidrug-Resistant MRSA in Murine Models of Bacteremia and Skin and Skin Structure Infection

Linezolid resistance mediated by the cfr gene in MRSA represents a global concern. We investigated relevant phenotype differences between cfr-positive and -negative MRSA that contribute to pathogenesis, and the efficacy of linezolid-based combination therapies in murine models of bacteremia and skin and skin structure infection (SSSI). As a group, cfr-positive MRSA exhibited significantly reduced susceptibilities to the host defense peptides tPMPs, human neutrophil peptide-1 (hNP-1), and cathelicidin LL-37 (P < 0.01). In addition, increased binding to fibronectin (FN) and endothelial cells paralleled robust biofilm formation in cfr-positive vs. -negative MRSA. In vitro phenotypes of cfr-positive MRSA translated into poor outcomes of linezolid monotherapy in vivo in murine bacteremia and SSSI models. Importantly, rifampicin showed synergistic activity as a combinatorial partner with linezolid, and the EC₅₀ of linezolid decreased 6-fold in the presence of rifampicin. Furthermore, this combination therapy displayed efficacy against cfr-positive MRSA at clinically relevant doses. Altogether, these data suggest that the use of linezolid in combination with rifampicin poses a viable therapeutic alternative for bacteremia and SSSI caused by cfr-positive multidrug resistant MRSA.

Ceftobiprole versus daptomycin in Staphylococcus aureus bacteremia: a novel protocol for a double-blind, Phase III trial

Although Staphylococcus aureus is a common cause of bacteremia, treatment options are limited. The need for new therapies is particularly urgent for methicillin-resistant S. aureus bacteremia (SAB). Ceftobiprole is an advanced-generation, broad-spectrum cephalosporin with activity against both methicillin-susceptible and -resistant S. aureus. This is a Phase III, randomized, double-blind, active-controlled, parallel-group, multicenter, two-part study to establish the efficacy and safety of ceftobiprole compared with daptomycin in the treatment of SAB, including infective endocarditis. Anticipated enrollment is 390 hospitalized adult patients, aged ≥18 years, with confirmed or suspected complicated SAB. The primary end point is overall success rate. Target completion of the study is in the second half of 2021.

Clinicaltrials.gov identifier: NCT03138733

Ability of biofilm production and molecular analysis of spa and ica genes among clinical isolates of methicillin-resistant Staphylococcus aureus

Objective

This study aimed to evaluate the phenotypic and genotypic characterization of biofilm formation and spa and ica genes among clinical isolates of methicillin-resistant Staphylococcus aureus.

Result

This cross-sectional study was performed on 146 Staphylococcus aureus isolates from hospitalized patients in Isfahan Province Hospitals. MRSA isolates were confirmed using disk diffusion test with oxacillin disk and amplification of mecA gene by PCR assays. Ability of biofilm production was evaluated targeting the icaA and icaD genes. Of 146 Staphylococcus aureus isolates, 24 (16.4%) carried mecA genes and identified as MRSA strains. Strong ability of biofilm production was seen among 76.02% (111/146) S. aureus isolates and 87.5% (21/24) MRSA strains, respectively. Also, 75.0% (18/24) MRSA isolates carried icaA and icaD was not detected in these strains. Analysis of spa gene showed 70.83% (17/24) MRSA strains were spa positive. From which 14 and 3 strains identified with one band (150, 270, 300, 360, 400 bp) and two bands (150–300 bp), respectively. According to data obtained, the prevalence of MRSA isolates from Isfahan Province Hospitals is relatively high and a remarkable percentage of them show strong power in biofilm production. Also analysis of spa gene showed a fairly large diversity among MRSA strains.

Comparison of In Vitro Antibacterial Activity of Epaltes divaricata and Vetiveria zizanioides against Methicillin-Resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of hospital- and community-acquired infections worldwide. Therefore, this study was conducted to explore the antibacterial activity of the two medicinal plants Epaltes divaricata and Vetiveria zizanioides against strains of MRSA which were isolated from patients with skin and soft tissue infections. Hexane, ethanol, and water extracts of E. divaricata (whole plant) and V. zizanioides (roots) were prepared. Clinical isolates of MRSA strains (n = 20) were used for the study. Bacterial susceptibility was tested using a disc diffusion assay. Minimum inhibitory concentration (MIC) was determined by a broth microdilution method. Vancomycin was used as the positive control. Hexane, ethanol, and water extracts of E. divaricata showed inhibitory zones against MRSA. Except for water extract, both hexane and ethanol extracts of V. zizanioides showed inhibitory zones. MIC ranges of hexane, ethanol, and water extracts in E. divaricata were 0.012-0.32 mg/mL, 0.019-2.4 mg/mL, and 0.019-0.48 mg/mL, respectively. Respective MIC ranges of hexane and ethanol extracts of V. zizanioides were 0.003-0.032 mg/mL and 0.019-2.4 mg/mL. The hexane extract of V. zizanioides inhibited 55% of the selected MRSA strains at a relatively low MIC value of 0.012 mg/mL. The hexane extract of both plants demonstrated inhibition of 75% of MRSA strains at a MIC value of 0.064 mg/mL. Ethanol extract of V. zizanioides and E. divaricata, respectively, inhibited 70% and 45% of MRSA strains at the MIC of 0.096 mg/mL, whereas water extract of E. divaricata inhibited 80% of MRSA strains at the same MIC. Both E. divaricata and V. zizanioides were equally effective against MRSA at a MIC of 0.064 mg/mL. But V. zizanioides was more effective since the hexane extract inhibited more than 50% of MRSA strains at significantly a lower MIC value of 0.012 mg/mL. Fractionation, purification, and identification of active compounds will warrant further evaluation of the therapeutic potential of both plant extracts.

Comparison of Vancomycin Area-Under-the-Curve Dosing Versus Trough Target-Based Dosing in Obese and Nonobese Patients With Methicillin-Resistant Staphylococcus aureus Bacteremia

Background: A vancomycin target of area under the curve to minimum inhibitory concentration (AUC:MIC) ratio ≥400 is recommended for treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. Objective: To evaluate vancomycin total daily dose (TDD) achieving trough targets versus a calculated strategy achieving AUC targets based on body mass index (BMI). Methods: A retrospective cohort study was performed within a large hospital network. Patients with MRSA bacteremia were eligible if they received vancomycin with a steady-state trough (15-20 mg/L). Cockcroft-Gault was used to estimate creatinine clearance, calculating vancomycin clearance and AUC. Patients were stratified by BMI (less than/greater than 30 kg/m²). The primary outcome was vancomycin TDD for the trough-based strategy compared with an AUC-dosing strategy. Results: A total of 119 patients were included, including 51 (42.9%) and 68 (57.1%) patients with high- and low-BMI, respectively. The TDD for trough-based dosing (2390.76 ± 1224.59 mg) differed significantly from AUC-based dosing (1985.07 ± 616.18 mg) across the cohort (P = 0.0014). For patients with high BMI, there was a significant difference (P < 0.0001) in TDD between trough (2637.25 ± 1327.89 mg) versus AUC (1918.71 ± 625.89 mg) strategies. No difference in TDD between dosing strategies was observed among low-BMI patients. Across all patients, 46 (38.7%) experienced acute kidney injury (AKI); high-BMI patients experienced higher rates of AKI compared with low-BMI patients (54.9 vs 26.5%; P = 0.002). Conclusions and Relevance: An AUC-based dosing strategy may reduce vancomycin TDD required for MRSA bacteremia compared with trough-based dosing, particularly for patients with higher BMI.

Febrile Neutropenia in Acute Leukemia. Epidemiology, Etiology, Pathophysiology and Treatment

Acute leukemias are a group of aggressive malignant diseases associated with a high degree of morbidity and mortality. An important cause of both the latter is infectious complications. Patients with acute leukemia are highly susceptible to infectious diseases due to factors related to the disease itself, factors attributed to treatment, and specific individual risk factors in each patient. Patients with chemotherapy-induced neutropenia are at particularly high risk, and microbiological agents include viral, bacterial, and fungal agents. The etiology is often unknown in infectious complications, although adequate patient evaluation and sampling have diagnostic, prognostic and treatment-related consequences. Bacterial infections include a wide range of potential microbes, both Gram-negative and Gram-positive species, while fungal infections include both mold and yeast. A recurring problem is increasing resistance to antimicrobial agents, and in particular, this applies to extended-spectrum beta-lactamase resistance (ESBL), Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and even carbapenemase-producing Enterobacteriaceae (CPE). International guidelines for the treatment of sepsis in leukemia patients include the use of broad-spectrum Pseudomonas-acting antibiotics. However, one should implant the knowledge of local microbiological epidemiology and resistance conditions in treatment decisions. In this review, we discuss infectious diseases in acute leukemia with a major focus on febrile neutropenia and sepsis, and we problematize the diagnostic, prognostic, and therapeutic aspects of infectious complications in this patient group. Meticulously and thorough clinical and radiological examination combined with adequate microbiology samples are cornerstones of the examination. Diagnostic and prognostic evaluation includes patient review according to the multinational association for supportive care in cancer (MASCC) and sequential organ failure assessment (SOFA) scoring system. Antimicrobial treatments for important etiological agents are presented. The main challenge for reducing the spread of resistant microbes is to avoid unnecessary antibiotic treatment, but without giving to narrow treatment to the febrile neutropenic patient that reduce the prognosis.

Clinical, Epidemiologic, and Laboratory Aspects of Methicillin-Resistant Staphylococcus aureus Infections

Oxacillin-resistant Staphylococcus aureus (abbreviated MRSA for historical reasons) is a major pathogen responsible for both hospital- and community-onset disease. Resistance to oxacillin in most clinical isolates of S. aureus is mediated by PBP2a, a penicillin-binding protein with low affinity to beta-lactams, encoded primarily by the mecA gene. Rapid and accurate methods of susceptibility testing of S. aureus isolates to identify MRSA infections are important tools to limit the spread of this organism. This review focuses on the clinical significance of MRSA infections and new approaches for the laboratory diagnosis and epidemiologic typing of MRSA strains.

Phylogeographical Analysis Reveals the Historic Origin, Emergence, and Evolutionary Dynamics of Methicillin-Resistant Staphylococcus aureus ST228

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a common healthcare-associated pathogen that remains a major public health concern. Sequence type 228 (ST228) was first described in Germany and spread to become a successful MRSA clone in several European countries. In 2000, ST228 emerged in Lausanne and has subsequently caused several large outbreaks. Here, we describe the evolutionary history of this clone and identify the genetic changes underlying its expansion in Switzerland.

MATERIALS AND METHODS

We aimed to understand the phylogeographic and demographic dynamics of MRSA ST228/ST111 by sequencing 530 representative isolates of this clone that were collected from 14 European countries between 1997 and 2012.

RESULTS

The phylogenetic analysis revealed distinct lineages of ST228 isolates associated with specific geographic origins. In contrast, isolates of ST111, which is a single locus variant of ST228 sharing the same spa type t041, formed a monophyletic cluster associated with multiple countries. The evidence points to a German origin of the sampled population, with the basal German lineage being characterized by spa type t001. The highly successful Swiss ST228 lineage diverged from this progenitor clone through the loss of the aminoglycoside-streptothricin resistance gene cluster and the gain of mupirocin resistance. This lineage was introduced first in Geneva and was subsequently introduced into Lausanne.

CONCLUSION

Our results reveal the radiation of distinct lineages of MRSA ST228 from a German progenitor, as the clone spread into different European countries. In Switzerland, ST228 was introduced first in Geneva and was subsequently introduced into Lausanne.

Molecular characterization and susceptibility screening for methicillin-resistant Staphylococcus aureus reveals the dominant clones in a tertiary care hospital in Al Qassim, Saudi Arabia

OBJECTIVE

Staphylococcus aureus has become an important pathogen in hospitals worldwide. Despite its differentiation into human and animal lineages, common methods are used for genotyping. While these methods are useful, they are based on the stable genome, and hence, are insensitive to host-specific subtyping. The objectives of this study were to investigate the repeat-domain of the Clumping-Factor A gene (clfA- R) as an objective and adaptation-sensitive approach.

METHODOLOGY

We have used 113 isolates for susceptibility testing and genotyping by polymerase chain reaction amplification of the clfA- R regions. Of these, 105 were from King Fahad Specialist Hospital, Buraidah and eight were published sequences used as references. Isolates were further confirmed as S. aureus by the commercial Kits. Amplicon sizes were measured and the number of the 18-bp-repeating-units in each isolate was determined against that of methicillin-resistant S. aureus COL (MRSA) sequence.

RESULTS

Results showed that all 42 nasal screening isolates (100%) and all but six isolates from clinical specimens were MRSA with 37% of the former and 50% of the latter isolates showing community-acquired-MRSA susceptibility patterns. clfA-R analysis grouped 113 isolates into 14 repeat-genotypes. The two dominant types, D and X, represented the long- and short clfA-R types found in humans and animals, respectively. Linezolid, rifampicin, and vancomycin were the drugs of choice.

CONCLUSIONS

clfA-R was useful in rapid genotyping and implied host-specific phenotypic properties of the ClfA. It has been recommended that the approach used in regional laboratories for uniform strain-profiling. Future work will show more insights into the gene content and origins of clones .

Prevalence and Therapies of Antibiotic-Resistance in Staphylococcus aureus

Infectious diseases are the second most important cause of human death worldwide; Staphylococcus aureus (S. aureus) is a very common human pathogenic microorganism that can trigger a variety of infectious diseases, such as skin and soft tissue infections, endocarditis, osteomyelitis, bacteremia, and lethal pneumonia. Moreover, according to the sensitivity to antibiotic drugs, S. aureus can be divided into methicillin-sensitive Staphylococcus aureus (MSSA) and methicillin-resistant Staphylococcus aureus (MRSA). In recent decades, due to the evolution of bacteria and the abuse of antibiotics, the drug resistance of S. aureus has gradually increased, the infection rate of MRSA has increased worldwide, and the clinical anti-infective treatment for MRSA has become more difficult. Accumulating evidence has demonstrated that the resistance mechanisms of S. aureus are very complex, especially for MRSA, which is resistant to many kinds of antibiotics. Therefore, understanding the drug resistance of MRSA in a timely manner and elucidating its drug resistance mechanism at the molecular level are of great significance for the treatment of S. aureus infection. A large number of researchers believe that analyzing the molecular characteristics of S. aureus can help provide a basis for designing effective prevention and treatment measures against hospital infections caused by S. aureus and further monitor the evolution of S. aureus. This paper reviews the research status of MSSA and MRSA, the detailed mechanisms of the intrinsic antibiotic resistance and the acquired antibiotic resistance, the advanced research on anti-MRSA antibiotics and novel therapeutic strategies for MRSA treatment.

The Antibacterial Activity of Lavender Essential Oil Alone and In Combination with Octenidine Dihydrochloride against MRSA Strains

In the post-antibiotic era the issue of bacterial resistance refers not only to antibiotics themselves but also to common antiseptics like octenidine dihydrochloride (OCT). This appears as an emerging challenge in terms of preventing staphylococcal infections, which are both potentially severe and easy to transfer horizontally. Essential oils have shown synergisms both with antibiotics and antiseptics. Therefore the aim of this study was to investigate the impact of lavender essential oil (LEO) on OCT efficiency towards methicillin-resistant S. aureus strains (MRSA). The LEO analyzed in this study increased the OCT’s susceptibility against MRSA strains. Subsequent FTIR analysis revealed cellular wall modifications in MRSA strain cultured in media supplemented with OCT or LEO/OCT. In conclusion, LEO appears to be a promising candidate for an efficient enhancer of conventional antiseptics.