A study of coagulase-negative staphylococci with reference to slime production, adherence, antibiotic resistance patterns and clinical significance

Virulence Factors in Coagulase-Negative Staphylococci

Coagulase-negative staphylococci (CoNS) have emerged as major pathogens in healthcare-associated facilities, being S. epidermidis, S. haemolyticus and, more recently, S. lugdunensis, the most clinically relevant species. Despite being less virulent than the well-studied pathogen S. aureus, the number of CoNS strains sequenced is constantly increasing and, with that, the number of virulence factors identified in those strains. In this regard, biofilm formation is considered the most important. Besides virulence factors, the presence of several antibiotic-resistance genes identified in CoNS is worrisome and makes treatment very challenging. In this review, we analyzed the different aspects involved in CoNS virulence and their impact on health and food.

Application of tuf gene sequence analysis for the identification of species of coagulase-negative staphylococci in clinical samples and evaluation of their antimicrobial resistance pattern

Introduction

Coagulase-negative staphylococci (CoNS) are normal inhabitants of human skin and mucous membranes. However, CoNS represent one of the major nosocomial pathogens, especially in immunocompromised patients. The increasing incidence of CoNS and mainly methicillin-resistant strains underlines the need for an accurate identification of Staphylococcus isolates at the species level. Analysis of the tuf gene proved to be an accurate tool for the species identification of CoNS. The aims of this study were to identify the CoNS species by tuf gene-based polymerase chain reaction method and sequencing, and to determine the frequency of CoNS clinical isolates resistant to methicillin (MRCoNS) and other antibiotics.

Methods

A total of 200 staphylococci isolates were collected from various clinical samples. Phenotyping methods were used for initial identification followed by polymerase chain reaction amplification of tuf gene with subsequent sequencing. The phylogenetic relationships among species were analyzed using the neighbor-joining method based on the partial gene sequence of tuf. Microbroth dilution test was used for screening methicillin resistance, and disk diffusion susceptibility testing was performed for evaluation of antibiotic resistance among the isolates.

Results

In the present study, 125 isolates were identified as CoNS; among them, Staphylococcus epidermidis 54(43.2%) and Staphylococcus haemolyticus 50 (40.0%) were demonstrated as the most prevalent species. Resistance to methicillin was detected in 54.4% of the CoNS based on microbroth dilution method. In disk diffusion susceptibility testing, the greatest resistance of CoNS was demonstrated for cefoxitin (65.4%), cotrimethoxazole (54.4%), and clindamycin (49.6%), while daptomycin (87.2%) and linezolid (83.2%) showed the greatest effectiveness for CoNS isolates.

Conclusion

Our results confirmed the predominance of S. epidermidis and S. haemolyticus among CoNS isolates. The high prevalence of MRCoNS strains is a serious concern and strongly suggests the need for control program measures in our hospitals in order to reduce MRCoNS infections, especially in immunocompromised patients.

Comparison of coagulase-negative staphylococci isolated from blood cultures as a true bacteremia agent and contaminant in terms of slime production and methicillin resistance

OBJECTIVE

The aim of this study is to determine the species distribution, slime activity, and methicillin resistance of coagulase-negative staphylococci (CoNS) isolated from blood cultures as either contaminants or true bacteremia agents.

MATERIALS AND METHODS

In this study, 13.268 blood culture samples sent to our laboratory from various clinics during a two-year period were examined in terms of the presence of CoNS to clarify whether the isolates are true bacteremia agents, as defined by Centers for Disease Control and Prevention (CDC) criteria. The slime activities of true bacteremia agents (58 CoNS strains) and contaminants (50 randomly selected CoNS strains) were investigated by the Christensen method. The methicillin susceptibilities of the strains were determined by the disk diffusion method.

RESULTS

Although the frequency of slime production was 39.7% among the true bacteremia CoNS agents, it was 18% in CoNS that were judged to be contaminants (p<0.05). S. epidermidis was the most frequently isolated species for both the true bacteremia agent group (56.9%) and contaminant group (74%). Additionally, S. epidermidis was the bacterium most frequently characterized as slime producing in both groups. The methicillin resistance of slime-producing CoNS was determined to be 82.6% for the true bacteremia agent group and 77.8% for the contaminant group.

CONCLUSION

The presence of slime activity in CoNS isolated from blood culture samples is supportive evidence that they are most likely the agents of true bacteremia cases.

Genotypes, antibiotic resistance, and virulence factors of staphylococci from ready-to-eat food

Sixty-seven staphylococcal isolates belonging to 12 species were obtained from 70 ready-to-eat food products. Staphylococcus aureus (n=25), and Staphylococcus epidermidis (n=13) were dominant. Susceptibility to penicillin, oxacillin, tetracycline, clindamycin, gentamicin, erythromycin, ciprofloxacin, and vancomycin was determined. All investigated S. aureus isolates were resistant to at least one antibiotic, and fifteen isolates were resistant to four and more antibiotics. Thirty-eight coagulase-negative staphylococci (CNS) isolates were resistant to at least one antibiotic, and seventeen to four and more antibiotics. Fifteen CNS isolates were mecA positive, and grew in the presence of 6 μg/mL oxacillin. All S. aureus isolates were mecA-negative. Arginine catabolic mobile element (ACME) was found in seven S. epidermidis isolates. Five S. epidermidis isolates harbored ica operon, ACME and were able to form biofilm. Three of them also possessed IS256 element and were mecA-positive. The expression of icaA gene was comparable in five ica-positive S. epidermidis isolates. One of six mecA positive S. epidermidis isolates was classified as sequence type (ST)155, one as ST110, and two as ST88. Two methicillin-resistant Staphylococcus epidermis (MRSE) belonged to new STs, that is, ST362, and ST363. Enterotoxin genes were found in 92% of S. aureus isolates. No enterotoxin gene was detected in analyzed CNS population. We show that ready-to-eat products are an important source of antibiotic-resistant CNS and potentially virulent strains of S. epidermidis, including genotypes undistinguishable from hospital-adapted clones.

Prevalence, aetiology and antibiotic resistance profiles of coagulase negative staphylococci isolated in a teaching hospital

In this paper we carried out a study about prevalence of the clinically significant coagulase negative staphylococcal (CNS) isolates found in an university hospital. Two hundred four CNS isolates from 191 patients obtained between the period of 1998 to 2002, were studied. About 27% (52/191) of the infection cases studied were confirmed as CNS-associated diseases. Blood stream infection (BSI) was the most frequent CNS associated-disease (25%; 13/52). The great majority of the BSI was verified in the Neonatal Intensive Care Unit (NICU). The analysis of the 52 patients medical history showed that 85% of the BSI was acquired in hospital. Most of the CNS nosocomial infections were associated with the use of indwelling medical devices. The incidence of methicillin-resistance among significant CNS isolates was 38%. In this study, a high percentage of exogenous contaminant was verified (60%), indicating that contamination of clinical specimens during sample collection is critical.

Correlation of Slime Production Investigated via Three Different Methods in Coagulase-Negative Staphylococci with Crystal Violet Reaction and Antimicrobial Resistance

This study investigated slime production by coagulase-negative staphylococci (CNS) using the standard tube (ST), Congo red agar (CRA) plate and Christensen's tube (CT) methods, and compared the results with those of the crystal violet reaction (CVR) test. The potential correlation between slime production and antimicrobial resistance was also evaluated. In total, 205 CNS strains were isolated from biological samples: 92 (44.9%) were shown to produce slime by the ST method; 96 (46.8%) by the CRA plate method; 90 (43.9%) by the CT method; and 89 (43.4%) strains were CVR positive. Eighty-three (40.5%) CNS strains were positive for slime production by the ST, CRA and CT methods. The findings of the ST, CRA and CT test methods were consistent with each other but were not related to CVR positivity. Based on the ST method, rates of antibiotic resistance to several antimicrobial agents were higher in slime-positive strains than in slime-negative strains and, in some cases, this was statistically significant.

Clonal dissemination of Staphylococcus epidermidis in an oncology ward

Coagulase-negative staphylococci (CoNS) are the main cause of catheter-related infections, especially among immunosuppressed and neutropenic patients, as well as a source of bacterial contamination in blood cultures. Using biochemical identification and pulsed-field gel electrophoresis (PFGE), we sought to identify possible clonal isolates of bacteremia in patients with central lines in an oncology ward (OW), with comparison to isolates that were recovered by venipuncture from an adult emergency room (ER). A total of 243 CoNS isolates were identified to species level from the OW (126) and ER (117), with Staphylococcus epidermidis isolates being the most common (OW, 79.4%; ER, 45.3%). PFGE demonstrated a predominant clone of S. epidermidis (major subtype A) which was 35.5 times more likely (odds ratio [OR] = 35.5; 95% confidence interval [CI] = 4.7 to 267.0; P < 0.00001) to be present in the OW versus the ER. These (CoNS or major subtype A) isolates were more frequently resistant to gentamicin (OR = 2.83; 95% CI = 1.23 to 6.53; P = 0.016) and less frequently resistant to trimethoprim-sulfamethoxazole (OR = 0.38; 95% CI = 0.18 to 0.80; P = 0.013). Subset analysis of S. epidermidis isolates 2 years after the study period showed the persistence of the clone of major subtype A within the OW. This study demonstrates the presence of a predominant clone among central line isolates from an OW that is not present in CoNS venipuncture isolates from an ER.

The ica operon and biofilm production in coagulase-negative Staphylococci associated with carriage and disease in a neonatal intensive care unit

Coagulase-negative staphylococci (CoNS) are a major cause of sepsis in the neonatal intensive care unit (NICU). We evaluated the hypothesis that the ica operon and biofilm production are associated with CoNS disease in this setting. CoNS associated with bacteremia or blood culture contamination and from the skin of infants with CoNS bacteremia or healthy controls were obtained during a prospective case-control study on a busy NICU. A total of 180 strains were identified, of which 122 (68%) were Staphylococcus epidermidis and the remainder were S. capitis (n = 29), S. haemolyticus (n = 11), S. hominis (n = 9), S. warneri (n = 8), and S. auricularis (n = 1). The presence of the genes icaA, icaB, icaC, and icaD was determined by PCR, and biofilm production was examined using qualitative (Congo red agar [CRA]) and quantitative (microtiter plate) techniques. There were no significant differences in the presence of the ica operon or CRA positivity among the four groups of strains. However, quantitative biofilm production was significantly greater in strains isolated from either the blood or the skin of neonates with S. epidermidis bacteremia. We conclude that the quantity of biofilm produced may be associated with the ability to cause CoNS infection. This conclusion suggests that the regulation of biofilm expression may play a central role in the disease process.

Antimicrobial resistance of coagulase-negative staphylococci from a Kuwait hospital

This study investigated the incidence of antimicrobial resistance in clinically significant coagulase-negative staphylococci at the Mubarak Al Kabeer Hospital, Kuwait. A total of 104 isolates of coagulase-negative staphylococci consisting of S. epidermidis (67), S. haemolyticus (16), S. saprophyticus (6), S. simulans (2), S. hominis (4), S. albus (2), S. sciuri (3), S. warneri (2), S. capitis (1), and S. xylosus (1) were isolated from clinical specimens over a 6-7 month period and tested for resistance to 22 antibacterial agents and the ability to produce slime. They were all susceptible to vancomycin and mupirocin but intermediate resistance to teicoplanin was detected in seven isolates: 83 and 47.7% were resistant to penicillin G and methicillin, respectively, 57% were resistant to gentamicin, 49.5% to erythromycin, 50.4% to tetracycline, and 52.3% to trimethoprim. Resistance to heavy metals and the nucleic-acid binding compound was also detected. More than half of S. epidermidis, S. saprophyticus, S. simulans, S. hominis, and all of S. haemolyticus were multiply resistant to three or more groups of antibiotics and there was a significant association between slime production and resistance to multiple antimicrobial agents in S. epidermidis. The results revealed a high level of resistance to commonly used agents.

Biofilm production by Staphylococcus epidermidis isolates associated with catheter related bacteremia

The mean biofilm production of 22 Staphylococcus epidermidis isolates associated with catheter related bacteremia was significantly higher than that of 32 nose isolates from healthy individuals. This difference was due to seven catheter related isolates. These findings do not show a clear association between biofilm production and virulence.

Interaction of coagulase negative staphylococci with lectins

AIMS

To investigate the reaction of 118 blood culture isolates of coagulase negative staphylococci with a panel of seven lectins.

METHODS

The interactions between the bacterial suspensions and lectins from Arachnis hypogaea (peanut agglutinin), Bauhina purpurea, Solanum tuberosum (potato starch), Triticum vulgaris (wheat germ agglutinin), Wisteria floribunda, Concanavalin ensiformis and Limulus polphemus (horse-shoe crab agglutinin) were assayed in microtitre plates incubated for 1 hour at room temperature then left overnight at 4 degrees C. Agglutinating activity was detected by examining the pattern of cell settlement compared with that of the controls.

RESULTS

Lectins from Solanum tuberosum, Triticum vulgaris, Concanavalin ensiformis and Limulus polyphemus agglutinated 90% of the strains and displayed 11 agglutination patterns which were unrelated to species, clinical relevance, or antibiotic resistance. Fifty three per cent of the isolates fell into three reaction patterns and the other patterns were represented by nine or fewer strains. Replicate cultures investigated simultaneously gave consistent results, but some strains exhibited variation in agglutination patterns on repeat testing.

CONCLUSIONS

Based on these observations lectin agglutination patterns seem to offer a method with potential for strain differentiation among coagulase negative staphylococci. Reproducibility may be improved by the use of biotinylated lectins and growing the coagulase negative staphylococci on defined media. Discrimination can be increased by the inclusion of other reactive lectins.