Discrimination of S. aureus strains by PCR for r-RNA gene spacer size polymorphism and comparison to SmaI macrorestriction patterns

The occurrence and dissemination of methicillin and vancomycin-resistant Staphylococcus in samples from patients and health professionals of a university hospital in Recife, State of Pernambuco, Brazil

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) strains have been responsible for many nosocomial outbreaks. Within hospitals, colonized employees often act as reservoirs for the spread of this organism. This study collected clinical samples of 91 patients admitted to the intensive care unit (ICU), hemodialysis/nephrology service and surgical clinic, and biological samples from the nasal cavities of 120 professionals working in those environments, of a University Hospital in Recife, in the State of Pernambuco, Brazil. The main objective of this study was to determine the occurrence and dissemination of methicillin- and vancomycin-resistant Staphylococcus spp.

METHODS

The isolates obtained were tested for susceptibility to oxacillin and vancomycin and detection of the mecA gene. In addition, the isolates were evaluated for the presence of clones by ribotyping-polymerase chain reaction (PCR).

RESULTS

MRSA occurrence, as detected by the presence of the mecA gene, was more prevalent among nursing technicians; 48.1% (13/27) and 40.7% (11/27) of the isolates were from health professionals of the surgical clinic. In patients, the most frequent occurrence of mecA-positive isolates was among the samples from catheter tips (33.3%; 3/9), obtained mostly from the hemodialysis/nephrology service. Eight vancomycin-resistant strains were found among the MRSA isolates through vancomycin screening. Based on the amplification patterns, 17 ribotypes were identified, with some distributed between patients and professionals.

CONCLUSIONS

Despite the great diversity of clones, which makes it difficult to trace the source of the infection, knowledge of the molecular and phenotypic profiles of Staphylococcus samples can contribute towards guiding therapeutic approaches in the treatment and control of nosocomial infections.

Harmonization of pulsed-field gel electrophoresis protocols for epidemiological typing of strains of methicillin-resistant Staphylococcus aureus: a single approach developed by consensus in 10 European laboratories and its application for tracing the spread of related strains

Pulsed-fieldgel electrophoresis (PFGE) is the most common genotypic method used in reference and clinical laboratories for typing methicillin-resistant Staphylococcus aureus (MRSA). Many different protocols have been developed in laboratories that have extensive experience with the technique and have established national databases. However, the comparabilities of the different European PFGE protocols for MRSA and of the various national MRSA clones themselves had not been addressed until now. This multinational European Union (EU) project has established for the first time a European database of representative epidemic MRSA (EMRSA) strains and has compared them by using a new "harmonized" PFGE protocol developed by a consensus approach that has demonstrated sufficient reproducibility to allow the successful comparison of pulsed-field gels between laboratories and the tracking of strains around the EU. In-house protocols from 10 laboratories in eight European countries were compared by each center with a "gold standard" or initial harmonized protocol in which many of the parameters had been standardized. The group found that it was not important to standardize some elements of the protocol, such as the type of agarose, DNA block preparation, and plug digestion. Other elements were shown to be critical, namely, a standard gel volume and concentration of agarose, the DNA concentration in the plug, the ionic strength and volume of running buffer used, the running temperature, the voltage, and the switching times of electrophoresis. A new harmonized protocol was agreed on, further modified in a pilot study in two laboratories, and finally tested by all others. Seven laboratories' gels were found to be of sufficiently good quality to allow comparison of the strains by using a computer software program, while two gels could not be analyzed because of inadequate destaining and DNA overloading. Good-quality gels and inclusion of an internal quality control strain are essential before attempting intercenter PFGE comparisons. A number of clonally related strains have been shown to be present in multiple countries throughout Europe. The well-known Iberian clone has been demonstrated in Belgium, Finland, France, Germany, and Spain (and from the wider HARMONY collection in Portugal, Slovenia, and Sweden). Strains from the United Kingdom (EMRSA-15 and -16) have been identified in several othercountries, and other clonally related strains have also been identified. This highlights the need for closer international collaboration to monitor the spread of current epidemic strains as well as the emergence of new ones.

Characteristics of a new epidemic MRSA in Germany ancestral to United Kingdom EMRSA 15

In 1996 a new epidemic MRSA emerged in three hospitals North of Berlin. This strain, Barnim epidemic MRSA, was isolated in 15 hospitals in Northern Germany in 1997 and 29 hospitals throughout Germany in 1998. Isolates of this clone are non-typeable by phages, its resistance phenotype is PEN, OXA, ERY, CLI, CIP (genotype: mecA, ermC, mutations in grlA and gyrA). The Sma I macrorestriction pattern corresponds to particular phage group II strains which is confirmed by the 16S-23S rRNA gene spacer pattern. Isolates of this clone differ by less than three Sma I macrorestriction fragments from isolates of the EMRSA15 clone from the United Kingdom, the most common epidemic MRSA isolates in the United Kingdom in recent years. Both epidemic strains produce enterotoxin C and possess the sec determinant for this toxin, the configuration of the mec regulon is mecI-, mecRB+, mecRC+. Both share the same Alu I pattern of PCR amplimers of the 3' end region of the coagulase gene. EMRSA 15 and Barnim EMRSA share a common multilocus sequence type indicating a recent, shared evolutionary origin.

Use of fluorescent amplified fragment length polymorphism (fAELP) to characterise methicillin-resistant Staphylococcus aureus

The new PCR-based genotyping technique, fluorescent amplified fragment length polymorphism (fAFLP), was compared for discriminatory power and reproducibility with standard phenotypic methods, a coagulase gene (coa) restriction fragment length polymorphism (RFLP) method and pulsed-field gel electrophoresis (PFGE), in typing 34 isolates and four reference strains of methicillin-resistant Staphylococcus aureus (MRSA). The fAFLP showed from 40 to 75 fragments, 50 to 450 base pairs (bp) in size. Based on replicate studies, the isolates were judged indistinguishable when their fAFLP pattern was >93.7% similar. Only two of the isolates were indistinguishable by this criterion. Thirty-one MRSA fell into four major fAFLP groups (1, 2, 3 and 4) at the level of >79.9% similarity. Three other isolates and an EMRSA-16 strain fell outside these major groups. Within both fAFLP groups 1 and 2, two subgroups, A and B, could be identified at approximately 82.0% similarity. While most isolates within group 1 could also be separated by their phenotypic and coagulase gene (coa) RFLP pattern, all the isolates within fAFLP groups 2A and 2B were identical on the basis of these characters. The MRSA within fAFLP groups 3 and 4 were heterogeneous by their phenotypic characteristics and coa gene RFLP patterns. fAFLP was reproducible and distinguished between MRSA isolates that appeared identical by other methods. It is likely to contribute to the epidemiological analysis of outbreaks of MRSA infection.

Molecular subtyping of Staphylococcus aureus isolates from cases of bovine mastitis in Brazil

Sixty-six isolates of Staphylococcus aureus obtained from milk samples of dairy cows suffering from subclinical mastitis in southern Brazil were analysed by five different molecular typing methods. These included the analysis of plasmid profiles, the analysis of coagulase (coa) gene polymorphisms by PCR amplification of the 3' terminal region of the coa gene, the PCR-based detection of polymorphisms in the X region of the protein A gene (spa), the PCR-directed analysis of variations in the spacer region between 16S and 23S rRNA, and the comparison of pulsed-field gel electrophoretically separated genomic SmaI fragment patterns. The molecular typing methods were supplemented with the biochemical characterization of the isolates and the determination of their in-vitro susceptibility to 14 different antibiotics. All genotypic and phenotypic typing methods were analyzed for their ability to discriminate between the isolates. Macrorestriction analysis proved to be the most discriminatory single method (D = 0.96) followed by rRNA spacer typing (D = 0.85), coa PCR (D = 0.82), and spa PCR (D = 0.80).

Molecular typing of Staphylococcus aureus based on PCR restriction fragment length polymorphism and DNA sequence analysis of the coagulase gene

A typing procedure for Staphylococcus aureus was developed based on improved PCR amplification of the coagulase gene and restriction fragment length polymorphism (RFLP) analysis of the product. All coagulase-positive staphylococci produced a single PCR amplification product of either 875, 660, 603, or 547 bp. Those strains of epidemic methicillin-resistant S. aureus 16 (EMRSA-16) studied all gave a product of 547 bp. PCR products were digested with AluI and CfoI, and the fragments were separated by gel electrophoresis. Ten distinct RFLP patterns were found among 85 isolates of methicillin-resistant S. aureus (MRSA) and 10 propagating strains (PS) of methicillin-sensitive S. aureus (MSSA) examined. RFLP patterns 1, 2, and 3 were specific to strains of EMRSA-3, -15, and -16, respectively. By contrast, RFLP patterns 4 and 5 were seen with a heterogeneous collection of strains, together with drug-resistant forms of S. aureus isolated in Europe and four propagating strains used for the international phage set. RFLP pattern 6 was given by the Airedale isolate and PS 95. RFLP pattern 7 encompassed EMRSA-2 (isolate 331), PS 94, and PS 96. An isolate from Germany gave RFLP pattern 8. Eight strains of MSSA gave patterns similar to those of methicillin-resistant strains (RFLP patterns 3, 4, 5, 6, and 7), but two, PS 42E and PS 71, gave unique RFLP patterns 9 and 10, respectively. The coagulase gene PCR products for 24 isolates of MRSA and two isolates of MSSA were sequenced for both strands. The sequences were aligned, and evolutionary lineages were inferred based on pairwise distances between isolates.

Association of borderline oxacillin-susceptible strains of Staphylococcus aureus with surgical wound infections

Staphylococcus aureus isolates which produce type A staphylococcal beta-lactamase have been associated with wound infections complicating the use of cefazolin prophylaxis in surgery. To further evaluate this finding, 215 wound isolates from 14 cities in the United States were characterized by antimicrobial susceptibility and beta-lactamase type and correlated with the preoperative prophylactic regimen. Borderline-susceptible S. aureus isolates of phage group 5 (BSSA-5), which produce large amounts of type A beta-lactamase and exhibit borderline susceptibility to oxacillin, comprised a greater percentage of the 120 wound isolates associated with cefazolin prophylaxis than they did of the 95 isolates associated with other prophylactic regimens (25% versus 12.6%, respectively; P < 0.05). In contrast, methicillin-resistant S. aureus isolates were distributed evenly between the two groups (8.3% versus 11.6%, respectively). In vitro assays demonstrated that cefazolin was hydrolyzed faster by BSSA-5 strains than by other beta-lactamase-producing, methicillin-susceptible strains (1.54 versus 0.50 microg/min/10(8) CFU, respectively; P < 0.0001). These data demonstrate that BSSA-5 strains are a distinct subpopulation of methicillin-susceptible S. aureus which frequently cause deep surgical wound infections. Cefazolin use in prophylaxis is a risk factor for BSSA-5 infection.

Increasing incidence and widespread dissemination of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals in central Europe, with special reference to German hospitals

OBJECTIVE: to present data on prevalence and interregional spread of methicillin-resistant Staphylococcus aureus (MRSA) in Germany. METHODS: A nationwide collection of MRSA isolates from nosocomial infections in 143 hospitals was established from isolates (n=4368) sent to a microbiological reference center during 1993--95. As chosen by distinguishable resistance phenotypes at each time of occurrence during the study period, 1830 isolates were subjected to molecular typing by means of Smal macrorestriction patterns, PCR for RNA gene spacer patterns, and PCR for patterns of DNA stretches flanked by the ERIC-2 sequence and flanked by Tn916 and ribosomal binding site. In addition, data from a multicenter study on the incidence of antibiotic resistance have been analyzed (32 centers, 637 S. aureus isolates). RESULTS: In 1995 the prevalence of MRSA among S. aureus isolates was 8.7% overall in central Europe (including Germany), in comparison to 1.7% in 1990. From 1993 until now, a continuous interregional dissemination of six epidemic strains, which were identified by molecular typing, was recorded. Besides these epidemic strains, 15 MRSA strains were identified which could not be allocated to the epidemic MRSA or to the known clonal groups of the species S. aureus. MRSA from three cases of sporadic nosocomial infections exhibited characteristics of the clonal group of S. aureus with the capacity for toxic shock syndrome formation. The pattern of one MRSA corresponded to those of the S. aureus group exhibiting phage pattern 94,96. CONCLUSIONS: The prevalence of MRSA has increased in central Europe (and Germany) during the last 5 years, to 8.7%. The main source of infection with MRSA is obviously interregional dissemination of epidemic strains. At the same time, the mecA gene has been acquired by strains previously sensitive to methicillin.

Typing of Staphylococcus aureus by PCR for DNA sequences flanked by transposon Tn916 target region and ribosomal binding site

The continuous intra- and interhospital spread of multiresistant Staphylococcus aureus demands a rapid molecular typing system. This study describes the fingerprinting of S. aureus by PCR amplification of DNA sequences flanked by the target site for transposon Tn916 and the ribosomal binding site and neighboring nucleotides (target 916-Shine-Dalgarno PCR [tar 916-shida PCR]). Both starting points for PCR are known to be randomly distributed on the S. aureus chromosome. By use of SmaI-macrorestriction patterns as the reference method it was shown that this PCR genotyping discriminates among strains of the major clonal groups of the species S. aureus (strains with phage patterns 29, +, 94, 96, and 95 as well as group II and group III patterns) and identifies the six epidemic methicillin-resistant S. aureus strains prevalent in German hospitals. All of the investigated strains including methicillin-sensitive. S. aureus were typeable. Tar 916-shida patterns are stable during the dissemination of epidemic methicillin-resistant S. aureus among different hospitals.