Enterotoxin and toxic shock syndrome toxin-1 production of methicillin resistant and methicillin sensitive Staphylococcus aureus strains

Prevalence and virulence genes of Staphylococcus aureus from food contact surfaces in Thai restaurants

Background

Staphylococcus aureus is one of the most common pathogens responsible for food poisoning due to its ability to produce staphylococcal enterotoxin (SE). S. aureus can form biofilms on the surfaces of food processing devices, enabling the distribution of SE on foods through cross-contamination events. Thailand is known for its exotic cuisine, but there is no data on the prevalence of SE-harboring S. aureus in restaurants in Thailand.

Methods

In this study, we conducted surface swabs on surfaces of kitchen utensil that come into contact with food and on the hands of food handlers working in restaurants in the north part of Thailand. Isolated S. aureus was investigated for biofilm formation, virulence, and SE genes.

Results

Two hundred S. aureus were isolated from 650 samples. The highest prevalence of S. aureus contamination was detected on the hands of food handlers (78%), followed by chopping boards (26%), plates (23%), knives (16%), spoons (13%), and glasses (5%). All of them were methicillin-sensitive S. aureus (MSSA) and the mecA gene was not present in any strains. Biofilm formation was detected using the CRA method, and 49 (24.5%) were identified as biofilm-producing strains, with the hands of food handlers identified as the primary source of biofilm-producing strains. The prevelence of biofilm-related adhesion genes detected were: icaAD (13%), fnbA (14.5%), cna (6.5%), and bap (0.5%). Two classical enterotoxin genes, sec and sed, were also found in four and six of the S. aureus isolates, respectively, from hands and utensils.

Conclusion

The highest prevelence of S. aureus was detected on the hands of food handlers. S. aureus strains with biofilm and enterotoxin production abilities were discovered on food contact surfaces and the hands of food handlers, implying significant risk of food contamination from these sources that could be harmful to consumers. To avoid cross-contamination of food with food contact items, the food handlers' hands should be properly washed, and all food preparation equipment should be thoroughly cleaned.

Clonal Diversity, Antimicrobial Susceptibility and Presence of Genes Encoding Virulence Factors in Staphylococcus aureus Strains Isolated from Cut Wound Infections

The aim of the study was to evaluate the clonal relatedness and antimicrobial susceptibility in 52 Staphylococcus aureus strains isolated from cut wound infections in non-related community patients and to determine the presence of selected virulence genes. To analyse the clonal relatedness of investigated strains, pulsed-field gel electrophoresis (PFGE) of macrorestricted DNA fragments was conducted. Antimicrobial susceptibility testing was performed using the AST-P644 card in the VITEK 2 Compact system. All strains were tested for the presence of selected virulence genes using Single and Multiplex PCR. All isolates were classified into 15 PFGE genotypes and seven unique patterns. The vast majority of investigated S. aureus strains were susceptible to all tested antimicrobial agents. Among examined S. aureus strains, 24 combinations of virulence factors were identified. 62.5% of S. aureus strains contained various egc types, alone or together with other staphylococcal enterotoxin genes. A high percentage (86.5%) of isolates harboured superantigen genes. The most frequent enterotoxin gene identified was encoding for sep. All S. aureus strains were classified as agr-positive, and the most frequent agr gene was agr-1. Our results indicate that all examined strains isolated from cut wound infections demonstrated high clonal diversity, diversified gene distribution and good susceptibility to antimicrobial agents.

Epidemiological and Clinical Evidence for the Role of Toxins in S. aureus Human Disease

Staphylococcus aureus asymptomatically colonizes approximately 30–50% of the population and is a leading cause of bacteremia, bone/joint infections, and skin infections in the US. S. aureus has become a major public health threat due to antibiotic resistance and an increasing number of failed vaccine attempts. To develop new anti-staphylococcal preventive therapies, it will take a more thorough understanding of the current role S. aureus virulence factors play in contributing to human disease. This review focuses on the clinical association of individual toxins with S. aureus infection as well as attempted treatment options. Further understanding of these associations will increase understanding of toxins and their importance to S. aureus pathogenesis.

Staphylococcal species less frequently isolated from human clinical specimens - are they a threat for hospital patients?

Background

Coagulase-negative staphylococci belonging to S. haemolyticus, S. hominis subsp. hominis, S. simulans, and S. warneri are often described as etiological factors of infections. Staphylococci are a phylogenetically coherent group; nevertheless, there are differences among the species which may be important to clinicians.

Methods

We investigated selected virulence factors and antibiotic resistance that were phenotypically demonstrated, the presence and expression of genes encoding the virulence factors, and the type of the SCCmec cassette.

Results

The differences between the tested species were revealed. A great number of isolates produced a biofilm and many of them contained single icaADBC operon genes. Clear differences between species in the lipolytic activity spectrum could be related to their ability to cause various types of infections. Our studies also revealed the presence of genes encoding virulence factors homologous to S. aureus in the analysed species such as enterotoxin and pvl genes, which were also expressed in single isolates of S. simulans and S. warneri. S. haemolyticus and S. hominis subsp. hominis isolates were resistant to all clinically important antibiotics including ß-lactams. The identified SCCmec cassettes belonged to IV, V, VII, and IX type but most of the detected cassettes were non-typeable. Among the investigated species, S. hominis subsp. hominis isolates accumulated virulence genes typical for S. aureus in the most efficient way and were widely resistant to antibiotics.

Conclusions

Our results clearly indicated significant differences between the tested species, which might be a result of the horizontal gene transfer (HGT) and can lead to the formation and selection of multi-drug resistant strains as well as strains with new virulence features. Such strains can have a new clinical relevance.

Molecular Typing and Variations in Amount of tst Gene Expression of TSST-1-Producing Clinical Staphylococcus aureus Isolates

The toxic shock syndrome toxin-1 (TSST-1), encoded by tst gene, has been proposed to cause staphylococcal toxic shock syndrome (TSS) in a susceptible host, which highlights the need to evaluate the level of tst gene expression and molecular genetic characteristics of the tst-positive isolates. A total of 916 S. aureus isolates collected from seven hospitals in China were screened for the tst gene. The tst positive isolates were characterized by spa, SCCmec, PFGE, and agr typing. Representative strains were also subjected to MLST typing. qRT-PCR was used to quantify tst and major virulence regulator genes expression. We also sequenced the regions of promoter and open reading frame (ORF) of tst to investigate whether they correlate with the variation in tst expression. We found 208 (22.7%) of surveyed isolates including 198 (29.8%) of MRSA and 10 (4.0%) of MSSA isolates harbored the tst gene. The most common clone among tst positive MRSA isolates belonged to ST5 (CC5)-agr2-t002-SCCmecII. The amount of tst mRNA varied 8.4-folds among clinical S. aureus isolates. Sequencing the tst promoter revealed a base T deletion in tst high expressed isolates. As for major virulence regulators, srrA, sarT, RNAIII, and ccpA in four tst differentially expressed strains were detected to be highly expressed, respectively. Our study revealed high prevalence of ST5 (CC5)-agr2-t002-SCCmecII clone among tst positive MRSA in hospitals from China. The levels of tst expression among clinical S. aureus isolates varied, which may be associated with tst promoter and variations in specific virulence regulators.

Distribution of tsst-1 and mecA Genes in Staphylococcus aureus Isolated From Clinical Specimens

Background

Staphylococcus aureus is a harmful pathogen known to express numerous virulence factors and cause severe infections. High levels of methicillin-resistant Staphylococcus aureus (MRSA) strains are one of the important healthcare problems because of the inefficient treatment of these infections.

Objectives

The purpose of the current study is to evaluate the incidence of the toxic shock syndrome toxin (tsst-1) gene and its association with the prevalence of the mecA gene and drug resistance.

Materials and Methods

The presence of the tsst-1 and mecA genes was investigated by polymerase chain reaction (PCR) among S. aureus isolated from 197 clinical samples. In addition, resistance tests to 12 antibiotics were carried out by the disc diffusion method.

Results

Among the 197 isolates, 134 (68%) contained the tsst-1 genes and 172 (87.3%) contained the mecA genes. The prevalence of both genes was higher among male cases and samples purified from wounds and blood. We found no significant correlation between the presences of the two mentioned genes within isolates. The highest resistance we observed among our samples was to penicillin. None of isolates was resistant to vancomycin or linezolid. A significant correlation was observed between the presence of the mecA gene and resistance to oxacillin, gentamicin, kanamycin, erythromycin, tetracycline, cotrimoxazole, clindamycin, cephazolin and the multi-drug resistant property, which is resistance to more than three antibiotics (P < 0.05).

Conclusions

Our outcomes showed elevated incidences of tsst-1 positive and MRSA strains with higher rates of antibiotic resistance. The conflict between our findings and other records may be due to differences in geographic regions.

Strain Discrimination of Staphylococcus aureus Using Superantigen Profiles

Staphylococcus aureus is one of the major bacterial species that may cause clinical infection and food-poisoning cases. Strains of this species may produce a series of superantigens (SAgs). Due to the importance of staphylococcal infections, reliable methods for the discrimination of strains of this species are important. Such data may allow us to trace the infection origins and be used for epidemiological study. For strain discrimination, genotyping methods, such as pulsed-field gel electrophoresis (PFGE), random amplified polymorphic DNA (RAPD), and multi-locus sequence typing (MLST), etc., could be used. Recently, toxin gene profiles, which can be used for the elucidation of the genetic and pathogenic relatedness between strains, also have been used to improve the strain discrimination. For S. aureus, as more SAg genes were discovered, the SAg profiles become more useful for the strain discrimination of S. aureus. In this chapter, a method for the discrimination of S. aureus strains using superantigen profiles will be described in detail.

Improvement of strain discrimination by combination of superantigen profiles, PFGE, and RAPD for Staphylococcus aureus isolates from clinical samples and food-poisoning cases

Staphylococcus aureus is one of the major bacterial species that may cause clinical infection and food-poisoning cases. Strains of this bacterial species may produce a series of superantigens (SAgs) (i.e., staphylococcal enterotoxins [SEs], staphylococcal enterotoxin-like toxins, and toxic shock syndrome toxin). In this study, S. aureus strains from clinical samples and food-poisoning cases in Taiwan were collected; their SAg profiles, and SmaI digestion patterns determined by pulsed-field gel electrophoresis (PFGE), were then analyzed. Results showed that their SAg gene profiles and SmaI digestion patterns of chromosomal DNA were highly diverse. Although PFGE has been used as a criterion standard for typing of S. aureus strains, and the SAg profiles have been used in combination with PFGE for typing of S. aureus strains, we found that strains grouped in these combined patterns could be further discriminated by the random amplified polymorphic DNA (RAPD) method. Thus, the combined use of SAg profiles, PFGE, and RAPD patterns permits high discrimination for typing of S. aureus strains from not only the clinical samples but also the food-poisoning cases. Such a combined method may be used as a highly accurate approach for epidemiological study and tracing of the contamination origin of staphylococcal infections either in hospitals or food-poisoning cases.

Natural indoles, indole-3-carbinol and 3,3'-diindolymethane, inhibit T cell activation by staphylococcal enterotoxin B through epigenetic regulation involving HDAC expression

Staphylococcal enterotoxin B (SEB) is a potent exotoxin produced by the Staphylococcus aureus. This toxin is classified as a superantigen because of its ability to directly bind with MHC-II class molecules followed by activation of a large proportion of T cells bearing specific Vβ-T cell receptors. Commonly associated with classic food poisoning, SEB has also been shown to induce toxic shock syndrome, and is also considered to be a potential biological warfare agent because it is easily aerosolized. In the present study, we assessed the ability of indole-3-carbinol (I3C) and one of its byproducts, 3,3'-diindolylmethane (DIM), found in cruciferous vegetables, to counteract the effects of SEB-induced activation of T cells in mice. Both I3C and DIM were found to decrease the activation, proliferation, and cytokine production by SEB-activated Vβ8(+) T cells in vitro and in vivo. Interestingly, inhibitors of histone deacetylase class I (HDAC-I), but not class II (HDAC-II), showed significant decrease in SEB-induced T cell activation and cytokine production, thereby suggesting that epigenetic modulation plays a critical role in the regulation of SEB-induced inflammation. In addition, I3C and DIM caused a decrease in HDAC-I but not HDAC-II in SEB-activated T cells, thereby suggesting that I3C and DIM may inhibit SEB-mediated T cell activation by acting as HDAC-I inhibitors. These studies not only suggest for the first time that plant-derived indoles are potent suppressors of SEB-induced T cell activation and cytokine storm but also that they may mediate these effects by acting as HDAC inhibitors.

The potential use of toxin antibodies as a strategy for controlling acute Staphylococcus aureus infections

INTRODUCTION

The pandemic human pathogen, Staphylococcus aureus, displays high levels of antibiotic resistance and is a major cause of hospital- and community-associated infections. S. aureus disease manifestation is to a great extent due to the production of a large arsenal of virulence factors, which include a series of secreted toxins. Antibodies to S. aureus toxins are found in people who are infected or asymptomatically colonized with S. aureus. Immunotherapies consisting of neutralizing anti-toxin antibodies could provide immediate aid to patients with impaired immune systems or in advanced stages of disease.

AREAS COVERED

Important S. aureus toxins, their roles in pathogenesis, rationales for selecting S. aureus toxins for immunization efforts, and caveats associated with monoclonal antibody-based passive immunization are discussed. This review will focus on hyper-virulent community-associated methicillin-resistant S. aureus because of their recent surge and clinical importance.

EXPERT OPINION

Antibodies against genome-encoded toxins may be more broadly applicable than those directed against toxins found only in a sub-population of S. aureus isolates. Furthermore, there is substantial functional redundancy among S. aureus toxins. Thus, an optimal anti-S. aureus formulation may consist of multiple antibodies directed against a series of key S. aureus genome-encoded toxins.

The interface between antibiotic resistance and virulence in Staphylococcus aureus and its impact upon clinical outcomes

The ability of Staphylococcus aureus to rapidly acquire antibiotic resistance in the face of antimicrobial challenge has enabled it to remain an ongoing, significant human pathogen. Mechanisms behind the evolution of resistance in S. aureus are well documented, but the effects of these phenotypes upon virulence are less clear. By exploring available clinical and experimental data, we have shown that a number of the major steps in the evolution of antibacterial resistance in S. aureus have been accompanied by alterations in virulence. This review also highlights that further experimentation is required to fully elucidate the mechanisms involved in the interface between virulence and antibiotic resistance, with the intention of identifying novel preventative or therapeutic strategies for this important human pathogen.

Staphylococcal enterotoxins

Staphylococcus aureus (S. aureus) is a Gram positive bacterium that is carried by about one third of the general population and is responsible for common and serious diseases. These diseases include food poisoning and toxic shock syndrome, which are caused by exotoxins produced by S. aureus. Of the more than 20 Staphylococcal enterotoxins, SEA and SEB are the best characterized and are also regarded as superantigens because of their ability to bind to class II MHC molecules on antigen presenting cells and stimulate large populations of T cells that share variable regions on the β chain of the T cell receptor. The result of this massive T cell activation is a cytokine bolus leading to an acute toxic shock. These proteins are highly resistant to denaturation, which allows them to remain intact in contaminated food and trigger disease outbreaks. A recognized problem is the emergence of multi-drug resistant strains of S. aureus and these are a concern in the clinical setting as they are a common cause of antibiotic-associated diarrhea in hospitalized patients. In this review, we provide an overview of the current understanding of these proteins.

Population structure of Staphylococcus aureus strains isolated from intensive care unit patients in the netherlands over an 11-year period (1996 to 2006)

The genetic background and the presence of several virulence factors of Staphylococcus aureus isolates from intensive care unit (ICU) patients from 14 hospitals in The Netherlands isolated from 1996 until 2006 were investigated. In total, 936 methicillin-susceptible S. aureus (MSSA) and 7 methicillin-resistant S. aureus (MRSA) isolates were collected. The genetic background was determined by spa typing and multilocus sequence typing (MLST). The virulence determinants Panton-Valentine leukocidin (PVL), toxic shock syndrome toxin 1 (TSST-1), and collagen adhesion (CNA) were detected with real-time PCR assays. On the MRSA isolates, mobile resistance staphylococcal cassette chromosome mec (SCCmec) typing was performed. Among the MSSA isolates, 313 different spa types were observed. A genetic background common to MRSA clones, e.g., MLST clonal complex 1 (CC1), CC5, CC8, CC22, CC30, and CC45, was observed among 62% of the isolates. The remaining isolates were associated with MSSA-related MLST CCs. MLST CC1, CC25, and CC30 were continuously present, and other MLST CCs fluctuated over time. Two percent of the MSSA isolates harbored PVL, 21% had TSST-1, and 46% were positive for CNA. There were no changes in the prevalence of the virulence factors over time. Four MRSA isolates were typed as ST8-MRSA-IV (where ST is the MLST sequence type and IV is the SCCmec type), two were ST5-MRSA-II, and one was ST228-MRSA-I. All MRSA isolates were PVL, CNA, and TSST-1 negative except for the two ST5-MRSA-II isolates, which were TSST-1 positive. No changes in the S. aureus genetic background and the prevalence of the virulence factors PVL, CNA, and TSST-1 were observed in ICU patients in The Netherlands over time.

Toll-like receptor 2 ligands on the staphylococcal cell wall downregulate superantigen-induced T cell activation and prevent toxic shock syndrome

Staphylococcal superantigens are pyrogenic exotoxins that cause massive T cell activation leading to toxic shock syndrome and death. Despite the strong adaptive immune response induced by these toxins, infections by superantigen-producing staphylococci are very common clinical events. We hypothesized that this may be partly a result of staphylococcal strains having developed strategies that downregulate the T cell response to these toxins. Here we show that the human interleukin-2 response to staphylococcal superantigens is inhibited by the simultaneous presence of bacteria. Such a downregulatory effect is the result of peptidoglycan-embedded molecules binding to Toll-like receptor 2 and inducing interleukin-10 production and apoptosis of antigen-presenting cells. We corroborated these findings in vivo by showing substantial prevention of mortality after simultaneous administration of staphylococcal enterotoxin B with either heat-killed staphylococci or Staphylococcus aureus peptidoglycan in mouse models of superantigen-induced toxic shock syndrome.

Phage typing, PCR amplification for mecA gene, and antibiotic resistance patterns as epidemiologic markers in nosocomial outbreaks of methicillin resistant Staphylococcus aureus

Staphylococcus aureus is one of the major causes of community and hospital-acquired infections. Bacteriophage considered as a major risk factor acquires S. aureus new virulence genetic elements. A total number of 119 S. aureus isolated from different specimens obtained from (RKH) were distinguished by susceptibility to 19 antimicrobial agents, phage typing, and PCR amplification for mecA gene. All of MRSA isolates harbored mecA gene, except three unique isolates. The predominant phage group is belonging to the (mixed group). Phage group (II) considered as an epidemiological marker correlated to β-lactamase hyper producer isolates. MRSA isolates indicated high prevalence of phage group (II) with highly increase for phage types (Ø3A), which were correlated to the skin. Phage types (Ø80/Ø81) played an important roll in Community Acquired Methicillin Resistant S. aureus (CAMRSA). Three outpatients MRSA isolates had low multiresistance against Bacitracin (Ba) and Fusidic acid (FD), considered as CAMRSA isolates. It was detected that group I typed all FD-resistant MSSA isolates. Phage groups (M) and (II) were found almost to be integrated for Gentamycin (GN) resistance especially phage type (Ø95) which relatively increased up to 20% in MRSA. Tetracycline (TE) resistant isolates typed by groups (II) and (III) in MSSA. Only one isolate resistant to Sulphamethoxazole/Trimethoprim (SXT) was typed by (III/V) alone in MSSA. MRSA isolates resistant to Chloramphenicol (C) and Ba were typed by all groups except (V). It could be concluded that (PERSA) S. aureus isolates from the wound that originated and colonized, and started to build up multi-resistance against the topical treatment antibiotics. In this study, some unique sporadic isolates for both MRSA and MSSA could be used as biological, molecular and epidemiological markers such as prospective tools.

[Molecular epidemiology of methicillin-resistant Staphylococcus aureus isolates with toxic shock syndrome toxin and staphylococcal enterotoxin C genes]

BACKGROUND

Many methicillin-resistant Staphylococcus aureus (MRSA) isolates in Korea possess a specific profile of staphylococcal enterotoxins in that the toxic shock syndrome toxin gene (tst) coexists with the staphylococcal enterotoxin C gene (sec). Because the analysis of staphylococcal cassette chromosome mec (SCCmec), a mobile genetic element mecA gene encoding methicillin resistance, showed that majority of these are SCCmec type II, these MRSA isolates with tst and sec may be genetically related with each other. This study was performed to investigate the genetic relatedness of tstand sec-harboring MRSA strains isolated in Korea by using pulsed-field gel electrophoresis (PFGE).

METHODS

A total of 59 strains of MRSA isolates of SCCmec type II possessing tst and sec were selected for PFGE and phylogenetic analyses. These isolates were collected from 13 health care facilities during nationwide surveillance of antimicrobial resistance in 2002.

RESULTS

The 59 MRSA isolates were clustered into 11 PFGE types, including one major group of 26 strains (44.1%) isolated from 7 healthcare facilities. Seven PFGE types contained 2 or more isolates each, comprising 55 isolates in total.

CONCLUSIONS

Most of SCCmec type II MRSA isolates containing tst and sec showed closely related PFGE patterns. Moreover, MRSA isolates collected from different healthcare facilities showed identical PFGE patterns. These findings suggested a clonal spread of MRSA strains possessing tst and sec in Korean hospitals.

Is MRSA more virulent than MSSA?

Numerous clinical studies have indicated, based on mortality rates, that methicillin-resistant Staphylococcus aureus (MRSA) strains are more virulent than methicillin-susceptible S. aureus (MSSA) strains. In contrast, quantitative laboratory examinations of the presence and magnitude of pathogenic mechanisms and virulence factors in strains of MRSA and MSSA have generated conflicting data. The most important reason for these conflicting results is probably the heterogeneic nature of the resistant population. A comparison of selected and congenic MRSA and MSSA sub-populations of the same strain is required to resolve this issue.

MRSA enteritis causing a high stoma output in the early postoperative phase after bowel surgery

INTRODUCTION

Nosocomial MRSA infection has become an important healthcare issue. We present 6 cases of MRSA enteritis, acquired following bowel surgery and ileostomy formation.

PATIENTS AND METHODS

The data set was obtained from the experience of one consultant surgeon over 6 years in one medical centre. The clinical features and course of six patients that developed MRSA enteritis postoperatively were obtained through review of case notes and laboratory data.

RESULTS

Four male and two female patients (age range, 22-80 years) developed a clinical syndrome postoperatively requiring treatment within the high dependency unit. Three developed respiratory distress syndrome, and one died from multi-organ failure. Exploratory laparotomy carried out in three patients was negative. All patients were MRSA-negative on admission but had swabs positive for MRSA from ileostomy site postoperatively. All of the three patients who had ileostomy effluent cultured for MRSA had positive results.

DISCUSSION

Fever, abdominal pain, distension and high stoma output in the early postoperative period following bowel surgery should alert the clinician to the possibility of MRSA enteritis. Patients require aggressive resuscitation and culture of ileostomy effluent for MRSA. Exploratory laparotomy has no obvious benefits. As MRSA enteritis has the potential to be a lethally effective disseminator of MRSA, such clinical features should prompt early instigation of appropriate infection control practices.

Community-acquired Staphylococcus aureus pneumonia accompanied by rapidly progressive glomerulonephritis and hemophagocytic syndrome

A 59-year-old woman without underlying disease was admitted to a local hospital because of lung abscess, cytopenias and renal failure. 3 days before admission, she was diagnosed as influenza infection and was under antiviral therapy. Blood cultures were positive for methicillin-sensitive Staphylococcus aureus (MSSA). She was transferred to our hospital on the 15th day at the local hospital because the clinical manifestations could not improve even though she was treated with multiple intravenous antibiotics directed against MSSA. Sputum cultures yielded methicillin-resistant S. aureus (MRSA) producing toxic shock syndrome toxin-1 (TSST-1) and serologic test indicated hypercytokinemia. She was diagnosed as rapidly progressive glomerulonephritis and hemophagocytic syndrome associated with staphylococcal infection. The pulmonary lesions, cytopenias and renal dysfunction improved as a result of long-term antimicrobial treatment including vancomycin, hemodialysis, short-term administration of corticosteroid and other supportive cares. She was finally weaned from hemodialysis on the 73rd hospital day. In recent years, the number of cases of S. aureus producing TSST-1 and enterotoxin has been increasing and in cases of staphylococcal infections, close attention should be given to toxin-mediated as well as non-toxin-mediated clinical manifestations.

Association between the methicillin resistance of clinical isolates of Staphylococcus aureus, their staphylococcal cassette chromosome mec (SCCmec) subtype classification, and their toxin gene profiles

Virulence and antimicrobial resistance are important determinators of the clinical manifestations and of the treatments of bacterial infections. Here, we studied the associations between the methicillin resistance of clinical Staphylococcus aureus isolates, their classifications as particular staphylococcal cassette chromosome mec (SCCmec) subtypes, and their toxin gene profiles. In total, 252 S. aureus isolates were collected from 13 healthcare facilities in 6 Korean provinces. The overall prevalence of methicillin-resistant S. aureus (MRSA) was 63%. SCCmec typing and toxin gene analysis were performed by multiplex polymerase chain reaction. One or more staphylococcal toxin genes were found in 190 (75.4%) strains. Methicillin-resistant S. aureus strains carried toxin genes more frequently than methicillin-susceptible S. aureus strains (85.5% versus 53.8%). SCCmec subtypes differed in terms of their frequencies of toxin gene carriage (95.9% in SCCmec II, 74.4% in SCCmec III, and 68.8% in SCCmec IV). Specific SCCmec subtypes frequently harbored particular toxin gene combinations: 77.3% of SCCmec II strains carried sec and tst genes, 48.8% of SCCmec III strains carried sea and see genes, and 46.9% of SCCmec IV carried sea and seb genes. Indeed, the most prevalent combination in MRSA strains, that of sec and tst, was only observed in SCCmec II strains, and these strains failed to show the coexistence of sea and see or sea and seb genes. Thus, the SCCmec subtypes of S. aureus revealed specific staphylococcal toxin profiles. We revealed that certain staphylococcal toxin gene profiles are associated not only with the methicillin resistance of S. aureus but also with their SCCmec subtypes.

Detection of new methicillin-resistant Staphylococcus aureus clones containing the toxic shock syndrome toxin 1 gene responsible for hospital- and community-acquired infections in France

Methicillin-resistant Staphylococcus aureus (MRSA) clones harboring the toxic shock syndrome toxin 1 (tst) gene have been detected in France and in Switzerland since 2002. During a passive survey conducted between 2002 and 2003, we collected 103 tst-positive S. aureus isolates from 42 towns in France, of which 27 were resistant to methicillin. The tst-positive MRSA belonged to two clones: a major clone comprising 25 isolates of sequence type (ST) 5 and agr group 2 and a minor clone comprising two isolates of ST30 and agr3. The tst-positive MRSA clones were associated with both hospital-acquired (12 cases) and community-acquired (8 cases) infections. The MRSA clones were mainly isolated from children (overall median age, 3 years). They caused a variety of clinical syndromes, including toxic shock syndrome and suppurative infections. Both clones were found to harbor a type IV staphylococcal chromosomal cassette mec (SCCmec) and to have similar antibiotic resistance profiles (usually resistant to oxacillin, kanamycin, and tobramycin and with intermediate resistance to fusidic acid). The origin of these clones is unclear. The tst-positive agr2 MRSA clone has the same sequence type (ST5) of two pandemic nosocomial MRSA clones, namely, the Pediatric clone and the New York/Japan clone. These findings suggest that all these clones are phylogenetically related. The pulsotype of the tst-positive MRSA clones differed from that of methicillin-sensitive S. aureus (MSSA) clones by a single band involving the SCCmec element. These findings suggest that the tst-positive MRSA clones may have emerged from their respective MSSA counterparts.

Heterogeneity of methicillin-susceptible Staphylococcus aureus strains at a German University Hospital implicates the circulating-strain pool as a potential source of emerging methicillin-resistant S. aureus clones

Recently, we demonstrated rapid dissemination of different methicillin-resistant Staphylococcus aureus (MRSA) clones at the Institute for Microbiology at the University of Magdeburg (B. Ghebremedhin, W. König, and B. König, Eur. J. Clin. Microbiol. Infect. Dis. 24:388-398, 2005). The majority of them harbored the readily transmissible mec cassette type IV. Thus, theoretically, methicillin-susceptible Staphylococcus aureus (MSSA) might capture the mecA gene from circulating MRSA, or MRSA strains might catch mobile toxin genes from MSSA. Therefore, we characterized MSSA strains circulating at the University Hospital in Magdeburg. Among a total of 84 MSSA strains under study, about 40% possessed the tst (toxic shock syndrome toxin) gene and up to four additional enterotoxin genes. tst-positive MSSA strains belonged to all known agr groups (I to IV) and to 14 different spa types (t008, t012, t015, t019, t024, t056, t065, t127, t133, t162, t271, t287, t399, and t400), and they were classified by multilocus sequence typing (MLST) as ST1, ST8, ST30, ST39, ST45, ST101, ST121, ST395, and ST426. In contrast, simultaneously circulating MRSA strains (n = 24) harbored in general two or three genes of the enterotoxin gene cluster, and the tst-positive MRSA isolates belonged to the well-known epidemic types ST22, ST45, and ST228 and were classified as spa types t001, t028, and t032. From our results, one may conclude that the pool of circulating MSSA strains is an important parameter with regard to the epidemiology of hospital- and community-acquired MRSA clones and their potential virulence.

Is Methicillin Resistance Associated with a Worse Prognosis in Staphylococcus aureus Ventilator-Associated Pneumonia?

BACKGROUND

Excess mortality associated with methicillin resistance in patients with Staphylococcus aureus ventilator-associated pneumonia (SA-VAP), taking into account such confounders as treatment adequacy and time in the intensive care unit (ICU), have not been adequately estimated.

METHODS

One hundred thirty-four episodes of SA-VAP entered in the Outcomerea database were studied. Patients from whom methicillin-resistant S. aureus (MRSA) was recovered were compared with those from whom methicillin-susceptible S. aureus (MSSA) was recovered, stratified for duration of stay in the ICU at the time of VAP diagnosis and adjusted for confounders (severity at admission, characteristics at VAP diagnosis, and treatment adequacy).

RESULTS

Treatment was adequate within 24 h after VAP diagnosis for 86% of the 65 MSSA-infected patients and 77% of the 69 MRSA-infected patients (P = .2). Polymicrobial VAP was more commonly associated with MSSA than with MRSA (49.2% vs. 25.7%; P = .01). MRSA infection was associated with a lower prevalence of coma at hospital admission and a higher rate of use of central venous lines and fluoroquinolones during the first 48 h of the ICU stay. The rates of shock, recurrence, and superinfection were similar in both groups. The crude hospital mortality rate was higher for MRSA-infected patients than for MSSA-infected patients (59.4% vs. 40%; P = .024). This difference disappeared after controlling for time in the ICU before VAP and parameters imbalanced at ICU admission (odds ratio [OR], 1.23; 95% confidence interval [CI], 0.49-3.12; P = .7) and remained unchanged after further adjustments for initial treatment adequacy and polymicrobial VAP (OR, 0.98; 95% CI, 0.36-2.66).

CONCLUSIONS

Differences in patient characteristics, initial ICU treatment, and time in the ICU confounded estimates of excess death due to MRSA VAP. After careful adjustment, methicillin resistance did not affect ICU or hospital mortality rates.

Risk factors for hematogenous complications of intravascular catheter-associated Staphylococcus aureus bacteremia

BACKGROUND

The role of both host and pathogen characteristics in hematogenous seeding following Staphylococcus aureus bacteremia is incompletely understood.

METHODS

Consecutive patients with intravascular catheter-associated Staphylococcus aureus bacteremia were prospectively recruited over a 91-month period. The corresponding bloodstream isolates were examined for the presence of 35 putative virulence determinants. Patient and bacterial characteristics associated with the development of hematogenous complications (HCs) (i.e., septic arthritis, vertebral osteomyelitis, or endocarditis) were defined.

RESULTS

HC occurred in 42 (13%) of 324 patients. Patient characteristics at diagnosis that were associated with HC included community onset (relative risk [RR], 2.25; 95% confidence interval [CI], 1.24-4.07; P=.007), increased symptom duration (odds ratio for each day, 1.14; 95% CI, 1.06-1.2; P<.001), presence of a long-term intravascular catheter or noncatheter prosthesis (RR, 4.02; 95% CI, 1.74-9.27; P<.001), hemodialysis dependence (RR, 3.84; 95% CI, 2.08-7.10; P<.001), and higher APACHE II score (P=.02). Bacterial characteristics included sea (RR, 2.03; 95% CI, 1.16-3.55; P=.011) and methicillin-resistant S. aureus (MRSA) (RR, 2.09; 95% CI, 1.19-3.67; P=.015). Subsequent failure to remove a catheter was also associated with HC (RR, 2.28; 95% CI, 1.22-4.27; P=.011). On multivariable analysis, symptom duration, hemodialysis dependence, presence of a long-term intravascular catheter or a noncatheter device, and infection with MRSA remained significantly associated with HC.

CONCLUSIONS

This investigation identifies 4 host- and pathogen-related risk factors for hematogenous bacterial seeding and reaffirms the importance of prompt catheter removal.

Impact of Methicillin Resistance on Outcome ofStaphylococcus aureusVentilator-associated Pneumonia

The impact of methicillin resistance on morbidity and mortality of patients suffering from severe Staphylococcus aureus infections remains highly controversial. We analyzed a retrospective cohort of 97 patients with methicillin-susceptible and 74 patients with methicillin-resistant Staphylococcus aureus ventilator-associated pneumonia (VAP). Initial empiric antibiotic therapy was appropriate for every patient. Patients with methicillin-resistant Staphylococcus aureus VAP were older, had higher disease-severity scores, and had been on mechanical ventilation longer at onset of VAP. Factors associated with 28-day mortality retained by multivariate logistic regression analysis were: age (odds ratio [OR] = 1.05, 95% confidence interval [CI], 1.02-1.08, p = 0.001) and Day 1 organ dysfunctions or infection (ODIN) score (OR = 1.90, 95% CI, 1.31-2.78, p = 0.001), but not methicillin resistance (OR = 1.72, 95% CI, 0.73-4.05, p = 0.22). The percentages of infection relapse or superinfection did not differ significantly between the two patient groups. In conclusion, after controlling for clinical and physiologic heterogeneity between groups, methicillin resistance did not significantly affect 28-day mortality of patients with Staphylococcus aureus VAP receiving appropriate antibiotics.

The Impact of Methicillin Resistance on the Outcome of Poststernotomy Mediastinitis Due toStaphylococcus aureus

The impact of methicillin resistance on morbidity and mortality among patients with severe Staphylococcus aureus infection remains highly controversial. We retrospectively analyzed patients with mediastinitis due to methicillin-susceptible S. aureus (MSSA; 145 patients) or methicillin-resistant S. aureus (MRSA; 73 patients) who were treated with closed drainage using Redon catheters. Initial empirical antibiotic therapy was appropriate for every patient. Patients with MRSA mediastinitis were older, had higher disease severity scores at admission to the intensive care unit (ICU), and had longer periods of MRSA incubation. Multivariate analysis revealed that ICU mortality was associated with age of > or =65 years, incubation time of < or =15 days, bacteremia, higher Acute Physiology and Chronic Health Evaluation II score, and receipt of mechanical ventilation > or =2 days after surgical debridement, but not with methicillin resistance. After adjustment, durations of mechanical ventilation and Redon catheter drainage were similar for both groups (for patients infected with MRSA, only the time to mediastinal effluent sterilization remained longer). Methicillin resistance did not significantly affect ICU mortality among patients with poststernotomy mediastinitis who benefited from optimal treatments.

Is Methicillin-Resistant Staphylococcus aureus More Virulent than Methicillin-Susceptible S. aureus? A Comparative Cohort Study of British Patients with Nosocomial Infection and Bacteremia

Staphylococcus aureus is the most common cause of hospital-acquired bacteremia. From 1995 through 2000, data on age, sex, patient specialty at time of first bacteremia, primary and secondary sites of infection, delay in initiating antimicrobial therapy, and patient outcome were prospectively recorded for 815 patients with nosocomial S. aureus bacteremia. The proportion of patients whose death was attributable to methicillin-resistant S. aureus (MRSA) was significantly higher than that for methicillin-susceptible S. aureus (MSSA) (11.8% vs. 5.1%; odds ratio [OR], 2.49; 95% confidence interval [CI], 1.46-4.24; P<.001). After adjustment for host variables, the OR decreased to 1.72 (95% CI, 0.92-3.20; P=.09). There was no significant difference between rates of disseminated infection (7.1% vs. 6.2% for MRSA-infected patients and MSSA-infected patients, respectively; P=.63), though the rate of death due to disseminated infection was significantly higher than death due to uncomplicated infection (37% vs. 10% for MRSA-infected patients [P<.001] and 37% vs. 3% for MSSA-infected patients [P<.001]). There was a strong statistical trend toward death due to nosocomial MRSA infection and bacteremia, compared with MSSA.

Prevalence of genes encoding pyrogenic toxin superantigens and exfoliative toxins among strains of Staphylococcus aureus isolated from blood and nasal specimens

A total of 429 different Staphylococcus aureus isolates encompassing 219 blood isolates and 210 isolates taken from anterior nares were systematically searched by two multiplex PCR-DNA enzyme immunoassays (PCR-DEIA) for exfoliative toxin (ET) genes eta and etb, as well as for the classical members of the pyrogenic toxin superantigen (PTSAg) gene family comprising the staphylococcal enterotoxin (SE) genes sea-see and the toxic shock syndrome toxin 1 gene tst. In addition, a third PCR-DEIA was established to investigate the possession of four recently described SE genes, viz. seg-sej. The most frequent PTSAg/ET genes amplified were seg and sei, which were found strictly in combination in 55.0% of the S. aureus isolates tested. Other frequently detected toxin genes were tst (20.3%), sea (15.9%), and sec (11.2%). Only five isolates harbored ET genes. Regarding the origin of the S. aureus isolates, a significant difference (P = 0.037) was found for the possession of the sed/sej gene combination (10.5% of blood isolates versus 3.3% of nasal strains). Overall, about half of S. aureus isolates tested harbored genes of the classical members of the PTSAg family and ETs (50.8%), whereas 73.0% of S. aureus isolates were toxin gene positive if the recently described SE genes were included. This notable higher prevalence indicates that the possession of PTSAg genes in particular seems to be a habitual feature of S. aureus. Moreover, mainly due to the fixed combinations of seg plus sei, as well as sed plus sej, the possession of multiple PTSAg genes (62.9%) is more frequent than assumed so far.

Two-dimensional analysis of exoproteins of methicillin-resistant Staphylococcus aureus (MRSA) for possible epidemiological applications

We applied two-dimensional gel electrophoresis (2-DE) to the total exoproteins secreted from pathogenic MRSA strains and identified major protein spots by N-terminal amino acid sequence analysis. In approximately 300 to 500 spots visualized on each gel, various exoproteins and cell-associated proteins were identified and their sites on the gels confirmed for construction of a reference map. Major exotoxins such as enterotoxins SEA, SEB, and SEC,, toxic shock syndrome toxin-1 (TSST-1), and hemolysins were distributed in the region of pI 6.8 to 8.1 and MW 21 to 35 kDa. Although the differences between calculated and observed values of pI and MW were relatively small in each exoprotein, those of several proteins including alpha-hemolysin and SEB were considerably deviated from the positions of the expected values. Some exoproteins were detected as multiple spots. These included beta-hemolysin, enterotoxins SEA, SEB, and SEC3, glutamic acid-specific endopeptidase, glycerophosphoryl diester phosphodiesterase and triacylglycerol lipase. The multiple spots of these exoproteins may be generated by the action of own proteases. Certain similarities of 2-DE patterns among strains belonging to the same coagulase types were observed. On the basis of 2-DE image analysis, coagulase type II strains secreted somewhat larger amounts of SEB and SEC3 as well as TSST-1 than the strains belonging to other coagulase types. Taken together, 2-DE analysis of exoproteins is applicable to epidemiological studies for MRSA, as compared with pulsed field gel electrophoresis of restricted chromosomal DNA.

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.

Screening for methicillin-resistant Staphylococcus aureus in the endemic hospital: what have we learned?

Control of methicillin-resistant Staphylococcus aureus (MRSA) still generates controversy among infection control practitioners. Opponents claim that once MRSA becomes endemic in an institution, control efforts are no longer justified. This review examines the usefulness, feasibility and cost-effectiveness of control programmes in acute-care hospitals where eradication of MRSA has either failed or has never been attempted; hence, the pathogen has become endemic. High endemicity is associated with increased hospital-acquired infection rates, increased use of glycopeptides and subsequent risk of emergence of antibiotic-resistant Gram-positive bacteria, and additional healthcare costs. Thus, MRSA control has many advantages. Indeed, in many institutions the actual benefit of containment efforts was manifested through the resultant decrease in the incidence of hospital-acquired MRSA infections. Successful programmes are based on an early identification of the MRSA reservoir and prompt implementation of contact precautions. The most efficacious strategy to detect occult MRSA carriage is via the screening of high-risk patients on admission to the hospital which has proven to be cost-effective in varied acute-care endemic settings.

Human antibody response during sepsis against targets expressed by methicillin resistant Staphylococcus aureus

The identification of target structures is a prerequisite for the development of new treatment options, like antibody based therapy, against methicillin resistant Staphylococcus aureus (MRSA). In this study we identified immunodominant structures which were expressed in vivo during sepsis caused by MRSA. Using human sera we compared the immune response of humans with MRSA sepsis with the immune response of normal individuals and asymptomatically colonized individuals. We identified and characterized four staphylococcal specific antigenic structures. One target is a staphylococcal protein of 29 kDa that exhibited 29% identity to secreted protein SceA precursor of Staphylococcus carnosus. The putative function of this protein, which was designated IsaA (immunodominant staphylococcal antigen), is unknown. The second target is an immunodominant protein of 17 kDa that showed no homology to any currently known protein. This immunodominant protein was designated IsaB. The third and fourth antigens are both immunodominant proteins of 10 kDa. One of these proteins showed 100% identity to major cold shock protein CspA of S. aureus and the other protein was identified as the phosphocarrier protein Hpr of S. aureus. The identified immunodominant proteins may serve as potential targets for the development of antibody based therapy against MRSA.

Expression of a clone specific DNA sequence from Staphylococcus aureus in Escherichia coli

Staphylococcus aureus produces a large number of factors thought to contribute to virulence, although the precise role of some of these individual factors is not clearly defined. To investigate whether specific virulence factors might be responsible for the selection and dominance of certain genotypes of methicillin- and multiply resistant S. aureus (MRSA), the method of subtractive hybridisation was used to identify conserved DNA sequences associated with the clinical, clonal populations of S. aureus. The findings described in this report indicate that the method of subtractive hybridisation is a valuable tool to identify clone specific virulence factors, which might be of potential as diagnostic markers and as alternative vaccine targets.