Staphylococcus aureus. The persistent pathogen (first of two parts)

Assessment of Staphylococcus Aureus growth on biocompatible 3D printed materials

The customizability of 3D printing allows for the manufacturing of personalized medical devices such as laryngectomy tubes, but it is vital to establish the biocompatibility of printing materials to ensure that they are safe and durable. The goal of this study was to assess the presence of S. aureus biofilms on a variety of 3D printed materials (two surgical guide resins, a photopolymer, an elastomer, and a thermoplastic elastomer filament) as compared to standard, commercially available laryngectomy tubes.C-shaped discs (15 mm in height, 20 mm in diameter, and 3 mm in thickness) were printed with five different biocompatible 3D printing materials and S. aureus growth was compared to Shiley™ laryngectomy tubes made from polyvinyl chloride. Discs of each material were inoculated with S. aureus cultures and incubated overnight. All materials were then removed from solution, washed in phosphate-buffered saline to remove planktonic bacteria, and sonicated to detach biofilms. Some solution from each disc was plated and colony-forming units were manually counted the following day. The resulting data was analyzed using a Kruskal-Wallis and Wilcoxon Rank Sum test to determine pairwise significance between the laryngectomy tube material and the 3D printed materials.The Shiley™ tube grew a median of 320 colonies (IQR 140-520), one surgical guide resin grew a median of 640 colonies (IQR 356-920), the photopolymer grew a median of 340 colonies (IQR 95.5-739), the other surgical guide resin grew a median of 431 colonies (IQR 266.5-735), the thermoplastic elastomer filament grew a median of 188 colonies (IQR 113.5-335), and the elastomer grew a median of 478 colonies (IQR 271-630). Using the Wilcoxon Rank Sum test, manual quantification showed a significant difference between biofilm formation only between the Shiley™ tube and a surgical guide resin (p = 0.018).This preliminary study demonstrates that bacterial colonization was comparable among most 3D printed materials as compared to the conventionally manufactured device. Continuation of this work with increased replicates will be necessary to determine which 3D printing materials optimally resist biofilm formation.

Profile of bacterial pathogens causing infections in children with sickle cell anaemia in Maiduguri

Background

Sickle cell disease (SCD) is a major cause of morbidity and mortality in African children. Infection has been found to be a major cause of hospitalisation, a major precipitant of crises and one of the greatest causes of death among SCD patients at all ages.

Objectives

The objective of the study was to determine the prevalence of bacterial infection, pattern of the isolates and the antibiotic sensitivity of isolated bacteria among children with sickle cell anaemia (SCA).

Materials and Methods

A cross-sectional study carried out in the University of Maiduguri Teaching Hospital. A total of 242 hospitalised children with SCA with symptoms and signs of infection were recruited for the study using consecutive sampling technique. Sociodemographic and clinical data were obtained. Blood, urine, aspirates, swabs and cerebrospinal fluid samples were collected based on their clinical presentation and subjected to microbiological analysis.

Results

A total of 242 patients were studied. The age range was 9 months-15 years, with a mean age of 6.36 years ± 3.75 years. Male-to-female ratio was 1:1.14, with 41.7% of them belonging to low social class. Seventy seven of the 242 had confirmed bacterial infection giving an incidence of bacterial infection in SCA patients of 31.8%. Gram-negative organisms accounted for 64.5% of the isolates and they include Salmonella, Klebsiella, Escherichia coli and Coliforms. However, Staphylococcus aureus (32.9%) was the most frequent microorganism isolated, followed by Salmonella, (20.3%), Klebsiella (12.6%) and Coliforms (12.6%). Amoxicillin-clavulanate, cefixime and gentamicin showed more than 50% activity against the isolated bacterial pathogens while chloramphenicol was found to have low activity against Salmonella.

Conclusion

High index of suspicion of bacterial infection should be borne in mind of the attending physician when children with SCA present with features of infection. Detailed clinical evaluation and appropriate sample collection for microbiological analysis are recommended. Empirical treatment should be started on SCA patients who have clinical evidence of infection and should be broad enough to cover for common bacterial pathogens.

Anti-TIF-1γ Antibody Detection Using a Commercial Kit vs In-House Immunoblot: Usefulness in Clinical Practice

Objectives

Anti-TIF-1γ autoantibody detection is important for cancer screening in patients with dermatomyositis. The gold standard for anti-TIF-1γ detection, immunoprecipitation, is only available from a few specialized laboratories worldwide, so commercial ELISA/immunoblot tests have emerged in recent years. To analyze their usefulness in diagnosing cancer-associated dermatomyositis, we compared Euroimmun Euroline profile with our previously validated in-house immunoblot assay with human recombinant TIF-1γ.

Methods

We included 308 adult patients from Hospital de la Santa Creu I Sant Pau and Vall Hebrón Hospital (Barcelona, Spain) tested for anti-TIF-1γ autoantibodies using the Euroline profile and an in-house immunoblot assay.

Results

A total of 27 anti-TIF-1γ were detected by the Euroline and 12 by the in-house assay. Fair agreement was observed between Euroline and the in-house immunoblot Cohen’s kappa 0.3163. Expected prevalence of anti-TIF-1γ autoantibodies was observed for the two methods for dermatomyositis and undifferentiated connective tissue diseases, but unexpectedly high prevalence of anti-TIF-1γ autoantibodies was detected by Euroline compared to the in-house immunoblot for other diseases (16.5% Euroline vs 0.8% in-house immunoblot, p<0.01). The in-house IB compared to Euroline more reliably detected cancer in patients with DM with anti-TIF-1γ antibodies (p=0.0014 vs p=0.0502 for in-house immunoblot vs Euroline).

Conclusion

We recommend using a second validated method to confirm Euroline-detected anti-TIF-1γ antibodies when the dermatomyositis diagnosis is not definitive. Furthermore, in the context of definite DM diagnosis with negative anti-TIF-1γ antibodies by Euroline and no other myositis specific antibody, is also recommendable to confirm by a second validated method.

Peritoneal Defence Mechanisms and Staphylococcus Aureus in Patients Treated with Continuous Ambulatory Peritoneal Dialysis (CAPD)

Peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients due to S. aureus is associated with an adverse clinical outcome, suggesting impaired clearance of this organism by the host. The ability of peritoneal macrophages (PMO) derived from CAPD patients to take up S. aureus and mount a respiratory burst was investigated. Whilst significant activity was observed in the absence of opsonin, both parameters of phagocytosis were augmented by addition of 20% pooled human serum (PHS), complement-depleted PHS, and fibronectin. When used as sole opsonin, fibronectin resulted in a dose-related increase in chemiluminescent response by both blood neutrophils and PMO.

The opsonic activity of dialysis effluent, as judged by neutrophil chemiluminescence, correlated with IgG and fibronectin content, but not with complement as assessed by C3 levels. The addition of urokinase to dialysate improved its opsonic properties whilst having no effect on the activity of PHS-20%; this would suggest that the formation of fibrin in dialysate, promoted by S. aureus, interferes with phagocytosis. This and the low IgG, complement and fibronectin levels in dialysate may explain in part the relatively poor clearance of this organism from the peritoneum.

The Staphylococcus aureus Transcriptome during Cystic Fibrosis Lung Infection

Laboratory models have been invaluable for the field of microbiology for over 100 years and have provided key insights into core aspects of bacterial physiology such as regulation and metabolism. However, it is important to identify the extent to which these models recapitulate bacterial physiology within a human infection environment. Here, we performed transcriptomics (RNA-seq), focusing on the physiology of the prominent pathogen Staphylococcus aureusin situ in human cystic fibrosis (CF) infection. Through principal-component and hierarchal clustering analyses, we found remarkable conservation in S. aureus gene expression in the CF lung despite differences in the patient clinic, clinical status, age, and therapeutic regimen. We used a machine learning approach to identify an S. aureus transcriptomic signature of 32 genes that can reliably distinguish between S. aureus transcriptomes in the CF lung and in vitro The majority of these genes were involved in virulence and metabolism and were used to improve a common CF infection model. Collectively, these results advance our knowledge of S. aureus physiology during human CF lung infection and demonstrate how in vitro models can be improved to better capture bacterial physiology in infection.IMPORTANCE Although bacteria have been studied in infection for over 100 years, the majority of these studies have utilized laboratory and animal models that often have unknown relevance to the human infections they are meant to represent. A primary challenge has been to assess bacterial physiology in the human host. To address this challenge, we performed transcriptomics of S. aureus during human cystic fibrosis (CF) lung infection. Using a machine learning framework, we defined a "human CF lung transcriptome signature" that primarily included genes involved in metabolism and virulence. In addition, we were able to apply our findings to improve an in vitro model of CF infection. Understanding bacterial gene expression within human infection is a critical step toward the development of improved laboratory models and new therapeutics.

Vaccine display on artificial bacterial spores enhances protective efficacy against Staphylococcus aureus infection

Spores of Bacillus subtilis are encased in a protein coat composed of ∼80 different proteins. Recently, we reconstituted the basement layer of the coat, composed of two structural proteins (SpoVM and SpoIVA) around spore-sized silica beads encased in a lipid bilayer, to create synthetic spore-like particles termed 'SSHELs'. We demonstrated that SSHELs could display thousands of copies of proteins and small molecules of interest covalently linked to SpoIVA. In this study, we investigated the efficacy of SSHELs in delivering vaccines. We show that intramuscular vaccination of mice with undecorated one micron-diameter SSHELs elicited an antibody response against SpoIVA. We further demonstrate that SSHELs covalently modified with a catalytically inactivated staphylococcal alpha toxin variant (HlaH35L), without an adjuvant, resulted in improved protection against Staphylococcus aureus infection in a bacteremia model as compared to vaccination with the antigen alone. Although vaccination with either HlaH35L or HlaH35L conjugated to SSHELs similarly elicited the production of neutralizing antibodies to Hla, we found that a subset of memory T cells was differentially activated when the antigen was delivered on SSHELs. We propose that the particulate nature of SSHELs elicits a more robust immune response to the vaccine that results in superior protection against subsequent S. aureus infection.

Oliver Cromwell׳s Fatal Ague

Although many people recognize Oliver Cromwell by name, few know more than the barest details of his life or his legacy, and fewer still of the "ague" that ended his brief reign as Lord Protector of the Commonwealth of England, Scotland and Ireland and one of Britain׳s greatest generals. He died suddenly at age 59. Cromwell was the "terror of Europe" during that period. His physicians diagnosed his fatal disorder as "bastard tertian ague." A contemporary analysis of his clinical record, including one with the aid of the U.S. Department of Energy׳s supercomputer at the Oak Ridge National Laboratory in Tennessee, suggests that he died of an infection, possibly 2 infections acting in concert.

Thermostabilization of indigenous multiplex polymerase chain reaction reagents for detection of enterotoxigenic Staphylococcus aureus

BACKGROUND/PURPOSE

Among DNA-based techniques, polymerase chain reaction (PCR) is the most widely accepted molecular tool for the detection of pathogens. However, the technique involves several reagents and multiple pipetting steps that often lead to error-prone results. Additionally, the reagents entail a cold-chain facility to maintain their stability during storage and transportation. The main aim of the present study was to simplify the utility of a pre-optimized multiplex PCR format that was developed to detect toxigenic strains of Staphylococcus aureus by providing stable, pre-mixed, and ready-to-use master mix in a lyophilized formulation.

METHODS

Master mix containing all reagents except the template was lyophilized in the presence of an excipient lyoprotectant to achieve long-term stability without altering the sensitivity, specificity and PCR performance. Bromophenol blue was also included in the master mix to reduce the risk of external contamination during gel loading. The stability of lyophilized master mix was analyzed at different temperatures. The PCR performance was also examined after exposure of master mix to notable temperature fluctuations during transportation.

RESULTS

The shelf-life of lyophilized master mix was estimated to be 1.5 months at ambient temperature and 6 months at 4°C. Stability was unaffected by temperature fluctuations during transportation even in cold-chain-free conditions, thus reducing the cost required for cold storage.

CONCLUSION

The sensitive, cost-effective, ready-to-use, and ambient temperature stable formulation could be implemented as a detection tool in food analysis and diagnostic laboratories and hospitals and for on-field application outside the laboratories, as well as for detection of toxigenic strains of S. aureus.

Development of a sandwiched microarray platform for studying the interactions of antibiotics with Staphylococcus aureus

It still confronts an outstanding challenge to screen efficient antibacterial drugs from millions of potential antibiotic candidates. In this regard, a sandwiched microarray platform has been developed to culture live bacteria and carry out high-throughput screening antibacterial drugs. The optimized lectin-hydrogel microarray can be used as an efficient bacterial capturing and culturing platform, which is beneficial to identify spots and collect data. At the same time, a matching drug-laden polyacrylamide microarray with Luria-Bertani (LB) culture medium can be generated automatically and accurately by using a standard non-contacting procedure. A large number of microscale culture chambers (more than 100 individual samples) between two microarrays can be formed by linking two aligned hydrogel spots using LB culture medium, where live bacteria can be co-cultured with drug candidates. Using Staphylococcus aureus (S. aureus) and four well-known antibiotics (amoxicillin, vancomycin, streptomycin and chloramphenicol) as model system, the MIC (minimum inhibitory concentration) values of the antibiotics can be determined by the drug induced change of bacterial growth, and the results demonstrate that the MIC values of amoxicillin, vancomycin and streptomycin are 1.7 μg mL(-1), 3.3 μg mL(-1) and 10.3 μg mL(-1), respectively.

Hymenolepis diminuta: analysis of the expression of Toll-like receptor genes (TLR2 and TLR4) in the small and large intestines of rats. Part II

Toll-like receptors in the gastrointestinal tract can influence intestinal homeostasis and play a role in the repair and restitution of intestinal epithelium following tissue damage. In our previous study a statistically significant increase in the level of TLR4 and TLR2 gene expression was observed in rats in early stages of hymenolepidosis. Moreover, the immunopositive cell number and the intensity of immunohistochemical staining (indicating the presence of TLRs within intestinal epithelial cells) increased over the infection period. In this paper, we determined changes in the expression of TLR2 and TLR4 and the number of anaerobic intestinal commensal bacteria in Hymenolepis diminuta infected rats. In the isolated jejunum of infected rats at 16 days post infection (dpi), the expression of TLR4 and TLR2 was significantly higher than uninfected rats. In the colon, a statistically significantly increased expression of TLR2 was observed from 16 to 40 dpi, and TLR4 from 16 to 60 dpi. The jejunum and colon of infected rats contained Gram-negative bacteria (Escherichia coli), Gram-positive bacteria (Enterococcus, Streptococcus, Staphylococcus, Bacillus, Lactobacillus) and Candida. The total number of intestinal bacteria was higher in H. diminuta infected rats, but the observed microbiota had only minor effects on the expression of TLR2 and TLR4. Toll-like receptors play a role in maintaining epithelial barrier function in response to enteric pathogens and parasites. In our study, the alteration of TLR2 and TLR4 expression in the infected rats indicates the potential role of the innate immune system in the pathomechanism of this infection.

Genotypic characterization of Staphylococcus aureus isolated from bovines, humans, and food in Indonesia

The present study determined the genetic relationships between 41 Staphyloccocus (S.) aureus isolates from bovines, humans, and food using a single enzyme amplified fragment length polymorphism (AFLP) technique. We evaluated the prevalence of staphylococcal enterotoxin (SE) genes and other virulence gene determinants by PCR. The identification of S. aureus was based on culturing and biochemical tests, and by amplifying a specific section of the 23S rRNA gene. PCR amplification of the SE genes (sea, seb, sec, see, seg, seh, and sei) singly or in combination was observed. Most isolates of bovine origin harbored hla (84%) and cap5 (74%), while most isolates from humans harbored hla (73%), cap8 (91%), and fnbA (100%). Strains from food sources were positive for hla (100%), cap5 (100%), and cap8 (64%) unlike isolates from humans or bovines. A single enzyme AFLP analysis revealed a correlation between AFLP clusters of some strains and the source of the isolates The genotypic results of the present study might help to better understand the distribution of prevalent S. aureus clones among humans, bovines, and food and will help control S. aureus infections in Indonesia.

Epidemiology and virulence insights from MRSA and MSSA genome analysis

Staphylococcus aureus is a major human pathogen responsible for a wide diversity of infections ranging from localized to life threatening diseases. From 1961 and the emergence of methicillin-resistant S. aureus (MRSA), this bacterium has shown a particular capacity to survive and adapt to drastic environmental changes and since the beginning of the 1990s it has spread worldwide. Until recently, S. aureus was considered as the prototype of a nosocomial pathogen but it has now been recognized as an agent responsible for outbreaks in the community. Several recent reports suggest that the epidemiology of MRSA is changing. Understanding of pathogenicity, virulence and emergence of epidemic clones within MRSA populations is not clearly defined, despite several attempts to identify common molecular features between strains that share similar epidemiological and/or virulence behavior. These studies included: pattern profiling of bacterial adhesins, analysis of clonal complex groups, molecular genotyping and enterotoxin content analysis. To date, all approaches failed to find a correlation between molecular determinants and clinical outcomes. We hypothesize that the capacity of the bacterium to become more invasive or virulent is determined by genetics. The utilization of massively parallel methods of analysis is therefore ideal to study the contribution of genetics. Therefore, this article focuses on the entire genome including coding sequences as well as noncoding sequences. This high resolution approach allows the monitoring micro- and macroevolution of MRSA and identification of specific genomic markers of evolution of invasive or highly virulent phenotypes.

Reduced vancomycin susceptibility in Staphylococcus aureus, including vancomycin-intermediate and heterogeneous vancomycin-intermediate strains: resistance mechanisms, laboratory detection, and clinical implications

The emergence of vancomycin-intermediate Staphylococcus aureus (VISA) and heterogeneous vancomycin-intermediate Staphylococcus aureus (hVISA) over the past decade has provided a challenge to diagnostic microbiologists to detect these strains, clinicians treating patients with infections due to these strains, and researchers attempting to understand the resistance mechanisms. Recent data show that these strains have been detected globally and in many cases are associated with glycopeptide treatment failure; however, more rigorous clinical studies are required to clearly define the contribution of hVISA to glycopeptide treatment outcomes. It is now becoming clear that sequential point mutations in key global regulatory genes contribute to the hVISA and VISA phenotypes, which are associated predominately with cell wall thickening and restricted vancomycin access to its site of activity in the division septum; however, the phenotypic features of these strains can vary because the mutations leading to resistance can vary. Interestingly, changes in the staphylococcal surface and expression of agr are likely to impact host-pathogen interactions in hVISA and VISA infections. Given the subtleties of vancomycin susceptibility testing against S. aureus, it is imperative that diagnostic laboratories use well-standardized methods and have a framework for detecting reduced vancomycin susceptibility in S. aureus.

Diverse functions of glycosaminoglycans in infectious diseases

Glycosaminoglycans (GAGs) are complex carbohydrates that are expressed ubiquitously and abundantly on the cell surface and in the extracellular matrix (ECM). The extraordinary structural diversity of GAGs enables them to interact with a wide variety of biological molecules. Through these interactions, GAGs modulate various biological processes, such as cell adhesion, proliferation and migration, ECM assembly, tissue repair, coagulation, and immune responses, among many others. Studies during the last several decades have indicated that GAGs also interact with microbial pathogens. GAG-pathogen interactions affect most, if not all, the key steps of microbial pathogenesis, including host cell attachment and invasion, cell-cell transmission, systemic dissemination and infection of secondary organs, and evasion of host defense mechanisms. These observations indicate that GAG-pathogen interactions serve diverse functions that affect the pathogenesis of infectious diseases.

Genetic requirements for Staphylococcus aureus abscess formation and persistence in host tissues

Staphylococcus aureus infections are associated with abscess formation and bacterial persistence; however, the genes that enable this lifestyle are not known. We show here that following intravenous infection of mice, S. aureus disseminates rapidly into organ tissues and elicits abscess lesions that develop over weeks but cannot be cleared by the host. Staphylococci grow as communities at the center of abscess lesions and are enclosed by pseudocapsules, separating the pathogen from immune cells. By testing insertional variants in genes for cell wall-anchored surface proteins, we are able to infer the stage at which these molecules function. Fibrinogen-binding proteins ClfA and ClfB are required during the early phase of staphylococcal dissemination. The heme scavenging factors IsdA and IsdB, as well as SdrD and protein A, are necessary for abscess formation. Envelope-associated proteins, Emp and Eap, are either required for abscess formation or contribute to persistence. Fluorescence microscopy revealed Eap deposition within the pseudocapsule, whereas Emp was localized within staphylococcal abscess communities. Antibodies directed against envelope-associated proteins generated vaccine protection against staphylococcal abscess formation. Thus, staphylococci employ envelope proteins at discrete stages of a developmental program that enables abscess formation and bacterial persistence in host tissues.

A point mutation in the sensor histidine kinase SaeS of Staphylococcus aureus strain Newman alters the response to biocide exposure

Staphylococcus aureus reacts to changing environmental conditions such as heat, pH, and chemicals through global regulators such as the sae (S. aureus exoprotein expression) two-component signaling system. Subinhibitory concentrations of some antibiotics were shown to increase virulence factor expression. Here, we investigated the S. aureus stress response to sublethal concentrations of a commonly used biocide (Perform), by real-time quantitative PCR (qRT-PCR), promoter activity assay, sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis, and a flow cytometric invasion assay. Perform, acting through the production of reactive oxygen species, generally downregulated expression of extracellular proteins in strains 6850, COL, ISP479C but upregulated these proteins in strain Newman. Upregulated proteins were sae dependent. The Perform component SDS, but not paraquat (another oxygen donor), mimicked the biocide effect. Eap (extracellular adherence protein) was most prominently augmented. Upregulation of eap and sae was confirmed by qRT-PCR. Promoter activity of sae P1 was increased by Perform and SDS. Both substances enhanced cellular invasiveness, by 2.5-fold and 3.2-fold, respectively. Increased invasiveness was dependent on Eap and the sae system, whereas agr, sarA, sigB, and fibronectin-binding proteins had no major effect in strain Newman. This unique response pattern was due to a point mutation in SaeS (the sensor histidine kinase), as demonstrated by allele swapping. Newman saePQRS(ISP479C) behaved like ISP479C, whereas saePQRS(Newman) rendered ISP479C equally responsive as Newman. Taken together, the findings indicate that a point mutation in SaeS of strain Newman was responsible for increased expression of Eap upon exposure to sublethal Perform and SDS concentrations, leading to increased Eap-dependent cellular invasiveness. This may be important for understanding the regulation of virulence in S. aureus.

Endocarditis caused by Staphylococcus aureus: A reappraisal of the epidemiologic, clinical, and pathologic manifestations with analysis of factors determining outcome

Staphylococcus aureus is the leading cause of infectious endocarditis and its mortality has remained high despite better diagnostic and therapeutic procedures over time. We conducted a retrospective review of 133 cases of definite S. aureus endocarditis seen at a single tertiary care hospital over 22 years to assess changes in the epidemiology and incidence of the infection, manifestations, outcome, risk factors for mortality, and impact of cardiac surgery on prognosis.Patients were classified into 2 groups: 1) right-sided endocarditis (64 patients) and 2) left-sided endocarditis (69 patients). While the number of cases of left-sided endocarditis remained steady at 1-3 cases per 10,000 admissions, the incidence of right-sided endocarditis, after a peak in the early 1990s, declined to almost disappear in 2001. Among the cases of right-sided endocarditis, we found 2 subsets of patients with different clinical features and prognosis: the first subset comprised 53 intravenous drug abusers, and the second subset comprised 11 patients with catheter-associated S. aureus bacteremia and endocarditis. Fifty-one patients were human immunodeficiency virus (HIV)-positive drug abusers, most of whom (80.3%) had right-sided endocarditis. We did not find differences in mortality between HIV-positive and HIV-negative individuals; mortality seemed to depend more on the site of the heart involved than on HIV status.Among the cases of left-sided endocarditis, the mitral valve was more commonly involved than the aortic valve (61% vs. 30%). Overall, 74% of patients with left-sided endocarditis developed 1 or more cardiac or extracardiac complication. In comparison, only 23.4% of patients with right-sided endocarditis developed complications.Prosthetic valve endocarditis (PVE) was hospital-acquired more frequently than native valve endocarditis (NVE). Patients with PVE had a shorter duration of symptoms until diagnosis and presented with or developed cardiac murmurs less frequently than patients with NVE. Cardiac failure (49%), renal failure (43%) and central nervous system (CNS) events (35%) were frequently observed in patients with both PVE and NVE. Valve replacement was more frequently needed and more rapidly performed in patients with PVE than in their counterparts with NVE.The overall mortality of patients with right-sided endocarditis was 17%. While the mortality of right-sided endocarditis in injection drug users was 3.7%, the mortality of patients with right-sided endocarditis associated with infected intravenous catheters was 82% (odds ratio [OR], 0.01; 95% confidence interval [CI], 0.001-0.07). For left-sided endocarditis mortality was 38% and was not significantly different in patients with NVE or PVE (OR, 0.65; 95% CI, 0.23-1.87). CNS complications were associated with mortality in both NVE (OR, 6.55; 95% CI, 1.78-24.04) and PVE (OR, 32; 95% CI, 2.63-465.40). Development of 2 or 3 complications was associated with an increased risk of mortality (OR, 5.59; 95% CI, 1.08-28.80 and OR, 9.25; 95% CI, 1.36-62.72 for 2 vs. 1 complication and for 3 vs. 2 complications, respectively).Surgical treatment did not significantly influence mortality in cases of NVE, (OR, 3.19; 95% CI, 0.76-13.38) but significantly improved the prognosis of patients with PVE (OR, 69; 95% CI, 2.89-1647.18).S. aureus endocarditis is an aggressive, often fatal, infection. The results of the current study suggest that valve replacement will improve the outcome of infection, particularly in patients with PVE.

Genome content determination in methicillin-resistant Staphylococcus aureus

Staphylococcus aureus is a major pathogen responsible for both nosocomial and community-acquired infections. While the first S. aureus isolates displaying resistance to methicillin were reported in the early 1960s, endemic strains of methicillin-resistant S. aureus (MRSA) carrying multiple resistance determinants only became a worldwide nosocomial problem in the early 1980s, carrying a threefold attributable cost and a threefold excess length of hospital stay when compared with methicillin-susceptible S. aureus bacteremia. Recent efforts in the field of high-throughput sequencing resulted in the release of several MRSA genome sequences enabling the development of massively parallel tools to study clinical isolates of MRSA at the organism scale. Microarrays covering whole genomes and high-throughput sequencing devices are the two main techniques currently utilizable for whole-genome characterization. These tools not only provide information for the development of genotyping assays but also allow evaluation of potential virulence of the strains, by enumerating genetic-encoded resistance markers and toxin content. This appears particularly attractive for understanding the epidemiology of MRSA and the relationship between genome content on one side and virulence potential or epidemicity on the other side. In addition, sequence information is mandatory for the development of molecular tests allowing the rapid identification, genotyping and characterization of clinical isolates.

Rapid identification of coagulase-negative staphylococci by Fourier transform infrared spectroscopy

Coagulase-negative staphylococci (CNS), frequently associated with both community-acquired and nosocomial bloodstream infections, must be distinguished from Staphylococcus aureus for clinical purposes. Conventional methods are too laborious and time-consuming and often lack sensitivity to CNS. Fourier transform infrared (FTIR) spectroscopy combined with the use of a universal growth medium (Que-Bact Universal Medium No. 2) and chemometrics was evaluated for its potential as a rapid and simple clinical tool for making this distinction. FTIR spectra of 11 methicillin-sensitive and 11 methicillin-resistant CNS isolates as well as 25 methicillin-sensitive, 47 methicillin-resistant, 34 borderline oxacillin-resistant and 35 glycopeptide intermediate S. aureus isolates were obtained from dried films of stationary-phase cells grown on the universal medium. Principal component analysis (PCA), self-organizing maps, and the K-nearest neighbor algorithm were employed to cluster the different phenotypes based on similarity of their FTIR spectra. PCA of the first-derivative normalized spectral data from a single narrow region (2888-2868 cm(-1)) yielded complete differentiation of CNS from both methicillin-sensitive and methicillin-resistant S. aureus. The rate of correct classification was somewhat reduced, from 100% to 90%, after inclusion of borderline oxacillin-resistant and glycopeptide intermediate S. aureus strains in the data set. Differentiation based on the data in broader spectral regions was much less reliable. The results of this study indicate that with proper spectral region selection, FTIR spectroscopy and cluster analysis may provide a simple and accurate means of CNS species identification.

Control and prevention of MRSA infections

Methicillin-resistant Staphylococcus aureus (MRSA) has posed an immense problem for clinicians in the hospital setting for years, emerging as the most frequent nosocomial infection. To deal with this problem pathogen and others, infectious disease specialists have developed a variety of procedures for their control and prevention, involving options from preventative measures such as decolonization and isolation of MRSA-confirmed patients, to the more simple procedures of hand washing, expanding glove use, and reducing time in the hospital. With the realization that MRSA is now a community problem, there are expanded efforts toward more direct intervention, such as the use of anti-MRSA antibacterials and vaccines, in an attempt to reduce the overall burden of MRSA.

Fifteen-year study of the changing epidemiology of methicillin-resistant Staphylococcus aureus

PURPOSE

The study's purpose was to elucidate the evolutionary, microbiologic, and clinical characteristics of methicillin-resistant Staphylococcus aureus (MRSA) infections.

METHODS

MRSA cases from military medical facilities in San Diego, from 1990 to 2004, were evaluated and categorized as community-acquired or nosocomial. Sequence type, staphylococcal chromosomal cassette gene type, and Panton-Valentine leukocidin gene status were determined for a subset of isolates.

RESULTS

Over the 15-year period, 1888 cases of MRSA were identified; 65% were community acquired. The incidence (155 infections/100000 person-year in 2004) and household-associated cases rapidly increased since 2002. Among persons with community-acquired MRSA, 16% were hospitalized and only 17% were initially given an effective antibiotic. Community-acquired MRSA cases compared with nosocomial MRSA cases were more often soft-tissue and less often urinary, lung, or bloodstream infections (P<.001). Patients with community-acquired MRSA were younger (22 vs 64 years, P<.001) and less likely to have concurrent medical conditions (9% vs 98%, P<.001). Clindamycin resistance increased among community-acquired MRSA isolates during 2003 and 2004 compared with previous years (79% vs 13%, P<.001). Genetically, nosocomial MRSA isolates were significantly different than those acquired in the community. Although community-acquired MRSA isolates were initially diverse by 2004, one strain (staphylococcal chromosomal cassette type IV, sequence type 8, Panton-Valentine leukocidin gene positive) became the predominant isolate.

CONCLUSIONS

Community-acquired and intrafamilial MRSA infections have increased rapidly since 2002. Our 15 years of surveillance revealed the emergence of distinct community-acquired MRSA strains that were genetically unrelated to nosocomial MRSA isolates from the same community.

Antibacterial activity directed isolation of compounds from Onosma hispidum

The chemical investigation of the ethanolic extract of the root bark of Onosma hispidum following antibacterial activity directed isolation led to the isolation of 4-hydroxy-3-methoxy cinnamic acid (ferulic acid) and 4-hydroxy-3-methoxy benzoic acid (vanillic acid) which have been reported for the first time in this species. In addition to these compounds, the crude ethanolic extract and methanol fraction exhibited substantial bioactivity against species of corynebacteria, enterococci, staphylococci and streptococci. Ferulic acid was found more bioactive (being relatively more hydrophobic) compared to vanillic acid.

MRSA – what is it, and how do we deal with the problem?

Methicillin-resistant Staphylococcus aureus (MRSA) has become a serious nosocomial pathogen, and more recent reports in the scientific literature underscore the potential issues with emerging community-MRSA. MRSA is reported to be involved in > 50% of hospital S. aureus infections, more in the intensive care unit (ICU) than the non-ICU, and increases in multi-drug resistant MRSA and increasingly virulent MRSA have been reported. Together with its broad-based beta-lactam resistance, MRSA often possesses a multi-drug resistance genotype, including cephalosporins, aminoglycosides, fluoroquinolones, and macrolide resistances. MRSA has now emerged as the predominant nosocomial Gram-positive pathogen, and it has a high rate of morbidity and mortality. Action must be taken to contain and eradicate MRSA through a combination of infection control, the development of novel anti-MRSA agents, development of vaccines and other non-traditional approaches of intervention.

Simultaneous detection of Staphylococcus aureus and coagulase-negative staphylococci in positive blood cultures by real-time PCR with two fluorescence resonance energy transfer probe sets

A real-time PCR assay that uses two fluorescence resonance energy transfer probe sets and targets the tuf gene of staphylococci is described here. One probe set detects the Staphylococcus genus, whereas the other probe set is specific for Staphylococcus aureus. One hundred thirty-eight cultured isolates, which contained 41 isolates of staphylococci representing at least nine species, and 100 positive blood cultures that contained gram-positive cocci in clusters were tested. This assay was 100% sensitive and 100% specific for the detection of the Staphylococcus genus and of S. aureus.

Interaction of Staphylococcus aureus fibronectin-binding protein with fibronectin: affinity, stoichiometry, and modular requirements

The repetitive D1, D2, and D3 elements of Staphylococcus aureus fibronectin-binding protein FnBPA each bind the N-terminal 29-kDa fragment (N29) of fibronectin with low micromolar dissociation constants (Kd), but in tandem they compose a high affinity domain, D1-3. An additional seven Fn-binding segments have been predicted in FnBPA in a region N-terminal of the D-repeats (Schwarz-Linek, U., Werner, J. M., Pickford, A. R., Gurusiddappa, S., Kim, J. H., Pilka, E. S., Briggs, J. A., Gough, T. S., Hook, M., Campbell, I. D., and Potts, J. R. (2003) Nature 423, 177-181). We have evaluated the requirements for high affinity binding of N29 to the D-repeat domain and determined the affinity and stoichiometry of N29 binding to segments that are N-terminal of the D-repeats in the related FnBPB adhesin. We confirmed that D1-3 has two equivalent high affinity sites (Kd, approximately 1 nm) and provided evidence for one or more lower affinity sites (Kd, approximately 0.5 microm). Bimodular D1-2 and D2-3 exhibit intermediate affinity sites with respective Kd values of 0.25 and 0.044 microm, as well as a low affinity site with a Kd value of 2.2-2.5 microm. We also identified two binding domains that are N-terminal of the D-repeats, designated DuB and DuA. Segments internal to these domains individually bound N29 with similar Kd values of approximately 2 microm, whereas the DuBA polypeptide possessing both segments and other intervening sites bound four molecules of N29 with much higher affinity (Kd, approximately 10 nm). DuBAD, a larger polypeptide harboring all of the known or predicted binding motifs in FnBPB, bound seven to eight molecules of N29, with a Kd of approximately 7 nm. Because most of the isolated binding segments display low affinity for N29 and lack motifs for binding of one or both of the 1F1 and 5F1 modules in the N-terminal domain of Fn, we propose that high affinity is achieved in part as a consequence of self-interaction between bound molecules of N29.

Staphylococcus aureus types 5 and 8 capsular polysaccharide-protein conjugate vaccines

BACKGROUND

Staphylococcus aureus, the first or second most common pathogen isolated from patients, is capsulated; there are at least 12 capsular types, and types 5 and 8 comprise approximately 85% of blood. Types 5 and 8, composed of a trisaccharide repeat unit including a mannose uronic acid and 2 fucoses, are non-immunogenic. As protein conjugates, they induce opsonophagocytic antibodies that confer type-specific active and passive protection in mice.

METHODS

A phase II study of patients with end-stage renal disease showed that these conjugates induced approximately one third of the immunoglobulin G antibody of healthy individuals. Increasing the dose to 100 microg of polysaccharide induced levels similar to that in healthy individuals injected with 25 microg.

RESULTS

In a double-blinded randomized and controlled study of patients undergoing renal dialysis, the conjugates induced statistically significant protection against bacteremia for as long as 10 months after immunization. The estimated protective level was 80 microg Ab/mL. At re-injection approximately 2 years later, 83 of 83 recipients responded with protective levels.

CONCLUSIONS

Conjugate vaccine-induced antibodies to the types 5 and 8 capsular polysaccharide antibodies of S aureus prevent bacteremia caused by this pathogen. The extent and duration of conjugate-induced immunity can be extended by re-immunization approximately 1 year later. Studies of patients undergoing cardiovascular surgery who would be immunized with the staphylococcus conjugates when they are immunologically intact are planned.

Activation of syndecan-1 ectodomain shedding by Staphylococcus aureus alpha-toxin and beta-toxin

Exploitation of host components by microbes to promote their survival in the hostile host environment has been a recurring theme in recent years. Available data indicate that bacterial pathogens activate ectodomain shedding of host cell surface molecules to enhance their virulence. We reported previously that several major bacterial pathogens activate ectodomain shedding of syndecan-1, the major heparan sulfate proteoglycan of epithelial cells. Here we define the molecular basis of how Staphylococcus aureus activates syndecan-1 shedding. We screened mutant S. aureus strains devoid of various toxin and protease genes and found that only strains lacking both alpha-toxin and beta-toxin genes do not stimulate shedding. Mutations in the agr global regulatory locus, which positively regulates expression of alpha- and beta-toxins and other exoproteins, also abrogated the capacity to stimulate syndecan-1 shedding. Furthermore, purified S. aureus alpha- and beta-toxins, but not enterotoxin A and toxic shock syndrome toxin-1, rapidly potentiated shedding in a concentration-dependent manner. These results establish that S. aureus activates syndecan-1 ectodomain shedding via its two virulence factors, alpha- and beta-toxins. Toxin-activated shedding was also selectively inhibited by antagonists of the host cell shedding mechanism, indicating that alpha- and beta-toxins shed syndecan-1 ectodomains through stimulation of the host cell's shedding machinery. Interestingly, beta-toxin, but not alpha-toxin, also enhanced ectodomain shedding of syndecan-4 and heparin-binding epidermal growth factor. Because shedding of these ectodomains has been implicated in promoting bacterial pathogenesis, activation of ectodomain shedding by alpha-toxin and beta-toxin may be a previously unknown virulence mechanism of S. aureus.

Risk factors for metastatic infection in patients with Staphylococcus aureus bacteremia with and without endocarditis

Background: Staphylococcus aureus bacteremia (SAB) may be complicated by endocarditis or metastatic infection without evidence of endocarditis (MIWE). The aim of this study was to identify risk factors for MIWE and endocarditis in patients with SAB. METHODS: We performed a retrospective chart review to compare characteristics of patients with uncomplicated SAB and patients whose SAB course was complicated by MIWE or endocarditis. We reviewed the charts of patients with SAB diagnosed in our department from 1992 to 1999 for S. aureus portal of entry, secondary foci of infection, underlying conditions, previous valvular defects, and foreign material. Endocarditis was defined according to the Duke criteria. Patients were classified as having MIWE when the diagnosis of endocarditis was not definite according to the Duke criteria and when there was evidence of at least one secondary metastatic infection other than endocarditis. RESULTS: Some 109 patients had 111 episodes of SAB. Sixty-three patients had no evidence of metastatic infection and constituted the control group. Twenty-seven patients developed at least one episode of MIWE. A community-acquired SAB (CI 95% OR: 1.4-12.3, P<0.02), two or fewer underlying conditions (CI 95% OR: 1.2-83, P<0.04), and a non-severe portal of entry (CI 95% OR: 1.2-20, P<0.03) were independently predictive for MIWE. The characteristics of 21 patients with endocarditis were compared with those of the control group. Only a previous valvular defect was significantly associated with endocarditis. CONCLUSION: A previous valvular defect seems to be an important factor for developing endocarditis during SAB. Risk factors for having MIWE may differ from those found for patients with endocarditis.

Characterization of the role of the divalent metal ion-dependent transcriptional repressor MntR in the virulence of Staphylococcus aureus

DtxR-type metal ion-dependent repressors, present in many bacterial pathogens, may regulate expression of virulence genes such as that encoding diphtheria toxin. SirR, a DtxR homologue initially identified in Staphylococcus epidermidis, governs the expression of the adjacent sitABC operon encoding a putative metal ion ABC transporter system. We identified a sirR homologue, mntR, in Staphylococcus aureus and demonstrated by gel shift assay that the corynebacterial repressor DtxR binds to the S. aureus mntABC operator in the presence of Fe(2+) or Mn(2+). Since a mutant DtxR, DtxR(E175K), functions as an iron-independent hyperrepressor in certain settings, we constructed a heterodiploid S. aureus strain expressing dtxR(E175K) from the native mntR promoter. Transcription of the S. aureus mntABC operon was repressed in the presence of Fe(2+) or Mn(2+) in wild-type and heterodiploid S. aureus strains. Under metal ion-limiting conditions, mntABC transcription was reduced but not abolished in S. aureus isolates expressing dtxR(E175K) compared with an isogenic control, suggesting that DtxR(E175K) binds the S. aureus MntR box in vivo. Under all conditions tested, mntABC transcription in the dtxR(E175K)-expressing strain was reduced relative to the isogenic control, indicating that DtxR(E175K) function was constitutively active. In the mouse skin abscess model, dtxR(E175K)-expressing S. aureus recombinants showed significantly reduced CFU levels compared with the isogenic wild-type control. We conclude that the S. aureus MntR box is recognized by corynebacterial DtxR proteins and thus belongs to the DtxR family of metal-dependent operator sites. Moreover, constitutive repression by DtxR(E175K) reduces the virulence of S. aureus in the mouse skin abscess model.

The challenge of staphylococcal pacemaker endocarditis in a patient with transposition of the great arteries endocarditis in congenital heart disease

Staphylococcus aureus is a leading cause of septicaemia and infective endocarditis. The overall incidence of staphylococcal bacteraemia is increasing, contributing to 16% of all hospital-acquired bacteraemias. The use of cardiac pacemakers has revolutionized the management of rhythm disturbances, yet this has also resulted in a group of patients at risk of pacemaker lead endocarditis and seeding in the range of 1% to 7%. We describe a 26-year-old man with transposition of the great arteries who had a pacemaker implanted and presented with S. aureus septicaemia 2 years postpacemaker implantation and went on to develop pacemaker lead endocarditis. This report illustrates the risk of endocarditis in the population with congenital heart disease and an intracardiac device.

Low molecular weight heparin aggravates infectious arthritis triggered by Staphylococcus aureus

PURPOSE

Staphylococcus aureus is responsible for the majority of wound infections in clean surgical procedures that involve implantation of foreign material, grafts or prosthetic devices. The aim of the study was to assess the effect of low molecular weight heparin on the development and progression of S. aureus arthritis.

MATERIALS AND METHODS

The murine model of hematogenously acquired septic arthritis was used injecting intravenously toxic shock syndrome toxin-1 (TSST-1) producing S. aureus of LS-1 strain. Mice lacking prosthetic implants were treated with intraperitoneal injections of low molecular weight heparin, used routinely as anti-thrombotic prophylaxis following joint prosthetic surgery. Evaluation of arthritis was performed clinically and histopathologically. In addition, the effect of low molecular weight heparin on T cell dependent and independent inflammation was assessed.

RESULTS

Seven days after inoculation with bacteria 18 out of 19 low molecular weight heparin treated mice displayed clinical symptoms of arthritis as compared to 9 out of 23 control animals (p < 0.05), and the severity of arthritis, expressed as arthritic index, was 2.6+/-0.5 versus 1.6+/-0.5 (p = 0.05). The histopathological examination confirmed the clinical findings showing that both inflammation and joint destruction were more substantial in heparin treated animals.

CONCLUSION

Our findings indicate that the routine anti-coagulation treatment with heparin contributes to more severe course of joint infection.

Proteolytic cleavage of staphylococcal exoproteins analyzed by two-dimensional gel electrophoresis

Extracellular proteases of Staphylococcus aureus are emerging as potential virulence factors that are relevant to the pathogenicity of staphylococcal infections. These proteases may also be involved in the proteolytic cleavage of other exoproteins released from this organism. To define the target exoproteins and their sites of cleavage by proteases, high-resolution two-dimensional polyacrylamide gel electrophoresis followed by N-terminal amino acid sequencing of exoprotein spots was performed. Two to three hundred exoprotein spots were detected at the early-stationary phase of cultures of S. aureus NCTC8325, and then at the late-stationary stage most of these high molecular protein spots became invisible due to further proteolytic degradation. As the result of N-terminal analysis, lipase, triacylglycerol lipase, orf619 protein and orf388 protein were detected as multiple spots at the early-stationary phase. We found that these exoproteins were cleaved at 3, 7, 4 and 4 different sites, respectively, by proteases. According to the M.W. and pI of each peptide spot obtained from the gel and their matches with calculated values in addition to their N-terminal sequences, we showed that the positions of putative peptides resulted from proteolytic cleavage of these proteins.

Mode of action of beta-barrel pore-forming toxins of the staphylococcal alpha-hemolysin family

Staphylococcal alpha-hemolysin is the prototype of a family of bacterial exotoxins with membrane-damaging function, which share sequence and structure homology. These toxins are secreted in a soluble form which finally converts into a transmembrane pore by assembling an oligomeric beta-barrel, with hydrophobic residues facing the lipids and hydrophilic residues facing the lumen of the channel. Besides alpha-hemolysin the family includes other single chain toxins forming homo-oligomers, e.g. beta-toxin of Clostridium perfringens, hemolysin II and cytotoxin K of Bacillus cereus, but also the staphylococcal bi-component toxins, like gamma-hemolysins and leucocidins, which are only active as the combination of two similar proteins which form hetero-oligomers. The molecular basis of membrane insertion has become clearer after the determination of the crystal structure of both the oligomeric pore and the soluble monomer. Studies on this family of beta-barrel pore-forming toxins are important for many aspects: (i) they are involved in serious pathologies of humans and farmed animals, (ii) they are a good model system to investigate protein-membrane interaction and (iii) they are the basic elements for the construction of nanopores with biotechnological applications in various fields.

Increased incidence of Staphylococcus aureus bacteremia in hospitalized patients with acquired immunodeficiency syndrome

Staphylococcus aureus is a common cause of bacterial infections in patients infected with human immunodeficiency virus (HIV). We studied 53 male patients who had 57 episodes of S. aureus bacteremia (SAB). The incidence of SAB per 1000 hospitalized patients was 13.2 among HIV-positive male patients and 0.8 among HIV-negative male patients, yielding a 16.5-fold increase in the odds ratio for SAB among HIV-positive male patients. Almost all episodes of SAB were community acquired. Long-term indwelling catheters were the most common predisposing factor. Prior antibiotic use was more frequently associated with SAB in HIV-positive patients than in HIV-negative patients. A trend was seen among HIV-positive patients toward more numerous infections with beta-lactam antibiotic-resistant (i.e., methicillin-resistant) S. aureus, but such patients had similar outcomes, even though they often did not receive vancomycin during the initial 48 hours of treatment. A better understanding of the epidemiology and clinical manifestations of SAB in HIV-positive patients will offer important opportunities for prevention of this frequent complication.

Development of a PCR assay for identification of staphylococci at genus and species levels

We have developed a PCR-based assay which allows the detection of staphylococci at the genus level by targeting the tuf gene, which encodes the elongation factor Tu. Degenerate PCR primers derived from consensus regions of several tuf genes were used to amplify a target region of 884 bp from 11 representative staphylococcal species. Subsequently, the entire nucleotide sequence of these amplicons was determined. The analysis of a multiple alignment of these sequences revealed regions conserved among staphylococci but distinct from those of other gram-positive bacteria genetically related to staphylococci. PCR primers complementary to these regions could amplify specifically and efficiently a DNA fragment of 370 bp for all of 27 different staphylococcal species tested. There was no amplification with genomic DNA prepared from 53 nonstaphylococcal species tested to verify the specificity of the assay (20 gram positive and 33 gram negative). Furthermore, this assay amplified efficiently all 27 American Type Culture Collection (ATCC) staphylococcal reference strains as well as 307 clinical isolates of staphylococci from the Québec City region. Analysis of the multiple sequence alignment for the 884-bp fragment for the 11 staphylococcal species as well as comparison of the sequences for the 370-bp amplicon from five unrelated ATCC and clinical strains for each of the species S. aureus, S. epidermidis, S. haemolyticus, S. hominis, and S. saprophyticus demonstrated sufficient interspecies polymorphism to generate genus- and species-specific capture probes. This sequence information allowed the development of Staphylococcus-specific and species-specific (targeting S. aureus, S. epidermidis, S. haemolyticus, S. hominis, or S. saprophyticus) capture probes hybridizing to the 370-bp amplicon. In conclusion, this PCR assay is suitable for detection of staphylococci at both genus and species levels.

Variance in fibronectin binding and fnb locus polymorphisms in Staphylococcus aureus: identification of antigenic variation in a fibronectin binding protein adhesin of the epidemic CMRSA-1 strain of methicillin-resistant S. aureus

The fnbA and fnbB genes of Staphylococcus aureus 8325-4 encode fibronectin (Fn) binding proteins FnBPA and FnBPB, which promote adherence to host tissues. Each adhesin contains three copies of a repeated D motif that binds Fn and is a target for vaccine development. In this study, we assess variability within the Fn-binding domain of the FnBP adhesins and evaluate factors that promote variance in Fn binding among clinical isolates. Based on variation in the number of fnb genes or the number of D motifs, we identified five polymorphism groups. S. aureus 8325-4 and 91% of methicillin-resistant S. aureus (MRSA) isolates belong to polymorphism group I, with two fnb genes and three copies of the D motif. Polymorphism group II contained one fnb gene with only two D motifs and was associated with the epidemic CMRSA-4 strain, which exhibited high protease activity and low Fn binding. Polymorphism group III was unique to the epidemic CMRSA-1 strain, defined by the presence of a fourth D motif that exhibited antigenic variation within a conserved sequence that is essential for Fn binding. However, the sequence of the D motifs was otherwise highly conserved among the other polymorphism groups. Variation in Fn binding among MRSA isolates was inversely related to protease activity but not to the number of fnb genes or the number of D motifs. Therefore, the fnb locus is polymorphic in a small number of strains, but this does not contribute to variation in Fn binding. The antigenic variation that was observed only in the epidemic CMRSA-1 strain may have evolved in response to a host immune response encountered during successive cycles of colonization, transmission, and infection in the nosocomial environment.

Impact of transcription factors AP-1 and NF-kappaB on the outcome of experimental Staphylococcus aureus arthritis and sepsis

Staphylococcus aureus infection is, despite adequate antibiotic treatment, a disease characterized by high mortality. The bacterium triggers an exaggerated immune response in the host, which on the one hand acts as an efficient defense, but on the other hand gives rise to tissue damage. In this study we have modulated the hosts response to S. aureus by inhibition of nuclear factor kappaB (NF-kappaB) and activator protein-1 (AP-1)-triggered release of pro-inflammatory cytokines and tissue-destructive proteins, respectively. Mice were administered with antisense oligonucleotides (ODN) to the p65 subunit of NF-kappaB and/or a double-stranded oligonucleotide (mCoAP-1) with homology to the murine AP-1 binding site of collagenase IV gene (metalloproteinase-9; MMP-9), solely or in combination with antibiotics. In mice systemically treated with antisense ODN to NF-kappaB p65 alone, the bacterial burden in the kidneys was significantly increased (P = 0.04) The same tendency was seen when mCoAP-1 was administered either alone or in combination with antibiotics. We also found significantly (P = 0.04) elevated levels of IL-6 in p65 antisense treated mice. Surprisingly, this p65 antisense therapy approach, which has turned out to be highly efficient in amelioration of aseptic arthritis and colitis, failed to change the clinical course of either septic arthritis or sepsis. We suggest that interaction with transcription factors leads to increased bacterial burden in vivo, abrogating the potential benefits of the anti-inflammatory properties exerted by these compounds.

Activities of bismuth thiols against staphylococci and staphylococcal biofilms

Indwelling medical devices are associated with infectious complications. Incorporating antimicrobials into indwelling materials may reduce bacterial colonization. Bismuth thiols are antibiofilm agents with up to 1,000-fold-greater antibacterial activity than other bismuth salts. Staphylococci are particularly sensitive, as determined by agar diffusion and broth dilution susceptibility testing. Bismuth-ethanedithiol inhibited 10 methicillin-resistant Staphylococcus epidermidis strains at 0.9 to 1.8, Staphylococcus aureus ATCC 25923 at 2.4, and S. epidermidis ATCC 12228 at 0.1 microM Bi(3+). Antiseptic-resistant S. aureus was sensitive to bismuth-2-3-dimercaptopropanol (BisBAL) at < or = 7 microM Bi(3+). Hydrogel-coated polyurethane rods soaked in BisBAL inhibited S. epidermidis for 39 days (inhibitory zone diameter in agar, > or = 30 mm for > 25 days). Slime from 16 slime-producing S. epidermidis strains was inhibited significantly by bismuth-3,4-dimercaptotoluene (BisTOL), but not by AgNO3, at subinhibitory concentrations. In conclusion, bismuth-thiols are bacteriostatic and bactericidal against staphylococci, including resistant organisms, but are also inhibitors of slime at subinhibitory concentrations. At subinhibitory concentrations, BisTOL may be useful in preventing the colonization and infection of indwelling intravascular lines, since staphylococci are important pathogens in this setting.

Attributable mortality rate and duration of hospital stay associated with enterococcal bacteremia

The mortality rate of patients with cases of enterococcal bacteremia is high, although it has often been related to the patients' underlying conditions rather than to the infection itself. To analyze the attributable prognosis of enterococcal bacteremia (assessed by its attributable mortality rate and duration of hospital stay), a prospective, matched case-control study was done. All adults with an episode of enterococcal bacteremia without endocarditis were included. A control patient was randomly selected for every case patient and matched by sex, age and hospital ward. Univariate and multivariate analyses were performed. A total of 122 pairs were included, and incidence of enterococcal bacteremia was 2.3 episodes/1000 discharges. Crude 30-day mortality rates for case patients and control patients were 23% and 17%, respectively (P=.29); thus, the estimated attributable mortality rate was 6% (95% confidence interval, -4% to 16%). The mean duration of hospital stay of case patients and control patients were 38 and 17 days, respectively (P<.001); thus, the estimated attributable duration of hospital stay was 21 days (95% CI, 7-32 days). Enterococcal bacteremia without endocarditis does not increase risk of death by itself but extends the duration of hospital stay of patients who develop it.

Systemic distribution of Staphylococcus aureus following intradermal footpad challenge of broilers

We conducted an experiment with broilers to determine if prior exposure to Staphylococcus aureus would facilitate the systemic infiltration of this pathogen following intradermal footpad challenge with live S. aureus. Litter-raised broilers were sensitized at 3 and 4 wk of age with s.c. injections in the neck with heat-killed S. aureus diluted in polyethylene glycol (PEG). Equal numbers of control birds were injected at the same times with PEG. At 7 wk of age, chicks previously sensitized to killed S. aureus or injected with PEG were injected intradermally in the right footpad with PBS or live S. aureus. The left footpads of all birds were injected with PBS. The difference in thickness between the right and left footpads was determined at 0, 24, and 48 h postchallenge. Blood, liver, spleen, lung, and synovial fluid were collected six times between 1 and 48 h postchallenge to determine the recovery of S. aureus. Sensitized and non-sensitized birds showed footpad swelling following challenge with live S. aureus in the right footpad (P < 0.001). Injection of PBS did not induce footpad swelling. Birds injected in the footpads with live S. aureus as compared to PBS had significantly higher isolation rates of S. aureus in the spleen, liver, and blood; however, recovery of S. aureus from S. aureus-sensitized and PEG-injected birds was not significantly different. Time postchallenge (1, 3, 7, 11, 24, and 48 h) had no significant effect on the recovery of S. aureus. It was concluded that the intradermal challenge of the footpad with S. aureus resulted in systemic infiltration of S. aureus into the spleen, liver, and blood. Prior exposures to killed S. aureus as compared to PEG controls did not affect the systemic distribution of S.

Description of staphylococcus serine protease (ssp) operon in Staphylococcus aureus and nonpolar inactivation of sspA-encoded serine protease

Signature tagged mutagenesis has recently revealed that the Ssp serine protease (V8 protease) contributes to in vivo growth and survival of Staphylococcus aureus in different infection models, and our previous work indicated that Ssp could play a role in controlling microbial adhesion. In this study, we describe an operon structure within the ssp locus of S. aureus RN6390. The ssp gene encoding V8 protease is designated as sspA, and is followed by sspB, which encodes a 40.6-kDa cysteine protease, and sspC, which encodes a 12.9-kDa protein of unknown function. S. aureus SP6391 is an isogenic derivative of RN6390, in which specific loss of SspA function was achieved through a nonpolar allelic replacement mutation. In addition to losing SspA, the culture supernatant of SP6391 showed a loss of 22- to 23-kDa proteins and the appearance of a 40-kDa protein corresponding to SspB. Although the 40-kDa SspB protein could degrade denatured collagen, our data establish that this is a precursor form which is normally processed by SspA to form a mature cysteine protease. Culture supernatant of SP6391 also showed a new 42-kDa glucosaminidase and enhanced glucosaminidase activity in the 29 to 32 kDa range. Although nonpolar inactivation of sspA exerted a pleiotropic effect, S. aureus SP6391 exhibited enhanced virulence in a tissue abscess infection model relative to RN6390. Therefore, we conclude that SspA is required for maturation of SspB and plays a role in controlling autolytic activity but does not by itself exert a significant contribution to the development of tissue abscess infections.

Staphylococcus aureus bacteremia: predictors of 30-day mortality in a large cohort

We performed a retrospective study of a large cohort of patients who had episodes of Staphylococcus aureus bacteremia (SAB) from January 1995 through February 1999 at 1 medical center to identify predictors of 30-day mortality in SAB. Among 293 patients with episodes of SAB, 68 died (23.2%) within 30 days of onset. There was no significant difference in 30-day mortality associated with treatment with vancomycin, a beta-lactam, or a miscellaneous group of antimicrobial agents (P=.180). By logistic regression, an acute physiology score (a component of the acute physiology and chronic health evaluation [APACHE III]) >60 at onset of SAB was the most important predictor of 30-day mortality (odds ratio [OR], 15.7). Other significant predictors were lung (OR, 5.8) or unknown (OR, 4.1) focus of SAB, age > or =65 years (OR, 2.0), and diabetes mellitus (OR, 2.4). Future investigators of SAB should take into consideration acute severity of illness at onset as well as other factors when evaluating or comparing outcomes.

Microspheres containing neutralizing antibodies to tumor necrosis factor-alpha and interleukin-1 beta protect rats from Staphylococcus aureus-induced peritonitis

Previous studies using microencapsulated neutralizing antibodies (NA) to tumor necrosis factor (TNF) and interleukin-1 (IL-1) in combination with gentamicin have demonstrated improved survival in a peritonitis model of gram-negative septic shock. Microencapsulation has been shown to improve the effectiveness of NA by delivering them intracellularly, taking advantage of the natural phagocytic activity of the macrophage. It is the purpose of this study to see if microencapsulated NA to TNF and IL-1 in combination with vancomycin can improve survival compared with NA in solution in Staphlococcus aureus-induced septic shock. Groups of 10 rats received the following treatments: (1) S. aureus plus no treatment, (2) S. aureus plus blank microspheres, (3) S. aureus plus vancomycin, (4) S. aureus plus a microsphere form of NA and vancomycin, (5) S. aureus plus a solution form of NA and vancomycin, (6) S. aureus plus a microsphere form of NA, and (7) S. aureus plus a solution form of NA. Survival was monitored for 5 days, and plasma TNF and IL-1 levels were measured for 48 h after S. aureus administration. All (100%) animals that received the microsphere form of NA plus vancomycin, 20%-70% of the animals that received the microsphere form of NA alone, and 20% of the animals that received antibiotics alone survived for 5 days or more. None of the animals in the no treatment group or blank microsphere treatment group and only 10% of the animals in the solution form of NA plus or minus vancomycin group survived for more than 5 days. Plasma TNF and IL-1 levels were significantly increased after S. aureus treatment. Simultaneous and delayed treatment with the microsphere form of NA plus or minus vancomycin significantly reduced TNF and IL-1 levels, and the solution form of NA significantly reduced only TNF levels after immediate treatment. The survival rate was higher in animals with lower TNF levels and IL-1 levels. The results demonstrate that the microsphere form of cytokine NA is 100% effective in combination with vancomycin in protecting rats from S. aureus-induced peritonitis. The microsphere form was also more efficient in attenuating both TNF and IL-1 levels.