Approach to skin problems in travellers: clinical and epidemiological clues

RATIONALE FOR REVIEW

Travel-related skin problems are a common reason for healthcare consultations. We present a clinical approach to diagnosing skin diseases in travellers, emphasizing clinical examination and epidemiological clues such as travel history, incubation time and at-risk behaviours.

KEY FINDINGS

Skin problems or manifestations of systemic infections are the third most common health issue encountered by travellers, though their causes and frequency may vary based on the season and destination. The four most frequent skin conditions affecting travellers include arthropod bites, sunburns, hookworm-related cutaneous larva migrans (CLM) and bacterial skin and soft tissue infections. Dengue fever is the leading cause of febrile exanthema in travellers returning from Asia, Latin America and the Caribbean, while hookworm-related CLM is the most common cause of creeping dermatitis. Notable travel-related infections associated with pruritus include cercarial dermatitis, scabies, creeping dermatitis and urticaria. Acute schistosomiasis is the most common parasitic cause of acute urticaria in travellers. African tick-bite fever is the most frequently encountered rickettsiosis, typically presenting with single or multiple eschars.

CONCLUSIONS

Diagnostic approaches emphasize the importance of travel history, at-risk activities during travel and lesion distribution. At-risk activities include sun exposure, walking barefoot, exposure to sea and fresh water, hiking in forested or jungle areas, exposure frequency to mosquitoes and sandflies, poor hygiene and food intake, drug history and sexual behaviour. Morphological characteristics (vesicula, bullae, pustule, papule, nodule, plaque, oedema and ulcer), distinguishing between single and multiple skin lesions, localized or generalized, and whether mucosa, scalp, palmar or plantar surfaces are affected, provide further clinical clues. Systemic signs and symptoms such as fever and pruritus will aid in the differential diagnosis algorithms. With a thorough clinical assessment and knowledge of geographic and exposure-related risk factors, the differential diagnosis of travel-associated skin conditions can be narrowed down allowing for timely clinical management.

Epidemiology and clinical features of Skin and Soft Tissue Infections Caused by PVL-Positive and PVL-Negative Methicillin-Resistant Staphylococcus aureus Isolates in inpatients in China: a single-center retrospective 7-year study

Previous studies have mainly focused on outpatient cases of skin and soft tissue infections (SSTIs), with limited attention to inpatient occurrences. Thus, we aimed to compare the clinical parameters of inpatients with SSTIs, performed genomic characterization, and determined the subtypes of Panton-Valentine leucocidin (PVL) bacteriophages of methicillin-resistant Staphylococcus aureus (MRSA) strains isolated from these patients. We found that PVL-positive patients had shorter hospital stays (mean, 9 vs. 24 days; p < 0.001) and abscess resolution durations (mean, 8 vs. 13 days; p < 0.01). PVL-positive MRSA-induced SSTIs were more frequently associated with abscesses [36/55 (65.5%) vs. 15/124 (12.1%), p < 0.001], with 52.7% undergoing incision and drainage; over 80% of PVL-negative patients received incision, drainage, and antibiotics. In PVL-positive patients receiving empirical antibiotics, anti-staphylococcal agents such as vancomycin and linezolid were administered less frequently (32.7%, 18/55) than in PVL-negative patients (74.2%, 92/124), indicating that patients with PVL-positive SSTIs are more likely to require surgical drainage rather than antimicrobial treatment. We also found that the ST59 lineage was predominant, regardless of PVL status (41.3%, 74/179). Additionally, we investigated the linear structure of the lukSF-PV gene, revealing that major clusters were associated with specific STs, suggesting independent acquisition of PVL by different strain types and indicating that significant diversity was observed even within PVL-positive strains detected in the same facility. Overall, our study provides comprehensive insights into the clinical, genetic, and phage-related aspects of MRSA-induced SSTIs in hospitalized patients and contributes to a more profound understanding of the epidemiology and evolution of these pathogens in the Chinese population.

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis - update from 2017 to 2023

Background

Antimicrobial resistance (AMR) is a critical global health concern. A previous systematic review showed that migrants in Europe are at increased risk of AMR. Since the COVID-19 pandemic there have been rapid changes in patterns of antibiotic use, AMR, and migration. We aimed to present an updated evidence synthesis on the current distribution of AMR among migrants in Europe.

Methods

We carried out a systematic review and meta-analysis in accordance with PRISMA guidelines (PROSPERO ID: CRD42022343263). We searched databases (MEDLINE, Embase, PubMed and Scopus) from 18 January 2017 until 18 January 2023 to identify primary data from observational studies reporting any laboratory-confirmed AMR among migrants in the European Economic Area (EEA) and European Union-15 (EU-15) countries using over 7 key search terms for migrants and over 70 terms for AMR and countries in Europe. Outcomes were infection with, or colonisation of AMR bacteria. Methodological quality was assessed using Joanna Briggs Institute Critical Appraisal Checklist for Observational Studies. We meta-analysed the pooled-prevalence of infection and/or colonisation of AMR organisms.

Findings

Among 630 articles, 21 observational studies met the inclusion criteria and were included in this review. The pooled prevalence for any detected AMR was 28.0% (95% CI 18.0%-41.0%, I 2  = 100%) compared to a 25.4% seen in the previous review; gram-negative bacteria 31.0% (95% CI 20.0%-44.0%, I 2  = 100%), and methicillin-resistant staphylococcus aureus 10.0% (95% CI 5.0%-16.0%, I 2  = 99%). Drug-resistant bacteria were more prevalent in community settings in large migrant populations (pooled prevalence: 41.0%, 95% CI 24.0%-60.0%, I 2  = 99%) than in hospitals (21.0%, 95% CI 12.0%-32.0%, I 2  = 99%). AMR estimates in 'other' migrants were 32.0%, (95% CI 12.0%-57.0%, I 2  = 100%) and 28.0% (95% CI 18.0%-38.0%, I 2 = 100%) in forced migrants. No firm evidence of AMR acquisition with arrival time or length of stay in the host country was found.

Interpretation

Studies investigating AMR in migrants are highly heterogenous. However, since the COVID-19 pandemic, migrants may be at higher risk of acquiring resistant bacteria, particularly gram-negative bacteria, within community settings such as refugee camps and detention centres in Europe. Our study highlights the importance of infrastructure and hygiene measures within these settings, to mitigate transmission of resistant pathogens. Policy-makers should screen for AMR in migrants prior to departure from countries of origin, where feasible, and upon arrival to a new country to ensure optimal health screening, infection control and effective treatment.

Funding

There was no funding source for this study.

[Bacterial infections of the skin in the context of climate change and migration]

BACKGROUND

In the context of climate change and migration, both common and previously less common pathogens are gaining importance as cutaneous bacterial infections.

OBJECTIVE

To inform medical professionals about challenges to dermatology posed by climate change and migration.

MATERIALS AND METHODS

Review of the current literature on emerging antimicrobial resistance and emerging pathogens in general and on the epidemiological situation in Germany in particular.

RESULTS

Climate change has a direct impact on microbiological ecosystems in Germany's warming coastal waters leading to an increase of marine V. vulnificus counts and human infections. Secondary to global warming, transmitting vectors of, for example, Lyme disease, rickettsioses and tularemia are also increasing. In addition, infectious diseases like cutaneous diphtheria and mycobacteriosis have been diagnosed in migrants, mostly likely acquired before migration or on the migration route and first diagnosed in Germany. In this context, antimicrobial resistance (e.g. methicillin-resistant Staphylococcus aureus [MRSA] and multidrug-resistant gram-negative bacteria) is gaining importance.

CONCLUSION

Due to progressive changes in global climate and ongoing migration, the aforementioned pathogens of infectious skin diseases and changes in antimicrobial resistance patterns have to be expected. Physicians should be aware of these developments in order to offer appropriate diagnostics and treatment. Epidemiological and biogeographic monitoring will be indispensable for managing emerging changes.

Acute Prosthetic Joint Infections with Poor Outcome Caused by Staphylococcus Aureus Strains Producing the Panton-Valentine Leukocidin

The aim of this study was to investigate whether the presence of Staphylococcus aureus (SA) producing the Panton-Valentine leukocidin (PVL) affects the outcome of Prosthetic Joint Infection (PJI). Patients with acute and chronic PJI sustained by SA were prospectively enrolled at the orthopedic unit of "Casa di Cura Santa Maria Maddalena", from January 2019 to October 2021. PJI diagnosis was reached according to the diagnostic criteria of the International Consensus Meeting on PJI of Philadelphia. Synovial fluid obtained via joint aspirations was collected in order to isolate SA. The detection of PVL was performed via real-time quantitative PCR (RT-qPCR). The outcome assessment was performed using the criteria of the Delphi-based International Multidisciplinary Consensus. Twelve cases of PJI caused by SA were included. Nine (75%) cases were acute PJI treated using debridement, antibiotic and implant retention (DAIR); the remaining three (25%) were chronic PJI treated using two-stage (n = 2) and one-stage revision (n = 1), respectively. The SA strains that tested positive for PVL genes were 5/12 (41.6%,). Treatment failure was documented in three cases of acute PJI treated using DAIR, all supported by SA-PVL strains (p < 0.045). The remaining two cases were chronic PJI treated with a revision arthroplasty (one and two stage, respectively), with a 100% eradication rate in a medium follow-up of 24 months. Although a small case series, our study showed a 100% failure rate in acute PJI, probably caused by SA PVL-producing strains treated conservatively (p < 0.04). In this setting, toxin research should guide radical surgical treatment and targeted antibiotic therapy.

Mandatory Notification of Panton-Valentine Leukocidin-Positive Methicillin-Resistant Staphylococcus aureus in Saxony, Germany: Analysis of Cases from the City of Leipzig in 2019

In Germany, Saxony is the only federal state where the detection of a Panton-Valentine Leukocidin (PVL)-positive Methicillin-resistant Staphylococcus aureus (MRSA) has to be notified to the local health authority (LHA). The LHA reports the case to the state health authority and introduces concrete infection control measures. We analyzed isolates from the respective cases in 2019, which were collected in local microbiological laboratories and sent to the National Reference Centre (NRC) for Staphylococci and Enterococci for strain characterization and typing. Antibiotic resistance testing was done by broth microdilution. Molecular characterization was performed using spa and SCCmec typing, MLST, and the PCR detection of marker genes associated with distinct MRSA lineages. Demographic and clinical data of the individual cases were assessed and the LHA performed epidemiological investigations. Thirty-nine (index) persons, diagnosed with a PVL-positive MRSA, were initially reported to the LHA. Most patients suffered from skin and soft-tissue infections (SSTI). For 21 of the index cases, household contacts were screened for MRSA. Seventeen out of 62 contacts were also colonized with a PVL-positive MRSA. The median age of altogether 58 individuals was 23.5 years. In over half of the cases, the home country was not Germany and/or a history of travel or migration was reported. Molecular characterization revealed the presence of various epidemic community-associated MRSA lineages, with "USA300", including the North American Epidemic (ST8-MRSA-IVa) and the South American Epidemic Clone (ST8-MRSA-IVc), the "Sri Lankan Clone" (ST5-MRSA-IVc), and the "Bengal Bay Clone" (ST772-MRSA-V) being more prevalent. In eight out of nine households, the contact persons were colonized with the same clone as the respective index case, suggesting a close epidemic and microbiological link. The obligation to report PVL-positive MRSA enables us to detect the occurrence of PVL-producing MRSA and its spread in the population as early as possible. Timely detection allows the targeted deployment of reliable anti-infective measures.

Hanitsch L, Krüger R, K. Lindner A, S. Stegemann M, Nurjadi D. Skin Infections Due to Panton-Valentine Leukocidin-Producing S. Aureus

BACKGROUND

Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus (PVL-SA) strains are frequently associated with large, recurring abscesses in otherwise healthy young individuals. The typical clinical presentation and the recommended diagnostic evaluation and treatment are not widely known.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, with special attention to international recommendations.

RESULTS

PVL-SA can cause leukocytolysis and dermatonecrosis through specific cell-wall pore formation. Unlike other types of pyoderma, such conditions caused by PVL-SA have no particular site of predilection. In Germany, the PVL gene can be detected in 61.3% (252/411) of skin and soft tissue infections with S. aureus. Skin and soft tissue infections with PVL-SA recur three times as frequently as those due to PVL-negative S. aureus. They are diagnosed by S. aureus culture from wound swabs and combined nasal/pharyngeal swabs, along with PCR for gene detection. The acute treatment of the skin abscesses consists of drainage, followed by antimicrobial therapy if needed. Important secondary preventive measures include topical cleansing with mupirocin nasal ointment and whole-body washing with chlorhexidine or octenidine. The limited evidence (level IIb) concerning PVL-SA is mainly derived from nonrandomized cohort studies and experimental analyses.

CONCLUSION

PVL-SA skin infections are easily distinguished from other skin diseases with targeted history-taking and diagnostic evaluation.

Characterization of Methicillin-resistant Staphylococcus aureus From Children at Hospital Admission: Experiences From a Hospital in a German Metropolitan Area

BACKGROUND

Since the 1990s, community-associated Methicillin-resistant Staphylococcus aureus (CA-MRSA) are described as emerging independent of health care. CA-MRSA is associated with the colonization and infection of healthy, immunocompetent younger individuals. While skin and soft tissue infections (SSTI) are predominant, life-threatening syndromes can also occur.

METHODS

In this retrospective study, we investigated MRSA stains isolated from community-onset infections and from MRSA screening of children at admission to a tertiary-care hospital in 2012-2018. In total, 102 isolates were subjected to antibiotic susceptibility testing by broth microdilution, spa -typing, multilocus sequence typing, SCC mec typing and virulence/resistance gene detection by polymerase chain reaction.

RESULTS

The majority of isolates originated from community-onset infections (80/102), of these primarily from SSTI (70/80). Additional strains were isolated by MRSA screening (22/102). In total 61.8% of the MRSA carried the gene for the Panton-Valentine leukocidin ( lukPV ). Molecular characterization of isolates revealed various epidemic MRSA clones, circulating in both community and hospital settings. Most prevalent epidemic lineages were isolates of the "European CA-MRSA clone" (CC80-MRSA-IV), the "Bengal Bay clone" (ST772-MRSA-V), or the "USA300 NAE clone" (ST8-MRSA-IVa).

CONCLUSIONS

Our data highlight the importance of CA-MRSA causing SSTI in children. More frequent microbiological and molecular analysis of these strains is important for targeted treatment and can provide valuable data for molecular surveillance of the pathogen.

Imported Panton-valentine leucocidin (PVL)-positive Staphylococcus aureus skin infections: patients' perspective on quality of life and quality of medical care

PVL-positive S. aureus skin and soft tissue infections have a major impact on quality of life and mental health, often for months and beyond the period of infection. Pre-treating physicians were poorly informed about the PVL toxin. Increased awareness for early diagnosis and treatment of this yet neglected disease are required.

Severe Staphylococcus aureus infections in children: Case reports and management of positive Panton-Valentine leucocidin cases

BACKGROUND

Staphylococcus aureus is a well-known bacterium associated with carriage and responsible for different types of infections. The Panton-Valentine leucocidin (PVL) is a key virulence factor causing tissue necrosis. PVL can, however, be present in both benign and life-threatening infections.

CASE REPORTS AND MANAGEMENT

We present three pediatric severe infections occurring over a period of only three weeks, in February 2021, and caused by genetically unrelated methicillin-sensitive Staphylococcus aureus producing PVL in a tertiary children's hospital in Belgium. The first one presented with necrotizing pneumonia, the second one with a neck abscess extended to the mediastinum, and the last one had sacral osteomyelitis complicated by endocarditis. The management of these infections is mostly based on expert opinions. The most appropriate treatment seems to be the combination of early surgical drainage of infected collections with an antibiotic regimen associating two antibiotics; beta-lactams and either clindamycin or linezolid. Human immunoglobulins also appear to be useful as adjunctive therapy.

CONCLUSION

PVL-producing Staphylococcus aureus is associated with life-threatening infections in children. Prompt management is needed including surgery and appropriate antibiotic regimens.

Life-Threatening Necrotizing Pneumonia with Panton-Valentine Leukocidin-Producing, Methicillin-Sensitive Staphylococcus aureus in a Healthy Male Co-Infected with Influenza B

A previously healthy male was rushed into a hospital critically ill with confusion, sepsis, and acute respiratory distress syndrome only 43 h after having a normal chest X-ray and with blood samples showing only minimally elevated C-reactive protein. Two days earlier, the patient had returned to his home country, the Faroe Islands, from a 10-day work trip aboard a Scandinavian ship in Colombia. The diagnosis turned out to be an influenza B infection and necrotizing pneumonia with Panton-Valentine leukocidin (PVL)-producing methicillin-sensitive Staphylococcus aureus (MSSA). It was influenza season in Colombia but not in the Faroe Islands. The frequency of MSSA with PVL-encoding genes among pediatric infection patients is very low in the Kingdom of Denmark and Faroe Islands and very high in Colombia, and the frequency generally varies highly by region. The patient in this case now suffers severe sequelae from the infection. With this case, we would like to remind clinicians of this rare but severe condition. PVL-producing S. aureus pneumonia should be considered in critically ill, previously healthy patients, especially during influenza season and if the patient has been traveling in countries with high frequencies of PVL-producing S. aureus.

Molecular analysis of an increase in trimethoprim/sulfamethoxazole-resistant MRSA reveals multiple introductions into a tertiary care hospital, Germany 2012-19

OBJECTIVES

Increasing spread of resistance could jeopardize the use of antifolates against MRSA infections.

METHODS

We compared the prevalence of phenotypic trimethoprim/sulfamethoxazole resistance in 20 534 clinical Staphylococcus aureus isolates (19 096 MSSA and 1438 MRSA) of non-redundant patients at Heidelberg University Hospital over 8 years and performed WGS on trimethoprim/sulfamethoxazole-resistant MRSA.

RESULTS

From 2012 to 2019, trimethoprim/sulfamethoxazole resistance in MSSA (674/19 096; 3.5%) ranged between 1.5% and 7.2% and in MRSA (135/1438; 9.4%) between 0.5% and 20.2%, reaching a peak in 2016 and 2018, respectively (Ptrend < 0.001). Trimethoprim/sulfamethoxazole resistance was more likely in outpatients than inpatients (P = 0.005), younger patients (P < 0.001), skin and soft tissue infections (SSTIs) (MRSA only, P = 0.05), submissions from pulmonology (MRSA only, P = 0.001), the upper respiratory tract (MSSA only, P < 0.001) and general surgery (MSSA only, P = 0.001). WGS of 76 trimethoprim/sulfamethoxazole-resistant MRSA revealed that 59% belonged to major pandemic CA-MRSA clones (ST22, ST8, ST398, ST772, ST30), 47% harboured Panton-Valentine leucocidin (PVL), 97% SCCmec IV/V, 71% dfrG and 28% dfrA. SNP-based phylogeny of trimethoprim/sulfamethoxazole-resistant MRSA core genomes favoured independent introduction over clonal expansion as the source, most prominently of dfrA+ trimethoprim/sulfamethoxazole-resistant ST22 MRSA from the Gaza Strip.

CONCLUSIONS

The presented results support that trimethoprim/sulfamethoxazole-resistant S. aureus, formerly associated with SSTI from outpatients and S. aureus in the (sub)tropics, is on the rise in the temperate zone, potentially due to migration. Closer monitoring of trimethoprim/sulfamethoxazole resistance in S. aureus is recommended to safeguard the effectiveness of antifolate compounds.

Examination of Staphylococcus aureus Prophages Circulating in Egypt

Staphylococcus aureus infections are of growing concern given the increased incidence of antibiotic resistant strains. Egypt, like several other countries, has seen alarming increases in methicillin-resistant S. aureus (MRSA) infections. This species can rapidly acquire genes associated with resistance, as well as virulence factors, through mobile genetic elements, including phages. Recently, we sequenced 56 S. aureus genomes from Alexandria Main University Hospital in Alexandria, Egypt, complementing 17 S. aureus genomes publicly available from other sites in Egypt. In the current study, we found that the majority (73.6%) of these strains contain intact prophages, including Biseptimaviruses, Phietaviruses, and Triaviruses. Further investigation of these prophages revealed evidence of horizontal exchange of the integrase for two of the prophages. These Egyptian S. aureus prophages are predicted to encode numerous virulence factors, including genes associated with immune evasion and toxins, including the Panton-Valentine leukocidin (PVL)-associated genes lukF-PV/lukS-PV. Thus, prophages are likely to be a major contributor to the virulence of S. aureus strains in circulation in Egypt.

Panton-Valentine Leukocidin-Producing Staphylococcus aureus Infection: A Case Series

Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-SA) is associated with relapsing multifocal skin and soft tissue infections (SSTI), necrotizing pneumonia (NP) and severe musculoskeletal infections. Epidemiology is underknown and underdiagnosis is likely. Recent travel abroad, case clustering and relapsing disease are often reported. We reviewed all cases of PVL-SA infection diagnosed at our center, and found 21 cases over a 43-month period. Most patients were adult males, had relevant travel history, reported recurrent disease and presented with SSTI. Etiologic diagnosis took up to five years; meanwhile, 42% of patients had antibiotic treatments. Draining procedures were required in 43% of patients and intensive care support in 19%. All patients recovered. Methicillin-resistance prevalence was 24%. Only 2/13 decolonized patients had posterior relapsing SSTI, both with likely infected contacts. PVL-SA infection’s severity and impact are clear, even in small case series as ours. Physician awareness and active PVL-gene search are crucial for an adequate management.

International travel as source of a hospital outbreak with an unusual meticillin-resistant Staphylococcus aureus clonal complex 398, Denmark, 2016

In May 2016, an unusual outbreak with the Panton-Valentine leukocidin-positive human variant of meticillin-resistant Staphylococcus aureus (MRSA) clonal complex 398 occurred among mothers and infants in the maternity unit of a Danish hospital. MRSA sharing genotypic and phenotypic characteristics was confirmed in 36 cases, including 26 patients, nine household members and a healthcare worker (HCW) who had contact with all the patients. The national MRSA database contained 37 seemingly unlinked MRSA cases whose isolates shared the same genotypic and phenotypic characteristics as the outbreak strain. Whole genome sequencing showed that three of these isolates clustered together with the 36 outbreak isolates, suggesting spread outside the hospital. The HCW and 21 of 37 cases from the national MRSA database had links to south-eastern Asia, where the outbreak strain is endemic. These findings suggest that the HCW acquired the outbreak strain while travelling in south-eastern Asia and then introduced it into the hospital; from there, it spread within the patients’ households and into the community. Screening of travellers returning from countries with high levels of MRSA could be an important intervention to prevent spread of these bacteria into hospitals via patients or HCWs.

Entry of Panton-Valentine leukocidin-positive methicillin-resistant Staphylococcus aureus into the hospital: prevalence and population structure in Heidelberg, Germany 2015-2018

Staphylococcus aureus is one of the major pathogens causing community—and healthcare-acquired infections. The presence of the virulence factor Panton–Valentine leukocidin (PVL) is associated with recurrent infection and clinical severity and generally regarded as a feature of community associated-methicillin-resistant Staphylococcus aureus (MRSA). To date, the focus of PVL-positive MRSA in hospitalized patients has been on outbreaks. We aimed to investigate whether PVL-positive MRSA has penetrated the community-hospital barrier by determining the prevalence of PVL in MRSA of hospitalized patients. MRSA strains isolated from patients hospitalized > 48 h in Heidelberg University Hospital between 2015 and 2018 Isolates were analysed for the presence of PVL and subjected to spa-typing. PVL-positive MRSA were then characterized by whole genome sequencing. We analysed 740 MRSA isolates in the study period and identified 6.2% (n = 46) PVL-positivity. 32.6% of PVL-positive MRSA met the criteria for nosocomial acquisition. The most frequent clones among the PVL-positive strains were ST80-t044 (21.7%, n = 10/46) and ST8-t008 (19.5%, n = 9/46). WGS identified three possible transmission clusters involving seven patients. In conclusion, we found successful epidemic PVL-positive MRSA clones entering the hospital and causing nosocomial infections. Preventive measures and constant surveillance should be maintained to prevent transmissions and clonal outbreaks.

Panton-Valentine leukocidin-positive Staphylococcus aureus in skin and soft tissue infections from primary care patients

OBJECTIVES

To characterize deep skin and soft tissue infections (dSSTI) caused by Panton-Valentine leukocidin (PVL)-positive versus PVL-negative Staphylococcus aureus isolates.

METHODS

We performed a retrospective analysis of patients' records including S. aureus isolates from outpatients with dSSTI. Samples had been submitted by primary care physicians, i.e. general practitioners, surgeons, dermatologists and paediatricians, located in Berlin, Germany, in 2007-2017. Bacterial isolates were identified and tested for antimicrobial susceptibility by VITEK 2; PVL was detected by PCR.

RESULTS

In total, 1199 S. aureus isolates from 1074 patients with dSSTI were identified, and 613 (51.1%) of 1199 samples were PVL⁺. The median age of patients with PVL⁺S. aureus was lower than in patients with PVL- S. aureus (34 years, range 0-88 years, vs. 44 years, range 0-98 years; p < 0.0001). PVL was associated with repeated/multiple samples compared to single sample submission (69/92, 75% vs. 448/982, 45.6%, p < 0.0001; odds ratio (OR), 3.6; 95% confidence interval (CI), 2.2-5.8). Interestingly, the highest PVL positivity rate was found in isolates from gluteal (82/108, 75.9%; OR, 3.6; 95% CI, 2-5) or axillary (76/123, 61.8%; OR, 2; 95% CI, 1.1-3.3) localizations compared to isolates from the arm. The PVL positivity rate did not increase over time. Yet we noticed an increase in the trimethoprim/sulfamethoxazole (SXT) resistance rate in PVL⁺ isolates, mainly methicillin-sensitive S. aureus, when considering SXT resistance rates of 2007-2012 versus 2013-2017 (35/226, 15.5% vs. 74/289, 25.6%; p 0.01).

CONCLUSIONS

In outpatients, gluteal and axillary dSSTI are indicative of PVL⁺S. aureus. Providing SXT as a complementary treatment for dSSTI should be based on susceptibility testing.

Outpatient decolonization after recurrent skin infection with Panton-Valentine leukocidin (PVL)-producing S. aureus-The importance of treatment repetition

BACKGROUND

Recurrent skin abscesses are often associated with Panton-Valentine leukocidin-producing strains of S. aureus (PVL-SA). Decolonization measures are required along with treatment of active infections to prevent re-infection and spreading. Even though most PVL-SA patients are treated as outpatients, there are few studies that assess the effectiveness of outpatient topical decolonization in PVL-SA patients.

METHODS

We assessed the results of topical decolonization of PVL-SA in a retrospective review of patient files and personal interviews. Successful decolonization was defined as the absence of any skin abscesses for at least 6 months after completion of the final decolonization treatment. Clinical and demographic data was assessed. An intention-to-treat protocol was used.

RESULTS

Our cohort consisted of 115 symptomatic patients, 66% from PVL-positive MSSA and 19% from PVL-positive MRSA. The remaining 16% consisted of symptomatic patients with close contact to PVL-SA positive index patients but without detection of PVL-SA. The majority of patients were female (66%). The median age was 29.87% of the patients lived in multiple person households. Our results showed a 48% reduction in symptomatic PVL-SA cases after the first decolonization treatment. The results also showed that the decrease continued with each repeated decolonization treatment and reached 89% following the 5th treatment. A built multivariable Cox proportional-hazards model showed that the absence of PVL-SA detection (OR 2.0) and living in single person households (OR 2.4) were associated with an independently increased chance of successful decolonization.

CONCLUSION

In our cohort, topical decolonization was a successful preventive measure for reducing the risk of PVL-SA skin abscesses in the outpatient setting. Special attention should be given to patients living in multiple person households because these settings could confer a risk that decolonization will not be successful.

Recurrent mucocutaneous infections caused by PVL-positive Staphylococcus aureus strains: a challenge in clinical practice

BACKGROUND

Recurrent mucocutaneous infections caused by PVL-positive Staphylococcus (S.) aureus strains represent an increasing problem in Germany. Although there have been several outbreaks at day care centers and in urban communities in recent years, there are currently no diagnostic algorithms or treatment recommendations for these particular infections in Germany.

METHODS

We performed a literature search in the PubMed/MEDLINE database with the goal of developing an algorithm for diagnosis and treatment of these infections. National and international recommendations were also considered.

RESULTS

Panton-Valentine leukocidin (PVL) is a pore-forming protein produced by certain S. aureus strains. Both methicillin-susceptible (MSSA) and methicillin-resistant S. aureus (MRSA) strains may carry the lukS-lukF gene responsible for PVL production. The clinical presentation of infections caused by PVL-positive S. aureus ranges from isolated recurrent abscesses to extensive furunculosis. Despite adequate treatment of primary infections, approximately 40 % of patients develop recurrent disease. The choice of treatment regimen is guided by the clinical presentation of the infection. In addition, some scientific literature recommends bacteriological screening of patients and their contacts, followed by decolonization of affected individuals.

CONCLUSIONS

The present article focuses on the pathogenesis and risk factors of recurrent mucocutaneous infections caused by PVL-positive S. aureus strains and proposes a diagnostic and therapeutic algorithm for optimal patient care.

Study of susceptibility to antibiotics and molecular characterization of high virulence Staphylococcus aureus strains isolated from a rural hospital in Ethiopia

We characterised 80 Staphylococcus aureus strains isolated from human patients with SSTIs at a rural hospital in Ethiopia. Susceptibility to antibiotic of all strains was tested. The MLST method was used to type and a phylogenetic analysis was conducted employing the sequences of 7 housekeeping genes. PCR amplification was used to investigate the presence of the following virulence genes in all strains: hla (α-haemolysin), tstH (toxic shock syndrome toxin), luk PV (Panton-Valentine leukocidin), fnbA (fibronectin binding protein A) and mecA (methicillin resistance). Most of the strains were resistant to penicillin and ampicillin, but only 3 strains were resistant to oxacillin, and 1 of them was a true MRSA. The MLST results showed a high diversity of sequence types (ST), 55% of which were new, and ST152 was the most prevalent. A phylogeny study showed that many of the new STs were phylogenetically related to other previously described STs, but bore little relationship to the only ST from Ethiopia described in the database. Virulence gene detection showed a high prevalence of strains encoding the hla, fnbA and pvl genes (98.77%, 96.3% and 72.84%, respectively), a low prevalence of the tst gene (13.58%) and a markedly low prevalence of MRSA (1.25%). S. aureus strains isolated from patients in a rural area in Ethiopia showed low levels of antibiotic resistance, except to penicillin. Moreover, this study reveals new STs in Eastern Africa that are phylogenetically related to other previously described STs, and confirm the high prevalence of the pvl gene and the low prevalence of MRSA on the continent.

Evolution and Global Transmission of a Multidrug-Resistant, Community-Associated Methicillin-Resistant Staphylococcus aureus Lineage from the Indian Subcontinent

The evolution and global transmission of antimicrobial resistance have been well documented for Gram-negative bacteria and health care-associated epidemic pathogens, often emerging from regions with heavy antimicrobial use. However, the degree to which similar processes occur with Gram-positive bacteria in the community setting is less well understood. In this study, we traced the recent origins and global spread of a multidrug-resistant, community-associated Staphylococcus aureus lineage from the Indian subcontinent, the Bengal Bay clone (ST772). We generated whole-genome sequence data of 340 isolates from 14 countries, including the first isolates from Bangladesh and India, to reconstruct the evolutionary history and genomic epidemiology of the lineage. Our data show that the clone emerged on the Indian subcontinent in the early 1960s and disseminated rapidly in the 1990s. Short-term outbreaks in community and health care settings occurred following intercontinental transmission, typically associated with travel and family contacts on the subcontinent, but ongoing endemic transmission was uncommon. Acquisition of a multidrug resistance integrated plasmid was instrumental in the emergence of a single dominant and globally disseminated clade in the early 1990s. Phenotypic data on biofilm, growth, and toxicity point to antimicrobial resistance as the driving force in the evolution of ST772. The Bengal Bay clone therefore combines the multidrug resistance of traditional health care-associated clones with the epidemiological transmission of community-associated methicillin-resistant S. aureus (MRSA). Our study demonstrates the importance of whole-genome sequencing for tracking the evolution of emerging and resistant pathogens. It provides a critical framework for ongoing surveillance of the clone on the Indian subcontinent and elsewhere.IMPORTANCE The Bengal Bay clone (ST772) is a community-associated and multidrug-resistant Staphylococcus aureus lineage first isolated from Bangladesh and India in 2004. In this study, we showed that the Bengal Bay clone emerged from a virulent progenitor circulating on the Indian subcontinent. Its subsequent global transmission was associated with travel or family contact in the region. ST772 progressively acquired specific resistance elements at limited cost to its fitness and continues to be exported globally, resulting in small-scale community and health care outbreaks. The Bengal Bay clone therefore combines the virulence potential and epidemiology of community-associated clones with the multidrug resistance of health care-associated S. aureus lineages. This study demonstrates the importance of whole-genome sequencing for the surveillance of highly antibiotic-resistant pathogens, which may emerge in the community setting of regions with poor antibiotic stewardship and rapidly spread into hospitals and communities across the world.

Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus nasal carriage in the West of Iran: a population-based cross-sectional study

Background

Several reports designate the recent increase in community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) nasal carriage. Because of the scanty information regarding the nasal carriage sate of MRSA in the west of Iran, the purpose of the present study was to determine the frequency of CA-MRSA in Sanandaj city.

Methods

Swabs collected from anterior nares of 600 volunteers were analyzed for the presence of S. aureus. The isolates were further investigated for methicillin resistance by using the cefoxitin disk diffusion test, followed by PCR-amplification of the mecA gene. SCCmec types and the presence of the Panton-Valentine Leukocidin (pvl) encoding genes were determined through PCR. Finally, the antimicrobial susceptibility of the isolates was determined by the agar diffusion method.

Results

Nasal screening identified 181 S. aureus, of which 55 isolates were MRSA. SCCmec types IV and V were detected in MRSA at frequencies of 80 and 20%, respectively. The overall frequency of pvl genes among the MRSA isolates was 14.54%. MRSA isolates were highly susceptible (98.18%) to mupirocin, gentamicin, and fusidic acid.

Conclusions

The high prevalence of CA-MRSA carriage in the population could pose a serious public health concern for the region. Additionally, advent of drug-resistant pvl-positive strains demands continuous surveillance on the colonization state of CA-MRSA in order to prevent dissemination of the bacterium in the community.

Temperate Phages of Staphylococcus aureus

Most Staphylococcus aureus isolates carry multiple bacteriophages in their genome, which provide the pathogen with traits important for niche adaptation. Such temperate S. aureus phages often encode a variety of accessory factors that influence virulence, immune evasion and host preference of the bacterial lysogen. Moreover, transducing phages are primary vehicles for horizontal gene transfer. Wall teichoic acid (WTA) acts as a common phage receptor for staphylococcal phages and structural variations of WTA govern phage-host specificity thereby shaping gene transfer across clonal lineages and even species. Thus, bacteriophages are central for the success of S. aureus as a human pathogen.

A molecular epidemiological study of methicillin-resistant and methicillin-susceptible Staphylococcus aureus contamination in the airport environment

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) causes a wide variety of serious infections worldwide. There are few studies on the prevalence, antimicrobial susceptibility, and molecular characteristics of MRSA contamination in the environment of airports.

MATERIALS AND METHODS

A cross-sectional survey was conducted in Guangzhou Baiyun Airport. Environmental surface sampling was conducted in frequently touched locations for S. aureus analysis. All isolates were characterized by multilocus sequence typing (MLST) and tested for antimicrobial susceptibility, resistance genes, and virulence genes. Data were analyzed by chi-squared test and correspondence analysis.

RESULTS

Of the 1,054 surface samples, the contamination rate was 7.2% (76/1,054) for S. aureus and 2.2% (23/1,054) for MRSA. There were 62.9% (56/89) S. aureus isolates classified as multidrug resistant (MDR), with six linezolid-resistant isolates and two cfr-carrying isolates. The most prevalent S. aureus genotypes were CC6 (ST6), CC59 (ST59), and CC188 (ST188), with ST59-MRSA-IV (pvl-) as the predominant MRSA. There were significant differences between methicillin-resistant and methicillin-sensitive isolates in rates of resistance to tetracycline (P<0.001) and sek carriage (P=0.029). The correspondence analyses revealed significant corresponding relationships between genotypes and phenotype-genotype characteristics of S. aureus isolates.

CONCLUSION

Our findings revealed a potential risk of cross-transmission of MRSA between human beings and environments, suggesting more stringent contamination control measures. In addition, this study revealed significant corresponding relationships between genotypes and phenotype-genotype characteristics of S. aureus isolates, which may provide new ideas for monitoring the latest epidemiological trends.

Increase in the prevalence of Panton-Valentine leukocidin and clonal shift in community-onset methicillin-resistant Staphylococcus aureus causing skin and soft-tissue infections in the Rhine-Neckar Region, Germany, 2012-2016

Methicillin-resistant Staphylococcus aureus (MRSA) remains a major challenge for patient care. Community-associated (CA)-MRSA often have a fitness and virulence advantage compared with their nosocomial counterparts. Increased mobility, travel activities and migration accelerate the intercontinental spread of virulent CA-MRSA strains. Outpatient clinics are the most important route of entry for CA-MRSA into hospitals. However, systematic data on CA-MRSA in Germany are limited. In this study, community-onset (CO)-MRSA skin and soft-tissue infection (SSTI) isolates in the Rhine-Neckar Region from 2012-2016 were characterised to gain an insight into their molecular epidemiology and to monitor potential introduction of virulent and dominant MRSA strains into our hospital. A total of 2475 patients with S. aureus SSTI were identified in the outpatient departments of our hospital, of which 94 (3.8%) were MRSA. In addition, 40.4% of the CO-MRSA harboured the virulence factor Panton-Valentine leukocidin (PVL). ST8-t008-MRSA-IVa/c (23.7%; 9/39) and ST80-t044-MRSA-IVc (15.8%; 6/38) were the predominant PVL-positive MRSA. Molecular typing and epidemiological data revealed that 42.6% (40/94) of strains could be traced back to a local origin and 44.7% (42/94) were endemic outside of Europe. Resistance to quinolones, clindamycin and macrolides was common, whilst resistance to trimethoprim/sulfamethoxazole, tetracycline, mupirocin, chlorhexidine and fusidic acid was low. No resistance to rifampicin, fosfomycin or linezolid was observed. This study provides insight into the clonal composition of CO-MRSA in the Rhine-Neckar Region. The increase of PVL-positive MRSA and the introduction of imported strains may affect the local MRSA landscape in the near future and should be monitored closely.

Import of community-associated, methicillin-resistant Staphylococcus aureus to Europe through skin and soft-tissue infection in intercontinental travellers, 2011-2016

OBJECTIVES

Recently, following import by travel and migration, epidemic community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has caused nosocomial outbreaks in Europe, sometimes with a fatal outcome. We describe clinico-epidemiological characteristics of CA-MRSA detected by the European Network for the Surveillance of imported S. aureus (www.staphtrav.eu) from May 2011 to November 2016.

METHODS

Sentinel surveillance at 13 travel clinics enrolling patients with travel-associated skin and soft-tissue infection (SSTI) and analysing lesion and nose swabs at one central laboratory.

RESULTS

A total of 564 independent case-patients with SSTI were enrolled and had 374 (67%) S. aureus-positive lesions, of which 14% (51/374) were MRSA. The majority of CA-MRSA isolates from SSTI were Panton-Valentine leucocidin (PVL) -positive (43/51, 84%). The risk of methicillin-resistance in imported S. aureus varied by travel region (p <0.001) and was highest in Latin America (16/57, 28%, 95% CI 17.0-41.5) and lowest in Sub-Saharan Africa (4/121, 3%, 95% CI 0.9-8.3). Major epidemic clones (USA300 / USA300 Latin-American Variant, Bengal Bay, South Pacific) accounted for more than one-third (19/51, 37%) of CA-MRSA imports. CA-MRSA SSTI in returnees was complicated (31/51 multiple lesions, 61%; 22/50 recurrences, 44%), led to health-care contact (22/51 surgical drainage, 43%; 7/50 hospitalization, 14%), was transmissible (13/47 reported similar SSTI in non-travelling contacts, 28%), and associated with S. aureus nasal colonization (28 of 51 CA-MRSA cases, 55%; 24 of 28 colonized with identical spa-type in nose and lesion, 85%).

CONCLUSIONS

Travel-associated CA-MRSA SSTI is a transmissible condition that leads to medical consultations and colonization of the infected host.

Methicillin-Resistant Staphylococcus aureus: Molecular Characterization, Evolution, and Epidemiology

Staphylococcus aureus, a major human pathogen, has a collection of virulence factors and the ability to acquire resistance to most antibiotics. This ability is further augmented by constant emergence of new clones, making S. aureus a "superbug." Clinical use of methicillin has led to the appearance of methicillin-resistant S. aureus (MRSA). The past few decades have witnessed the existence of new MRSA clones. Unlike traditional MRSA residing in hospitals, the new clones can invade community settings and infect people without predisposing risk factors. This evolution continues with the buildup of the MRSA reservoir in companion and food animals. This review focuses on imparting a better understanding of MRSA evolution and its molecular characterization and epidemiology. We first describe the origin of MRSA, with emphasis on the diverse nature of staphylococcal cassette chromosome mec (SCCmec). mecA and its new homologues (mecB, mecC, and mecD), SCCmec types (13 SCCmec types have been discovered to date), and their classification criteria are discussed. The review then describes various typing methods applied to study the molecular epidemiology and evolutionary nature of MRSA. Starting with the historical methods and continuing to the advanced whole-genome approaches, typing of collections of MRSA has shed light on the origin, spread, and evolutionary pathways of MRSA clones.

Travel and the Spread of Drug-Resistant Bacteria

PURPOSE OF REVIEW

The rise in antimicrobial resistance is an urgent public health threat which, in the absence of intervention, may result in a post-antibiotic era limiting the effectiveness of antibiotics to treat both common and serious infections. Globalization and human migration have profoundly contributed to the spread of drug-resistant bacteria. In this review, we summarize the recent literature on the importance of travelers in the spread of drug-resistant bacterial organisms. Our goal was to describe the importance of travel on a variety of clinically relevant drug-resistant bacterial organisms including extended-spectrum β-lactamase-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae, methicillin-resistant Staphylococcus aureus, Salmonella species, as well as other enteric infections.

RECENT FINDINGS

Travelers from high income countries, visiting low and middle income countries, frequently acquire drug-resistant bacteria, particularly extended-spectrum β-lactamase-producing Enterobacteriaceae. The highest risk is associated with travel to the Indian subcontinent. Multidrug-resistant enteric infections in travelers from Salmonella spp., Campylobacter spp., and Shigella spp. are increasing. Refugees, pilgrimages, and medical tourists are associated with considerable risk of multiple forms of drug resistance. This review highlights the importance of antimicrobial stewardship, infection control, and surveillance; particularly in low and middle income countries. International leadership with global coordination is vital in the battle against antimicrobial resistance.

Panton-Valentine Leukocidin associated with S. aureus osteomyelitis activates platelets via neutrophil secretion products

Globalization and migration promote the spread of Panton-Valentine leukocidin (PVL)-positive Staphylococcus aureus strains. The toxin PVL is linked to the development of thrombosis in association with osteomyelitis. The mechanisms by which PVL drives thrombosis development are however still unknown. We demonstrate that PVL-damaged neutrophils activate platelets via neutrophil secretion products, such as α-defensins and the myeloperoxidase product HOCl, as well as the formation of HOCl-modified proteins. Neutrophil damage by PVL is blocked by anti-PVL-antibodies, explaining why especially young osteomyelitis patients with a low antibody titre against PVL suffer from thrombotic complications. Platelet activation in the presence of PVL-damaged neutrophils is prevented by α-defensin inhibitors and by glutathione and resveratrol, which are both inhibitors of HOCl-modified protein-induced platelet activation. Remarkably, intravenously infused glutathione also prevents activation of human platelets in an ex vivo assay. We here describe a new mechanism of PVL-neutrophil-platelet interactions, which might be extrapolated to other toxins that act on neutrophils. Our observations may make us think about new approaches to treat and/or prevent thrombotic complications in the course of infections with PVL-producing S. aureus strains.

Dalbavancin for outpatient parenteral antimicrobial therapy of skin and soft tissue infections in a returning traveller : Proposal for novel treatment indications

Skin and soft tissue infections (SSTIs) are among the most common health problems in travellers returning from tropical and subtropical countries. Importantly, the prevalence of Staphylococcus aureus, the most common pathogen for purulent SSTIs, with specific drug resistance, such as methicillin resistant Staphylococcus aureus (MRSA) and those expressing virulence genes, such as Panton-Valentine-leukocidin is higher in tropical regions than in most high resource settings. This poses challenges for the empirical antimicrobial treatment of SSTIs in returning travellers. This short report describes a patient with a recent travel history to Hong Kong, Singapore and the Philippines who presented with multiple mosquito bites on both upper extremities and secondary bacterial superinfection. He had previously been prescribed oral beta-lactam antimicrobial therapy but lacked adherence to this treatment. Based on the risk for MRSA infection and problems with treatment adherence to oral therapy an outpatient parenteral antimicrobial therapy with dalbavancin was administered on days 0 and 7. Microbiological culture confirmed presence of MRSA and clinical follow-up demonstrated complete remission of the SSTI within 2 weeks. Dalbavancin is a promising treatment option for empirical parenteral treatment of SSTIs in returning travellers, a population at high risk for beta-lactam resistant S. aureus skin infections.

Changing epidemiology of community-associated methicillin-resistant Staphylococcus aureus in the Asia-Pacific region

INTRODUCTION

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has become an important threat to public health in the Asia-Pacific region, which is characterized by a large population and relatively insufficient resources. Better understanding on the current status of CA-MRSA in the region is of paramount importance. Areas covered: This article reviews the published literatures on the prevalence, molecular epidemiology, colonization, and hospital spread of CA-MRSA. Expert commentary: The burden of CA-MRSA has been increasing in the past two decades. The molecular epidemiology of CA-MRSA in the Asia-Pacific region shows a marked diversity in each country. Still, some strains - multilocus sequence type (MLST) ST59, ST30, ST72, ST8, and ST772 - are unique clones that have successfully established themselves as predominant, often spreading into nosocomial settings. More coordinated and comprehensive surveillance to understand the true epidemiology of CA-MRSA in the Asia-Pacific region is urgently needed.

Ratio of T-Helper Type 1 (Th1) to Th17 Cytokines in Whole Blood Is Associated With Human β-Defensin 3 Expression in Skin and Persistent Staphylococcus aureus Nasal Carriage

BACKGROUND

 Nasal colonization has gained attention as an effect modifier in Staphylococcus aureus vaccine trials, suggesting interference of carriage with T-cell immunity. Likewise, T-cell signals may be involved in regulating effectors of epithelial innate defense.

METHODS

 Whole blood from 43 persistent carriers and 49 noncarriers was stimulated with viable S. aureus T-helper type 1 (Th1), Th2, and Th17 cytokine expression was measured, compared between carrier groups, and linked with data on human β-defensin 3 (hBD-3) messenger RNA (mRNA) in skin while adjusting for transcriptionally relevant promoter haplotypes.

RESULTS

 Compared with carriers, stimulated whole blood from noncarriers contained on average 60% more interferon γ mRNA (P = .031) and 19% less interleukin 17A (IL-17A) mRNA (P = .11), resulting in, on average, a 90% higher IFN-γ to IL-17A mRNA ratio (P = .003). In a multivariable model, per duplication of the mRNA template, the risk of being a carrier increased by 93% for IL-17A (odds ratio [OR], 1.93; 95% confidence interval [CI], 1.10-3.41; P = .023) and decreased by 35% for IFN-γ (OR, 0.65; 95% CI, 0.47-0.91; P = .01). Independent of carriage and DEFB promotor haplotype, a 1-unit increase in the IFN-γ to IL-17A mRNA ratio (mean ± SD, 5.93 ± 1.60) led to a 24% increase in hBD-3 transcription in experimentally wounded human skin (P = .003).

CONCLUSIONS

 A low Th1 to Th17 mRNA ratio increases the propensity for persistent S. aureus nasal colonization, with downregulated hBD-3 transcription providing a potential link.

Common skin infection due to Panton-Valentine leucocidin-producing Staphylococcus aureus strains in asylum seekers from Eritrea: a genome-based investigation of a suspected outbreak

Since late 2014, multiple cases of abscesses and boils due to methicillin-susceptible Staphylococcus aureus (MSSA) expressing the Panton-Valentine leucocidin (PVL) were observed in Eritrean asylum seekers in Lausanne, Switzerland. Strains isolated from infected Eritrean and non-Eritrean patients were compared by whole genome sequencing to determine whether these numerous cases result from an outbreak. The genome of S. aureus PVL-producing strains were sequenced and compared. Clinical and epidemiological characteristics of patients infected by PVL-producing strains were investigated. This work reports 15 cases of infections due to PVL-producing strains affecting mostly asylum seekers (n = 10), people working with refugees and/or exposed to Africans (n = 3). Most infections were due to closely related strains of CC152 (n = 8) and CC15 (n = 3), two distantly related (>34 000 core single nucleotide polymorphisms) clonal complexes. An epidemiological link between the 15 cases could be ruled out by whole genome sequencing (33 to 172 core single nucleotide polymorphisms between the different strains of a given complex). Altogether, these results reflect the probable high incidence of CC15 and CC152 PVL-producing strains in eastern Africa. Clinicians facing unusual skin infections in African refugees (or in any person returning from this region of high endemicity) should consider S. aureus PVL-producer before suspecting rare infections such as leishmaniasis or rickettsiosis. Clinicians should also remember that PVL are frequently expressed by MSSA in some regions of the world and that antibiotics that are efficient on toxin expression, such as clindamycin, represent the best therapeutic option.

Predominance of dfrG as determinant of trimethoprim resistance in imported Staphylococcus aureus

To investigate the global occurrence of trimethoprim-sulfamethoxazole resistance and the genetic mechanisms of trimethoprim resistance, we analysed Staphylococcus aureus from travel-associated skin and soft-tissue infections treated at 13 travel clinics in Europe. Thirty-eight per cent (75/196) were trimethoprim-resistant and 21% (41/196) were resistant to trimethoprim-sulfamethoxazole. Among methicillin-resistant S. aureus, these proportions were 30% (7/23) and 17% (4/23), respectively. DfrG explained 92% (69/75) of all trimethoprim resistance in S. aureus. Travel to South Asia was associated with the highest risk of acquiring trimethoprim-sulfamethoxazole-resistant S. aureus. We conclude that globally dfrG is the predominant determinant of trimethoprim resistance in human S. aureus infection.

Single-molecule sequencing reveals the molecular basis of multidrug-resistance in ST772 methicillin-resistant Staphylococcus aureus

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of hospital-associated infection, but there is growing awareness of the emergence of multidrug-resistant lineages in community settings around the world. One such lineage is ST772-MRSA-V, which has disseminated globally and is increasingly prevalent in India. Here, we present the complete genome sequence of DAR4145, a strain of the ST772-MRSA-V lineage from India, and investigate its genomic characteristics in regards to antibiotic resistance and virulence factors.

RESULTS

Sequencing using single-molecule real-time technology resulted in the assembly of a single continuous chromosomal sequence, which was error-corrected, annotated and compared to nine draft genome assemblies of ST772-MRSA-V from Australia, Malaysia and India. We discovered numerous and redundant resistance genes associated with mobile genetic elements (MGEs) and known core genome mutations that explain the highly antibiotic resistant phenotype of DAR4145. Staphylococcal toxins and superantigens, including the leukotoxin Panton-Valentinin Leukocidin, were predominantly associated with genomic islands and the phage φ-IND772PVL. Some of these mobile resistance and virulence factors were variably present in other strains of the ST772-MRSA-V lineage.

CONCLUSIONS

The genomic characteristics presented here emphasize the contribution of MGEs to the emergence of multidrug-resistant and highly virulent strains of community-associated MRSA. Antibiotic resistance was further augmented by chromosomal mutations and redundancy of resistance genes. The complete genome of DAR4145 provides a valuable resource for future investigations into the global dissemination and phylogeography of ST772-MRSA-V.

Skin and soft tissue infections in intercontinental travellers and the import of multi-resistant Staphylococcus aureus to Europe

Staphylococcus aureus is emerging globally. Treatment of infections is complicated by increasing antibiotic resistance. We collected clinical data and swabs of returnees with skin and soft tissue infections (SSTI) at 13 travel-clinics in Europe (www.staphtrav.eu). Sixty-two percent (196/318) SSTI patients had S. aureus-positive lesions, of which almost two-thirds (122/196) were Panton-Valentine leukocidin (PVL) positive. PVL was associated with disease severity, including hospitalization for SSTI (OR 5.2, 95% CI 1.5-18.2). In returnees with SSTI, longer travel and more intense population contact were risk factors for nasal colonization with PVL-positive S. aureus. Imported S. aureus frequently proved resistant to trimethoprim-sulfamethoxazole (21%), erythromycin (21%), tetracycline (20%), ciprofloxacin (13%), methicillin (12%) and clindamycin (8%). Place of exposure was significantly (p < 0.05) associated with predominant resistance phenotypes and spa genotypes: Latin America (methicillin; t008/CC24/304), Africa (tetracycline, trimethoprim-sulfamethoxazole; t084/CC84, t314/singleton, t355/CC355), South Asia (trimethoprim-sulfamethoxazole, ciprofloxacin; t021/CC21/318), South-East Asia (clindamycin; t159/CC272). USA300-like isolates accounted for 30% of all methicillin-resistant S. aureus imported to Europe and were predominantly (71%) acquired in Latin America. Multi-resistance to non-β-lactams were present in 24% of imports and associated with travel to South Asia (ORcrude 5.3, 95% CI 2.4-11.8), even after adjusting for confounding by genotype (ORadjusted 3.8, 95% 1.5-9.5). Choosing randomly from compounds recommended for the empiric treatment of severe S. aureus SSTI, 15% of cases would have received ineffective antimicrobial therapy. These findings call for the development of regionally stratified guidance on the antibiotic management of severe imported S. aureus disease and put the infected and colonized traveller at the centre of interventions against the global spread of multi-resistant S. aureus.

Recurrent furunculosis in returning travelers: newly defined entity

BACKGROUND

Bacterial skin infection is a common dermatologic problem in travelers, which usually resolves without sequela. In contrast, post-travel recurrent furunculosis (PTRF) is a new unique entity of a sequential occurrence of many furuncles seen after returning home from a trip to the Tropics.

OBJECTIVE

The objective of this study was to characterize the disease course and possible causes of PTRF.

METHODS

A retrospective study was conducted on a group of young, healthy individuals (16 males and 5 females), who presented with PTRF after returning from tropical countries.

RESULTS

In all patients, the first furuncle appeared toward the end of the trip and continued for several months after returning home. The average duration of disease was 8.4 months with an average of 4.2 recurrences. Along the disease course, subsequent recurrences became shorter and milder with longer inter-recurrence intervals. Bacterial cultures most commonly grew methicillin-sensitive Staphylococcus aureus (MSSA, 76.5%). Nasal colonization was demonstrated in 47% of patients. There were neither companion travelers nor family members experiencing furuncles.

CONCLUSIONS

PTRF should be defined as a clinical entity with prolonged travel to the Tropics being its major risk factor. In the author's opinion, a transient immune change in a subpopulation of travelers ignites a series of recurrent furuncles, resolving upon restoration of normal immunity.

The risk to import ESBL-producing Enterobacteriaceae and Staphylococcus aureus through chicken meat trade in Gabon

Background

A main export market for chicken meat from industrialized countries is sub-Saharan Africa. We hypothesized that antibiotic resistant bacteria could be exported to developing countries through chicken meat trade. The objective was to investigate the occurrence and molecular types of ESBL-producing Enterobacteriaceae and Staphylococcus aureus in chicken meat in Gabon and to assess their dissemination among humans.

Results

Frozen chicken meat samples imported from industrialized countries to Gabon (n = 151) were screened for ESBL-producing Enterobacteriaceae and S. aureus. Genotypes and resistance genes (SHV, TEM, CTX-M, CMY-2) of isolates from meat were compared with isolates derived from humans.

The contamination rate per chicken part (i. e. leg, wing) with ESBL-producing Escherichia coli (ESBL E. coli, no other ESBL-producing Enterobacteriaceae were found) and S. aureus was 23% and 3%, respectively. The beta-lactamase CTX-M 1 was predominant in ESBL E. coli from meat samples but was not found in isolates from cases of human colonization or infection. S. aureus belonging to spa type t002 (multilocus sequence type ST5) were found both in chicken meat and humans.

Conclusion

There is a risk to import ESBL E. coli to Gabon but molecular differences between isolates from humans and chicken meat argue against a further dissemination. No MRSA isolate was detected in imported chicken meat.

Origin and evolution of European community-acquired methicillin-resistant Staphylococcus aureus

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) was recognized in Europe and worldwide in the late 1990s. Within a decade, several genetically and geographically distinct CA-MRSA lineages carrying the small SCCmec type IV and V genetic elements and the Panton-Valentine leukocidin (PVL) emerged around the world. In Europe, the predominant CA-MRSA strain belongs to clonal complex 80 (CC80) and is resistant to kanamycin/amikacin and fusidic acid. CC80 was first reported in 1993 but was relatively rare until the late 1990s. It has since been identified throughout North Africa, the Middle East, and Europe, with recent sporadic reports in sub-Saharan Africa. While strongly associated with skin and soft tissue infections, it is rarely found among asymptomatic carriers. Methicillin-sensitive S. aureus (MSSA) CC80 strains are extremely rare except in sub-Saharan Africa. In the current study, we applied whole-genome sequencing to a global collection of both MSSA and MRSA CC80 isolates. Phylogenetic analyses strongly suggest that the European epidemic CA-MRSA lineage is derived from a PVL-positive MSSA ancestor from sub-Saharan Africa. Moreover, the tree topology suggests a single acquisition of both the SCCmec element and a plasmid encoding the fusidic acid resistance determinant. Four canonical SNPs distinguish the derived CA-MRSA lineage and include a nonsynonymous mutation in accessory gene regulator C (agrC). These changes were associated with a star-like expansion into Europe, the Middle East, and North Africa in the early 1990s, including multiple cases of cross-continent imports likely driven by human migrations.

With increasing levels of CA-MRSA reported from most parts of the Western world, there is a great interest in understanding the origin and factors associated with the emergence of these epidemic lineages. To trace the origin, evolution, and dissemination pattern of the European CA-MRSA clone (CC80), we sequenced a global collection of strains of the S. aureus CC80 lineage. Our study determined that a single descendant of a PVL-positive methicillin-sensitive ancestor circulating in sub-Saharan Africa rose to become the dominant CA-MRSA clone in Europe, the Middle East, and North Africa. In the transition from a methicillin-susceptible lineage to a successful CA-MRSA clone, it simultaneously became resistant to fusidic acid, a widely used antibiotic for skin and soft tissue infections, thus demonstrating the importance of antibiotic selection in the success of this clone. This finding furthermore highlights the significance of horizontal gene acquisitions and underscores the combined importance of these factors for the success of CA-MRSA.

The role of international travel in the spread of methicillin-resistant Staphylococcus aureus

BACKGROUND

Increasing international travel has facilitated the transmission of various multidrug-resistant bacteria-including methicillin-resistant Staphylococcus aureus (MRSA)-across continents. Individuals may acquire MRSA from the community, healthcare facilities, or even from animal exposure. Skin contact with colonized individuals, fomites, or animals during an overseas trip may result in either asymptomatic colonization or subsequent clinically significant MRSA disease. MRSA strains that harbor the Panton-Valentine leucocidin toxin are particularly associated with community transmission and may potentially have enhanced virulence resulting in serious skin and soft tissue infections or even necrotizing pneumonia. More importantly, secondary transmission events upon return from traveling have been documented, leading to potentially detrimental outbreaks within the community or the healthcare setting. We sought to review the existing literature relating to the role of various aspects of travel in the spread of MRSA. Risk factors for acquiring MRSA during travel together with the need for targeted screening of high-risk individuals will also be explored.

METHODS

Data for this article were identified via PubMed searches using a combination of search terms: "methicillin resistance," "MRSA," "livestock-associated MRSA," "community-associated MRSA," "travel," and "outbreak." The relevant articles were extensively perused to determine secondary sources of data.

RESULTS AND CONCLUSIONS

Our review of the current literature suggests that international travel plays a significant role in the transmission of MRSA, potentially contributing to the replacement of existing endemic MRSA with fitter and more transmissible strains. Therefore, selective and targeted screening of travelers with risk factors for MRSA colonization may be beneficial. Healthcare professionals and patients should be considered for screening if they were to return from endemic areas, with the former group decolonized before returning to patient care work, in order to reduce the transmission of MRSA to vulnerable patient populations.