Assessment of ica operon carriage and biofilm production in Staphylococcus epidermidis isolates causing bacteraemia in bone marrow transplant recipients

Diclofenac May Induce PIA-Independent Biofilm Formation in Staphylococcus aureus Strains

Staphylococcus aureus is a pathogen commonly resistant to antibiotics. Biofilm formation is one of the important factors related to its virulence. Non-antibiotics drugs, such as nonsteroidal anti-inflammatory agents (NSAIDs), have been studied as an alternative for treating infections by multiresistant pathogens and biofilm-associated infections. In this study, the effects of NSAID sodium diclofenac on growth inhibition and biofilm formation of S. aureus were evaluated. The minimum inhibitory concentration (MIC) of diclofenac for fifty isolates ranged from 200 to 400 μg/mL. Diclofenac sub-MICs induced biofilm in 32.3% of biofilm-negative strains in tryptic soy broth. All biofilms induced by the drug showed a PIA- (polysaccharide intercellular adhesion-) independent composition, and the scanning electron microscopy showed that the induced biofilm presented a very discrete matrix. The combination of diclofenac with rifampicin sub-MICs induced strong production of PIA-dependent biofilm in three of four strains, while combination of NSAID with NaCl induced the formation of partially polysaccharide biofilm in two strains and PIA-independent biofilm in another strain. The combination of NSAID with glucose resulted in PIA-independent biofilms in all four strains tested. The results showed that diclofenac can commonly induce biofilm production by a PIA-independent pathway. However, when this NSAID is combined with other types of inducing agents, the composition of the biofilm produced may vary.

Production of Poly-γ-Glutamic Acid (γ-PGA) by Clinical Isolates of Staphylococcus Epidermidis

Background and Objective:

Poly-γ-glutamic acid (γ-PGA) is a constituent of theBacillus anthraciscapsule and a potential virulence factor ofS. epidermidis. In this study, a methodology for the isolation, purification and quantification of γ-PGA in the isolates was adapted. In addition, the fate of the produced γ-PGA and its antiphagocytic activity were investigated.

Methods:

ThecapBgene was investigated by the PCR method in 50 isolates ofS. epidermidis. A modified methodology was used for the extraction, purification, and quantification of γ-PGA using Cetyltrimethylammonium Bromide (CTAB) solution. The fate of γ-PGA was determined in Tryptic Soy Broth (TSB) medium, as well as the effect of ethanol, NaCl and KCl on the induction of the polymer production. The ability of neutrophils to phagocyte both FITC-labeled latex particles in the presence of free γ-PGA andS. epidermidiswith and without anchored γ-PGA was evaluated by cytometry.

Results:

The production of γ-PGA was detected in 40 isolates; all of them werecapBgene carriers. Free γ-PGA was detected and in the strain, the amount of released γ-PGA in the supernatant was 67% greater than the cell anchored γ-PGA. Phagocytosis tests performed with one γ-PGA producer isolate showed a significant reduction in neutrophil internalization.

Conclusion:

The adapted methodology was able to detect γ-PGA in the isolates studied. In addition to being found attached to the cell wall, it was demonstrated in this study that γ-PGA can also be found in the culture supernatant. Free γ-PGA did not determine a reduction in the internalization of latex by neutrophils, but cells with anchored γ-PGA showed significant protection against phagocytosis.

Comprehensive Virulence Gene Profiling of Bovine Non-aureus Staphylococci Based on Whole-Genome Sequencing Data

Non-aureus staphylococci (NAS) are the most frequently isolated pathogens from milk in dairy cattle worldwide. The virulence factors (VFs) and mechanisms by which these bacteria cause udder infection are not fully known. We determined the distribution and associations of 191 VFs in 25 NAS species and investigated the relationship between VFs and disease. Although the overall number of VFs was not associated with disease severity, increasing numbers of toxin and host immune evasion genes specifically were associated with more severe disease outcomes. These findings suggest that the development of disease and the interactions of VFs with the host are complex and determined by the interplay of genes rather than just the presence of virulence genes. Together, our results provide foundational genetic knowledge to other researchers to design and conduct further experiments, focusing on understanding the synergy between VFs and roles of individual NAS species in IMI and characterizing species-specific effects on udder health.

Non-aureus staphylococci (NAS) are the most frequently isolated pathogens from intramammary infection (IMI) in dairy cattle. Virulence factors (VFs) and mechanisms by which NAS cause IMI are not fully known. Herein, we analyzed the distribution of 191 VFs in 441 genomes of 25 NAS species, after classifying VFs into functional categories: adherence (n = 28), exoenzymes (n = 21), immune evasion (n = 20), iron metabolism (n = 29), and toxins (n = 93). In addition to establishing VF gene profiles, associations of VF genes between and among functional categories were computed, revealing distinctive patterns of association among VFs for various NAS species. Associations were also computed for low, medium, and high somatic cell count (SCC) and clinical mastitis (CM) isolates, demonstrating distinctive patterns of associations for low SCC and CM isolates, but no differences between high SCC and CM isolates. To determine whether VF distributions had any association with SCC or CM, various clustering approaches, including complete linkages, Ward clustering, and t-distributed stochastic neighbor embedding, were applied. However, no clustering of isolates representing low SCC, medium SCC, or high SCC or CM was identified. Regression analysis to test for associations with individual VF functional categories demonstrated that each additional toxin and host immune evasion gene increased the odds of having high SCC or CM, although an overall increase in the number of VFs was not associated with increased SCC or occurrence of CM. In conclusion, we established comprehensive VF gene profiling, determined VF gene distributions and associations, calculated pathogenic potentials of all NAS species, and detected no clear link between VF genes and mastitis.

IMPORTANCE Non-aureus staphylococci (NAS) are the most frequently isolated pathogens from milk in dairy cattle worldwide. The virulence factors (VFs) and mechanisms by which these bacteria cause udder infection are not fully known. We determined the distribution and associations of 191 VFs in 25 NAS species and investigated the relationship between VFs and disease. Although the overall number of VFs was not associated with disease severity, increasing numbers of toxin and host immune evasion genes specifically were associated with more severe disease outcomes. These findings suggest that the development of disease and the interactions of VFs with the host are complex and determined by the interplay of genes rather than just the presence of virulence genes. Together, our results provide foundational genetic knowledge to other researchers to design and conduct further experiments, focusing on understanding the synergy between VFs and roles of individual NAS species in IMI and characterizing species-specific effects on udder health.

Evaluation of Biofilm Formation and Presence of Ica Genes in Staphylococcus epidermidis Clinical Isolates

Objectives

Biofilm formation is one of the important features of Staphylococcus epidermidis, particularly in nosocomial infections. We aimed to investigate the biofilm production by phenotypic methods and the presence of ica genes in S epidermidis.

Methods

A total of 41 S epidermidis isolates were recovered from different clinical specimens. Biofilm formation was evaluated by microtiter plate, tube method and Congo red agar method. The presence of icaA and icaD genes was investigated by PCR. Validity of methods (sensitivity and specificity), and metrics for test performance (positive/negative predictive value, and positive/negative likelihood ratio) were determined.

Results

By both microtiter plate and tube method, 53.6% of S epidermidis isolates were able to produce biofilm, whilst only 24.4% of isolates provided a biofilm phenotype on Congo red agar plates. icaA and icaD genes were found in 100% and 95.1% of isolates, respectively. Biofilm phenotypes accounted for 4.8% by microtiter plate assay, despite the absence of the ica gene. Congo red agar and PCR exhibited a lower sensitivity (18% and 45.5%, respectively) for identifying the biofilm phenotype in comparison to microtiter plate.

Conclusion

The microtiter plate method remains generally a better tool to screen biofilm production in S epidermidis. In addition, the ability of S epidermidis to form biofilm is not always dependent on the presence of ica genes, highlighting the importance of ica-independent mechanisms of biofilm formation. The use of reliable methods to specifically detect biofilms can be helpful to treat the patients affected by such problematic bacteria.

Sub-Inhibitory Concentrations of Rifampicin Strongly Stimulated Biofilm Production in S. aureus

Background and Objectives:

Staphylococcus aureus is an important pathogen and a frequent cause of infections associated with biofilm production in implantable medical devices. Biofilm production can be induced by sub-inhibitory concentrations (sub-MICs) of certain antibiotics, but few studies have researched this occurrence in S. aureus. In this study, we investigated the effect of sub-MICs of rifampicin and minocycline on biofilm production by five clinical and five non-clinical S. aureus isolates.

Methods:

Microtiter Plate assay and Congo Red Agar Test were used to analyze the biofilm production. The biofilm composition was evaluated by the detachment assay with sodium metaperiodate and proteinase K.

Results:

Rifampicin sub-MICs induced very high biofilm formation in seven isolates that were non-producers in Tryptic Soy Broth. In one producer isolate, the biofilm formation level was not affected by sub-MICs of this drug. Sub-MICs of minocycline did not induce biofilm production in all isolates tested and in two producer isolates, instead, MIC/2 and MIC/4 inhibited biofilm production. The results of the drugs in combination were similar to those with rifampicin alone. The biofilm matrix was identified as polysaccharide, except for one producer isolate, classified as proteinaceous. Polysaccharide biofilm producer isolates, when grown on Congo Red Agar without sucrose, but with sub-MICs of rifampicin, showed results in agreement with those obtained in Microtiter Plate Test.

Conclusion:

The high biofilm production induced by sub-MICs of rifampicin has potential clinical relevance, because this is one of the drugs commonly used in the impregnation of catheters. In addition, it is used adjunctively to treat certain S. aureus infections.

Staphylococcus epidermidis and Staphylococcus haemolyticus: detection of biofilm genes and biofilm formation in blood culture isolates from patients in a Brazilian teaching hospital

Infections with coagulase-negative staphylococci are often related to biofilm formation. This study aimed to detect biofilm formation and biofilm-associated genes in blood culture isolates of Staphylococcus epidermidis and S. haemolyticus. Half (50.6%) of the 85 S. epidermidis isolates carried the icaAD genes and 15.3% the bhp gene, while these numbers were 42.9% and 0 for S. haemolyticus, respectively. According to the plate test, 30 S. epidermidis isolates were biofilm producers and 40% of them were strongly adherent, while only one (6%) of the 17 S. haemolyticus biofilm-producing isolates exhibited a strongly adherent biofilm. The concomitant presence of icaA and icaD was significantly associated with the plate and tube test results (P ≤ 0.0004). The higher frequency of icaA in S. epidermidis and of icaD in S. haemolyticus is correlated with the higher biofilm-producing capacity of the former since, in contrast to IcaD, IcaA activity is sufficient to produce small amounts of polysaccharide. Although this study emphasizes the importance of icaAD and bhp for biofilm formation in S. epidermidis, other mechanisms seem to be involved in S. haemolyticus.

Staphylococcus epidermidis device-related infections: pathogenesis and clinical management

Staphylococcus epidermidis, the most frequently isolated coagulase-negative staphylococcus, is the leading cause of infection related to implanted medical devices (IMDs). This is directly related to its capability to establish multilayered, highly structured biofilms on artificial surfaces. At present, conventional systemic therapies using standard antimicrobial agents represent the main strategy to treat and prevent medical device-associated infections. However, device-related infections are notoriously difficult to treat and bacteria within biofilm communities on the surface of IMDs frequently outlive treatment, and removal of the medical device is often required for successful therapy. Importantly, major advances in this research area have been made, leading to a greater understanding of the complexities of biofilm formation of S. epidermidis and resulting in significant developments in the treatment and prevention of infections related to this member of the coagulase-negative group of staphylococci. This review will examine the pathogenesis of the clinically significant S. epidermidis and provide an overview of the conventional and emerging antibiofilm approaches in the management of medical device-associated infections related to this important nosocomial pathogen.

Clinical implications of icaA and icaD genes in coagulase negative staphylococci and Staphylococcus aureus bacteremia in febrile neutropenic pediatric cancer patients

BACKGROUND

Staphylococci are the most frequently isolated organisms from blood cultures of febrile neutropenic (FN) cancer patients. We aimed to define the nature of these isolates by studying the prevalence of icaA and icaD genes in coagulase-negative staphylococci (CoNS) and Staphylococcus aureus isolates in relation to clinical and microbiological features.

PROCEDURE

Fifty-five CoNS and S. aureus isolates from blood cultures of FN pediatric patients receiving chemotherapy were tested for slime production using Congo red agar plate test (CRA test), and for the presence of icaA and icaD genes by PCR.

RESULTS

Of the CoNS isolates, eight were positive for ica genes, and three were slime positive/ica negative. A total of 11 (24.4%) cases of CoNS bacteremia were either ica genes or CRA test positive. There was a concordance between ica genes and CRA test positivity (P < 0.001). S. aureus isolates exhibited icaA and icaD genes more than CoNS isolates (P = 0.03). Vancomycin was significantly more prescribed in episodes of ica-positive cases (P = 0.029).

CONCLUSIONS

The results of the present study support the hypothesis that the ica genes are important virulence markers for clinically significant CoNS isolates, indicating their ability to produce slime. This could be used to assign a group with higher risk FN. On the other hand, absence of these genes may permit, along with other clinical criteria, the consideration of a low-risk FN episode and allow for safe early discharge.

Partial atlE sequencing of Staphylococcus epidermidis strains from prosthetic joint infections

Partial atlE sequencing (atlE nucleotides 2782 to 3114 [atlE(2782-3114)]) was performed in 41 Staphylococcus epidermidis isolates from prosthetic joint infections (PJIs) and 44 isolates from skin as controls. The atlE(2782-3114) allele 1 (type strain sequence) was significantly more frequent in PJI strains (38/41 versus 29/44 in controls; P = 0.0023). Most PJI strains were positive for mecA, icaA/icaD, and IS256, and most belonged to the sequence type 27 subgroup, suggesting the involvement of few related clones.

Bloodstream infections in haematology: risks and new challenges for prevention

Bloodstream infections are an important cause of morbidity and mortality in the haematology population, and may contribute to delayed administration of chemotherapy, increased length of hospitalisation, and increased healthcare expenditure. For gram-positive, gram-negative, anaerobic and fungal infections, specific risk factors are recognised. Unique host and environmental factors contributing to pathogenesis are acknowledged in this population. Trends in spectrum and antimicrobial susceptibility of pathogens are examined, and potential contributing factors are discussed. These include the widespread use of empiric antimicrobial therapy, increasingly intensive chemotherapeutic regimens, frequent use of central venous catheters, and local infection control practices. In addition, the risks and benefits of prophylaxis, and spectrum of endemic flora are identified as relevant factors within individual centres. Finally, challenges are presented regarding prevention, early detection, surveillance and prophylaxis. To reduce the rate and impact of bloodstream infections multifaceted and customised strategies are required within individual haematology units.

Clonality and occurrence of genes encoding antibiotic resistance and biofilm in methicillin-resistant Staphylococcus epidermidis strains isolated from catheters and bacteremia in neutropenic patients

Thirty methicillin-resistant Staphylococcus epidermidis strains isolated from catheters and blood cultures from neutropenic patients were studied. They were classified into 17 multidrug-resistance patterns. Polymerase cahin reaction analysis revealed that methicillin resistance was encoded by the mecA gene in all strains, and aminoglycosides resistance was due to aac(6')-Ie-aph(2'')-Ia (23 strains), ant(4')-Ia (13), and aph(3')-IIIa (1) genes. The aac(6')-Ie-aph(2'')-Ia gene was detected concomitantly with aph(3')-IIIa, and ant(4')-Ia genes in one and nine strains, respectively. Erythromycin resistance was encoded by the ermC (11 strains), ermA (6), and msrA (2) genes. The ermC gene was inducibly expressed in five strains, whereas the ermA was exclusively constitutively expressed. The icaA and icaC genes were detected in 19 strains; however, biofilm production was observed in only 16 strains. Most strains harbored multiple plasmids of variable sizes ranging from 2.2 to 70 kb, and two strains were plasmid-free. PFGE identified 15 distinct PFGE types, and five predominant genotypes were found. Our study showed the occurrence of complex genetic phenomenons. In unrelated strains, evidence of horizontal transfer of antibiotic-encoding genes and/or ica operon, and in indistinguishable strains, there is a quite good likelihood of independent steps of loss and/or gain of these genes. This genome dynamicity might have enhanced the invasiveness power of these methicillin-resistant S epidermidis strains.

Clonal dissemination of Staphylococcus epidermidis in an oncology ward

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

Genetic evidence for an alternative citrate-dependent biofilm formation pathway in Staphylococcus aureus that is dependent on fibronectin binding proteins and the GraRS two-component regulatory system

We reported previously that low concentrations of sodium citrate strongly promote biofilm formation by Staphylococcus aureus laboratory strains and clinical isolates. Here, we show that citrate promotes biofilm formation via stimulating both cell-to-surface and cell-to-cell interactions. Citrate-stimulated biofilm formation is independent of the ica locus, and in fact, citrate represses polysaccharide adhesin production. We show that fibronectin binding proteins FnbA and FnbB and the global regulator SarA, which positively regulates fnbA and fnbB gene expression, are required for citrate's positive effects on biofilm formation, and citrate also stimulates fnbA and fnbB gene expression. Biofilm formation is also stimulated by several other tricarboxylic acid (TCA) cycle intermediates in an FnbA-dependent fashion. While aconitase contributes to biofilm formation in the absence of TCA cycle intermediates, it is not required for biofilm stimulation by these compounds. Furthermore, the GraRS two-component regulator and the GraRS-regulated efflux pump VraFG, identified for their roles in intermediate vancomycin resistance, are required for citrate-stimulated cell-to-cell interactions, but the GraRS regulatory system does not impact the expression of the fnbA and fnbB genes. Our data suggest that distinct genetic factors are required for the early steps in citrate-stimulated biofilm formation. Given the role of FnbA/FnbB and SarA in virulence in vivo and the lack of a role for ica-mediated biofilm formation in S. aureus catheter models of infection, we propose that the citrate-stimulated biofilm formation pathway may represent a clinically relevant pathway for the formation of these bacterial communities on medical implants.

In vitro activity of daptomycin and tigecycline against coagulase-negative staphylococcus blood isolates from bone marrow transplant recipients

BACKGROUND AND OBJECTIVE

Multi-resistant coagulase-negative staphylococci (CNS) may cause systemic infections in patients undergoing bone marrow transplantation. Daptomycin, a new lipopeptide, and tigecycline, a new glycylcycline, have excellent activity against Gram-positive bacteria including methicillin-resistant staphylococci. This study presents the in vitro activity of daptomycin and tigecycline compared to vancomycin and fosfomycin against 105 CNS isolated from 76 bone marrow transplant patients with symptomatic bacteremia.

MATERIAL AND METHODS

Blood stream isolates of Staphylococcus epidermidis (n = 102) and Staphylococcus haemolyticus (n = 3) from bone marrow transplant patients were collected from 2000 to 2006. The susceptibility of all isolates was tested using methods of the Clinical Laboratory Standards Institute.

RESULTS

The minimal inhibitory concentrations MIC(50) and MIC(90) were 0.125 microg/mL and 0.25 microg/mL for daptomycin, 0.25 and 0.5 microg/mL for tigecycline, 1 microg/mL and 2 microg/mL for vancomycin, and 8 microg/mL and >256 microg/mL for fosfomycin, respectively. MIC values of tested agents were similar for both methicillin-sensitive and methicillin-resistant S. epidermidis strains.

CONCLUSIONS

All CNS isolates were susceptible to the new antistaphylococcal agents daptomycin and tigecycline. Although vancomycin had been used over the past 30 yr at our bone marrow transplant unit all CNS were still susceptible to vancomycin.

Formation and properties of in vitro biofilms of ica-negative Staphylococcus epidermidis clinical isolates

Coagulase-negative Staphylococcus epidermidis has become the leading cause of foreign-body infections due to its biofilm formation on all kinds of medical-device surfaces. The biofilm development of S. epidermidis includes two steps: the initial attachment phase and the accumulative phase. In the accumulative phase, the polysaccharide intercellular adhesin (PIA), encoded by the icaADBC locus, is the major component mediating intercellular adhesion. However, recent studies have revealed the emergence of biofilm-positive/ica-negative staphylococcal clinical isolates. In this report, two ica-negative S. epidermidis clinical strains, SE1 and SE4, exhibited their heterogeneity in biofilm architecture under static and flow conditions, compared with the biofilm-positive/ica-positive RP62A strain. Strains with this type of absence of PIA from biofilms also displayed intermediate resistance to vancomycin. More importantly, the cells of both SE1 and SE4 strains were more tolerant than those of RP62A to exposure to lysostaphin and vancomycin. Based on the results, it is suggested that the biofilm-positive/ica-negative strain represents a newly emergent subpopulation of S. epidermidis clinical strains, arising from selection by antibiotics in the nosocomial milieu, which displays a survival advantage in its host environment. Recent epidemiological data support this suggestion, by showing a tendency towards an increasing proportion of this subpopulation in staphylococci-associated infections.