Characterization of a conjugative staphylococcal mupirocin resistance plasmid

pSK41/pGO1-family conjugative plasmids of Staphylococcus aureus encode a cryptic repressor of replication

The majority of large multiresistance plasmids of Staphylococcus aureus utilise a RepA_N-type replication initiation protein, the expression of which is regulated by a small antisense RNA (RNAI) that overlaps the rep mRNA leader. The pSK41/pGO1-family of conjugative plasmids additionally possess a small (86 codon) divergently transcribed ORF (orf86) located upstream of the rep locus. The product of pSK41 orf86 was predicted to have a helix-turn-helix motif suggestive of a likely function in transcriptional repression. In this study, we investigated the effect of Orf86 on transcription of thirteen pSK41 backbone promoters. We found that Orf86 only repressed transcription from the rep promoter, and hence now redesignate the product as Cop. Over-expression of Cop in trans reduced the copy number of pSK41 mini-replicons, both in the presence and absence of rnaI. in vitro protein-DNA binding experiments with purified 6 × His-Cop demonstrated specific DNA binding, adjacent to, and partially overlapping the -35 hexamer of the rep promoter. The crystal structure of Cop revealed a dimeric structure similar to other known transcriptional regulators. Cop mRNA was found to result from "read-through" transcription from the strong RNAI promoter that escapes the rnaI terminator. Thus, PrnaI is responsible for transcription of two distinct negative regulators of plasmid copy number; the antisense RNAI that primarily represses Rep translation, and Cop protein that can repress rep transcription. Deletion of cop in a native plasmid did not appear to impact copy number, indicating a cryptic auxiliary role.

Identifying patient-level risk factors associated with non-β-lactam resistance outcomes in invasive MRSA infections in the United States using chain graphs

Background

MRSA is one of the most common causes of hospital- and community-acquired infections. MRSA is resistant to many antibiotics, including β-lactam antibiotics, fluoroquinolones, lincosamides, macrolides, aminoglycosides, tetracyclines and chloramphenicol.

Objectives

To identify patient-level characteristics that may be associated with phenotype variations and that may help improve prescribing practice and antimicrobial stewardship.

Methods

Chain graphs for resistance phenotypes were learned from invasive MRSA surveillance data collected by the CDC as part of the Emerging Infections Program to identify patient level risk factors for individual resistance outcomes reported as MIC while accounting for the correlations among the resistance traits. These chain graphs are multilevel probabilistic graphical models (PGMs) that can be used to quantify and visualize the complex associations among multiple resistance outcomes and their explanatory variables.

Results

Some phenotypic resistances had low connectivity to other outcomes or predictors (e.g. tetracycline, vancomycin, doxycycline and rifampicin). Only levofloxacin susceptibility was associated with healthcare-associated infections. Blood culture was the most common predictor of MIC. Patients with positive blood culture had significantly increased MIC of chloramphenicol, erythromycin, gentamicin, lincomycin and mupirocin, and decreased daptomycin and rifampicin MICs. Some regional variations were also observed.

Conclusions

The differences in resistance phenotypes between patients with previous healthcare use or positive blood cultures, or from different states, may be useful to inform first-choice antibiotics to treat clinical MRSA cases. Additionally, we demonstrated multilevel PGMs are useful to quantify and visualize interactions among multiple resistance outcomes and their explanatory variables.

Characterizing a novel SCCmec with a composite structure from a clinical strain of Staphylococcus hominis, C34847

Staphylococcal cassette chromosome mec (SCCmec) has predominantly been described in methicillin-resistant Staphylococcus aureus. However, studies have indicated that coagulase-negative staphylococci (CoNS) carry a larger diversity of SCC elements. We characterized a composite SCCmec element carrying an uncharacterized ccr1 and type A mec gene combination, in conjunction with a secondary element bearing ccr4, from a clinical strain of S. hominis. The element's complex structure points to a high degree of recombination occurring in SCCmec in CoNS.

Investigation of Staphylococcus aureus positive for Staphylococcal enterotoxin S and T genes

Staphylococcus aureus produces staphylococcal enterotoxins (SEs) and causes food poisoning. It is known that almost all SE-encoding genes are present on various types of mobile genetic elements and can mobilize among S. aureus populations. Further, plasmids comprise one of SE gene carriers. Previously, we reported novel SEs, SES and SET, harbored by the plasmid pF5 from Fukuoka5. In the present study, we analyzed the distribution of these SEs in various S. aureus isolates in Japan. We used 526 S. aureus strains and found 311 strains positive for at least one SE/SE-like toxin gene, but only two strains (Fukuoka5 and Hiroshima3) were positive for ses and set among the specimens. We analyzed two plasmids (pF5 and pH3) from these strains and found that they were different. Whereas these plasmids partially shared similar sequences involved in the ser/selj/set/ses gene cluster, other sequences were different. A comparison of these plasmids with those deposited in the NCBI database revealed that only one plasmid had the ser/selj/set/ses cluster with a stop mutation in set similar to that in pH3. In addition, the chromosomes of Fukuoka5 and Hiroshima3, positive for ses and set, were classified into different genotypes. Despite the low rate of gene positivity for these SEs, it is suggested that there is diversity in plasmids and strains carrying these two SEs. Consequently, regarding the entire feature of SE prevalence, we improved the multiplex PCR detection method for the SE superfamily to obtain further insight.

Type III-A CRISPR immunity promotes mutagenesis of staphylococci

Horizontal gene transfer and mutation are the two major drivers of microbial evolution that enable bacteria to adapt to fluctuating environmental stressors¹. Clustered, regularly interspaced, short palindromic repeats (CRISPR) systems use RNA-guided nucleases to direct sequence-specific destruction of the genomes of mobile genetic elements that mediate horizontal gene transfer, such as conjugative plasmids² and bacteriophages³, thus limiting the extent to which bacteria can evolve by this mechanism. A subset of CRISPR systems also exhibit non-specific degradation of DNA^4,5; however, whether and how this feature affects the host has not yet been examined. Here we show that the non-specific DNase activity of the staphylococcal type III-A CRISPR-Cas system increases mutations in the host and accelerates the generation of antibiotic resistance in Staphylococcus aureus and Staphylococcus epidermidis. These mutations require the induction of the SOS response to DNA damage and display a distinct pattern. Our results demonstrate that by differentially affecting both mechanisms that generate genetic diversity, type III-A CRISPR systems can modulate the evolution of the bacterial host.

Antimicrobial Resistance in ESKAPE Pathogens

Antimicrobial-resistant ESKAPE ( Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) pathogens represent a global threat to human health. The acquisition of antimicrobial resistance genes by ESKAPE pathogens has reduced the treatment options for serious infections, increased the burden of disease, and increased death rates due to treatment failure and requires a coordinated global response for antimicrobial resistance surveillance. This looming health threat has restimulated interest in the development of new antimicrobial therapies, has demanded the need for better patient care, and has facilitated heightened governance over stewardship practices.

Antimicrobial Resistance in ESKAPE Pathogens

Antimicrobial-resistant ESKAPE ( Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) pathogens represent a global threat to human health. The acquisition of antimicrobial resistance genes by ESKAPE pathogens has reduced the treatment options for serious infections, increased the burden of disease, and increased death rates due to treatment failure and requires a coordinated global response for antimicrobial resistance surveillance. This looming health threat has restimulated interest in the development of new antimicrobial therapies, has demanded the need for better patient care, and has facilitated heightened governance over stewardship practices.

Staphylococcal Plasmids, Transposable and Integrative Elements

Strains of Staphylococcus aureus, and to a lesser extent other staphylococcal species, are a significant cause of morbidity and mortality. An important factor in the notoriety of these organisms stems from their frequent resistance to many antimicrobial agents used for chemotherapy. This review catalogues the variety of mobile genetic elements that have been identified in staphylococci, with a primary focus on those associated with the recruitment and spread of antimicrobial resistance genes. These include plasmids, transposable elements such as insertion sequences and transposons, and integrative elements including ICE and SCC elements. In concert, these diverse entities facilitate the intra- and inter-cellular gene mobility that enables horizontal genetic exchange, and have also been found to play additional roles in modulating gene expression and genome rearrangement.

Mobile Genetic Elements Associated with Antimicrobial Resistance

Strains of bacteria resistant to antibiotics, particularly those that are multiresistant, are an increasing major health care problem around the world. It is now abundantly clear that both Gram-negative and Gram-positive bacteria are able to meet the evolutionary challenge of combating antimicrobial chemotherapy, often by acquiring preexisting resistance determinants from the bacterial gene pool. This is achieved through the concerted activities of mobile genetic elements able to move within or between DNA molecules, which include insertion sequences, transposons, and gene cassettes/integrons, and those that are able to transfer between bacterial cells, such as plasmids and integrative conjugative elements. Together these elements play a central role in facilitating horizontal genetic exchange and therefore promote the acquisition and spread of resistance genes. This review aims to outline the characteristics of the major types of mobile genetic elements involved in acquisition and spread of antibiotic resistance in both Gram-negative and Gram-positive bacteria, focusing on the so-called ESKAPEE group of organisms (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, Enterobacter spp., and Escherichia coli), which have become the most problematic hospital pathogens.

Dissemination of high-level mupirocin-resistant CC22-MRSA-IV in Saxony

Mupirocin is used for eradicating methicillin-resistant S. aureus (MRSA) in nasal colonization. A plasmid-borne gene, mupA, is associated with high-level mupirocin resistance. Despite the fact that, among all MRSA from a tertiary care center in the German state of Saxony, the prevalence of mupA, encoding high-level mupirocin resistance, was approximately 1% over a 15-year period from 2000-2015, a sharp increase to nearly 20% was observed in 2016/2017. DNA microarray profiling revealed that this was due to the dissemination of a variant of CC22-MRSA-IV ("Barnim Epidemic Strain" or "UK-EMRSA-15"), which, in addition to mecA, harbors mupA, aacA-aphD, qacA, and - in most isolates - erm(C). In order to prevent therapy failures and a further spread of this strain, the use of mupirocin should be more stringently controlled as well as guided by susceptibility testing. In addition, MRSA decolonization regimens that rely on other substances, such as betaisodona, polyhexanide or octenidine, should be considered.

Current and Emerging Topical Antibacterials and Antiseptics: Agents, Action, and Resistance Patterns

Bacterial skin infections represent some of the most common infectious diseases globally. Prevention and treatment of skin infections can involve application of a topical antimicrobial, which may be an antibiotic (such as mupirocin or fusidic acid) or an antiseptic (such as chlorhexidine or alcohol). However, there is limited evidence to support the widespread prophylactic or therapeutic use of topical agents. Challenges involved in the use of topical antimicrobials include increasing rates of bacterial resistance, local hypersensitivity reactions (particularly to older agents, such as bacitracin), and concerns about the indiscriminate use of antiseptics potentially coselecting for antibiotic resistance. We review the evidence for the major clinical uses of topical antibiotics and antiseptics. In addition, we review the mechanisms of action of common topical agents and define the clinical and molecular epidemiology of antimicrobial resistance in these agents. Moreover, we review the potential use of newer and emerging agents, such as retapamulin and ebselen, and discuss the role of antiseptic agents in preventing bacterial skin infections. A comprehensive understanding of the clinical efficacy and drivers of resistance to topical agents will inform the optimal use of these agents to preserve their activity in the future.

An Exploratory Descriptive Study of Antimicrobial Resistance Patterns of Staphylococcus Spp. Isolated from Horses Presented at a Veterinary Teaching Hospital

BACKGROUND

Antimicrobial resistant Staphylococcus are becoming increasingly important in horses because of the zoonotic nature of the pathogens and the associated risks to caregivers and owners. Knowledge of the burden and their antimicrobial resistance patterns are important to inform control strategies. This study is an exploratory descriptive investigation of the burden and antimicrobial drug resistance patterns of Staphylococcus isolates from horses presented at a veterinary teaching hospital in South Africa.

METHODS

Retrospective laboratory clinical records of 1027 horses presented at the University of Pretoria veterinary teaching hospital between 2007 and 2012 were included in the study. Crude and factor-specific percentages of Staphylococcus positive samples, antimicrobial resistant (AMR) and multidrug resistant (MDR) isolates were computed and compared across Staphylococcus spp., geographic locations, seasons, years, breed and sex using Chi-square and Fisher's exact tests.

RESULTS

Of the 1027 processed clinical samples, 12.0% were Staphylococcus positive. The majority of the isolates were S. aureus (41.5%) followed by S. pseudintermedius (14.6%). Fifty-two percent of the Staphylococcus positive isolates were AMR while 28.5% were MDR. Significant (p < 0.05) differences in the percentage of samples with isolates that were AMR or MDR was observed across seasons, horse breeds and Staphylococcus spp. Summer season had the highest (64.3%) and autumn the lowest (29.6%) percentages of AMR isolates. Highest percentage of AMR samples were observed among the Boerperds (85.7%) followed by the American saddler (75%) and the European warm blood (73.9%). Significantly (p < 0.001) more S. aureus isolates (72.5%) were AMR than S. pseudintermedius isolates (38.9%). Similarly, significantly (p < 0.001) more S. aureus (52.9%) exhibited MDR than S. pseudintermedius (16.7%). The highest levels of AMR were towards β-lactams (84.5%) followed by trimethoprim/sulfamethoxazole (folate pathway inhibitors) (60.9%) while the lowest levels of resistance were towards amikacin (14.%).

CONCLUSIONS

This exploratory study provides useful information to guide future studies that will be critical for guiding treatment decisions and control efforts. There is a need to implement appropriate infection control, and judicious use of antimicrobials to arrest development of antimicrobial resistance. A better understanding of the status of the problem is a first step towards that goal.

Conjugation Assay for Testing CRISPR-Cas Anti-plasmid Immunity in Staphylococci

CRISPR-Cas is a prokaryotic adaptive immune system that prevents uptake of mobile genetic elements such as bacteriophages and plasmids. Plasmid transfer between bacteria is of particular clinical concern due to increasing amounts of antibiotic resistant pathogens found in humans as a result of transfer of resistance plasmids within and between species. Testing the ability of CRISPR-Cas systems to block plasmid transfer in various conditions or with CRISPR-Cas mutants provides key insights into the functionality and mechanisms of CRISPR-Cas as well as how antibiotic resistance spreads within bacterial communities. Here, we describe a method for quantifying the impact of CRISPR-Cas on the efficiency of plasmid transfer by conjugation. While this method is presented in Staphylococcus species, it could be more broadly used for any conjugative prokaryote.

Prevention of Recurrent Staphylococcal Skin Infections

Staphylococcus aureus infections pose a significant health burden. The emergence of community-associated methicillin-resistant S aureus has resulted in an epidemic of skin and soft tissue infections (SSTI), and many patients experience recurrent SSTI. As S aureus colonization is associated with subsequent infection, decolonization is recommended for patients with recurrent SSTI or in settings of ongoing transmission. S aureus infections often cluster within households, and asymptomatic carriers serve as reservoirs for transmission; therefore, a household approach to decolonization is more effective than measures performed by individuals alone. Novel strategies for the prevention of recurrent SSTI are needed.

Transfer of the methicillin resistance genomic island among staphylococci by conjugation

Methicillin resistance creates a major obstacle for treatment of Staphylococcus aureus infections. The resistance gene, mecA, is carried on a large (20 kb to > 60 kb) genomic island, staphylococcal cassette chromosome mec (SCCmec), that excises from and inserts site-specifically into the staphylococcal chromosome. However, although SCCmec has been designated a mobile genetic element, a mechanism for its transfer has not been defined. Here we demonstrate the capture and conjugative transfer of excised SCCmec. SCCmec was captured on pGO400, a mupirocin-resistant derivative of the pGO1/pSK41 staphylococcal conjugative plasmid lineage, and pGO400::SCCmec (pRM27) was transferred by filter-mating into both homologous and heterologous S. aureus recipients representing a range of clonal complexes as well as S. epidermidis. The DNA sequence of pRM27 showed that SCCmec had been transferred in its entirety and that its capture had occurred by recombination between IS257/431 elements present on all SCCmec types and pGO1/pSK41 conjugative plasmids. The captured SCCmec excised from the plasmid and inserted site-specifically into the chromosomal att site of both an isogenic S. aureus and a S. epidermidis recipient. These studies describe a means by which methicillin resistance can be environmentally disseminated and a novel mechanism, IS-mediated recombination, for the capture and conjugative transfer of genomic islands.

Impact of Different Target Sequences on Type III CRISPR-Cas Immunity

Clustered regularly interspaced short palindromic repeat (CRISPR) loci encode an adaptive immune system of prokaryotes. Within these loci, sequences intercalated between repeats known as "spacers" specify the targets of CRISPR immunity. The majority of spacers match sequences present in phages and plasmids; however, it is not known whether there are differences in the immunity provided against these diverse invaders. We studied this issue using the Staphylococcus epidermidis CRISPR system, which harbors spacers matching both phages and plasmids. We determined that this CRISPR system provides similar levels of defense against the conjugative plasmid pG0400 and the bacteriophage CNPX. However, whereas antiplasmid immunity was very sensitive to the introduction of mismatches in the target sequence, mutations in the phage target were largely tolerated. Placing the phage and plasmid targets into a vector that can be both conjugated and transduced, we demonstrated that the route of entry of the target has no impact on the effect of the mismatches on immunity. Instead, we established that the specific sequences of each spacer/target determine the susceptibility of the S. epidermidis CRISPR system to mutations. Therefore, spacers that are more resistant to mismatches would provide long-term immunity against phages and plasmids that otherwise would escape CRISPR targeting through the accumulation of mutations in the target sequence. These results uncover an unexpected complexity in the arms race between CRISPR-Cas systems and prokaryotic infectious genetic elements.

IMPORTANCE

CRISPR-Cas loci protect bacteria and archaea from both phage infection and plasmid invasion. These loci harbor short sequences of phage and plasmid origin known as "spacers" that specify the targets of CRISPR-Cas immunity. The presence of a spacer sequence matching a phage or plasmid ensures host immunity against infection by these genetic elements. In turn, phages and plasmids constantly mutate their targets to avoid recognition by the spacers of the CRISPR-Cas immune system. In this study, we demonstrated that different spacer sequences vary in their ability to tolerate target mutations that allow phages and plasmids to escape from CRISPR-Cas immunity. These results uncover an unexpected complexity in the arms race between CRISPR-Cas systems and prokaryotic infectious genetic elements.

Correlation of mupirocin resistance with biofilm production in methicillin-resistant Staphylococcus aureus from surgical site infections in a tertiary centre, Egypt

The aim of this study was to detect mupirocin-resistant isolates from pus/wound swabs taken postoperatively in a tertiary centre in Egypt and to determine their ability to form biofilm in order to establish its correlation with mupirocin resistance. This was a prospective study including 513pus/wound swabs from patients suffering from postoperative surgical site infections over the period July 2013-January 2015. Samples were cultured and isolates were identified by coagulase activity, DNase test, mannitol fermentation by mannitol salt agar followed by API Staph 32. Oxacillin agar screen test, agar dilution test for mupirocin, and mupA gene detection by PCR were performed for all methicillin-resistant Staphylococcus aureus (MRSA) isolates. Biofilm detection was carried out by the microtitre plate and Congo red agar methods. Of the 161 S. aureus isolates identified, 73 (45.3%) were MRSA, among which 82.2% were mupirocin-susceptible and 17.8% were mupirocin-resistant. Among the resistant isolates, 38.5% showed low-level resistance and 61.5% were high-level mupirocin-resistant. The mupA gene was detected in 75.0% of high-level mupirocin-resistant strains and in none of the low-level mupirocin-resistant strains. Among the mupirocin-susceptible isolates, 95.0% were biofilm-producers and 5.0% did not produce biofilm. All mupirocin-resistant isolates produced biofilm. Moreover, 15.3% of high-level mupirocin-resistant strains were negative for the mupA gene but showed evidence of biofilm formation. In conclusion, biofilm formation may be suggested to play a role in mupirocin resistance besides the presence of a genetic element encoding abnormal isoleucyl-tRNA synthetase, however further studies are needed to confirm these findings.

Chlorhexidine and mupirocin susceptibilities in methicillin-resistant Staphylococcus aureus isolates from bacteraemia and nasal colonisation

Chlorhexidine and mupirocin have been increasingly used in healthcare facilities to eradicate methicillin-resistant Staphylococcus aureus (MRSA) carriage. The aim of this study was to determine the prevalence and mechanisms of chlorhexidine and mupirocin resistance in MRSA from invasive infections and colonisation. MRSA isolates obtained from blood and nasal samples between 2012 and 2014 were analysed. Susceptibility to mupirocin was determined by disk diffusion and Etest and susceptibility to chlorhexidine by broth microdilution. The presence of mupA and qac (A/B and C) genes was investigated by PCR. Molecular typing was performed in high-level mupirocin-resistant (HLMR) isolates. Mupirocin resistance was identified in 15.6% of blood isolates (10.9% HLMR) and 15.1% of nasal isolates (12.0% HLMR). Presence of the mupA gene was confirmed in all HLMR isolates. For blood isolates, chlorhexidine minimum inhibitory concentrations (MICs) ranged from ≤0.125 to 4mg/L and minimum bactericidal concentrations (MBCs) from ≤0.125 to 8mg/L. In nasal isolates, chlorhexidine MICs and MBCs ranged from ≤0.125 to 2mg/L. The qacA/B gene was detected in 2.2% of MRSA isolates (chlorhexidine MIC range 0.25-2mg/L) and the qacC gene in 8.2% (chlorhexidine MIC range ≤0.125-1mg/L). The prevalence of qacC was 18.9% in HLMR isolates and 3.6% in mupirocin-susceptible isolates (P=0.009). Most of the HLMR isolates (97.1%) belonged to ST125 clone. These results suggest that chlorhexidine has a higher potential to prevent infections caused by MRSA. In contrast, mupirocin treatment should be used cautiously to avoid the spread of HLMR MRSA.

Dealing with the evolutionary downside of CRISPR immunity: bacteria and beneficial plasmids

The immune systems that protect organisms from infectious agents invariably have a cost for the host. In bacteria and archaea CRISPR-Cas loci can serve as adaptive immune systems that protect these microbes from infectiously transmitted DNAs. When those DNAs are borne by lytic viruses (phages), this protection can provide a considerable advantage. CRISPR-Cas immunity can also prevent cells from acquiring plasmids and free DNA bearing genes that increase their fitness. Here, we use a combination of experiments and mathematical-computer simulation models to explore this downside of CRISPR-Cas immunity and its implications for the maintenance of CRISPR-Cas loci in microbial populations. We analyzed the conjugational transfer of the staphylococcal plasmid pG0400 into Staphylococcus epidermidis RP62a recipients that bear a CRISPR-Cas locus targeting this plasmid. Contrary to what is anticipated for lytic phages, which evade CRISPR by mutations in the target region, the evasion of CRISPR immunity by plasmids occurs at the level of the host through loss of functional CRISPR-Cas immunity. The results of our experiments and models indicate that more than 10⁻⁴ of the cells in CRISPR-Cas positive populations are defective or deleted for the CRISPR-Cas region and thereby able to receive and carry the plasmid. Most intriguingly, the loss of CRISPR function even by large deletions can have little or no fitness cost in vitro. These theoretical and experimental results can account for the considerable variation in the existence, number and function of CRISPR-Cas loci within and between bacterial species. We postulate that as a consequence of the opposing positive and negative selection for immunity, CRISPR-Cas systems are in a continuous state of flux. They are lost when they bear immunity to laterally transferred beneficial genes, re-acquired by horizontal gene transfer, and ascend in environments where phage are a major source of mortality.

In addition to the virtue of protecting archaea and bacteria from the ravages of lethal viruses (phage), the immunity generated by the CRISPR-Cas systems have an evolutionary downside; they can prevent the acquisition of genes and genetic elements required for the adaptation and even the survival of these microbes. Using mathematical models and experiments with Staphylococcus epidermidis and the staphylococcal conjugative plasmid pG0400, we explore how bacteria deal with this evolutionary downside of CRISPR-Cas immunity. Although there are mechanisms by which immune populations of bacteria can acquire essential plasmids without the loss of CRISPR-Cas immunity, the results of our conjugation and fitness cost experiments suggest the most likely mechanism is the deactivation and deletion of this region. These results provide an explanation for the considerable variation in the existence, number and function of CRISPR-Cas within and between species of microbes. Along with other observations our work also suggests that the CRISPR-Cas loci are in a continuous state of flux: acquired by horizontal gene transfer, ascend when populations are confronted with phage and are rapidly lost when infectiously transmitted genes and genetic elements are required for the adaptation and survival of the population.

CRISPR decoys: competitive inhibitors of CRISPR immunity

CRISPR loci consist of an array of short repeats separated by spacer sequences that match the genome of viruses and plasmids that infect prokaryotes. Transcription of the CRISPR array generates small antisense RNAs that mediate immunity against these invaders. In recent years, there has been a notable increase in the investigation of CRISPR immunity, but studies have been restricted to organisms in which genetic manipulations are possible. Therefore, there is a need for the development of simple genetic tools that facilitate the study of this important pathway. Here we describe the use of CRISPR decoys, plasmids containing a non-transcribed repeat-spacer unit that disrupt CRISPR immunity. We show that decoys abrogate immunity against conjugation in S. epidermidis to levels comparable to a CRISPR deletion mutant. This technique can be used to generate full or spacer-specific CRISPR knockdowns in organisms in which decoy plasmids can be introduced.

Mupirocin and chlorhexidine resistance in Staphylococcus aureus in patients with community-onset skin and soft tissue infections

Decolonization measures, including mupirocin and chlorhexidine, are often prescribed to prevent Staphylococcus aureus skin and soft tissue infections (SSTI). The objective of this study was to determine the prevalence of high-level mupirocin and chlorhexidine resistance in S. aureus strains recovered from patients with SSTI before and after mupirocin and chlorhexidine administration and to determine whether carriage of a mupirocin- or chlorhexidine-resistant strain at baseline precluded S. aureus eradication. We recruited 1,089 patients with community-onset SSTI with or without S. aureus colonization. In addition to routine care, 483 patients were enrolled in a decolonization trial: 408 received intranasal mupirocin (with or without antimicrobial baths), and 258 performed chlorhexidine body washes. Patients were followed for up to 12 months with repeat colonization cultures. All S. aureus isolates were tested for high-level mupirocin and chlorhexidine resistance. At baseline, 23/1,089 (2.1%) patients carried a mupirocin-resistant S. aureus strain and 10/1,089 (0.9%) patients carried chlorhexidine-resistant S. aureus. Of 4 patients prescribed mupirocin, who carried a mupirocin-resistant S. aureus strain at baseline, 100% remained colonized at 1 month compared to 44% of the 324 patients without mupirocin resistance at baseline (P = 0.041). Of 2 patients prescribed chlorhexidine, who carried a chlorhexidine-resistant S. aureus strain at baseline, 50% remained colonized at 1 month compared to 48% of the 209 patients without chlorhexidine resistance at baseline (P = 1.0). The overall prevalence of mupirocin and chlorhexidine resistance is low in S. aureus isolates recovered from outpatients, but eradication efforts were less successful in patients carrying a mupirocin-resistant S. aureus strain at baseline.

Prevalence of high-level mupirocin resistance among meticillin-resistant Staphylococcus aureus isolates in a tertiary care hospital in Singapore

High-level resistance to mupirocin in meticillin-resistant Staphylococcus aureus (MRSA) jeopardizes its role in nasal decolonization protocols. We carried out a study in 2010 to determine the prevalence of high-level mupirocin resistance in our tertiary-care hospital. The prevalence of high-level resistance to mupirocin in MRSA in this hospital was 11%. There was also complete agreement between the genotypic and phenotypic methods of detection of high-level mupirocin resistance in 24 of the screening isolates.

Emergence of resistance among USA300 methicillin-resistant Staphylococcus aureus isolates causing invasive disease in the United States

USA300 methicillin-resistant Staphylococcus aureus (MRSA) isolates are usually resistant only to oxacillin, erythromycin, and, increasingly, levofloxacin. Of these, oxacillin and levofloxacin resistances are chromosomally encoded. Plasmid-mediated clindamycin, mupirocin, and/or tetracycline resistance has been observed among USA300 isolates, but these descriptions were limited to specific patient populations or isolated occurrences. We examined the antimicrobial susceptibilities of invasive MRSA isolates from a national surveillance population in order to identify USA300 isolates with unusual, possibly emerging, plasmid-mediated antimicrobial resistance. DNA from these isolates was assayed for the presence of resistance determinants and the presence of a pSK41-like conjugative plasmid. Of 823 USA300 isolates, 72 (9%) were tetracycline resistant; 69 of these were doxycycline susceptible and tetK positive, and 3 were doxycycline resistant and tetM positive. Fifty-one (6.2%) isolates were clindamycin resistant and ermC positive; 22 (2.7%) isolates were high-level mupirocin resistant (mupA positive); 5 (0.6%) isolates were trimethoprim-sulfamethoxazole (TMP-SMZ) resistant, of which 4 were dfrA positive; and 7 (0.9%) isolates were gentamicin resistant and aac6'-aph2'' positive. Isolates with pSK41-like plasmids (n = 24) were positive for mupA (n = 19), dfrA (n = 6), aac6'-aph2'' (n = 6), tetM (n = 2), and ermC (n = 8); 20 pSK41-positive isolates were positive for two or more resistance genes. Conjugative transfer of resistance was demonstrated between four gentamicin- and mupirocin-resistant and three gentamicin- and TMP-SMZ-resistant USA300 isolates; transconjugants harbored a single pSK41-like plasmid, which was PCR positive for aac6'-aph2'' and either mupA and/or dfrA. USA300 and USA100 isolates from the same state with identical resistance profiles contained pSK41-like plasmids with indistinguishable restriction and Southern blot profiles, suggesting horizontal plasmid transfer between USA100 and USA300 isolates.

Complete nucleotide sequences of plasmids pACK1 and pACK3 from Staphylococcus simulans biovar staphylolyticus

Staphylococcus simulans biovar staphylolyticus contains five plasmids designated pACK1-pACK5. The complete nucleotide sequences of pACK1 (55171bp) and pACK3 (28613bp) were determined and sequence comparison revealed that the entire pACK3 sequence is present on pACK1 (99.98% identical on the nucleotide level) with the sequence unique to pACK1 located between sin and blaZ, which are adjacent in pACK3. The common region contains the staphylococcal beta-lactamase transposon Tn552 and ORFs with similarity to genes encoding a serine-recombinase, enzymes involved in pantothenate biosynthesis, and components of the secA2 region involved in bacterial adherence to host tissues. The common region also contains a cluster of six ORFs that share no significant similarity to sequences previously described in GenBank. The region unique to pACK1, in addition to the genes for lysostaphin and lysostaphin resistance, contains ORFswith similarity to genes encoding a toxin-antitoxin addiction system and proteins involved in plasmid partitioning. The unique region also contains several ORFs that are similar to genes typically found on the chromosome such as those encoding catalase, ferrochelatase, and an enzyme involved in pantothenate biosynthesis. In pACK1, the ends of the unique region contain IS431 elements with direct repeats marking the points where the two plasmid sequences diverge. Several observations suggest that pACK1 was derived by insertion of the unique region into pACK3.

Complete nucleotide sequence and comparative analysis of pPR9, a 41.7-kilobase conjugative staphylococcal multiresistance plasmid conferring high-level mupirocin resistance

We have sequenced the conjugative plasmid pPR9, which carries the ileS2 gene, which had contributed to the dissemination of high-level mupirocin resistance at our institution. The plasmid backbone shows extensive genetic conservation with plasmids belonging to the pSK41/pGO1 family, but comparative analyses have revealed key differences that provide important insights into the evolution of these medically important plasmids and high-level mupirocin resistance in staphylococci and highlight the role of insertion sequence IS257 in these processes.

Self versus non-self discrimination during CRISPR RNA-directed immunity

All immune systems must distinguish self from non-self to repel invaders without inducing autoimmunity. Clustered, regularly interspaced, short palindromic repeat (CRISPR) loci protect bacteria and archaea from invasion by phage and plasmid DNA through a genetic interference pathway1–9. CRISPR loci are present in ~ 40% and ~90% of sequenced bacterial and archaeal genomes respectively10 and evolve rapidly, acquiring new spacer sequences to adapt to highly dynamic viral populations1, 11–13. Immunity requires a sequence match between the invasive DNA and the spacers that lie between CRISPR repeats1–9. Each cluster is genetically linked to a subset of the cas (CRISPR-associated) genes14–16 that collectively encode >40 families of proteins involved in adaptation and interference. CRISPR loci encode small CRISPR RNAs (crRNAs) that contain a full spacer flanked by partial repeat sequences2, 17–19. CrRNA spacers are thought to identify targets by direct Watson-Crick pairing with invasive “protospacer” DNA2, 3, but how they avoid targeting the spacer DNA within the encoding CRISPR locus itself is unknown. Here we have defined the mechanism of CRISPR self/non-self discrimination. In Staphylococcus epidermidis, target/crRNA mismatches at specific positions outside of the spacer sequence license foreign DNA for interference, whereas extended pairing between crRNA and CRISPR DNA repeats prevents autoimmunity. Hence, this CRISPR system uses the base-pairing potential of crRNAs not only to specify a target but also to spare the bacterial chromosome from interference. Differential complementarity outside of the spacer sequence is a built-in feature of all CRISPR systems, suggesting that this mechanism is a broadly applicable solution to the self/non-self dilemma that confronts all immune pathways.

Constitutive expression of the ileS-2 gene responsible for high-level mupirocin resistance in Staphylococcus aureus

Mupirocin is a topical antimicrobial agent that is used for the treatment of skin and postoperative wound infections, and the prevention of nasal carriage of meticillin-resistant Staphylococcus aureus (MRSA). However, the prevalence of mupirocin resistance in S. aureus, particularly in MRSA, has increased. High-level mupirocin resistance, with MICs ≥512 μg ml−1, is mediated by the ileS-2 gene, which is located on conjugative plasmids. In the present study, we investigated whether mupirocin influences the expression of the ileS-2 gene responsible for high-level mupirocin resistance, and we present some evidence that this gene is not upregulated but constitutively expressed in S. aureus.

Phenotypic and molecular characterization of Staphylococcus aureus isolates expressing low- and high-level mupirocin resistance in Nigeria and South Africa

BACKGROUND

Mupirocin is a topical antimicrobial agent which is used for the treatment of skin and postoperative wound infections, and the prevention of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). However, the prevalence of mupirocin resistance in S. aureus, particularly in MRSA, has increased with the extensive and widespread use of this agent in hospital settings. This study characterized low- and high-level mupirocin-resistant S. aureus isolates obtained from Nigeria and South Africa.

METHODS

A total of 17 mupirocin-resistant S. aureus isolates obtained from two previous studies in Nigeria and South Africa, were characterized by antibiogram, PCR-RFLP of the coagulase gene and PFGE. High-level mupirocin resistant isolates were confirmed by PCR detection of the mupA gene. The genetic location of the resistance determinants was established by curing and transfer experiments.

RESULTS

All the low-level mupirocin resistant isolates were MRSA and resistant to gentamicin, tetracycline and trimethoprim. PFGE identified a major clone in two health care institutions located in Durban and a health care facility in Pietermaritzburg, Greytown and Empangeni. Curing and transfer experiments indicated that high-level mupirocin resistance was located on a 41.1 kb plasmid in the South African strain (A15). Furthermore, the transfer of high-level mupirocin resistance was demonstrated by the conjugative transfer of the 41.1 kb plasmid alone or with the co-transfer of a plasmid encoding resistance to cadmium. The size of the mupirocin-resistance encoding plasmid in the Nigerian strain (35 IBA) was approximately 35 kb.

CONCLUSION

The emergence of mupirocin-resistant S. aureus isolates in Nigeria and South Africa should be of great concern to medical personnel in these countries. It is recommended that methicillin-susceptible S. aureus (MSSA) and MRSA should be routinely tested for mupirocin resistance even in facilities where the agent is not administered. Urgent measures, including judicious use of mupirocin, need to be taken to prevent clonal dissemination of the mupirocin/methicillin resistant S. aureus in KZN, South Africa and the transfer of the conjugative plasmid encoding high-level mupirocin resistance identified in this study.

CRISPR interference limits horizontal gene transfer in staphylococci by targeting DNA

Horizontal gene transfer (HGT) in bacteria and archaea occurs through phage transduction, transformation, or conjugation, and the latter is particularly important for the spread of antibiotic resistance. Clustered, regularly interspaced, short palindromic repeat (CRISPR) loci confer sequence-directed immunity against phages. A clinical isolate of Staphylococcus epidermidis harbors a CRISPR spacer that matches the nickase gene present in nearly all staphylococcal conjugative plasmids. Here we show that CRISPR interference prevents conjugation and plasmid transformation in S. epidermidis. Insertion of a self-splicing intron into nickase blocks interference despite the reconstitution of the target sequence in the spliced mRNA, which indicates that the interference machinery targets DNA directly. We conclude that CRISPR loci counteract multiple routes of HGT and can limit the spread of antibiotic resistance in pathogenic bacteria.

High-level mupirocin resistance within methicillin-resistant Staphylococcus aureus pandemic lineages

The methicillin-resistant Staphylococcus aureus (MRSA) population in the Hospital Universitario Nuestra Señora de Candelaria over a 5-year period (1998 to 2002) was marked by shifts in the circulation of pandemic clones. Here, we investigated the emergence of high-level mupirocin resistance (Hi-Mup(r)). In addition to clonal spread, transfer of ileS2-carrying plasmids played a significant role in the dissemination of Hi-Mup(r) among pandemic MRSA lineages.

Molecular characterization of the capsule locus from non-typeable Staphylococcus aureus

Most Staphylococcus aureus express a serotype 5 or 8 capsular polysaccharide (CP). However, 20-25% of human isolates and up to 86% of bovine strains of S. aureus are non-typeable (NT), i.e. non-reactive with antibodies to CP types 1, 2, 5 or 8. A vaccine that targets the S. aureus CP would not protect against NT strains. The aim of this study was to characterize NT S. aureus isolates at the molecular level to explain their lack of type 5 or 8 capsule production. The cap5(8) locus was present in all 22 NT clinical isolates from humans, eight of 21 bovine isolates, and in all eight sequenced strains. NT strains positive for the cap5(8) transcript had mutations within essential capsule genes and could be complemented in trans. S. aureus strains with reduced cap5(8) transcript had mutations within the cap5A promoter, decreased RNAIII levels, or a truncated arlR gene product. More than one mutation was identified in several isolates. The cap5(8) locus was replaced by IS257 in 13 of 21 NT bovine isolates of S. aureus. Lack of capsule expression in NT S. aureus can be explained by multiple mechanisms, and the data argue against the existence of capsule serotypes other than 1, 2, 5 and 8.

Clonal dissemination and mupA gene polymorphism of mupirocin-resistant Staphylococcus aureus isolates from long-term-care facilities in South Korea

We identified 25 high-level mupirocin-resistant (MuH) and 21 low-level mupirocin-resistant (MuL) Staphylococcus aureus isolates from eight long-term-care facilities (LTCFs). The pulsed-field gel electrophoresis patterns of 19 MuH and 19 MuL isolates from two facilities were identical for 18 and 15 isolates, respectively. The most predominant mupA restriction fragment length polymorphism type was found in 21 MuH isolates. We conclude that clonal transmission of MuH and MuL S. aureus strains occurred in these LTCFs. This is the first report of clonal transfer of mupirocin resistance in LTCFs.

Molecular analysis of methicillin-resistant Staphylococcus aureus reveals an absence of plasmid DNA in multidrug-resistant isolates

The number, diversity and restriction enzyme fragmentation patterns of plasmids harboured by 44 multidrug-resistant hospital-acquired methicillin-resistant Staphylococcus aureus (MR-HA-MRSA) isolates, two multidrug-resistant community-acquired MRSA (MR-CA-MRSA), 50 hospital-acquired MRSA (HA-MRSA) isolates (from the University Hospital Birmingham, NHS Trust, UK) and 34 community-acquired MRSA (CA-MRSA) isolates (from general practitioners in Birmingham, UK) were compared. In addition, pulsed-field gel electrophoresis (PFGE) type following SmaI chromosomal digest and SCCmec element type assignment were ascertained for each isolate. All MR-HA-MRSA and MR-CA-MRSA isolates possessed the type II SCCmec, harboured no plasmid DNA and belonged to one of five PFGE types. Forty-three out of 50 HA-MRSA isolates and all 34 CA-MRSA isolates possessed the type IV SCCmec and all but 10 of the type IV HA-MRSA isolates and nine CA-MRSA isolates carried one or two plasmids. The 19 non-multidrug-resistant isolates (NMR) that did not harbour plasmids were only resistant to methicillin whereas all the NMR isolates harbouring at least one plasmid were resistant to at least one additional antibiotic. We conclude that although plasmid carriage plays an important role in antibiotic resistance, especially in NMR-HA-MRSA and CA-MRSA, the multidrug resistance phenotype from HA-MRSA is not associated with increased plasmid carriage and indeed is characterised by an absence of plasmid DNA.

Decrease in the incidence of mupirocin resistance among methicillin-resistant Staphylococcus aureus in carriers from an intensive care unit

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a serious nosocomial problem, globally distributed. Decolonization with mupirocin can be used to control its dissemination.

OBJECTIVE

To determine the incidence of mupirocin resistance among MRSA carriers from an intensive care unit.

METHODS

We obtained 2723 nasal swabs during 3 years. Resistance to methicillin and mupirocin were verified (agar diffusion and the E test) and confirmed by polymerase chain reaction (PCR) (mecA for methicillin; ileS-2 and mupA for mupirocin). Plasmid-curing procedure and pulsed-field gel electrophoresis (PFGE) were employed in isolates exhibiting high resistance to mupirocin (HR-Mup) and in other selected organisms.

RESULTS

The overall incidence of HR-Mup among MRSA carriers during the studied period was 4.84% (8/165); however, the incidence decreased from 13.04% (6/46) in the first year to 3.5% (2/57) in the second year and was 0% in the last year (P = .02). LR-Mup, in contrast, increased significantly (P = .01).

CONCLUSION

Plasmid-curing procedure showed the plasmid location of genes responsible for HR-Mup. PFGE demonstrated that most MRSA, including the isolates with HR-Mup, were genetically related. The decline in HR-Mup may be attributable to the plasmid location of genes (ileS-2/mupA) and to the fact that all patients colonized with HR-Mup MRSA died or were discharged in a relatively short period of time.

Advancing age and the risk of nasal carriage of Staphylococcus aureus among patients on long-term hospital-based hemodialysis

BACKGROUND

Elevated nasal carriage rates of Staphylococcus aureus and ensuing complications among the elderly and in those on long-term hemodialysis (HD) are well recognized. The aim of the present study was to determine the extent to which advancing age is associated with the risk of persistent S. aureus nasal carriage among end-stage renal disease (ESRD) patients on long-term HD.

PATIENTS AND METHODS

This prospective study involved 205 ESRD patients enrolled for maintenance HD from July 1997 to July 2000. Persistent nasal carriage was defined by two or more positive cultures for methicillin-susceptible (MSSA) or methicillin-resistant S. aureus (MRSA). Five standardized swabs were taken from the anterior nares of all the patients on long-term HD. S. aureus nasal carriage rates were estimated and compared among ESRD patients of different age groups.

RESULTS

Overall, a prevalence of 38.05% (78/205) for S. aureus nasal carriage was observed, including 27.3% (56/205) for MSSA and 10.7% (22/205) for MRSA. Patients aged 75 to 84 years had the highest (84.6%, 11/13) prevalence of S. aureus nasal carriage (RR, 7.000, 95% CI, 4.350-11.763, P<0.00001). Those aged 65 to 74 years had the next highest (49.0%, 25/51) nasal carriage rates (RR, 4.083, 95% CI, 2.302-7.658, P<0.0001) while patients aged 15 to 24 years (reference group) had the lowest (12.8%, 1/8) prevalence of nasal carriage. The 75 to 84 year age group also had the highest rates of MSSA (46.2%, 6/13), (RR- 3.833, 95% CI, 2.144-7.234, P<0.0001) and MRSA (38.5 %, 5/13) (RR, 6.333, 95%CI, 2.767-16.198, P<0.0001) nasal carriage compared to the reference group.

CONCLUSIONS

Significantly higher persistent MSSA and MRSA nasal carriage rates among ESRD patients >75 years of age are suggestive of an elevated risk of potentially serious S. aureus- related complications among the very elderly during long-term HD. These findings might be helpful in the identification of elderly HD patients as a high-risk group for S. aureus-linked vascular access-related septicemia (VRS) and to evolve appropriate preventive strategies.

Molecular characterization of resistance to mupirocin in methicillin-susceptible and -resistant isolates of Staphylococcus aureus from nasal samples

A total of 15 of 101 (14.8%) nasal methicillin-resistant Staphylococcus aureus (MRSA) isolates exhibited mupirocin resistance (Mup(r)) compared with 1 of 154 (0.6%) methicillin-susceptible Staphylococcus aureus isolates. A total of 14 (93%) isolates exhibiting high-level Mup(r) belonged to a single clone. Horizontal plasmid transfer and transmission of Mup(r) strains contribute to a high incidence of Mup(r) MRSA at our institution.

Plasmids ofStaphylococcus cohnii isolated from the intensive-care unit

Numerous isolates of both subspecies of Staphylococcus cohnii were found in the environment of the intensive-care unit of a pediatric hospital. These isolates carried in their cells many plasmids, up to fourteen, of a wide range of sizes (< 2 to > 56 kb). Striking was the occurrence of large plasmids not very common in staphylococci. These were present in > 80% of S. cohnii isolates. Fifty-two different plasmid profiles were found in 79 investigated isolates belonging to S. cohnii ssp. cohnii and S. cohnii ssp. urealyticus. Isolates similar in plasmid profiles were grouped in antibiotic-resistance clusters established for 9 antibiotics (gentamicin, ciprofloxacin, clindamycin, erythromycin, tetracycline, chloramphenicol, mupirocin, trimethoprim-sulfamethoxazole, vancomycin) using the method of unweighted pair group mathematical averages (UPGMA). Many isolates were multiresistant to antibiotics and produced bacteriocins.

Lysostaphin cream eradicates Staphylococcus aureus nasal colonization in a cotton rat model

The anterior nares are a primary ecologic niche for Staphylococcus aureus, and nasal colonization by this opportunistic pathogen increases the risk of development of S. aureus infection. Clearance of S. aureus nasal colonization greatly reduces this risk. Mupirocin ointment is the current standard of care for clearance of S. aureus nasal colonization, but resistance to this antibiotic is emerging. Lysostaphin is a glycylglycine endopeptidase which specifically cleaves the cross-linking pentaglycine bridges in the cell walls of staphylococci. Lysostaphin is extremely staphylocidal (MIC at which 90% of isolates are inhibited, 0.001 to 0.064 micro g/ml) and rapidly lyses both actively growing and quiescent S. aureus. This study demonstrates that a single application of 0.5% lysostaphin (actual dose, approximately 150 micro g of lysostaphin), formulated in a petrolatum-based cream, dramatically reduces S. aureus nasal colonization in 100% of animals tested and eradicates S. aureus nasal colonization in 93% of animals in a cotton rat model. A single dose of lysostaphin cream is more effective than a single dose of mupirocin ointment in eradicating S. aureus nasal colonization in this animal model. The lantibiotic peptide nisin, which has potent in vitro antistaphylococcal activity, was ineffective in reducing staphylococcal nasal carriage in this model. Nasal colonization was not reduced after three treatments with 5% nisin ( approximately 1,500 micro g/dose) in any of the treated animals. Lysostaphin formulated in cream may prove to be a superior alternative to mupirocin ointment for clearance of S. aureus nasal colonization.

Aminoacyl-tRNA synthetases and their inhibitors as a novel family of antibiotics

The emergence of multidrug-resistant strains of pathogenic microorganisms and the slow progress in new antibiotic development has led in recent years to a resurgence of infectious diseases that threaten the well-being of humans. The result of many microorganisms becoming immune to major antibiotics means that fighting off infection by these pathogens is more difficult. The best strategy to get around drug resistance is to discover new drug targets, taking advantage of the abundant information that was recently obtained from genomic and proteomic research, and explore them for drug development. In this regard, aminoacyl-tRNA synthetases (ARSs) provide a promising platform to develop novel antibiotics that show no cross-resistance to other classical antibiotics. During the last few years there has been a comprehensive attempt to find the compounds that can specifically target ARSs and inhibit bacterial growth. In this review, the current status in the development of ARS inhibitors will be briefly summarized, based on their chemical structures and working mechanisms.

Mupirocin resistance in clinical isolates of Staphylococcus aureus

One hundred isolates of Staphylococcs aureus were collected in a laboratory serving several hospitals and clinics in southeastern Wisconsin and tested for mupirocin susceptibility. Only two isolates of S. aureus showed mupirocin resistance. The mupirocin-resistant isolates were from hospitalized patients with positive blood cultures.

Genomic rearrangement of the mec regulator region mediated by insertion of IS431 in methicillin-resistant staphylococci

Genomic diversification of the mec regulator region mediated by IS431 was investigated for clinical isolates of methicillin-resistant staphylococci. A single rearranged form of the mecR1 gene due to IS431 insertion was detected in the three staphylococcal species, while another type of mecR1 truncation with IS431 and an IS431 located downstream of mecI were found only in Staphylococcus haemolyticus. Genetic differentiation of IS431 and staphylococcal isolates suggested transmission of mecDNA with IS431-mediated rearrangement among different staphylococcal species.

Analysis on distribution of insertion sequence IS431 in clinical isolates of staphylococci

Distribution of insertion sequence IS431 in clinical isolates of Staphylococcus aureus, Staphylococcus epidermidis, and Staphylococcus haemolyticus was investigated. Except for methicillin susceptible-S. aureus (MSSA), IS431 was detected in all isolates of the three staphylococcal species. In MSSA, only 20% of isolates with distinct coagulase types and genetic types possessed IS431. In a few MSSA isolates, an IS431 variant with internal deletion was found.

The epidemiology of mupirocin resistance among methicillin-resistant Staphylococcus aureus at a Veterans' Affairs hospital

OBJECTIVE

To describe the clinical and molecular epidemiology of mupirocin-resistant (MR) and mupirocin-susceptible (MS) methicillin-resistant Staphylococcus aureus (MRSA) at a Veterans' Affairs hospital and to assess risk factors associated with the acquisition of MR MRSA.

DESIGN

All clinical MRSA isolates for the period October 1990 through March 1995 underwent susceptibility testing to mupirocin. Mupirocin resistance trends were measured, and MS MRSA and MR MRSA isolates underwent typing by pulsed-field gel electrophoresis (PFGE). A retrospective case-control study was conducted to evaluate risk factors for having MR versus MS MRSA.

SETTING

The James H. Quillen Veterans' Affairs Medical Center in Mountain Home, Tennessee, included a 324-bed acute-care hospital, a 120-bed nursing home, and a 525-bed domiciliary. Colonizations and infections with MRSA were endemic, and mupirocin ointment was commonly used.

PATIENTS

Inpatients and outpatients at the facility.

RESULTS

MS MRSA was recovered from 506 patients and MR MRSA from 126. Among MR MRSA isolates, 58% showed low-level mupirocin resistance (minimum inhibitory concentration [MIC] > or = 4 to 256 microg/mL), and 42% showed high-level mupirocin resistance (MIC > or = 512 microg/mL). A significant increase (P=.002) in the number of high-level MR isolates occurred during the 1993 to 1995 period. A case-control study showed that presence of a decubitus ulcer correlated with high-level resistant isolates (P<.05). The distribution of PFGE patterns did not differ for MR and MS MRSA CONCLUSIONS: Use of mupirocin ointment in a program aimed at managing endemic MRSA infection or colonization resulted in a significant increase in the recovery of high-level MR MRSA isolates. These isolates appeared to emerge from our existing MRSA pool. A case-control study provided few clues concerning patients likely to harbor MR MRSA. We confirmed the position that the extended use of mupirocin ointment should be avoided in settings where MRSA is endemic.