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Burke Ó, Zeden MS, O'Gara JP. The pathogenicity and virulence of the opportunistic pathogen Staphylococcus epidermidis. Virulence 2024; 15:2359483. [PMID: 38868991 DOI: 10.1080/21505594.2024.2359483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/19/2024] [Indexed: 06/14/2024] Open
Abstract
The pervasive presence of Staphylococcus epidermidis and other coagulase-negative staphylococci on the skin and mucous membranes has long underpinned a casual disregard for the infection risk that these organisms pose to vulnerable patients in healthcare settings. Prior to the recognition of biofilm as an important virulence determinant in S. epidermidis, isolation of this microorganism in diagnostic specimens was often overlooked as clinically insignificant with potential delays in diagnosis and onset of appropriate treatment, contributing to the establishment of chronic infection and increased morbidity or mortality. While impressive progress has been made in our understanding of biofilm mechanisms in this important opportunistic pathogen, research into other virulence determinants has lagged S. aureus. In this review, the broader virulence potential of S. epidermidis including biofilm, toxins, proteases, immune evasion strategies and antibiotic resistance mechanisms is surveyed, together with current and future approaches for improved therapeutic interventions.
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Affiliation(s)
- Órla Burke
- Microbiology, School of Biological and Chemical Sciences, University of Galway, Galway, Ireland
| | | | - James P O'Gara
- Microbiology, School of Biological and Chemical Sciences, University of Galway, Galway, Ireland
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2
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Kirsch JM, Hryckowian AJ, Duerkop BA. A metagenomics pipeline reveals insertion sequence-driven evolution of the microbiota. Cell Host Microbe 2024; 32:739-754.e4. [PMID: 38565143 PMCID: PMC11081829 DOI: 10.1016/j.chom.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/06/2024] [Accepted: 03/08/2024] [Indexed: 04/04/2024]
Abstract
Insertion sequence (IS) elements are mobile genetic elements in bacterial genomes that support adaptation. We developed a database of IS elements coupled to a computational pipeline that identifies IS element insertions in the microbiota. We discovered that diverse IS elements insert into the genomes of intestinal bacteria regardless of human host lifestyle. These insertions target bacterial accessory genes that aid in their adaptation to unique environmental conditions. Using IS expansion in Bacteroides, we show that IS activity leads to the insertion of "hot spots" in accessory genes. We show that IS insertions are stable and can be transferred between humans. Extreme environmental perturbations force IS elements to fall out of the microbiota, and many fail to rebound following homeostasis. Our work shows that IS elements drive bacterial genome diversification within the microbiota and establishes a framework for understanding how strain-level variation within the microbiota impacts human health.
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Affiliation(s)
- Joshua M Kirsch
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, CO 80045, USA
| | - Andrew J Hryckowian
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA; Department of Medical Microbiology & Immunology, University of Wisconsin School of Medicine and Public Health, Madison, WI 53706, USA
| | - Breck A Duerkop
- Department of Immunology and Microbiology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, CO 80045, USA.
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3
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Lin LC, Kao CY, Chang SC, Hidrosollo JH, Lu JJ. Molecular characterization of lugdunin inactivation mechanisms and their association with Staphylococcus lugdunensis genetic types. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:278-287. [PMID: 38296696 DOI: 10.1016/j.jmii.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/03/2024] [Accepted: 01/09/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND AND PURPOSE Our previous studies showed that lugdunin activities are associated with Staphylococcus lugdunensis genotypes, and most isolates do not exhibit lugdunin activity. As a continuation of our previous analysis, we focused on the reasons for defects in lugdunin production in S. lugdunensis clinical isolates. METHODS A comparative analysis of 36 S. lugdunensis whole genome sequencing data revealed three major mutation types, unknown deletion mechanism that caused most of lug operon genes lost, mobile genetic element (MGE) insertion, and nonsense mutations, which potentially damaged lugdunin production. A total of 152 S. lugdunensis clinical isolates belonging to lugdunin nonproducers were further examined for the above three mutation types. PCR products were sequenced to examine these variations. RESULTS Forty-six of the 152 isolates were CRISPR-Cas IIC isolates, including 26 ST27, 14 ST4, and 6 ST29 isolates; further investigation confirmed that all of their lug operons had lost almost all lug operon genes except lugM. An IS256 insertion in lugA was identified in 16 isolates, and most isolates (15 over 16) belonged to ST3. In addition, three nonsense mutations caused by single nucleotide substitutions (an adenine deletion in lugB at the 361th and 1219th nucleotides and an adenine deletion in lugC at the 1612nd nucleotide) that were frequently observed among 36 S. lugdunensis whole genome sequencing data were further observed in our clinical isolates. These three nonsense mutations were frequently found in most of CRISPR-Cas IIIA strains, especially in ST6 isolates. CONCLUSION Our findings suggest that the mechanisms affecting lugdunin production are associated with S. lugdunensis molecular types.
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Affiliation(s)
- Lee-Chung Lin
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Yen Kao
- Institute of Microbiology and Immunology, College of Life Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Cheng Chang
- Department of Medical Laboratory, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jazon Harl Hidrosollo
- Institute of Microbiology and Immunology, College of Life Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan; University of San Agustin, College of Pharmacy and Medical Technology, Iloilo City, Philippines
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Medical Biotechnology and Laboratory Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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4
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Kirsch JM, Hryckowian AJ, Duerkop BA. A metagenomics pipeline reveals insertion sequence-driven evolution of the microbiota. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.10.06.561241. [PMID: 37873088 PMCID: PMC10592638 DOI: 10.1101/2023.10.06.561241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Insertion sequence (IS) elements are mobile genetic elements in bacterial genomes that support adaptation. We developed a database of IS elements coupled to a computational pipeline that identifies IS element insertions in the microbiota. We discovered that diverse IS elements insert into the genomes of intestinal bacteria regardless of human host lifestyle. These insertions target bacterial accessory genes that aid in their adaptation to unique environmental conditions. Using IS expansion in Bacteroides, we show that IS activity leads to insertion "hot spots" in accessory genes. We show that IS insertions are stable and can be transferred between humans. Extreme environmental perturbations force IS elements to fall out of the microbiota and many fail to rebound following homeostasis. Our work shows that IS elements drive bacterial genome diversification within the microbiota and establishes a framework for understanding how strain level variation within the microbiota impacts human health.
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Affiliation(s)
- Joshua M. Kirsch
- Department of Immunology and Microbiology, University of Colorado - Anschutz Medical Campus, School of Medicine, Aurora, Colorado, 80045, USA
| | - Andrew J. Hryckowian
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, 53706, USA
- Department of Medical Microbiology & Immunology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, 53706, USA
| | - Breck A. Duerkop
- Department of Immunology and Microbiology, University of Colorado - Anschutz Medical Campus, School of Medicine, Aurora, Colorado, 80045, USA
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5
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Ahmad S, Rahman H, Mumtaz S, Qasim M, Rahman ZU, Alsuwat MA, Halawani IF, Alzahrani FM, Ali S. mecA and fdh: markers of pathogenicity and commensalism in Staphylococcus epidermidis of pediatric origin from Pakistan. Diagn Microbiol Infect Dis 2024; 108:116109. [PMID: 37918188 DOI: 10.1016/j.diagmicrobio.2023.116109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 10/11/2023] [Accepted: 10/12/2023] [Indexed: 11/04/2023]
Abstract
Staphylococcus epidermidis is an opportunistic bacterial pathogen. The study screened isolates of S. epidermidis of pediatric origin for genetic markers of discriminatory potential. 103 isolates (n = 75 clinical; n = 28 community) were screened for methicillin resistance (mecA), formate dehydrogenase (fdh) and an array of virulence factors through multiplex PCR and Congo red assay. The isolates were typed in four distinct categories, based on the presence of selected virulent factors. The type A clinical isolates carrying icaADBC operon (n = 22; 29.3%, P = 0.117) were not significantly differentiating the origin of isolates. The type B clinical isolates representing methicillin resistant S. epidermidis (MRSE) (n = 73; 97.3%, P < 0.00001) and the type C clinical isolates lacking formate dehydrogenase fdh (n = 62; 82.6%, P < 0.00001) were having significant discriminatory potential of clinical isolates, respectively. All type D community isolates were carrying fdh (n = 28; 100%, P < 0.00001). MecA and fdh are significant differential markers of pathogenicity and commensalism in S. epidermidis of pediatric origin.
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Affiliation(s)
- Saghir Ahmad
- Department of Microbiology, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Hazir Rahman
- Department of Microbiology, Abdul Wali Khan University Mardan, Mardan, Pakistan.
| | - Sumbal Mumtaz
- Department of Microbiology, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Muhammad Qasim
- Department of Microbiology, Kohat University of Science and Technology, Kohat, Pakistan
| | - Zia Ur Rahman
- Department of Microbiology, Abdul Wali Khan University Mardan, Mardan, Pakistan
| | - Meshari A Alsuwat
- Department of Clinical Laboratories Sciences, College of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
| | - Ibrahim F Halawani
- Department of Clinical Laboratories Sciences, College of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
| | - Fuad M Alzahrani
- Department of Clinical Laboratories Sciences, College of Applied Medical Sciences, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia
| | - Sajid Ali
- Department of Biotechnology, Abdul Wali Khan University Mardan, Mardan, Pakistan
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Zhang K, Potter RF, Marino J, Muenks CE, Lammers MG, Dien Bard J, Dingle TC, Humphries R, Westblade LF, Burnham CAD, Dantas G. Comparative genomics reveals the correlations of stress response genes and bacteriophages in developing antibiotic resistance of Staphylococcus saprophyticus. mSystems 2023; 8:e0069723. [PMID: 38051037 PMCID: PMC10734486 DOI: 10.1128/msystems.00697-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/23/2023] [Indexed: 12/07/2023] Open
Abstract
IMPORTANCE Staphylococcus saprophyticus is the second most common bacteria associated with urinary tract infections (UTIs) in women. The antimicrobial treatment regimen for uncomplicated UTI is normally nitrofurantoin, trimethoprim-sulfamethoxazole (TMP-SMX), or a fluoroquinolone without routine susceptibility testing of S. saprophyticus recovered from urine specimens. However, TMP-SMX-resistant S. saprophyticus has been detected recently in UTI patients, as well as in our cohort. Herein, we investigated the understudied resistance patterns of this pathogenic species by linking genomic antibiotic resistance gene (ARG) content to susceptibility phenotypes. We describe ARG associations with known and novel SCCmec configurations as well as phage elements in S. saprophyticus, which may serve as intervention or diagnostic targets to limit resistance transmission. Our analyses yielded a comprehensive database of phenotypic data associated with the ARG sequence in clinical S. saprophyticus isolates, which will be crucial for resistance surveillance and prediction to enable precise diagnosis and effective treatment of S. saprophyticus UTIs.
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Affiliation(s)
- Kailun Zhang
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Robert F. Potter
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jamie Marino
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, USA
| | - Carol E. Muenks
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Matthew G. Lammers
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jennifer Dien Bard
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Tanis C. Dingle
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Romney Humphries
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lars F. Westblade
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, USA
| | - Carey-Ann D. Burnham
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Gautam Dantas
- Department of Pathology and Immunology, Division of Laboratory and Genomic Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Molecular Microbiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
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Campoccia D, Ravaioli S, Mirzaei R, Bua G, Daglia M, Arciola CR. Interactions of Neutrophils with the Polymeric Molecular Components of the Biofilm Matrix in the Context of Implant-Associated Bone and Joint Infections. Int J Mol Sci 2023; 24:17042. [PMID: 38069365 PMCID: PMC10707472 DOI: 10.3390/ijms242317042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
In the presence of orthopedic implants, opportunistic pathogens can easily colonize the biomaterial surfaces, forming protective biofilms. Life in biofilm is a central pathogenetic mechanism enabling bacteria to elude the host immune response and survive conventional medical treatments. The formation of mature biofilms is universally recognized as the main cause of septic prosthetic failures. Neutrophils are the first leukocytes to be recruited at the site of infection. They are highly efficient in detecting and killing planktonic bacteria. However, the interactions of these fundamental effector cells of the immune system with the biofilm matrix, which is the true interface of a biofilm with the host cells, have only recently started to be unveiled and are still to be fully understood. Biofilm matrix macromolecules consist of exopolysaccharides, proteins, lipids, teichoic acids, and the most recently described extracellular DNA. The latter can also be stolen from neutrophil extracellular traps (NETs) by bacteria, who use it to strengthen their biofilms. This paper aims to review the specific interactions that neutrophils develop when they physically encounter the matrix of a biofilm and come to interact with its polymeric molecular components.
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Affiliation(s)
- Davide Campoccia
- Laboratorio di Patologia Delle Infezioni Associate all’Impianto, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy; (D.C.); (S.R.); (G.B.)
| | - Stefano Ravaioli
- Laboratorio di Patologia Delle Infezioni Associate all’Impianto, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy; (D.C.); (S.R.); (G.B.)
| | - Rasoul Mirzaei
- Venom and Biotherapeutics Molecules Laboratory, Medical Biotechnology Department, Biotechnology Research Center, Pasteur Institute of Iran, Tehran 1316943551, Iran;
| | - Gloria Bua
- Laboratorio di Patologia Delle Infezioni Associate all’Impianto, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy; (D.C.); (S.R.); (G.B.)
| | - Maria Daglia
- Department of Pharmacy, University of Napoli Federico II, Via D. Montesano 49, 80131 Naples, Italy;
- International Research Center for Food Nutrition and Safety, Jiangsu University, Zhenjiang 212013, China
| | - Carla Renata Arciola
- Laboratory of Immunorheumatology and Tissue Regeneration, Laboratory of Pathology of Implant Infections, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10, 40136 Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Via San Giacomo 14, 40126 Bologna, Italy
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Kalantar-Neyestanaki D, Mansouri S, Tadjrobehkar O, Isaei E. The frequency of adherence, biofilm-associated, Arginine Catabolic Mobile element genes, and biofilm formation in clinical and healthcare worker coagulase-negative staphylococci isolates. BMC Microbiol 2023; 23:222. [PMID: 37582708 PMCID: PMC10426181 DOI: 10.1186/s12866-023-02959-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/25/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Healthcare workers may pave the way for increased infections in hospitalized patients by coagulase-negative staphylococci (CoNS). Biofilm formation and antibiotic resistance are the major problems posed by CoNS in nosocomial infections. In this study, we determined biofilm production level and the distribution of biofilm-associated and virulence genes, including icaADBC, aap, bhp, atlE, embp, and fbe, as well as IS256, IS257, mecA, and ACME clusters (arc-A, opp-3AB) among 114 clinical (n = 57) and healthcare workers (n = 57) CoNS isolates in Kerman, Iran. RESULTS In this study, more than 80% (n = 96) of isolates were methicillin-resistant CoNS (MR-CoNS). Out of 114 isolates, 33% (n = 38) were strong biofilm producers. Strong biofilm formation was found to be significantly different between clinical and healthcare workers' isolates (P < 0.050). In addition, 28% (n = 32) of isolates were positive for icaADBC simultaneously, and all were strong biofilm producers. The prevalence of icaADBC, mecA, bhp, fbe, and IS256 in clinical isolates was higher than that in healthcare workers' isolates (P < 0.050). A significant relationship was observed between clinical isolates and the presence of icaADBC, mecA, bhp, and IS256. Although these elements were detected in healthcare workers' isolates, they were more frequent in clinical isolates compared to those of healthcare workers. CONCLUSIONS The high prevalence of ACME clusters in healthcare workers' isolates and biofilm formation of these isolates partially confirms the bacterial colonization in the skin of healthcare workers. Isolating MR-CoNS from healthcare workers' skin through similar genetic elements to clinical isolates, such as icaADBC, mecA, and IS256, calls for appropriate strategies to control and prevent hospital infections.
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Affiliation(s)
- Davood Kalantar-Neyestanaki
- Medical Mycology and Bacteriology Research Center, Kerman University of Medical Sciences, Kerman, Iran
- Department of Medical Microbiology (Bacteriology and Virology), Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahla Mansouri
- Medical Mycology and Bacteriology Research Center, Kerman University of Medical Sciences, Kerman, Iran
- Department of Medical Microbiology (Bacteriology and Virology), Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Omid Tadjrobehkar
- Medical Mycology and Bacteriology Research Center, Kerman University of Medical Sciences, Kerman, Iran
- Department of Medical Microbiology (Bacteriology and Virology), Afzalipour Faculty of Medicine, Kerman University of Medical Sciences, Kerman, Iran
| | - Elham Isaei
- Noncommunicable Diseases Research Center, Bam University Of Medical Sciences, Bam, Iran.
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9
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Kirsch JM, Ely S, Stellfox ME, Hullahalli K, Luong P, Palmer KL, Van Tyne D, Duerkop BA. Targeted IS-element sequencing uncovers transposition dynamics during selective pressure in enterococci. PLoS Pathog 2023; 19:e1011424. [PMID: 37267422 PMCID: PMC10266640 DOI: 10.1371/journal.ppat.1011424] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/14/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023] Open
Abstract
Insertion sequences (IS) are simple transposons implicated in the genome evolution of diverse pathogenic bacterial species. Enterococci have emerged as important human intestinal pathogens with newly adapted virulence potential and antibiotic resistance. These genetic features arose in tandem with large-scale genome evolution mediated by mobile elements. Pathoadaptation in enterococci is thought to be mediated in part by the IS element IS256 through gene inactivation and recombination events. However, the regulation of IS256 and the mechanisms controlling its activation are not well understood. Here, we adapt an IS256-specfic deep sequencing method to describe how chronic lytic phage infection drives widespread diversification of IS256 in E. faecalis and how antibiotic exposure is associated with IS256 diversification in E. faecium during a clinical human infection. We show through comparative genomics that IS256 is primarily found in hospital-adapted enterococcal isolates. Analyses of IS256 transposase gene levels reveal that IS256 mobility is regulated at the transcriptional level by multiple mechanisms in E. faecalis, indicating tight control of IS256 activation in the absence of selective pressure. Our findings reveal that stressors such as phages and antibiotic exposure drives rapid genome-scale transposition in the enterococci. IS256 diversification can therefore explain how selective pressures mediate evolution of the enterococcal genome, ultimately leading to the emergence of dominant nosocomial lineages that threaten human health.
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Affiliation(s)
- Joshua M. Kirsch
- Department of Immunology and Microbiology, University of Colorado–Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States of America
| | - Shannon Ely
- Department of Immunology and Microbiology, University of Colorado–Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States of America
| | - Madison E. Stellfox
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Karthik Hullahalli
- Department of Biological Sciences, University of Texas at Dallas, Richardson, Texas, United States of America
| | - Phat Luong
- Department of Immunology and Microbiology, University of Colorado–Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States of America
| | - Kelli L. Palmer
- Department of Biological Sciences, University of Texas at Dallas, Richardson, Texas, United States of America
| | - Daria Van Tyne
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Breck A. Duerkop
- Department of Immunology and Microbiology, University of Colorado–Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States of America
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10
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Maki JJ, Howard M, Connelly S, Pettengill MA, Hardy DJ, Cameron A. Species Delineation and Comparative Genomics within the Campylobacter ureolyticus Complex. J Clin Microbiol 2023; 61:e0004623. [PMID: 37129508 DOI: 10.1128/jcm.00046-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Campylobacter ureolyticus is an emerging pathogen increasingly appreciated as a common cause of gastroenteritis and extra-intestinal infections in humans. Outside the setting of gastroenteritis, little work has been done to describe the genomic content and relatedness of the species, especially regarding clinical isolates. We reviewed the epidemiology of clinical C. ureolyticus cultured by our institution over the past 10 years. Fifty-one unique C. ureolyticus isolates were identified between January 2010 and August 2022, mostly originating from abscesses and blood cultures. To clarify the taxonomic relationships between isolates and to attribute specific genes with different clinical manifestations, we sequenced 19 available isolates from a variety of clinical specimen types and conducted a pangenomic analysis with publicly available C. ureolyticus genomes. Digital DNA:DNA hybridization suggested that these C. ureolyticus comprised a species complex of 10 species clusters (SCs) and several subspecies clusters. Although some orthologous genes or gene functions were enriched in isolates found in different SCs and clinical specimens, no association was significant. Nearly a third of the isolates possessed antimicrobial resistance genes, including the ermA resistance gene, potentially conferring resistance to macrolides, the treatment of choice for severe human campylobacteriosis. This work effectively doubles the number of publicly available C. ureolyticus genomes, provides further clarification of taxonomic relationships within this bacterial complex, and identifies target SCs for future analysis.
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Affiliation(s)
- Joel J Maki
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Mondraya Howard
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Sara Connelly
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew A Pettengill
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Dwight J Hardy
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, New York, USA
| | - Andrew Cameron
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York, USA
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11
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Hellmann KT, Challagundla L, Gray BM, Robinson DA. Improved Genomic Prediction of Staphylococcus epidermidis Isolation Sources with a Novel Polygenic Score. J Clin Microbiol 2023; 61:e0141222. [PMID: 36840569 PMCID: PMC10035303 DOI: 10.1128/jcm.01412-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/22/2023] [Indexed: 02/25/2023] Open
Abstract
Staphylococcus epidermidis infections can be challenging to diagnose due to the species frequent contamination of clinical specimens and indolent course of infection. Nevertheless, S. epidermidis is the major cause of late-onset sepsis among premature infants and of intravascular infection in all age groups. Prior work has shown that bacterial virulence factors, antimicrobial resistances, and strains have up to 80% in-sample accuracy to distinguish hospital from community sources, but are unable to distinguish true bacteremia from blood culture contamination. Here, a phylogeny-informed genome-wide association study of 88 isolates was used to estimate effect sizes of particular genomic variants for isolation sources. A "polygenic score" was calculated for each isolate as the summed effect sizes of its repertoire of genomic variants. Predictive models of isolation sources based on polygenic scores were tested with in-samples and out-samples from prior studies of different patient populations. Polygenic scores from accessory genes (AGs) distinguished hospital from community sources with the highest accuracy to date, up to 98% for in-samples and 65% to 91% for various out-samples, whereas scores from single nucleotide polymorphisms (SNPs) had lower accuracy. Scores from AGs and SNPs achieved the highest in-sample accuracy to date, up to 76%, in distinguishing infection from contaminant sources within a hospital. Model training and testing data sets with more similar population structures resulted in more accurate predictions. This study reports the first use of a polygenic score for predicting a complex bacterial phenotype and shows the potential of this approach for enhancing S. epidermidis diagnosis.
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Affiliation(s)
- K. Taylor Hellmann
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Lavanya Challagundla
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Barry M. Gray
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - D. Ashley Robinson
- Department of Cell and Molecular Biology, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Center for Immunology and Microbial Research, University of Mississippi Medical Center, Jackson, Mississippi, USA
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12
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Staphylococcus epidermidis and its dual lifestyle in skin health and infection. Nat Rev Microbiol 2023; 21:97-111. [PMID: 36042296 PMCID: PMC9903335 DOI: 10.1038/s41579-022-00780-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 01/20/2023]
Abstract
The coagulase-negative bacterium Staphylococcus epidermidis is a member of the human skin microbiota. S. epidermidis is not merely a passive resident on skin but actively primes the cutaneous immune response, maintains skin homeostasis and prevents opportunistic pathogens from causing disease via colonization resistance. However, it is now appreciated that S. epidermidis and its interactions with the host exist on a spectrum of potential pathogenicity derived from its high strain-level heterogeneity. S. epidermidis is the most common cause of implant-associated infections and is a canonical opportunistic biofilm former. Additional emerging evidence suggests that some strains of S. epidermidis may contribute to the pathogenesis of common skin diseases. Here, we highlight new developments in our understanding of S. epidermidis strain diversity, skin colonization dynamics and its multifaceted interactions with the host and other members of the skin microbiota.
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Martínez-Santos VI, Torres-Añorve DA, Echániz-Aviles G, Parra-Rojas I, Ramírez-Peralta A, Castro-Alarcón N. Characterization of Staphylococcus epidermidis clinical isolates from hospitalized patients with bloodstream infection obtained in two time periods. PeerJ 2022; 10:e14030. [PMID: 36213498 PMCID: PMC9541613 DOI: 10.7717/peerj.14030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/16/2022] [Indexed: 01/19/2023] Open
Abstract
Background In recent years Staphylococcus epidermidis has been considered an important and frequent causative agent of health care-associated infections (HAIs), increasing the costs of hospitalization, morbidity, and mortality. Antibiotic resistance and biofilm formation are the most important obstacles in the treatment of infections caused by this microorganism. The aim of this work was to determine the most prevalent STs, as well as the antibiotic resistance profile and biofilm formation of S. epidermidis clinical isolates obtained from hospitalized patients in two hospitals in Acapulco, Guerrero in two time periods. Methods Twenty methicillin-resistant S. epidermidis strains isolated from patients with bacteremia in two hospitals in two time periods were analyzed. Identification and antibiotic susceptibility were performed using the Vitek automated system. Molecular confirmation of the identification and methicillin resistance was performed by duplex PCR of the mecA and nuc genes. Biofilm production was analyzed, and the clonal origin was determined by multilocus sequence typing (MLST). Results We identified 14 antibiotic resistance profiles as well as 13 sequence types (ST), including the new ST761. We also found that ST2 and ST23 were the most prevalent and, together with ST59, were found in both time periods. Seventeen of our clinical isolates were multidrug-resistant, but all of them were sensitive to linezolid and vancomycin, and this was not related to biofilm production. Additionally, we standardized a duplex PCR to identify methicillin-resistant S. epidermidis strains. In conclusion, S. epidermidis STs 2, 23, and 59 were found in both time periods. This study is the first report of S. epidermidis ST761. The clinical isolates obtained in this work showed a high multidrug resistance that is apparently not related to biofilm production.
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Affiliation(s)
| | - David A. Torres-Añorve
- Laboratorio de Investigación en Microbiología, Facultad de Ciencias Químico Biológicas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | - Gabriela Echániz-Aviles
- Centro de Investigación Sobre Enfermedades Infecciosas, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México
| | - Isela Parra-Rojas
- Labotatorio de Investigación en Obesidad y Diabetes, Facultad de Ciencias Químico Biológicas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | - Arturo Ramírez-Peralta
- Laboratorio de Investigación en Patometabolismo Microbiano, Facultad de Ciencias Químico Biológicas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
| | - Natividad Castro-Alarcón
- Laboratorio de Investigación en Microbiología, Facultad de Ciencias Químico Biológicas, Universidad Autónoma de Guerrero, Chilpancingo, Guerrero, Mexico
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Phumthanakorn N, Wongsurawat T, Jenjaroenpun P, Kurilung A, Prapasarakul N. Novel Organization of the Staphylococcal Cassette Chromosome mec Composite Island in Clinical Staphylococcus haemolyticus and Staphylococcus hominis Subspecies hominis Isolates from Dogs. Microbiol Spectr 2022; 10:e0099722. [PMID: 35862947 PMCID: PMC9430635 DOI: 10.1128/spectrum.00997-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Staphylococcus haemolyticus and Staphylococcus hominis subsp. hominis are common coagulase-negative staphylococcus opportunistic pathogens. In Thailand, the clinical strains S. haemolyticus 1864 and 48 and S. hominis subsp. hominis 384 and 371 have been recovered from sick dogs. These strains were methicillin resistant with the nontypeable staphylococcal cassette chromosome mec (NT-SCCmec). The SCCmec element distribution in the clinical isolates from dogs was analyzed using whole-genome sequencing, which revealed the presence of different SCCmec composite islands (CIs) and gene structure. The SCCmec-CIs of ψSCCmec1864 (13 kb) and ψSCC1864 (11 kb) with a class C1 mec complex but no ccr gene were discovered in S. haemolyticus 1864. The CIs of ψSCCmec48 with a C1 mec complex (28 kb), SCC48 with ccrA4B4 (23 kb), and ψSCC48 (2.6 kb) were discovered in S. haemolyticus 48. In SCC48, insertion sequence IS256 contained an aminoglycoside-resistant gene [aph(2″)-Ia]. Two copies of IS431 containing the tetracycline-resistant gene tet(K) were found downstream of ψSCC48. In S. hominis subsp. hominis, the SCCmec-CI in strain 384 had two separate sections: ψSCCmec384 (20 kb) and SCCars (23 kb). ψSCCmec384 lacked the ccr gene complex but carried the class A mec complex. Trimethoprim-resistant dihydrofolate reductase (dfrC) was discovered on ψSCCmec384 between two copies of IS257. In strain 371, SCCmec VIII (4A) (37 kb) lacking a direct repeat at the chromosomal end was identified. This study found SCCmec elements in clinical isolates from dogs that were structurally complex and varied in their genetic content, with novel organization. IMPORTANCE In Thailand, the staphylococcal cassette chromosome mec (SCCmec) element, which causes methicillin resistance through acquisition of the mec gene, has been studied in clinical coagulase-negative Staphylococcus isolates from various companion animals, and Staphylococcus haemolyticus and Staphylococcus hominis subsp. hominis were found to have the most nontypeable (NT)-SCCmec elements. These species are more prone to causing illness and more resistant to a variety of antimicrobials than other coagulase-negative staphylococci. However, full characterization of NT-SCCmec in clinical S. haemolyticus and S. hominis subsp. hominis isolates from such animals has been limited. Our findings support the use of full nucleotide sequencing rather than PCR designed for Staphylococcus aureus in further research of novel SCCmec elements. Moreover, several antimicrobial resistance and heavy metal resistance genes were identified on the SCCmec elements; these are important as they could limit the therapeutic options available in veterinary medicine.
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Affiliation(s)
- Nathita Phumthanakorn
- Department of Pre-Clinic and Applied Animal Science, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom, Thailand
- Center of Excellence in Diagnostic and Monitoring of Animal Pathogens, Chulalongkorn University, Bangkok, Thailand
| | - Thidathip Wongsurawat
- Division of Bioinformatics and Data Management for Research, Research Group and Research Network Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Piroon Jenjaroenpun
- Division of Bioinformatics and Data Management for Research, Research Group and Research Network Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Alongkorn Kurilung
- Siriraj Metabolomics and Phenomics Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuvee Prapasarakul
- Department of Veterinary Microbiology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Diagnostic and Monitoring of Animal Pathogens, Chulalongkorn University, Bangkok, Thailand
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15
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Sands K, Carvalho MJ, Spiller OB, Portal EAR, Thomson K, Watkins WJ, Mathias J, Dyer C, Akpulu C, Andrews R, Ferreira A, Hender T, Milton R, Nieto M, Zahra R, Shirazi H, Muhammad A, Akif S, Jan MH, Iregbu K, Modibbo F, Uwaezuoke S, Chan GJ, Bekele D, Solomon S, Basu S, Nandy RK, Naha S, Mazarati JB, Rucogoza A, Gaju L, Mehtar S, Bulabula ANH, Whitelaw A, Walsh TR. Characterisation of Staphylococci species from neonatal blood cultures in low- and middle-income countries. BMC Infect Dis 2022; 22:593. [PMID: 35790903 PMCID: PMC9254428 DOI: 10.1186/s12879-022-07541-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/15/2022] [Indexed: 11/14/2022] Open
Abstract
Background In low- and middle-income countries (LMIC) Staphylococcus aureus is regarded as one of the leading bacterial causes of neonatal sepsis, however there is limited knowledge on the species diversity and antimicrobial resistance caused by Gram-positive bacteria (GPB). Methods We characterised GPB isolates from neonatal blood cultures from LMICs in Africa (Ethiopia, Nigeria, Rwanda, and South Africa) and South-Asia (Bangladesh and Pakistan) between 2015–2017. We determined minimum inhibitory concentrations and performed whole genome sequencing (WGS) on Staphylococci isolates recovered and clinical data collected related to the onset of sepsis and the outcome of the neonate up to 60 days of age. Results From the isolates recovered from blood cultures, Staphylococci species were most frequently identified. Out of 100 S. aureus isolates sequenced, 18 different sequence types (ST) were found which unveiled two small epidemiological clusters caused by methicillin resistant S. aureus (MRSA) in Pakistan (ST8) and South Africa (ST5), both with high mortality (n = 6/17). One-third of S. aureus was MRSA, with methicillin resistance also detected in Staphylococcus epidermidis, Staphylococcus haemolyticus and Mammaliicoccus sciuri. Through additional WGS analysis we report a cluster of M. sciuri in Pakistan identified between July-November 2017. Conclusions In total we identified 14 different GPB bacterial species, however Staphylococci was dominant. These findings highlight the need of a prospective genomic epidemiology study to comprehensively assess the true burden of GPB neonatal sepsis focusing specifically on mechanisms of resistance and virulence across species and in relation to neonatal outcome. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07541-w.
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Nasaj M, Hosseini SM, Saeidi Z, Dehbashi S, Tahmasebi H, Arabestani MR. Analysis of phenotypic and genotypic methods for determining the biofilm-forming abilities of CoNS isolates: Association with hemolysin production and the bacterial insertion sequence elements IS256/257. GENE REPORTS 2021. [DOI: 10.1016/j.genrep.2021.101036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Distinct clonal lineages and within-host diversification shape invasive Staphylococcus epidermidis populations. PLoS Pathog 2021; 17:e1009304. [PMID: 33544760 PMCID: PMC7891712 DOI: 10.1371/journal.ppat.1009304] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 02/18/2021] [Accepted: 01/11/2021] [Indexed: 12/15/2022] Open
Abstract
S. epidermidis is a substantial component of the human skin microbiota, but also one of the major causes of nosocomial infection in the context of implanted medical devices. We here aimed to advance the understanding of S. epidermidis genotypes and phenotypes conducive to infection establishment. Furthermore, we investigate the adaptation of individual clonal lines to the infection lifestyle based on the detailed analysis of individual S. epidermidis populations of 23 patients suffering from prosthetic joint infection. Analysis of invasive and colonizing S. epidermidis provided evidence that invasive S. epidermidis are characterized by infection-supporting phenotypes (e.g. increased biofilm formation, growth in nutrient poor media and antibiotic resistance), as well as specific genetic traits. The discriminating gene loci were almost exclusively assigned to the mobilome. Here, in addition to IS256 and SCCmec, chromosomally integrated phages was identified for the first time. These phenotypic and genotypic features were more likely present in isolates belonging to sequence type (ST) 2. By comparing seven patient-matched nasal and invasive S. epidermidis isolates belonging to identical genetic lineages, infection-associated phenotypic and genotypic changes were documented. Besides increased biofilm production, the invasive isolates were characterized by better growth in nutrient-poor media and reduced hemolysis. By examining several colonies grown in parallel from each infection, evidence for genetic within-host population heterogeneity was obtained. Importantly, subpopulations carrying IS insertions in agrC, mutations in the acetate kinase (AckA) and deletions in the SCCmec element emerged in several infections. In summary, these results shed light on the multifactorial processes of infection adaptation and demonstrate how S. epidermidis is able to flexibly repurpose and edit factors important for colonization to facilitate survival in hostile infection environments. S. epidermidis is a substantial component of the human skin microbiota, but also a major cause of nosocomial infections related to implanted medical devices. While phenotypic and genotypic determinants supporting invasion were identified, none appears to be necessary. By analysis of S. epidermidis from prosthetic joint infections, we here show that adaptive events are of importance during the transition from commensalism to infection. Adaptation to the infectious lifestyle is characterised by the development of intra-clonal heterogeneity, increased biofilm formation and enhanced growth in iron-free and nutrient-poor media, as well as reduced production of hemolysins. Importantly, during infection subpopulations emerge that carry mutations in a number of genes, most importantly the acetate kinase (ackA) and the β-subunit of the RNA polymerase (rpoB), have deleted larger chromosomal fragments (e.g. within the SCCmec element) or IS insertions in AgrC, a component of the master quorum sensing system in S. epidermidis. These results shed light on the multifactorial processes of infection adaptation and demonstrate how S. epidermidis is able to flexibly repurpose and edit factors important for colonization to facilitate survival under hostile infection conditions. While mobilome associated factors are important for S. epidermidis invasive potential, the species possesses a multi-layered and complex ability for adaptation to hostile environments, supporting the progression to chronic implant-associated infections.
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Månsson E, Bech Johannesen T, Nilsdotter-Augustinsson Å, Söderquist B, Stegger M. Comparative genomics of Staphylococcus epidermidis from prosthetic-joint infections and nares highlights genetic traits associated with antimicrobial resistance, not virulence. Microb Genom 2021; 7:000504. [PMID: 33439116 PMCID: PMC8208700 DOI: 10.1099/mgen.0.000504] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 12/15/2020] [Indexed: 12/24/2022] Open
Abstract
There is increased awareness of the worldwide spread of specific epidemic multidrug-resistant (MDR) lineages of the human commensal Staphylococcus epidermidis. Here, using bioinformatic analyses accounting for population structure, we determined genomic traits (genes, SNPs and k-mers) that distinguish S. epidermidis causing prosthetic-joint infections (PJIs) from commensal isolates from nares, by analysing whole-genome sequencing data from S. epidermidis from PJIs prospectively collected over 10 years in Sweden, and contemporary S. epidermidis from the nares of patients scheduled for arthroplasty surgery. Previously suggested virulence determinants and the presence of genes and mutations linked to antimicrobial resistance (AMR) were also investigated. Publicly available S. epidermidis sequences were used for international extrapolation and validation of findings. Our data show that S. epidermidis causing PJIs differed from nasal isolates not by virulence but by traits associated with resistance to compounds used in prevention of PJIs: β-lactams, aminoglycosides and chlorhexidine. Almost a quarter of the PJI isolates did not belong to any of the previously described major nosocomial lineages, but the AMR-related traits were also over-represented in these isolates, as well as in international S. epidermidis isolates originating from PJIs. Genes previously associated with virulence in S. epidermidis were over-represented in individual lineages, but failed to reach statistical significance when adjusted for population structure. Our findings suggest that the current strategies for prevention of PJIs select for nosocomial MDR S. epidermidis lineages that have arisen from horizontal gene transfer of AMR-related traits into multiple genetic backgrounds.
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Affiliation(s)
- Emeli Månsson
- Department of Laboratory Medicine, Clinical Microbiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Centre for Clinical Research, Hospital of Västmanland, Region Västmanland – Uppsala University, Västerås, Sweden
| | - Thor Bech Johannesen
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Åsa Nilsdotter-Augustinsson
- Department of Infectious Diseases, Linköping University, Norrköping, Sweden
- Department of Clinical and Experimental Medicine, Linköping University, Norrköping, Sweden
| | - Bo Söderquist
- Department of Laboratory Medicine, Clinical Microbiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Marc Stegger
- Department of Laboratory Medicine, Clinical Microbiology, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
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The staphylococcal exopolysaccharide PIA - Biosynthesis and role in biofilm formation, colonization, and infection. Comput Struct Biotechnol J 2020. [PMID: 33240473 DOI: 10.1016/jcsbj202010027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Exopolysaccharide is a key part of the extracellular matrix that contributes to important mechanisms of bacterial pathogenicity, most notably biofilm formation and immune evasion. In the human pathogens Staphylococcus aureus and S. epidermidis, as well as in many other staphylococcal species, the only exopolysaccharide is polysaccharide intercellular adhesin (PIA), a cationic, partially deacetylated homopolymer of N-acetylglucosamine, whose biosynthetic machinery is encoded in the ica locus. PIA production is strongly dependent on environmental conditions and controlled by many regulatory systems. PIA contributes significantly to staphylococcal biofilm formation and immune evasion mechanisms, such as resistance to antimicrobial peptides and ingestion and killing by phagocytes, and presence of the ica genes is associated with infectivity. Due to its role in pathogenesis, PIA has raised considerable interest as a potential vaccine component or target.
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20
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Nguyen HTT, Nguyen TH, Otto M. The staphylococcal exopolysaccharide PIA - Biosynthesis and role in biofilm formation, colonization, and infection. Comput Struct Biotechnol J 2020; 18:3324-3334. [PMID: 33240473 PMCID: PMC7674160 DOI: 10.1016/j.csbj.2020.10.027] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/23/2020] [Accepted: 10/25/2020] [Indexed: 12/20/2022] Open
Abstract
PIA is a key extracellular matrix component in staphylococci and other bacteria. PIA is a cationic, partially deacetylated N-acetylglucosamine polymer. PIA has a major role in bacterial biofilms and biofilm-associated infection.
Exopolysaccharide is a key part of the extracellular matrix that contributes to important mechanisms of bacterial pathogenicity, most notably biofilm formation and immune evasion. In the human pathogens Staphylococcus aureus and S. epidermidis, as well as in many other staphylococcal species, the only exopolysaccharide is polysaccharide intercellular adhesin (PIA), a cationic, partially deacetylated homopolymer of N-acetylglucosamine, whose biosynthetic machinery is encoded in the ica locus. PIA production is strongly dependent on environmental conditions and controlled by many regulatory systems. PIA contributes significantly to staphylococcal biofilm formation and immune evasion mechanisms, such as resistance to antimicrobial peptides and ingestion and killing by phagocytes, and presence of the ica genes is associated with infectivity. Due to its role in pathogenesis, PIA has raised considerable interest as a potential vaccine component or target.
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Affiliation(s)
- Hoai T T Nguyen
- Pathogen Molecular Genetics Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, U.S. National Institutes of Health, 50 South Drive, Bethesda 20814, MD, USA.,School of Biotechnology, International University, Vietnam National University of Ho Chi Minh City, Khu Pho 6, Thu Duc, Ho Chi Minh City, Viet Nam
| | - Thuan H Nguyen
- Pathogen Molecular Genetics Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, U.S. National Institutes of Health, 50 South Drive, Bethesda 20814, MD, USA
| | - Michael Otto
- Pathogen Molecular Genetics Section, Laboratory of Bacteriology, National Institute of Allergy and Infectious Diseases, U.S. National Institutes of Health, 50 South Drive, Bethesda 20814, MD, USA
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Nasaj M, Saeidi Z, Tahmasebi H, Dehbashi S, Arabestani MR. Prevalence and distribution of resistance and enterotoxins/enterotoxin-like genes in different clinical isolates of coagulase-negative Staphylococcus. Eur J Med Res 2020; 25:48. [PMID: 33046122 PMCID: PMC7552519 DOI: 10.1186/s40001-020-00447-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 09/25/2020] [Indexed: 01/19/2023] Open
Abstract
Background Coagulase-negative staphylococcus (CoNS) is considered to be the major reservoirs for genes facilitating the evolution of S. aureus as a successful pathogen. The present study aimed to determine the occurrence of genes conferring resistance to fluoroquinolone, determining of the prevalence of insertion sequence elements IS256, IS257 and different superantigens (SAgs) among CoNS isolates obtained from various clinical sources. Materials and methods The current study conducted on a total of the 91 CoNS species recovered from clinical specimens in Hamadan hospitals in western Iran in 2017–2019. The antimicrobial susceptibility testing was performed using disk diffusion method and the presence of the IS256 and IS257, genes conferring resistance to fluoroquinolone and enterotoxins/enterotoxin-like encoding genes were investigated by polymerase chain reaction (PCR) method. Results Among genes encoding classic enterotoxins, sec was the most frequent which was carried by 48.4% of the 91 isolates, followed by seb in 27.5% of the isolates. None of the CoNS isolates was found to be positive to enterotoxin-like encoding genes. In 11(12%) of all isolates that were phenotypically resistant to levofloxacin, 9 isolates (81.8%) were positive for gyrB, 8 isolates (72.7%) were positive for gyrA, 8 isolates (72.7%) harbored grlB and 7 isolates (63.6%) were found to carry grlA. The IS256 and IS257 were identified in 31.8% and 74.7% of the isolates, respectively. The results of statistical analysis showed a significant association between the occurrence of staphylococcal enterotoxins (SEs) encoding genes and antimicrobial resistance. Conclusion Antimicrobial resistant determinants and SEs are co-present in clinical CoNS isolates that confer selective advantage for colonization and survival in hospital settings. The coexistence of insertion elements and antibiotic resistance indicate their role in pathogenesis and infectious diseases.
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Affiliation(s)
- Mona Nasaj
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Shahid Fahmideh Street, Park Mardome, Hamadan, IR, Iran
| | - Zahra Saeidi
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Shahid Fahmideh Street, Park Mardome, Hamadan, IR, Iran
| | - Hamed Tahmasebi
- School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Sanaz Dehbashi
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Shahid Fahmideh Street, Park Mardome, Hamadan, IR, Iran
| | - Mohammad Reza Arabestani
- Department of Microbiology, Faculty of Medicine, Hamadan University of Medical Sciences, Shahid Fahmideh Street, Park Mardome, Hamadan, IR, Iran. .,Nutrition Research Center, Hamadan University of Medical Sciences, Hamadan, IR, Iran.
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Tang B, Gong T, Cui Y, Wang L, He C, Lu M, Chen J, Jing M, Zhang A, Li Y. Characteristics of oral methicillin-resistant Staphylococcus epidermidis isolated from dental plaque. Int J Oral Sci 2020; 12:15. [PMID: 32385260 PMCID: PMC7210960 DOI: 10.1038/s41368-020-0079-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/29/2020] [Accepted: 03/30/2020] [Indexed: 02/05/2023] Open
Abstract
The oral microbial community is widely regarded as a latent reservoir of antibiotic resistance genes. This study assessed the molecular epidemiology, susceptibility profile, and resistance mechanisms of 35 methicillin-resistant Staphylococcus epidermidis (MRSE) strains isolated from the dental plaque of a healthy human population. Broth microdilution minimum inhibitory concentrations (MICs) revealed that all the isolates were nonsusceptible to oxacillin and penicillin G. Most of them were also resistant to trimethoprim (65.7%) and erythromycin (54.3%). The resistance to multiple antibiotics was found to be largely due to the acquisition of plasmid-borne genes. The mecA and dfrA genes were found in all the isolates, mostly dfrG (80%), aacA-aphD (20%), aadD (28.6%), aphA3 (22.9%), msrA (5.7%), and the ermC gene (14.3%). Classical mutational mechanisms found in these isolates were mainly efflux pumps such as qacA (31.4%), qacC (25.7%), tetK (17.1%), and norA (8.6%). Multilocus sequence type analysis revealed that sequence type 59 (ST59) strains comprised 71.43% of the typed isolates, and the eBURST algorithm clustered STs into the clonal complex 2-II(CC2-II). The staphyloccoccal cassette chromosome mec (SCCmec) type results showed that 25 (71.43%) were assigned to type IV. Moreover, 88.66% of the isolates were found to harbor six or more biofilm-associated genes. The aap, atlE, embp, sdrF, and IS256 genes were detected in all 35 isolates. This research demonstrates that biofilm-positive multiple-antibiotic-resistant ST59-SCCmec IV S. epidermidis strains exist in the dental plaque of healthy people and may be a potential risk for the transmission of antibiotic resistance.
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Affiliation(s)
- Boyu Tang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Tao Gong
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yujia Cui
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Lingyun Wang
- Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Chao He
- Department of Laboratory Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Miao Lu
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Jiamin Chen
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Meiling Jing
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Anqi Zhang
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Yuqing Li
- State Key Laboratory of Oral Diseases & National Clinical Research Center for Oral Diseases & West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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Hosseini M, Shapouri Moghaddam A, Derakhshan S, Hashemipour SMA, Hadadi-Fishani M, Pirouzi A, Khaledi A. Correlation Between Biofilm Formation and Antibiotic Resistance in MRSA and MSSA Isolated from Clinical Samples in Iran: A Systematic Review and Meta-Analysis. Microb Drug Resist 2020; 26:1071-1080. [PMID: 32159447 DOI: 10.1089/mdr.2020.0001] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Objectives: This study aimed at reviewing the correlation between biofilm formation and antibiotic resistance in methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) isolates. Materials and Methods: This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. The literature search was conducted in PubMed, Web of Science (ISI), and Scopus databases. Combinations of Mesh terms such as "biofilms" OR "biofilm formation," AND "Drug Resistance" OR "Antimicrobial Drug Resistance" OR "Antibiotic Resistance" AND "Staphylococcus aureus" OR "Methicillin-resistant Staphylococcus aureus" or "MRSA" AND "Methicillin-sensitive Staphylococcus aureus" OR "MSSA" AND "biofilm-related genes" AND "Prevalence" AND "Iran" were searched. Two reviewers independently searched the databases. Analyses were performed in Comprehensive Meta-Analysis software. The random-effects model was used to obtain the combined prevalence with a 95% confidence interval (CI). Results: The combined prevalence of MRSA retrieved from Iranian clinical samples was 48.3% (95% CI: 40.8-55.9). The pooled rate of biofilm formation in MRSA strains was reported as 80.9% (95% CI: 67.8-89.4). Overall, 52.9%, 45.3%, and 22.5% of MRSA isolates were strong, moderate, and weak biofilm producers, respectively. The highest frequency of biofilm-related genes was observed for icaD gene (67.7%) followed by clfA gene with a frequency of 64.7%. Among seven studies that addressed the relationship between biofilm formation and antibiotic resistance, six reported positive associations. Conclusions: Regarding the MRSA strains, they had a significantly higher ability of biofilm formation than MSSA strains; therefore, preventive measures against infections caused by them are required.
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Affiliation(s)
| | - Abbas Shapouri Moghaddam
- BuAli Research Institute, Department of Immunology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Solmaz Derakhshan
- Department of Internal Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
| | | | - Mehdi Hadadi-Fishani
- Department of Medical Bacteriology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Aliyar Pirouzi
- Cellular and Molecular Gerash Research Center, Gerash University of Medical Sciences, Gerash, Iran
| | - Azad Khaledi
- Infectious Diseases Research Center, Department of Microbiology and Immunology, Faculty of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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24
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Quebrachitol from Rhizophora mucronata inhibits biofilm formation and virulence production in Staphylococcus epidermidis by impairment of initial attachment and intercellular adhesion. Arch Microbiol 2020; 202:1327-1340. [DOI: 10.1007/s00203-020-01844-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/19/2020] [Accepted: 02/21/2020] [Indexed: 01/05/2023]
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25
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Cabrera-Contreras R, Santamaría RI, Bustos P, Martínez-Flores I, Meléndez-Herrada E, Morelos-Ramírez R, Barbosa-Amezcua M, González-Covarrubias V, Silva-Herzog E, Soberón X, González V. Genomic diversity of prevalent Staphylococcus epidermidis multidrug-resistant strains isolated from a Children's Hospital in México City in an eight-years survey. PeerJ 2019; 7:e8068. [PMID: 31768302 PMCID: PMC6874853 DOI: 10.7717/peerj.8068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/20/2019] [Indexed: 11/20/2022] Open
Abstract
Staphylococcus epidermidis is a human commensal and pathogen worldwide distributed. In this work, we surveyed for multi-resistant S. epidermidis strains in eight years at a children's health-care unit in México City. Multidrug-resistant S. epidermidis were present in all years of the study, including resistance to methicillin, beta-lactams, fluoroquinolones, and macrolides. To understand the genetic basis of antibiotic resistance and its association with virulence and gene exchange, we sequenced the genomes of 17 S. epidermidis isolates. Whole-genome nucleotide identities between all the pairs of S. epidermidis strains were about 97% to 99%. We inferred a clonal structure and eight Multilocus Sequence Types (MLSTs) in the S. epidermidis sequenced collection. The profile of virulence includes genes involved in biofilm formation and phenol-soluble modulins (PSMs). Half of the S. epidermidis analyzed lacked the ica operon for biofilm formation. Likely, they are commensal S. epidermidis strains but multi-antibiotic resistant. Uneven distribution of insertion sequences, phages, and CRISPR-Cas immunity phage systems suggest frequent horizontal gene transfer. Rates of recombination between S. epidermidis strains were more prevalent than the mutation rate and affected the whole genome. Therefore, the multidrug resistance, independently of the pathogenic traits, might explain the persistence of specific highly adapted S. epidermidis clonal lineages in nosocomial settings.
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Affiliation(s)
- Roberto Cabrera-Contreras
- Laboratorio de Patogenicidad Bacteriana, Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Rosa I Santamaría
- Centro de Ciencias Genómicas, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, México
| | - Patricia Bustos
- Centro de Ciencias Genómicas, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, México
| | - Irma Martínez-Flores
- Centro de Ciencias Genómicas, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, México
| | - Enrique Meléndez-Herrada
- Laboratorio de Patogenicidad Bacteriana, Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México
| | - Rubén Morelos-Ramírez
- Laboratorio de Patogenicidad Bacteriana, Departamento de Salud Pública, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, México
| | | | | | | | - Xavier Soberón
- Instituto Nacional de Medicina Genómica, Ciudad de México, México
| | - Víctor González
- Centro de Ciencias Genómicas, Universidad Nacional Autónoma de México, Cuernavaca, Morelos, México
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26
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Pain M, Hjerde E, Klingenberg C, Cavanagh JP. Comparative Genomic Analysis of Staphylococcus haemolyticus Reveals Key to Hospital Adaptation and Pathogenicity. Front Microbiol 2019; 10:2096. [PMID: 31552006 PMCID: PMC6747052 DOI: 10.3389/fmicb.2019.02096] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/26/2019] [Indexed: 12/17/2022] Open
Abstract
Staphylococcus haemolyticus is a skin commensal gaining increased attention as an emerging pathogen of nosocomial infections. However, knowledge about the transition from a commensal to an invasive lifestyle remains sparse and there is a paucity of studies comparing pathogenicity traits between commensal and clinical isolates. In this study, we used a pan-genomic approach to identify factors important for infection and hospital adaptation by exploring the genomic variability of 123 clinical isolates and 46 commensal S. haemolyticus isolates. Phylogenetic reconstruction grouped the 169 isolates into six clades with a distinct distribution of clinical and commensal isolates in the different clades. Phenotypically, multi-drug antibiotic resistance was detected in 108/123 (88%) of the clinical isolates and 5/46 (11%) of the commensal isolates (p < 0.05). In the clinical isolates, we commonly identified a homolog of the serine-rich repeat glycoproteins sraP. Additionally, three novel capsular polysaccharide operons were detected, with a potential role in S. haemolyticus virulence. Clinical S. haemolyticus isolates showed specific signatures associated with successful hospital adaption. Biofilm forming S. haemolyticus isolates that are resistant to oxacillin (mecA) and aminoglycosides (aacA-aphD) are most likely invasive isolates whereas absence of these traits strongly indicates a commensal isolate. We conclude that our data show a clear segregation of isolates of commensal origin, and specific genetic signatures distinguishing the clinical isolates from the commensal isolates. The widespread use of antimicrobial agents has probably promoted the development of successful hospital adapted clones of S. haemolyticus clones through acquisition of mobile genetic elements or beneficial point mutations and rearrangements in surface associated genes.
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Affiliation(s)
- Maria Pain
- Pediatric Infections Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Erik Hjerde
- Department of Chemistry, Norstruct, UiT The Arcic University of Norway, Tromsø, Norway
| | - Claus Klingenberg
- Pediatric Infections Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Jorunn Pauline Cavanagh
- Pediatric Infections Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
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27
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Arciola CR, Campoccia D, Montanaro L. Implant infections: adhesion, biofilm formation and immune evasion. Nat Rev Microbiol 2019; 16:397-409. [PMID: 29720707 DOI: 10.1038/s41579-018-0019-y] [Citation(s) in RCA: 1037] [Impact Index Per Article: 207.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Medical device-associated infections account for a large proportion of hospital-acquired infections. A variety of opportunistic pathogens can cause implant infections, depending on the type of the implant and on the anatomical site of implantation. The success of these versatile pathogens depends on rapid adhesion to virtually all biomaterial surfaces and survival in the hostile host environment. Biofilm formation on implant surfaces shelters the bacteria and encourages persistence of infection. Furthermore, implant-infecting bacteria can elude innate and adaptive host defences as well as biocides and antibiotic chemotherapies. In this Review, we explore the fundamental pathogenic mechanisms underlying implant infections, highlighting orthopaedic implants and Staphylococcus aureus as a prime example, and discuss innovative targets for preventive and therapeutic strategies.
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Affiliation(s)
- Carla Renata Arciola
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy. .,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy.
| | - Davide Campoccia
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy
| | - Lucio Montanaro
- Research Unit on Implant Infections, Rizzoli Orthopaedic Institute, Bologna, Italy.,Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
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28
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Espadinha D, Sobral RG, Mendes CI, Méric G, Sheppard SK, Carriço JA, de Lencastre H, Miragaia M. Distinct Phenotypic and Genomic Signatures Underlie Contrasting Pathogenic Potential of Staphylococcus epidermidis Clonal Lineages. Front Microbiol 2019; 10:1971. [PMID: 31507574 PMCID: PMC6719527 DOI: 10.3389/fmicb.2019.01971] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 08/12/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Staphylococcus epidermidis is a common skin commensal that has emerged as a pathogen in hospitals, mainly related to medical devices-associated infections. Noteworthy, infection rates by S. epidermidis have the tendency to rise steeply in next decades together with medical devices use and immunocompromized population growth. Staphylococcus epidermidis population structure includes two major clonal lineages (A/C and B) that present contrasting pathogenic potentials. To address this distinction and explore the basis of increased pathogenicity of A/C lineage, we performed a detailed comparative analysis using phylogenetic and integrated pangenome-wide-association study (panGWAS) approaches and compared the lineages's phenotypes in in vitro conditions mimicking carriage and infection. Results: Each S. epidermidis lineage had distinct phenotypic signatures in skin and infection conditions and differed in genomic content. Combination of phenotypic and genotypic data revealed that both lineages were well adapted to skin environmental cues. However, they appear to occupy different skin niches, perform distinct biological functions in the skin and use different mechanisms to complete the same function: lineage B strains showed evidence of specialization to survival in microaerobic and lipid rich environment, characteristic of hair follicle and sebaceous glands; lineage A/C strains showed evidence for adaption to diverse osmotic and pH conditions, potentially allowing them to occupy a broader and more superficial skin niche. In infection conditions, A/C strains had an advantage, having the potential to bind blood-associated host matrix proteins, form biofilms at blood pH, resist antibiotics and macrophage acidity and to produce proteases. These features were observed to be rare in the lineage B strains. PanGWAS analysis produced a catalog of putative S. epidermidis virulence factors and identified an epidemiological molecular marker for the more pathogenic lineage. Conclusion: The prevalence of A/C lineage in infection is probably related to a higher metabolic and genomic versatility that allows rapid adaptation during transition from a commensal to a pathogenic lifestyle. The putative virulence and phenotypic factors associated to A/C lineage constitute a reliable framework for future studies on S. epidermidis pathogenesis and the finding of an epidemiological marker for the more pathogenic lineage is an asset for the management of S. epidermidis infections.
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Affiliation(s)
- Diana Espadinha
- Laboratory of Bacterial Evolution and Molecular Epidemiology, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Oeiras, Portugal
- Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Oeiras, Portugal
| | - Rita G. Sobral
- Laboratory of Molecular Microbiology of Bacterial Pathogens, UCIBIO/REQUIMTE, Faculdade de Ciências e Tecnologia, Universidade Nova de Lisboa, Costa de Caparica, Portugal
| | - Catarina Inês Mendes
- Molecular Microbiology and Infection Unit, Instituto de Medicina Molecular, Faculdade de Medicina de Lisboa, Universidade de Lisboa, Lisbon, Portugal
| | - Guillaume Méric
- The Milner Centre for Evolution, University of Bath, Bath, United Kingdom
| | - Samuel K. Sheppard
- The Milner Centre for Evolution, University of Bath, Bath, United Kingdom
- MRC CLIMB Consortium, Bath, United Kingdom
| | - João A. Carriço
- Molecular Microbiology and Infection Unit, Instituto de Medicina Molecular, Faculdade de Medicina de Lisboa, Universidade de Lisboa, Lisbon, Portugal
| | - Hermínia de Lencastre
- Laboratory of Molecular Genetics, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Oeiras, Portugal
- Laboratory of Microbiology and Infectious Diseases, The Rockefeller University, New York, NY, United States
| | - Maria Miragaia
- Laboratory of Bacterial Evolution and Molecular Epidemiology, Instituto de Tecnologia Química e Biológica António Xavier, Universidade Nova de Lisboa, Oeiras, Portugal
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29
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Chang SC, Lin LC, Ge MC, Liu TP, Lu JJ. Characterization of a novel, type II staphylococcal cassette chromosome mec element from an endemic oxacillin-resistant Staphylococcus lugdunensis clone in a hospital setting. J Antimicrob Chemother 2019; 74:2162-2165. [PMID: 31106369 DOI: 10.1093/jac/dkz189] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 03/06/2019] [Accepted: 04/02/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Staphylococcus lugdunensis is a significant pathogen that causes community-acquired and nosocomial infections. The high prevalence of oxacillin-resistant S. lugdunensis (ORSL) is of major concern. Resistance to β-lactams is caused by acquisition of the staphylococcal cassette chromosome mec (SCCmec) element. The cassette is highly diverse, both structurally and genetically, among CoNS. Isolates carrying SCCmec II-ST6 are the major persistent clones in hospitals. OBJECTIVES To investigate the structure and evolutionary origin of a novel type II SCCmec element in an endemic ST6 S. lugdunensis clone. METHODS The structure of the SCCmec II element carried by ST6 strain CGMH-SL118 was determined by WGS and compared with those reported previously. RESULTS A novel 39 kb SCCmec element, SCCmecCGMH-SL118, with a unique mosaic structure comprising 41 ORFs integrated into the 3' end of the rlmH gene, was observed. Some regions of SCCmecCGMH-SL118 were homologous to SCCmec IIa of the prototype MRSA strain N315. The structure of SCCmecCGMH-SL118 was similar to that of SCCmec IIb of the MRSA strain, JCSC3063, mainly lacking the aminoglycoside resistance determinant pUB110 in the J3 region but containing the insertion sequence IS256 in the J2 region. Notably, SCCmecCGMH-SL118 deletions in the J1 region compared with SCCmec types IIa and IIb, and a high homology to SCCmec elements of Staphylococcus aureus JCSC4610 and Staphylococcus haemolyticus strain 621 were found. CONCLUSIONS The genetic diversity of the type II SCCmec element in ORSL suggests that CoNS is a potential reservoir for interspecies transfer of SCCmec to S. aureus in hospitals.
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Affiliation(s)
- Shih-Cheng Chang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan
| | - Lee-Chung Lin
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Mao-Cheng Ge
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsui-Ping Liu
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jang-Jih Lu
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Taoyuan, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
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30
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Guo Y, Ding Y, Liu L, Shen X, Hao Z, Duan J, Jin Y, Chen Z, Yu F. Antimicrobial susceptibility, virulence determinants profiles and molecular characteristics of Staphylococcus epidermidis isolates in Wenzhou, eastern China. BMC Microbiol 2019; 19:157. [PMID: 31288755 PMCID: PMC6617921 DOI: 10.1186/s12866-019-1523-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 06/20/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Staphylococcus epidermidis has emerged as an often encountered pathogen responsible for hospital-acquired infections. The aim of present study is to investigate the microbiological characteristic of S. epidermidis isolates isolated from sterile specimens and skin in a Chinese tertiary hospital. METHODS A total of 223 non-duplicate S. epidermidis were collected from various sterile specimens of inpatients among 10 years in Wenzhou, China. 106 S. epidermidis obtained from the skin (urethral orifices) of healthy volunteers. All isolates were tested for antimicrobial susceptibility. PCR was used to detect the virulence- and resistance-associated genes and 7 housekeeping genes to determine the sequence types (STs) of selected isolates. RESULTS The resistance rates to antimicrobials tested except linezolid and vancomycin and the prevalence of methicillin-resistant S. epidermidis (MRSE) of S. epidermidis clinical isolates were significantly higher than those among colonized isolates (P < 0.05). The positive rates of virulence-associated genes including aap, sesI, ACME-arcA, IS256, bhp, altE, aae and gehD for S. epidermidis clinical isolates were significantly higher than those for colonized isolate (P < 0.05). A total of 60 STs including 28 from clinical isolates and 32 from colonized isolates were identified by MLST. A novel, rarely encountered clone, ST466, was found to be the second prevalent clone among clinical isolates. The great majority of the S. epidermidis isolates tested (73.86%) belonged to clone complex 2 (CC2). Compared with ST2, ST130, ST20 and ST59 clones, ST466 clone had the highest resistance rate to tetracycline (50.00%), the second highest prevalence of ACME-arcA (65.00%), bhp (30.00%) and qacA/B (65.00%), very low prevalence of carriage of icaA (0.00%) and biofilm formation (0.00%), the lack of sesI and high prevalence of aap, altE and aae (> 90%), which was similar to the characteristics of ST59 clone with one locus difference from ST466. ST466 clone competence with Staphylococcus aureus was relatively stronger, relative to ST2, ST20, ST130 and ST59 clones. CONCLUSION Taken together, a high-level of genetic diversity was found between clinical and colonized S. epidermidis isolates. A novel ST466 clone with distinct and similar characteristics relative to other prevalent clones, emerging as a prevalent clone in China, should be of major concern.
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Affiliation(s)
- Yinjuan Guo
- Department of Laboratory Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, 200082, China
| | - Yu Ding
- Department of Laboratory Medicine, Hunan Provincial People's Hospital, Changsha, 410000, China
| | - Li Liu
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Xiaofei Shen
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Zhihao Hao
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Jingjing Duan
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Ye Jin
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Zengqiang Chen
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Fangyou Yu
- Department of Laboratory Medicine, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China.
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31
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Dengler Haunreiter V, Boumasmoud M, Häffner N, Wipfli D, Leimer N, Rachmühl C, Kühnert D, Achermann Y, Zbinden R, Benussi S, Vulin C, Zinkernagel AS. In-host evolution of Staphylococcus epidermidis in a pacemaker-associated endocarditis resulting in increased antibiotic tolerance. Nat Commun 2019; 10:1149. [PMID: 30850614 PMCID: PMC6408453 DOI: 10.1038/s41467-019-09053-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 02/13/2019] [Indexed: 02/05/2023] Open
Abstract
Treatment failure in biofilm-associated bacterial infections is an important healthcare issue. In vitro studies and mouse models suggest that bacteria enter a slow-growing/non-growing state that results in transient tolerance to antibiotics in the absence of a specific resistance mechanism. However, little clinical confirmation of antibiotic tolerant bacteria in patients exists. In this study we investigate a Staphylococcus epidermidis pacemaker-associated endocarditis, in a patient who developed a break-through bacteremia despite taking antibiotics to which the S. epidermidis isolate is fully susceptible in vitro. Characterization of the clinical S. epidermidis isolates reveals in-host evolution over the 16-week infection period, resulting in increased antibiotic tolerance of the entire population due to a prolonged lag time until growth resumption and a reduced growth rate. Furthermore, we observe adaptation towards an increased biofilm formation capacity and genetic diversification of the S. epidermidis isolates within the patient.
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Affiliation(s)
- Vanina Dengler Haunreiter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Mathilde Boumasmoud
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Nicola Häffner
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Dennis Wipfli
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Nadja Leimer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
- Antimicrobial Discovery Center, Department of Biology, Northeastern University, 02115, Boston, MA, USA
| | - Carole Rachmühl
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
- Institute of Food, Nutrition and Health, ETH Zurich, 8092, Zurich, Switzerland
| | - Denise Kühnert
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
- Max Planck Institute for the Science of Human History, 07745, Jena, Germany
| | - Yvonne Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Reinhard Zbinden
- Institute of Medical Microbiology, University of Zurich, 8006, Zurich, Switzerland
| | - Stefano Benussi
- Department of Cardiac Surgery, University Heart Center, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland
| | - Clement Vulin
- Institute of Biogeochemistry and Pollutant Dynamics, ETH Zurich, 8092, Zurich, Switzerland
- Department of Environmental Microbiology, Eawag, 8600, Dübendorf, Switzerland
| | - Annelies S Zinkernagel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, 8091, Zurich, Switzerland.
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32
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Evaluation of Antibacterial Activity of Zataria multiflora Against the Expression of icaADB and aap Gene and Biofilm Formation in Staphylococcus epidermidis. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2019. [DOI: 10.5812/archcid.65321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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33
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Ahmed W, Zhai Z, Gao C. Adaptive antibacterial biomaterial surfaces and their applications. Mater Today Bio 2019; 2:100017. [PMID: 32159147 PMCID: PMC7061676 DOI: 10.1016/j.mtbio.2019.100017] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/14/2019] [Accepted: 06/18/2019] [Indexed: 12/20/2022] Open
Abstract
Bacterial infections on the implant surface may eventually lead to biofilm formation and thus threaten the use of implants in body. Despite efficient host immune system, the implant surface can be rapidly occupied by bacteria, resulting in infection persistence, implant failure, and even death of the patients. It is difficult to cope with these problems because bacteria exhibit complex adhesion mechanisms to the implants that vary according to bacterial strains. Different biomaterial coatings have been produced to release antibiotics to kill bacteria. However, antibiotic resistance occurs very frequently. Stimuli-responsive biomaterials have gained much attention in recent years but are not effective enough in killing the pathogens because of the complex mechanisms in bacteria. This review is focused on the development of highly efficient and specifically targeted biomaterials that release the antimicrobial agents or respond to bacteria on demands in body. The mechanisms of bacterial adhesion, biofilm formation, and antibiotic resistance are discussed, and the released substances accounting for implant infection are described. Strategies that have been used in past for the eradication of bacterial infections are also discussed. Different types of stimuli can be triggered only upon the existence of bacteria, leading to the release of antibacterial molecules that in turn kill the bacteria. In particular, the toxin-triggered, pH-responsive, and dual stimulus-responsive adaptive antibacterial biomaterials are introduced. Finally, the state of the art in fabrication of dual responsive antibacterial biomaterials and tissue integration in medical implants is discussed.
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Affiliation(s)
| | | | - C. Gao
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, 310027, China
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34
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Chajęcka-Wierzchowska W, Zadernowska A, Gajewska J. S. epidermidis strains from artisanal cheese made from unpasteurized milk in Poland - Genetic characterization of antimicrobial resistance and virulence determinants. Int J Food Microbiol 2019; 294:55-59. [PMID: 30771666 DOI: 10.1016/j.ijfoodmicro.2019.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 01/24/2019] [Accepted: 02/06/2019] [Indexed: 12/21/2022]
Abstract
In Poland artisanal cheese production is an important local economic activity. Artisanal cheese is usually produced using raw cow's milk, animal rennet and salt, without the addition of starter cultures. Coagulase negative staphylococci (CoNS) are often present in artisanal cheeses. Pathogenic potential of some CoNS species, especially S. epidermidis, suggests that they could correspond to emerging pathogens. The identified risk factors correspond to virulence, antibiotic resistance and biofilm formation. Therefore, we aimed to characterize S. epidermidis isolated along the artisanal raw milk production chain. Seventy artisanal cheeses samples from unpasteurized cow milk purchased in Podlasie and Warmia and Mazury region in Poland, were included in this study. A total of 26 S. epidermidis isolates were obtained. Most of them were antimicrobial resistant, such as to penicillin (84,6%), clindamycin (46,2%), tetracycline (42,3%), erythromycin (42,3%) and cefoxitin (26,9%). Only one isolate was susceptible to all antibiotics used in the study. All methicillin resistant S. epidermidis strains (26,9%) harbored mecA gene. Isolates, phenotypic resistant to tetracycline, harbored at least one tetracycline resistance determinant on which tet(M) was most frequent. Moreover, all tetracycline resistant strains harbored Tn916-Tn1545-like integrase family gene. In the erythromycin resistant isolates, the macrolide resistance genes ermC, ermB or msrA/B were present. Seven strains demonstrated a strong ability to form biofilm and moderate and weak biofilm was demonstrated by 4 strains, whereas 11 of S. epidermidis isolates were found to be unable to form a biofilm. All strains producing strong biofilm harbored the icaD gene which occurred independently or in combination with the icaA. Insertion element IS256, was identified in 15,4% of S. epidermidis strains, all of which were multidrug resistant. Arginine Catabolic Mobile Element (ACME) was identified in 13 of the 26 examined strains (50%). Most common was ACME type I (26,9%), followed by type III (15,4%) and type II (7,7%). Our data indicate that S. epidermidis are widely present in artisanal cheeses from raw whole cow milk in Poland. Many isolated strains containing more virulence factors and antibiotic resistant and carry mobile genetic elements which represent a potential source of resistance transmission to bacteria in humans.
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Affiliation(s)
- Wioleta Chajęcka-Wierzchowska
- Chair of Industrial and Food Microbiology, Faculty of Food Science, University of Warmia and Mazury, Plac Cieszyński 1, 10-726 Olsztyn, Poland.
| | - Anna Zadernowska
- Chair of Industrial and Food Microbiology, Faculty of Food Science, University of Warmia and Mazury, Plac Cieszyński 1, 10-726 Olsztyn, Poland
| | - Joanna Gajewska
- Chair of Industrial and Food Microbiology, Faculty of Food Science, University of Warmia and Mazury, Plac Cieszyński 1, 10-726 Olsztyn, Poland
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Heilmann C, Ziebuhr W, Becker K. Are coagulase-negative staphylococci virulent? Clin Microbiol Infect 2018; 25:1071-1080. [PMID: 30502487 DOI: 10.1016/j.cmi.2018.11.012] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/06/2018] [Accepted: 11/11/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Progress in contemporary medicine is associated with an increasing number of immunocompromised individuals. In this vulnerable group, the underlying disease together with long-term hospitalization and the use of medical devices facilitate infections by opportunistic pathogens, of which coagulase-negative staphylococci (CoNS) represent a prime example. OBJECTIVES The diversity of CoNS with species- and strain-specific differences concerning virulence and clinical impact is highlighted. A focus is on the ability of CoNS to generate biofilms on biotic and abiotic surfaces, which enables skin and mucosa colonization as well as establishment of CoNS on indwelling foreign bodies. SOURCES Literature about the virulence of CoNS listed in PubMed was reviewed. CONTENT Most catheter-related and prosthetic joint infections as well as most other device-related infections are caused by CoNS, specifically by Staphylococcus epidermidis and Staphylococcus haemolyticus. A common theme of CoNS infections is a high antibiotic resistance rate, which often limits treatment options and contributes to the significant health and economic burden imposed by CoNS. IMPLICATIONS Breaching the skin barrier along with the insertion of medical devices offers CoNS opportunities to gain access to host tissues and to sustain there by forming biofilms on foreign body surfaces. Biofilms represent the perfect niche to protect CoNS from both the host immune response and the action of antibiotics. Their particular lifestyle, combined with conditions that facilitate host colonization and infection, has led to the growing impact of CoNS as pathogens. Moreover, CoNS may serve as hidden reservoirs for antibiotic resistance and virulence traits.
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Affiliation(s)
- C Heilmann
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany
| | - W Ziebuhr
- Institute for Molecular Infection Biology, University of Würzburg, Würzburg, Germany
| | - K Becker
- Institute of Medical Microbiology, University Hospital Münster, Münster, Germany.
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Molecular Characteristics of Biofilm-Producing Methicillin-Resistant Staphylococcus epidermidis Isolates Causing Urinary Tract Infections. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2018. [DOI: 10.5812/archcid.61704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Babakhani S, Oloomi M. Transposons: the agents of antibiotic resistance in bacteria. J Basic Microbiol 2018; 58:905-917. [PMID: 30113080 DOI: 10.1002/jobm.201800204] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/08/2018] [Accepted: 07/31/2018] [Indexed: 12/29/2022]
Abstract
Transposons are a group of mobile genetic elements that are defined as a DNA sequence. Transposons can jump into different places of the genome; for this reason, they are called jumping genes. However, some transposons are always kept at the insertion site in the genome. Most transposons are inactivated and as a result, cannot move. Transposons are divided into two main groups: retrotransposons (class І) and DNA transposons (class ІІ). Retrotransposons are often found in eukaryotes. DNA transposons can be found in both eukaryotes and prokaryotes. The bacterial transposons belong to the DNA transposons and the Tn family, which are usually the carrier of additional genes for antibiotic resistance. Transposons can transfer from a plasmid to other plasmids or from a DNA chromosome to plasmid and vice versa that cause the transmission of antibiotic resistance genes in bacteria. The treatment of bacterial infectious diseases is difficult because of existing antibiotic resistance that part of this antibiotic resistance is caused by transposons. Bacterial infectious diseases are responsible for the increasing rise in world mortality rate. In this review, transposons and their roles have been studied in bacterial antibiotic resistance, in detail.
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Affiliation(s)
- Sajad Babakhani
- Department of Microbiology, North Tehran Branch, Islamic Azad University, Tehran, Iran
| | - Mana Oloomi
- Department of Molecular Biology, Pasteur Institute of Iran, Tehran, Iran
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Sharma S, Chaudhry V, Kumar S, Patil PB. Phylogenomic Based Comparative Studies on Indian and American Commensal Staphylococcus epidermidis Isolates. Front Microbiol 2018. [PMID: 29535698 PMCID: PMC5835047 DOI: 10.3389/fmicb.2018.00333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Staphylococcus epidermidis is a prominent commensal member of human skin microbiome and an emerging nosocomial pathogen, making it a good model organism to provide genomic insights, correlating its transition between commensalism and pathogenicity. While there are numerous studies to understand differences in commensal and pathogenic isolates, systematic efforts to understand variation and evolutionary pattern in multiple strains isolated from healthy individuals are lacking. In the present study, using whole genome sequencing and analysis, we report presence of diverse lineages of S. epidermidis isolates in healthy individuals from two geographically diverse locations of India and North America. Further, there is distinct pattern in the distribution of candidate gene(s) for pathogenicity and commensalism. The pattern is not only reflected in lineages but is also based on geographic origin of the isolates. This is evident by the fact that North American isolates under this study are more genomically dynamic and harbor pathogenicity markers in higher frequency. On the other hand, isolates of Indian origin are less genomically dynamic, harbor less pathogenicity marker genes and possess two unique antimicrobial peptide gene clusters. This study provides a basis to understand the nature of selection pressure in a key human skin commensal bacterium with implications in its management as an opportunistic pathogen.
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Affiliation(s)
- Shikha Sharma
- Bacterial Genomics and Evolution Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Vasvi Chaudhry
- Bacterial Genomics and Evolution Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Sanjeet Kumar
- Bacterial Genomics and Evolution Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
| | - Prabhu B Patil
- Bacterial Genomics and Evolution Laboratory, CSIR-Institute of Microbial Technology, Chandigarh, India
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Comparative characterisation of the biofilm-production abilities of Staphylococcus epidermidis isolated from human skin and platelet concentrates. J Med Microbiol 2018; 67:190-197. [DOI: 10.1099/jmm.0.000673] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Campoccia D, Montanaro L, Baldassarri L, An YH, Arciola CR. Antibiotic Resistance in Staphylococcus Aureus and Staphylococcus Epidermidis Clinical Isolates from Implant Orthopedic Infections. Int J Artif Organs 2018; 28:1186-91. [PMID: 16353126 DOI: 10.1177/039139880502801117] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the last decade the rising phenomenon of resistance to most common antibiotic drugs among staphylococcal clinical isolates has been a reason for serious concern and alarm. The present study investigated the prevalence of antibiotic resistance within a large microbial collection including 530 clinical strains of S. aureus and 408 strains of S. epidermidis to a panel of 16 different drugs. All strains were isolated from orthopedic infections, either associated or non-associated with implant materials. Interestingly, our data show that the profile of the prevalence of antibiotic resistance within the two species of pathogens is extremely similar for the vast majority of the drugs screened. The only statistically significant variations in prevalence concerned, in order of relevance, the following 5 out of 16 antibiotics: sulfamethoxazole (in combination with trimethoprim), erythromycin, and, to a lesser extent, oxacillin, imipenem, and clindamycin. In the case of Staphylococcus aureus, the isolates associated to implant materials were found more frequently resistant to all 4 aminoglycosides screened as well as to ciprofloxacin.
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Affiliation(s)
- D Campoccia
- Research Unit on Implant Infections, Rizzoli Orthopedic Institute, Bologna, Italy
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Vadyvaloo V, Otto M. Molecular Genetics of Staphylococcus Epidermidis Biofilms on Indwelling Medical Devices. Int J Artif Organs 2018; 28:1069-78. [PMID: 16353113 DOI: 10.1177/039139880502801104] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Staphylococcus epidermidis is an opportunistic pathogen associated with foreign body infections and nosocomial sepsis. The pathogenicity of S. epidermidis is mostly due to its ability to colonize indwelling polymeric devices and form a thick, multilayered biofilm. Biofilm formation is a major problem in treating S. epidermidis infection as biofilms provide significant resistance to antibiotics and to components of the innate host defenses. Various cell surface associated bacterial factors play a role in adherence and accumulation of the biofilm such as the polysaccharide intercellular adhesin and the autolysin AtlE. Furthermore, recent studies have shown that global regulators such as the agr quorum sensing system, the transcriptional regulator sarA and the alternative sigma factor sigB have an important function in the regulation of biofilm formation. Understanding the many complex mechanisms involved in biofilm formation is a key factor in the search for new anti-staphylococcal therapeutics.
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Affiliation(s)
- V Vadyvaloo
- Rocky Mountain Laboratories, NIAID/NIH, Hamilton, MT, USA
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Comparative Genomics Study of Staphylococcus epidermidis Isolates from Orthopedic-Device-Related Infections Correlated with Patient Outcome. J Clin Microbiol 2017; 55:3089-3103. [PMID: 28794175 DOI: 10.1128/jcm.00881-17] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/18/2017] [Indexed: 12/16/2022] Open
Abstract
Staphylococcus epidermidis has emerged as an important opportunistic pathogen causing orthopedic-device-related infections (ODRI). This study investigated the association of genome variation and phenotypic features of the infecting S. epidermidis isolate with the clinical outcome for the infected patient. S. epidermidis isolates were collected from 104 patients with ODRI. Their clinical outcomes were evaluated, after an average of 26 months, as either "cured" or "not cured." The isolates were tested for antibiotic susceptibility and biofilm formation. Whole-genome sequencing was performed on all isolates, and genomic variation was related to features associated with "cured" and "not cured." Strong biofilm formation and aminoglycoside resistance were associated with a "not-cured" outcome (P = 0.031 and P < 0.001, respectively). Based on gene-by-gene analysis, some accessory genes were more prevalent in isolates from the "not-cured" group. These included the biofilm-associated bhp gene, the antiseptic resistance qacA gene, the cassette chromosome recombinase-encoding genes ccrA and ccrB, and the IS256-like transposase gene. This study identifies biofilm formation and antibiotic resistance as associated with poor outcome in S. epidermidis ODRI. Whole-genome sequencing identified specific genes associated with a "not-cured" outcome that should be validated in future studies. (The study has been registered at ClinicalTrials.gov with identifier NCT02640937.).
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Hashem AA, Abd El Fadeal NM, Shehata AS. In vitro activities of vancomycin and linezolid against biofilm-producing methicillin-resistant staphylococci species isolated from catheter-related bloodstream infections from an Egyptian tertiary hospital. J Med Microbiol 2017; 66:744-752. [DOI: 10.1099/jmm.0.000490] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Asmaa A. Hashem
- Department of Microbiology and Immunology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Noha M. Abd El Fadeal
- Department of Medical Biochemistry, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Atef S. Shehata
- Department of Microbiology and Immunology, Faculty of Medicine, Jazan University, Jazan, Kingdom of Saudi Arabia
- Department of Microbiology and Immunology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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Prevalence, clonality, and pathogenicity of Staphylococcus epidermidis isolates in newborn feces. Eur J Clin Microbiol Infect Dis 2017; 36:1955-1964. [PMID: 28560472 DOI: 10.1007/s10096-017-3019-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/15/2017] [Indexed: 01/29/2023]
Abstract
Coagulase-negative staphylococci (CoNS) are the most prevalent pathogens causing late-onset sepsis in neonates. The question is whether neonates acquire endemic hospital-adapted clones or incidentally occurring CoNS strains after birth during their hospital stay. Therefore, a prospective study was performed on the prevalence of CoNS in the stool of babies (born vaginally or by cesarean section) during their first days of life. Their clonal relatedness and potential to induce invasive disease were characterized. CoNS were analyzed from the stool samples of newborns with a load of CoNS above 103 colony-forming units (CFU)/mL. The identification of CoNS was performed phenotypically and genotypically. For typing, repetitive polymerase chain reaction (PCR), pulsed-field gel electrophoresis, and multilocus sequence typing were used. Resistance profiles, biofilm production, the presence of icaAD and of IS256 were determined as well. From a total of 207 stool samples (56 newborns), CoNS were detected in 41% of the newborns, mostly on day 3 for the first time (62.5%). Staphylococcus epidermidis was isolated in 85.7% of cases, harbored no IS256 element, and mostly expressed no biofilm. The isolates were separated into four main clusters by repetitive sequence-based PCR. 24% of the strains showed no antimicrobial resistance. 20% were resistant against four antibiotics of two different antibiotic classes. The remaining strains were resistant only against one antimicrobial substance class. Thus, it can be concluded that newborns do not acquire hospital-adapted endemic, multidrug-resistant S. epidermidis isolates during their first days of life. Yet, the results support the thesis that, during hospital stay, environmental parameters may convert sensible/noninvasive S. epidermidis strains into multidrug-resistant strains with characteristics of invasiveness.
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Brady AJ, Laverty G, Gilpin DF, Kearney P, Tunney M. Antibiotic susceptibility of planktonic- and biofilm-grown staphylococci isolated from implant-associated infections: should MBEC and nature of biofilm formation replace MIC? J Med Microbiol 2017; 66:461-469. [DOI: 10.1099/jmm.0.000466] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Aaron J Brady
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast, Belfast, BT97BL, UK
| | - Garry Laverty
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast, Belfast, BT97BL, UK
| | - Deirdre F Gilpin
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast, Belfast, BT97BL, UK
| | - Patricia Kearney
- Antrim Area Laboratory, United Hospitals Trust, Antrim, BT41, UK
| | - Michael Tunney
- School of Pharmacy, Queen’s University Belfast, 97 Lisburn Road, Belfast, Belfast, BT97BL, UK
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46
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Patel S. Drivers of bacterial genomes plasticity and roles they play in pathogen virulence, persistence and drug resistance. INFECTION GENETICS AND EVOLUTION 2016; 45:151-164. [DOI: 10.1016/j.meegid.2016.08.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 08/26/2016] [Accepted: 08/27/2016] [Indexed: 12/11/2022]
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Versatility of Biofilm Matrix Molecules in Staphylococcus epidermidis Clinical Isolates and Importance of Polysaccharide Intercellular Adhesin Expression during High Shear Stress. mSphere 2016; 1:mSphere00165-16. [PMID: 27747298 PMCID: PMC5064449 DOI: 10.1128/msphere.00165-16] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/20/2016] [Indexed: 01/13/2023] Open
Abstract
Staphylococcus epidermidis is a leading cause of infections related to biomaterials, mostly due to their ability to form biofilm. Biofilm accumulation mechanisms vary, including those that are dependent on specific proteins, environmental DNA (eDNA), or polysaccharide intercellular adhesin (PIA). We found that those isolates obtained from high-shear environments, such as the lumen of a catheter, are more likely to produce PIA-mediated biofilms than those isolates obtained from a low-shear biomaterial-related infection. This suggests that PIA functions as a mechanism that is protective against shear flow. Finally, we performed selection experiments documenting the heterogeneity of biofilm accumulation molecules that function in the absence of PIA, further documenting the biofilm-forming potential of S. epidermidis. Staphylococcus epidermidis is a leading cause of hospital-associated infections, including those of intravascular catheters, cerebrospinal fluid shunts, and orthopedic implants. Multiple biofilm matrix molecules with heterogeneous characteristics have been identified, including proteinaceous, polysaccharide, and nucleic acid factors. Two of the best-studied components in S. epidermidis include accumulation-associated protein (Aap) and polysaccharide intercellular adhesin (PIA), produced by the enzymatic products of the icaADBC operon. Biofilm composition varies by strain as well as environmental conditions, and strains producing PIA-mediated biofilms are more robust. Clinically, biofilm-mediated infections occur in a variety of anatomical sites with diverse physiological properties. To test the hypothesis that matrix composition exhibits niche specificity, biofilm-related genetic and physical properties were compared between S. epidermidis strains isolated from high-shear and low-shear environments. Among a collection of 105 clinical strains, significantly more isolates from high-shear environments carried the icaADBC operon than did those from low-shear settings (43.9% versus 22.9%, P < 0.05), while there was no significant difference in the presence of aap (77.2% versus 75.0%, P > 0.05). Additionally, a significantly greater number of high-shear isolates were capable of forming biofilm in vitro in a microtiter assay (82.5% versus 45.8%, P < 0.0001). However, even among high-shear clinical isolates, less than half contained the icaADBC locus; therefore, we selected for ica-negative variants with increased attachment to abiotic surfaces to examine PIA-independent biofilm mechanisms. Sequencing of selected variants identified substitutions capable of enhancing biofilm formation in multiple genes, further highlighting the heterogeneity of S. epidermidis biofilm molecules and mechanisms. IMPORTANCEStaphylococcus epidermidis is a leading cause of infections related to biomaterials, mostly due to their ability to form biofilm. Biofilm accumulation mechanisms vary, including those that are dependent on specific proteins, environmental DNA (eDNA), or polysaccharide intercellular adhesin (PIA). We found that those isolates obtained from high-shear environments, such as the lumen of a catheter, are more likely to produce PIA-mediated biofilms than those isolates obtained from a low-shear biomaterial-related infection. This suggests that PIA functions as a mechanism that is protective against shear flow. Finally, we performed selection experiments documenting the heterogeneity of biofilm accumulation molecules that function in the absence of PIA, further documenting the biofilm-forming potential of S. epidermidis.
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Kossakowska-Zwierucho M, Kaźmierkiewicz R, Bielawski KP, Nakonieczna J. Factors Determining Staphylococcus aureus Susceptibility to Photoantimicrobial Chemotherapy: RsbU Activity, Staphyloxanthin Level, and Membrane Fluidity. Front Microbiol 2016; 7:1141. [PMID: 27486456 PMCID: PMC4949386 DOI: 10.3389/fmicb.2016.01141] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 07/07/2016] [Indexed: 12/22/2022] Open
Abstract
Photoantimicrobial chemotherapy (PACT) constitutes a particular type of stress condition, in which bacterial cells induce a pleiotropic and as yet unexplored effect. In light of this, the key master regulators are of putative significance to the overall phototoxic outcome. In Staphylococcus aureus, the alternative sigma factor σB controls the expression of genes involved in the response to environmental stress. We show that aberration of any sigB operon genes in S. aureus USA300 isogenic mutants causes a pronounced sensitization (>5 log10 reduction in CFU drop) to PACT with selected photosensitizers, namely protoporphyrin diarginate, zinc phthalocyanine and rose bengal. This effect is partly due to aberration-coupled staphyloxanthin synthesis inhibition. We identified frequent mutations in RsbU, a σB activator, in PACT-vulnerable clinical isolates of S. aureus, resulting in σB activity impairment. Locations of significant changes in protein structure (IS256 insertion, early STOP codon occurrence, substitutions A230T and A276D) were shown in a theoretical model of S. aureus RsbU. As a phenotypic hallmark of PACT-vulnerable S. aureus strains, we observed an increased fluidity of bacterial cell membrane, which is a result of staphyloxanthin content and other yet unidentified factors. Our research indicates σB as a promising target of adjunctive antimicrobial therapy and suggests that enhanced cell membrane fluidity may be an adjuvant strategy in PACT.
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Affiliation(s)
- Monika Kossakowska-Zwierucho
- Laboratory of Molecular Diagnostics, Department of Biotechnology, Intercollegiate Faculty of Biotechnology, University of Gdansk and Medical University of Gdansk Gdansk, Poland
| | - Rajmund Kaźmierkiewicz
- Laboratory of Biomolecular Systems Simulation, Intercollegiate Faculty of Biotechnology, University of Gdansk and Medical University of Gdansk Gdansk, Poland
| | - Krzysztof P Bielawski
- Laboratory of Molecular Diagnostics, Department of Biotechnology, Intercollegiate Faculty of Biotechnology, University of Gdansk and Medical University of Gdansk Gdansk, Poland
| | - Joanna Nakonieczna
- Laboratory of Molecular Diagnostics, Department of Biotechnology, Intercollegiate Faculty of Biotechnology, University of Gdansk and Medical University of Gdansk Gdansk, Poland
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Tolo I, Thomas JC, Fischer RSB, Brown EL, Gray BM, Robinson DA. Do Staphylococcus epidermidis Genetic Clusters Predict Isolation Sources? J Clin Microbiol 2016; 54:1711-1719. [PMID: 27076664 PMCID: PMC4922092 DOI: 10.1128/jcm.03345-15] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/07/2016] [Indexed: 12/24/2022] Open
Abstract
Staphylococcus epidermidis is a ubiquitous colonizer of human skin and a common cause of medical device-associated infections. The extent to which the population genetic structure of S. epidermidis distinguishes commensal from pathogenic isolates is unclear. Previously, Bayesian clustering of 437 multilocus sequence types (STs) in the international database revealed a population structure of six genetic clusters (GCs) that may reflect the species' ecology. Here, we first verified the presence of six GCs, including two (GC3 and GC5) with significant admixture, in an updated database of 578 STs. Next, a single nucleotide polymorphism (SNP) assay was developed that accurately assigned 545 (94%) of 578 STs to GCs. Finally, the hypothesis that GCs could distinguish isolation sources was tested by SNP typing and GC assignment of 154 isolates from hospital patients with bacteremia and those with blood culture contaminants and from nonhospital carriage. GC5 was isolated almost exclusively from hospital sources. GC1 and GC6 were isolated from all sources but were overrepresented in isolates from nonhospital and infection sources, respectively. GC2, GC3, and GC4 were relatively rare in this collection. No association was detected between fdh-positive isolates (GC2 and GC4) and nonhospital sources. Using a machine learning algorithm, GCs predicted hospital and nonhospital sources with 80% accuracy and predicted infection and contaminant sources with 45% accuracy, which was comparable to the results seen with a combination of five genetic markers (icaA, IS256, sesD [bhp], mecA, and arginine catabolic mobile element [ACME]). Thus, analysis of population structure with subgenomic data shows the distinction of hospital and nonhospital sources and the near-inseparability of sources within a hospital.
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Affiliation(s)
- Isaiah Tolo
- Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Rebecca S B Fischer
- Center for Infectious Disease, University of Texas Health Science Center, Houston, Texas, USA
| | - Eric L Brown
- Center for Infectious Disease, University of Texas Health Science Center, Houston, Texas, USA
| | - Barry M Gray
- Department of Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, Illinois, USA
| | - D Ashley Robinson
- Department of Microbiology and Immunology, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Biofilm Producing Staphylococcus epidermidis Strains Isolated From Clinical Samples in Tehran, Iran. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2016. [DOI: 10.5812/archcid.33343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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