Performance of four slide agglutination methods for identification of Staphylococcus aureus when testing methicillin-resistant staphylococci

In Vitro Assay for Quantifying Clumping of Staphylococcus aureus

Staphylococcus aureus interacts with fibrinogen in plasma to form macroscopic clumps of cells. A simple and rapid slide agglutination test using rabbit plasma has been employed in clinical labs to distinguish S. aureus from most coagulase-negative Staphylococci. The method described here is a quantitative clumping assay in which S. aureus cells are mixed with either plasma or purified fibrinogen, and clumps are allowed to sediment out of solution. Clearing of the overlying solution is monitored over time by measuring the optical density at 600 nm and comparing these values to the initial turbidity. This simple assay can be used to study regulation and expression of various cell wall-anchored adhesins.

Genotypic relatedness and phenotypic characterization of Staphylococcus schleiferi subspecies in clinical samples from dogs

OBJECTIVE

To assess the degree of biological similarity (on the basis of genotype determined via pulsed-field gel electrophoresis [PFGE]) between isolates of 2 Staphylococcus schleiferi subspecies (S schleiferi subsp coagulans and S schleiferi subsp schleiferi) in clinical samples obtained from dogs.

SAMPLE POPULATION

161 S schleiferi isolates from 160 canine patients.

PROCEDURES

A commercial microbiology identification system was used to identify each isolate as S schleiferi. Isolates underwent slide and tube coagulase testing and antimicrobial susceptibility testing. A mecA PCR assay and a latex agglutination test for penicillin-binding protein 2a (PBP2a) were also performed on each isolate. Clonal clusters with a similarity cutoff value of 80% were identified via PFGE.

RESULTS

Of the 161 isolates, 61 (38%), 79 (49%), and 21 (13%) were obtained from cutaneous sites, ears, and other sites, respectively; 110 (68%) were coagulase negative, and 51 (32%) were coagulase positive. Among the coagulase-negative and coagulase-positive isolates, 65% (71/110) and 39% (20/51) were oxacillin resistant, respectively. All oxacillin-resistant isolates yielded positive results via mecA PCR assay and PBP2a latex agglutination testing. Via PFGE, 15 major clusters and 108 individual pulsed-field profiles were identified. Oxacillin-resistant and oxacillin-susceptible isolates clustered separately. Clonal clusters were heterogeneous and contained representatives of both subspecies.

CONCLUSIONS AND CLINICAL RELEVANCE

Coagulase-positive and coagulase-negative isolates were not genotypically distinct and may represent a single S schleiferi sp with variable coagulase production, rather than 2 biologically distinct subspecies. Further studies are needed to characterize clinical or epidemiological differences associated with infections with coagulase-positive and coagulase-negative S schleiferi in dogs.

Evaluation of six agglutination tests for Staphylococcus aureus identification depending upon local prevalence of meticillin-resistant S. aureus (MRSA)

Most routine laboratory detection of Staphylococcus aureus isolates is based on rapid agglutination test systems. Failure of agglutination assays to identify meticillin-resistant S. aureus strains (MRSA) has been demonstrated. The aim of this study was to evaluate six commercially available agglutination tests for the detection of meticillin-sensitive S. aureus (MSSA) and mecA-positive MRSA strains. The Dry Spot Staphytect Plus test (Oxoid), the Pastorex Staph Plus test (Bio-Rad), the Slidex Staph-Kit and Slidex Staph Plus test (bioMérieux), the Staphaurex Plus test (Remel) and the Staphylase Test (Oxoid) were used. As determined by pulsed field gel electrophoresis, 52 distinct MRSA strains from five countries, 83 MSSA strains and 150 coagulase-negative staphylococci were included. Species identification and determination of susceptibility patterns were performed using colony morphology, Gram stain, catalase testing, tube coagulase testing, DNase testing, mannitol fermentation, susceptibility testing towards oxacillin by Etest, coagulase gene PCR, fibrinogen receptor gene PCR and PCR of the mecA gene. Sensitivity of the agglutination tests ranged from 82.7 to 100.0 % for MRSA strains and 92.8 to 100.0 % for MSSA strains, respectively. Specificity of the test systems ranged from 91.3 to 99.1 %. None of the six agglutination assays produced correct reactions for all staphylococci tested. Only the Dry Spot Staphytect Plus test correctly identified all 52 MRSA strains. For the other tests kits, sensitivity of MRSA detection was lower than for MSSA isolates. Depending upon the local MRSA prevalence and the parameter of interest (sensitivity or specificity), these test systems may be useful for routine diagnostic purposes.

Dissemination of two methicillin-resistant Staphylococcus aureus clones exhibiting negative staphylase reactions in intensive care units

From December 1997 to March 1998, 25 methicillin-resistant Staphylococcus aureus (MRSA) isolates exhibiting negative Staphylase (Oxoid Ltd., Basingstoke, England) reactions were identified from various clinical specimens from 13 patients in six intensive care units (ICUs) or in wards following a stay in an ICU at the National Taiwan University Hospital. The characteristics of these isolates have not been previously noted in other MRSA isolates from this hospital. Colonies of all these isolates were grown on Trypticase soy agar supplemented with 5% sheep blood and were nonhemolytic and unpigmented. Seven isolates, initially reported as Staphylococcus haemolyticus (5 isolates) and Staphylococcus epidermidis (2 isolates) by the routine identification scheme and with the Vitek GPI system (bioMerieux Vitek, Inc., Hazelwood, Mo.), were subsequently identified as S. aureus by positive tube coagulase tests, standard biochemical reactions, and characteristic cellular fatty acid chromatograms. The antibiotypes obtained by the E test, coagulase types, restriction fragment length polymorphism profiles of the staphylococcal coagulase gene, and random amplified polymorphic DNA patterns generated by arbitrarily primed PCR of the isolates disclosed that two major clones disseminated in the ICUs. Clone 1 (16 isolates) was resistant to clindamycin and was susceptible to trimethoprim-sulfamethoxazole (TMP-SMZ) and was coagulase type II. Clone 2 (eight isolates) was resistant to clindamycin and TMP-SMZ and was coagulase type IV. These two epidemic clones from ICUs are unique and underline the need for caution in identifying MRSA strains with colonial morphologies not of the typical type and with negative Staphylase reactions.

Comparison of six rapid agglutination tests for the identification of Staphylococcus aureus, including methicillin-resistant strains

Six rapid agglutination tests for the identification of Staphylococcus aureus were evaluated by testing 416 strains of staphylococci. The sensitivities and specificities of the tests were as follows: Staphyloslide, 97.7% and 99.3% respectively; Prolex Staph Latex, 96.9% and 93.6%; Staphaurex, 95.4% and 94.2%; Staphaurex Plus, 100% and 93.4%; Slidex Staph Plus, 98.9% and 99.3%; and Staphytect Plus, 99.6% and 88.2%. The three tests utilizing latex particles coated with staphylococcal capsular antibodies were better able to identify methicillin-resistant S. aureus, but only Staphyloslide and Slidex Staph Plus had adequate specificity.

Sensitivity and specificity of an improved rapid latex agglutination test for identification of methicillin-sensitive and -resistant Staphylococcus aureus isolates

The performance of a second-generation rapid agglutination kit, Slidex Staph Plus (SSP; bioMérieux), was compared to those of the Slidex Staph (SS; bioMérieux), Staphaurex (SRX; Murex Diagnostics), and BBL Staphyloslide (BBL; Becton Dickinson) kits by using 508 clinical isolates composed of 150 methicillin-sensitive Staphylococcus aureus (MSSA) organisms, 154 methicillin-resistant S. aureus (MRSA) organisms, and 204 non-S. aureus Staphylococcus spp. Of the 508 isolates tested, 75% were fresh clinical isolates, with the remainder taken from five different freezer collections. All four agglutination tests had comparable sensitivities for MSSA and MRSA. However, the SS kit was significantly less specific (93.1%) than the three other tests (P > 0.05, McNemar test). These results demonstrate that the new rapid latex agglutination kit, SSP, was more specific for the identification of S. aureus than the previous version and performed comparably to the SRX and BBL kits.

Comparison of five agglutination tests for identification of Staphylococcus aureus

Various commercially produced agglutination kits are widely used for the identification of Staphylococcus aureus. These kits detect the presence of protein A and/or clumping factor on S. aureus. The literature has shown that methicillin-resistant S. aureus (MRSA) isolates which are deficient in both clumping factor and protein A may be misidentified. Two products, Slidex and Staphaurex Plus, utilize specific anti-S. aureus antibodies, potentially giving them greater sensitivity compared to products without these antibodies. We report a prospective study designed to compare the performance characteristics of Fastaph, Slidex, Staphaurex, Staphaurex Plus, Staphyloslide, and the tube coagulase test for the identification of staphylococcal isolates. All discrepant isolates were tested with the Gen-Probe AccuProbe S. aureus test and were identified to the species level with conventional reference biochemicals. A total of 1,193 isolates were tested, including 33 MRSA and 423 methicillin-sensitive S. aureus isolates. The sensitivities and specificities of the tests, respectively, were as follows: Fastaph, 99.1 and 98.9%; Slidex, 99.6 and 96.4%; Staphaurex, 98.9 and 99.9%; Staphaurex Plus, 99.6 and 93.9%; Staphyloslide, 99.1 and 98.9%; and tube coagulase, 99.3 and 100%. Sensitivity was excellent for all of the products tested. The specificities of Fastaph, Staphaurex, and Staphyloslide were excellent, while Staphaurex Plus and Slidex demonstrated less optimal results.

Evaluation of new agglutination test for identification of oxacillin-susceptible and oxacillin-resistant Staphylococcus aureus

A new agglutination test (Monostaph +; Bionor, Skien, Norway) has been developed. This new agglutination test has been compared with two other agglutination tests for the identification of 128 isolates of Staphylococcus aureus and 82 coagulase-negative staphylococci. The sensitivities of both Monostaph + and Pastorex Staph-Plus were excellent (98.7 and 97.4%, respectively) in detection of oxacillin-resistant Staphylococcus aureus. The specificity was 96.4% (two Staphylococcus epidermidis isolates and one Staphylococcus hominis isolate were false positive).

Rapid detection of methicillin-resistant Staphylococcus aureus strains not identified by slide agglutination tests

Seventy-nine methicillin-resistant Staphylococcus aureus (MRSA) strains, isolated during 1980 to 1990, were classified as MRSA Aggl- (14 strains) and MRSA Aggl+ (65 strains) strains on the basis of test results in slide agglutination assays designed to detect fibrinogen-binding protein (clumping factor) and protein A on the staphylococcal surface. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis revealed that lysostaphin digests of MRSA Aggl- strains contained a high-molecular-weight protein which was not detected in digests of MRSA Aggl+ strains. Immunization of rabbits with an MRSA Aggl- strain produced an antiserum which agglutinated all MRSA Aggl- strains and also 64 of 65 MRSA Aggl+ strains. Only 1 of 68 coagulase-negative staphylococci showed agglutination in this assay. The anti-MRSA Aggl- antiserum reacted mainly with a 230-kDa staphylococcal surface protein but also with a 175-kDa protein, probably formed by proteolysis of the former and a few slightly smaller proteins. These could not be immunologically detected in lysostaphin digests of MRSA Aggl+ strains. Purified antibodies reacting with the 230-kDa protein agglutinated all MRSA Aggl- strains, indicating that the protein is located on the surfaces of staphylococci. The results suggest a tentative role for the 230-kDa protein or its fragments as a novel target to develop more efficient rapid identification methods for S. aureus, including MRSA.

Use of commercial particle agglutination systems for the rapid identification of methicillin-susceptible and methicillin-resistant Staphylococcus aureus

The performance of a recently introduced Staphylococcus aureus identification system (Slidex Staph-Kit) was compared with that of currently available systems (Immuno Scan Staphlatex, Staphyloslide, Staphaurex and SeroSTAT II) for the identification of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible Staphylococcus aureus. The new system, which detects a capsular antigen common in MRSA, performed with equal or greater sensitivity than the other systems. None of the commercial systems was adversely affected by the methicillin susceptibility of the staphylococci when isolates were recovered from non-selective media. The greatest advantage of the anti-capsular monoclonal reagent was its improved performance on isolates recovered from selective media.

Comparison of various methods and reagents for species identification of Staphylococcus aureus positive or negative for the mecA gene

The reliability of various methods for species identification of Staphylococcus aureus was evaluated. A total of 135 coagulase-positive (SA) or -negative (SS) staphylococcal isolates were tested, including methicillin-resistant (MR) and -susceptible (MS) strains. When the nuc gene which encodes the S. aureus thermonuclease (TNase) was amplified in a multiplex PCR simultaneously with the mecA gene which encodes for the MR-associated penicillin-binding protein 2a of staphylococci, the nuc amplification showed full agreement with the results of the coagulase test. TNase detected by an enzymatic method or as protein in a sandwich ELISA identified S. aureus with nearly the same precision as the PCR. The Staphylase, Monostaph and Staphaurex agglutination kits were all reliable for identification of MSSA, but not for MRSA. Most of the negative MRSA strains were identified by the Pastorex agglutination kit, in which reagents for fibrinogen receptor and protein A detection have been supplemented with antibodies for capsular polysaccharides of the serotypes 5 and 8. These results show that detection of the nuc gene or its TNase product is highly reliable for identification of both MRSA and MSSA strains, while various widely used agglutination kits do not show the same reliability for identification of MRSA strains.

Rapid methods for identification of Staphylococcus aureus when both human and animal staphylococci are tested: comparison with a new immunoenzymatic assay

A new immunoenzymatic assay (IEA) for the identification of Staphylococcus aureus strains of both human and animal origin was compared with rapid commercial kits. The sensitivities and specificities of the commercial kits varied from 90.2 to 96% and 90.8 to 93.7%, respectively. The IEA did not give any false-negative or false-positive results, while commercial kits gave high percentages of false-positive results among clumping factor-positive non-S. aureus strains. The IEA is particularly useful for isolates for which identification is doubtful, for large-scale epidemiological studies, and for identifying isolates from animals as S. aureus.

Comparative evaluation of five agglutination techniques and a new miniaturized system for rapid identification of methicillin-resistant strains of Staphylococcus aureus

The speciation of methicillin-resistant Staphylococcus aureus (MRSA) poses a significant diagnostic problem when rapid identification methods such as slide agglutination tests, are used, because of the high proportion of false-negative reactions. 150 perfectly identified MRSA strains were tested on 5 commonly used agglutination reagents ("Bacto staph latex test", "Monostaph", "Pastorex staph", "Staphaurex", and "Staphyslide test") in comparison with a new micromethod ("RAPIDEC staph") which detects a type of staphylocoagulase within 2 hours by a fluorescence test. The "RAPIDEC staph" reagent enabled identification of all the MRSA while the agglutination tests gave poorer results: "Monostaph" correctly identified 64.6% of strains, "Staphyslide", 59.3%, "Bacto staph latex test", 44.6%, "Pastorex staph", 38.6% and "Staphaurex", 28.6%. These results show that agglutination slide tests are not reliable enough for the identification of MRSA which are more and more encountered in hospital wards. The authors recommend not to use slide agglutination methods. They suggest the tube test for coagulase which is the reference technique, although it is time-consuming and not well standardized. The results of this evaluation encourage the use of the "RAPIDEC staph" reagent since it is an easy-to-use, reliable technique for the rapid identification of Staphylococcus aureus.

Latex agglutination for rapid identification of methicillin-resistant Staphylococcus aureus recovered from selective media

The accuracy of combining latex agglutination with selective media for the identification of methicillin-resistant Staphylococcus aureus (MRSA) was determined. Test strains were identified by latex agglutination on blood agar, the heat-stable thermonuclease test and broth microdilution MICs of oxacillin and included 97 MRSA, 56 methicillin-susceptible Staphylococcus aureus, 52 methicillin resistant, and 49 methicillin-susceptible Staphylococcus species. Isolates were grown on trypticase-soy agar with 5% sheep red blood cells (TSAB), Mueller-Hinton agar (MHA), mannitol-salt agar (MSA), and four media designed for the selective growth of MRSA:TSAB with clindamycin and gentamicin, MHA with oxacillin, MSA with oxacillin, and lipovitellin-salt-mannitol agar (LVSM) with 1 microgram oxacillin disks applied. The mean sensitivity, specificity, and positive predictive value for the combination of latex agglutination with selective media for the identification of MRSA was 96%, 99% and 98% respectively.

Evaluation of a direct identification method for Staphylococcus aureus from blood culture broth

We evaluated the reliability of Staphaurex (Wellcome Diagnostics, Dartford, England) for the direct identification of staphylococci from blood culture broth with evidence of positivity and a suggestive Gram-stained smear. Our evaluation indicates that this application is of limited sensitivity, thus reducing the value of a negative test. However, since the test is highly specific, a positive test is significant in predicting the isolation of Staphylococcus aureus.

Problems with rapid agglutination methods for identification of Staphylococcus aureus when Staphylococcus saprophyticus is being tested

Six rapid agglutination tests for identification of Staphylococcus aureus were evaluated by using 62 strains of S. aureus, 63 strains of S. saprophyticus, and 67 strains of other coagulase-negative staphylococci. S. saprophyticus was responsible for 19 of 26 false-positive results and 20 uninterpretable reactions. Thus, urinary staphylococcal isolates that are positive by rapid agglutination tests may require other confirmatory tests for the identification of possible S. saprophyticus.