A novel multiplex real-time PCR assay for rapid typing of major staphylococcal cassette chromosome mec elements

A pseudo-outbreak of MRSA due to laboratory contamination related to MRSA carriage of a laboratory staff member

BACKGROUND

Methicillin resistant Staphylococcus aureus (MRSA) is a major burden for hospitals globally. However, in the Netherlands, the MRSA prevalence is relatively low due to the 'search and destroy' policy. Routine multiple-locus variable-number of tandem repeat analysis (MLVA) of MRSA isolates supports outbreak detection. However, whole genome multiple locus sequence typing (wgMLST) is superior to MLVA in identifying (pseudo-)outbreaks with MRSA. The present study describes a pseudo-outbreak of MRSA at the bacteriology laboratory of a large Dutch teaching hospital.

METHODS

All staff members of the bacteriology laboratory of the Elisabeth-TweeSteden hospital were screened for MRSA carriage, after a laboratory contamination with MRSA was suspected. Clonal relatedness between the index isolate and the MRSA isolates from laboratory staff members and all previous MRSA isolates from the Elisabeth-TweeSteden hospital with the same MLVA-type as the index case was examined based on wgMLST using whole genome sequencing.

RESULTS

One of the staff members was identified as the probable source of the laboratory contamination, because of carriage of a MRSA possessing the same MLVA-type as the index case. Eleven other isolates with the same molecular characteristics were found in the database, of which seven were retrospectively suspected of contamination. Clonal relatedness was found between ten isolates, including the isolate found in the staff member and the MRSA found in the index patient with a maximum of eleven alleles difference. All isolates were epidemiologically linked through the laboratory staff member, who had worked on all these cultures.

CONCLUSIONS

The present study describes a MRSA pseudo-outbreak over a 2.5-year period due to laboratory contamination caused by a MRSA carrying laboratory staff member involving nine patients. In case of unexpected bacteriological findings, the possibility of a laboratory contamination should be considered.

Prevalence and characterization of Staphylococcus aureus in wastewater treatment plants by whole genomic sequencing

Infections with Staphylococcus aureus are being spread through contact with the community environment, but the role of wastewater treatment plants in the transmission routes is not defined. This study investigated the prevalence, types, genetic elements, and potential for transmission of S. aureus by these engineered systems. Synchronized sampling events at two wastewater treatment plants were conducted with isolates of S. aureus obtained by a selective enrichment method using acriflavine that suppressed Staphylococcus epidermidis growth. DNA was extracted from a subset of the S. aureus isolates, checked by PCR to assure the absence of S. epidermidis, and sequenced to determine the multilocus sequence type, spa type, and carriage of the methicillin resistance and Panton-Valentine leukocidin genetic elements. Sequences were analyzed for single nucleotide polymorphism differences in pairwise comparison of isolates. There were two dominant S. aureus clonal complexes identified in the isolates, one commonly identified as hospital-related (CC5) and one community-related (CC8). Both types of isolates were found at both treatment facilities, even though only one facility had significant hospital sewage inputs. The presence of S. aureus persisted through treatment, with some isolates recovered from the final processes showing genetic diversity. The presence of the Panton-Valentine leukocidin genetic element was greater than the 1-5% expected from global reports. Our results suggest that treatment provides an opportunity for genetic shift, while the persistence and release of evolved strains of S. aureus may provide an environmentally relevant pathway to new hosts in the environment.

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

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

Characterization of Staphylococcus aureus Isolated from Food Products in Western Algeria

The current study aimed to characterize Staphylococcus aureus isolates from foodstuffs collected from western Algeria. A total of 153 S. aureus isolates from various raw and processed foods were obtained and identified using matrix-assisted laser desorption and ionization time-of-flight mass spectrometry. Isolates were characterized by antimicrobial susceptibility testing and toxin gene detection. Methicillin-resistant Staphylococcus aureus (MRSA) isolates were identified by detection of the mecA gene and characterized by staphylococcal cassette chromosome mec (SCCmec) typing. We found that 30.9% (153/495) of food samples were contaminated with S. aureus. Thirty-three (21.5%) S. aureus isolates were identified as MRSA, and 16.9% (26/153) carried the mecA gene. Three SCCmec types were identified of which type IV was the most common (69.2%) followed by type V (15.3%) and type II (7.6%). Two MRSA isolates were not typable with SCCmec typing. None of the examined isolates harbored mecC. Furthermore, 14.3% (22/153) of the isolates were toxigenic S. aureus. The cytotoxin gene pvl was detected in 11.1% of the S. aureus isolates. This gene was more commonly detected (76.4%) in MRSA isolates than in methicillin-suceptible Staphylococcus aureus (MSSA) isolates. The tsst-1 gene coding for toxic shock syndrome toxin was isolated rarely (3.2%) and only in MSSA isolates. According to disk diffusion test results, 70 isolates were resistant to only one antimicrobial drug, and 51 (33.3%) isolates were multidrug resistant. Other 32 isolates were susceptible to all antibiotics. Our study highlights, for the first time, a high prevalence of multidrug-resistant S. aureus isolates carrying pvl or tsst-1 found in food products in Algeria. The risk of MRSA transmission through the food chain cannot be disregarded, particularly in uncooked foods.

Eradication of Methicillin-ResistantStaphylococcus AureusFrom a Neonatal Intensive Care Unit by Active Surveillance and Aggressive Infection Control Measures

Objectives:

To describe an outbreak of hospital-acquired MRSA in a NICU and to identify the risk factors for, outcomes of, and interventions that eliminated it.

Setting:

An 18-bed, level III-IV NICU in a community hospital.

Methods:

Interventions to control MRSA included active surveillance, aggressive contact isolation, and cohorting and decolonization of infants and HCWs with MRSA. A case–control study was performed to compare infants with and without MRSA.

Results:

A cluster of 6 cases of MRSA infection between September and October 2001 represented an increased attack rate of 21.2% compared with 5.3% in the previous months. Active surveillance identified unsuspected MRSA colonization in 6 (21.4%) of 28 patients and 6 (5.5%) of 110 HCWs screened. They were all successfully decolonized. There was an increased risk of MRSA colonization and infection among infants with low birth weight or younger gestational age. Multiple gestation was associated with an increased risk of colonization (OR, 37.5; CI95, 3.9–363.1) and infection (OR, 5.36; CI95, 1.37–20.96). Gavage feeding (OR, 10.33; CI95, 1.28–83.37) and intubation (OR, 5.97; CI95, 1.22–29.31) were associated with increased risk of infection. Infants with MRSA infection had a significantly longer hospital stay than infants without MRSA (51.83 vs 21.46 days;P= .003). Rep-PCR withmectyping and PVL analysis confirmed the presence of a single common strain of hospital-acquired MRSA.

Conclusion:

Active surveillance, aggressive implementation of contact isolation, cohorting, and decolonization effectively eradicated MRSA from the NICU for 2½ years following the outbreak. (Infect Control Hosp Epidemiol 2005;26:616-621)

Epidemiological and molecular characteristics of meticillin-resistant Staphylococcus aureus in Turkey: A multicentre study

The aim of this study was to investigate the epidemiological and molecular features of clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates in Turkey. MRSA isolates were collected from six regions of Turkey. The mecA and nuc genes were detected by PCR. Antimicrobial susceptibilities were determined by the disk diffusion method. Staphylococcal cassette chromosome mec (SCCmec) and staphylococcal protein A (spa) typing were performed by the sequencing method for 270 randomly selected MRSA isolates. The US Centers for Disease Control and Prevention (CDC) definition was used for epidemiological diagnosis of community-associated MRSA (CA-MRSA). Resistance rates of MRSA to ciprofloxacin, gentamicin, clindamycin, erythromycin, rifampicin, trimethoprim/sulfamethoxazole and tetracycline were 93.4%, 81.2%, 38.5%, 57.8%, 93.9%, 1.1% and 93.1%, respectively. The most frequent SCCmec type was SCCmec III (91.1%). SCCmec type IV was found in 5.2% of the isolates. The most frequent spa type was t030 (81.1%). Five isolates were CA-MRSA if only the epidemiological definition was used (5/725; 0.7%). Two isolates were defined as CA-MRSA both by epidemiological features and SCCmec typing (2/270; 0.7%). Of 14 SCCmec type IV isolates, 12 were not defined as CA-MRSA by epidemiological features. In conclusion, this is the most comprehensive multicentre study in Turkey investigating MRSA using both epidemiological and genotypic features. The CA-MRSA rate is low in Turkey. Combined use of epidemiological and genotypic methods is the most accurate approach for the diagnosis of CA-MRSA.

Methicillin-resistant Staphylococcus aureus carrying the new mecC gene--a meta-analysis

In 2011, a new mecA gene homolog, named mecC gene, was found in isolates from both humans and animals. The discovery of methicillin-resistant Staphylococcus aureus (MRSA) carrying the mecC gene has caused speculations about the origin, epidemiology, and impact of these isolates. The objective of this work is to perform a meta-analysis on the prevalence of mecC MRSA, based on previously published results. Meta-analysis showed that the overall pooled prevalence is 0.009% (95% confidence interval=0.05-0.013) and that there was evidence of heterogeneity (P<0.01, I(2)=97%). In conclusion, the very low reported prevalence provides an important baseline to monitor the epidemiology of this emerging form of MRSA.

Comparative Genomics of Community-Associated Methicillin-Resistant Staphylococcus aureus Shows the Emergence of Clone ST8-USA300 in Geneva, Switzerland

BACKGROUND

Previous investigations of community-associated methicillin-resistant Staphylococcus aureus(CA-MRSA) isolates have revealed a wide diversity of genetic backgrounds, with only sporadic occurrence of ST8-USA300, in Geneva, Switzerland. We conducted a molecular epidemiologic analysis to identify the origin of a sudden increase of ST8 PVL-positive isolates in Geneva during 2013.

METHODS

On the basis of prospective CA-MRSA surveillance, we collected colonizing and infecting ST8-USA300 isolates and compared them to non-ST8 CA-MRSA isolates. Whole-genome sequencing (WGS) was performed for each isolate of this collection, and discriminating molecular features were linked to patient data.

RESULTS

In 2013, 22 isolates with the ST8-USA300 profile were identified among 46 cases of CA-MRSA. WGS revealed 2 groups of strains that differed by the type of the SCCmec IV element encoded and whether they harbored an arginine catabolism mobile element (ACME) locus. ACME-negative strains were mainly isolated from patients traveling in or originating from South America. Single-nucleotide polymorphism positions in isolate groups were used to infer their common ancestor, determine their geographical origin, and trace their relatedness.

CONCLUSIONS

WGS allowed the identification of transmission events and revealed that the increased prevalence of USA300 CA-MRSA isolates resulted from multiple importation events from the Americas but not from local clonal expansion of a successful clone.

Multiple-locus VNTR Analyses of Methicillin-resistant Staphylococcus aureus from Jamaica

BACKGROUND

This study assessed the antimicrobial susceptibilities and the presence of inducible macrolide–lincosamide–streptogramin B (iMLSB) resistance in methicillin-resistant Staphylococcus aureus (MRSA) of Jamaica as well as the relatedness using polymerase chain reaction-based staphylococcal cassette chromosome mec (SCCmec) and multiple-locus variable numbers of tandem repeat analyses (MLVAs).

MATERIALS AND METHODS

Antimicrobial susceptibility, the presence of MLS_B resistance, and SCCmec and MLVA patterns were assessed for 61 nonduplicate isolates of MRSA from hospitalized patients.

RESULTS

While no isolate was resistant to vancomycin, 53 (86.9%) isolates were resistant to ciprofloxacin, 52 (85.3%) to erythromycin, 49 (80%) to lincomycin, and 45 (74%) to clindamycin. Of the 52 erythromycin-resistant isolates, 48% exhibited constitutive resistance and 8% showed inducible MLS_B (iMLS_B) resistance. Most (85%) of typable isolates were SCCmec type IV, and among these, 16 MLVA patterns were identified.

CONCLUSION

Multidrug resistance continues to characterize MRSA. Among the erythromycin-resistant isolates, constitutive resistance and iMLS_B resistance are common. These facts will complicate the treatment of MRSA infections and warrant continued surveillance and judicial use of antimicrobial agents.

Rapid Bacterial Identification, Resistance, Virulence and Type Profiling using Selected Reaction Monitoring Mass Spectrometry

Mass spectrometry (MS) in Selected Reaction Monitoring (SRM) mode is proposed for in-depth characterisation of microorganisms in a multiplexed analysis. Within 60–80 minutes, the SRM method performs microbial identification (I), antibiotic-resistance detection (R), virulence assessment (V) and it provides epidemiological typing information (T). This SRM application is illustrated by the analysis of the human pathogen Staphylococcus aureus, demonstrating its promise for rapid characterisation of bacteria from positive blood cultures of sepsis patients.

Missense mutations in PBP2A Affecting ceftaroline susceptibility detected in epidemic hospital-acquired methicillin-resistant Staphylococcus aureus clonotypes ST228 and ST247 in Western Switzerland archived since 1998

The development and maintenance of an arsenal of antibiotics is a major health care challenge. Ceftaroline is a new cephalosporin with activity against methicillin-resistant Staphylococcus aureus (MRSA); however, no reports concerning MRSA ceftaroline susceptibility have been reported in Switzerland. We tested the in vitro activity of ceftaroline against an archived set of 60 MRSA strains from the University Hospital of Geneva collected from 1994 to 2003. Our results surprisingly revealed ceftaroline-resistant strains (MIC, >1 μg/ml in 40/60 strains; EUCAST breakpoints, susceptible [S], ≤1 μg/ml; resistant [R], >1 μg/ml) were present from 1998 to 2003. The detected resistant strains predominantly belonged to sequence type 228 (ST228) (South German clonotype) but also to ST247 (Iberian clonotype). A sequence analysis of these strains revealed missense mutations in the penicillin-binding protein 2A (PBP2A) allosteric domain (N146K or E239K and N146K-E150K-G246E). The majority of our ST228 PBP2A mutations (N146K or E150K) were distinct from ST228 PBP2A allosteric domain mutations (primarily E239K) recently described for MRSA strains collected in Thailand and Spain during the 2010 Assessing Worldwide Antimicrobial Resistance Evaluation (AWARE) global surveillance program. We also found that similar allosteric domain PBP2A mutations (N146K) correlated with ceftaroline resistance in an independent external ST228 MRSA set obtained from the nearby University Hospital of Lausanne, Lausanne, Switzerland, collected from 2003 to 2008. Thus, ceftaroline resistance was observed in our archived strains (including two examples of an MIC of 4 µg/ml for the Iberian ST247 clonotype with the triple mutation N146K/E150K/G246E), at least as far back as 1998, considerably predating the commercial introduction of ceftaroline. Our results reinforce the notion that unknown parameters can potentially exert selective pressure on PBP2A that can subsequently modulate ceftaroline resistance.

Clinical characteristics of Staphylococcus epidermidis: a systematic review

Staphylococci are known as clustering Gram-positive cocci, nonmotile, non-spore forming facultatively anaerobic that classified in two main groups, coagulase-positive and coagulase-negative. Staphylococcus epidermidis with the highest percentage has the prominent role among coagulase-negative Staphylococci that is the most important reason of clinical infections. Due to various virulence factors and unique features, this microorganism is respected as a common cause of nosocomial infections. Because of potential ability in biofilm formation and colonization in different surfaces, also using of medical implant devices in immunocompromised and hospitalized patients the related infections have been increased. In recent decades the clinical importance and the emergence of methicillin-resistant Staphylococcus epidermidis strains have created many challenges in the treatment process.

Comparison of biofilm formation between major clonal lineages of methicillin resistant Staphylococcus aureus

Objectives

Epidemic methicillin-resistant S. aureus (MRSA) clones cause infections in both hospital and community settings. As a biofilm phenotype further facilitates evasion of the host immune system and antibiotics, we compared the biofilm-forming capacities of various MRSA clones.

Methods

Seventy-six MRSA classified into 13 clones (USA300, EMRSA-15, Hungarian/Brazilian etc.), and isolated from infections or from carriers were studied for biofilm formation under static and dynamic conditions. Static biofilms in microtitre plates were quantified colorimetrically. Dynamic biofilms (Bioflux 200, Fluxion, USA) were studied by confocal laser-scanning and time-lapse microscopy, and the total volume occupied by live/dead bacteria quantified by Volocity 5.4.1 (Improvision, UK).

Results

MRSA harbouring SCCmec IV produced significantly more biomass under static conditions than SCCmec I–III (P = 0.003), and those harbouring SCCmec II significantly less than those harbouring SCCmec I or III (P<0.001). In the dynamic model, SCCmec I–III harbouring MRSA were significantly better biofilm formers than SCCmec IV (P = 0.036). Only 16 strains successfully formed biofilms under both conditions, of which 13 harboured SCCmec IV and included all tested USA300 strains (n = 3). However, USA300 demonstrated remarkably lower percentages of cell-occupied space (6.6%) compared to the other clones (EMRSA-15 = 19.0%) under dynamic conditions. Time-lapse microscopy of dynamic biofilms demonstrated that USA300 formed long viscoelastic tethers that stretched far from the point of attachment, while EMRSA-15 consisted of micro-colonies attached densely to the surface.

Conclusions

MRSA harbouring SCCmec types IV and I–III demonstrate distinct biofilm forming capacities, possibly owing to their adaptation to the community and hospital settings, respectively. USA300 demonstrated abundant biofilm formation under both conditions, which probably confers a competitive advantage, contributing to its remarkable success as a pathogen.

Characterization of PVL-positive MRSA from Norway

Norway is a country in which the Methicillin-resistant Staphylococcus aureus (MRSA) prevalence has been low for the last decades. There are virtually no epidemic, hospital-acquired MRSA because of an emphasis on strict infection control rules and restrictive use of antibiotics. However, community-acquired and/or Panton-Valentine leucocidin (PVL)-positive MRSA need to be monitored as these strains are transmitted outside of healthcare facilities and cannot be contained by healthcare-centred strategies. All 179 non-repetitive isolates of PVL-positive MRSA that were received during 2011 at the regional infection control laboratory at Akershus University Hospital were preserved and spa typed. Seventy isolates were further characterized by DNA microarray hybridization. The most common PVL-MRSA lineages were ST8-MRSA-IV and CC30-MRSA-IV. Further common clones were CC80-MRSA-IV and CC5-MRSA-IV. Other clones were found sporadically. These included ST772-MRSA-V and ST834-MRSA-IV, the latter in patients with epidemiological connections to the Philippines. Small-scale family outbreaks affecting at least 49 individuals were noted, with numbers of known cases per outbreak ranging from two to seven. At least 24 cases were related to foreign travel to Eritrea, India, Iraq, Macedonia, Pakistan, the Philippines, Poland, Singapore, Turkey, the USA and Vietnam. These data show that community-acquired/PVL-positive MRSA are not yet a major public health problem in Southern Norway. Our study corroborates the current practice of mandatory screening of patients and staff with travel histories, admissions or employment in healthcare institutions outside the Scandinavian countries or with known MRSA contacts.

[Cases of MRSA in nursing homes in Oslo 2005-11]

BACKGROUND

The number of infections caused by MRSA has increased substantially in Norway in the past decade. It is an objective to prevent MRSA from becoming established in nursing homes and hospitals. The purpose of the article is to describe the features of the development of MRSA cases found in nursing homes in Oslo.

MATERIALS AND METHOD

We carried out a retrospective study of registered cases of MRSA (both sufferers and carriers) in Oslo in 2005-11. Data were obtained from the City of Oslo municipal health services' MRSA database and from genotyping carried out at Akershus University Hospital.

RESULTS

The annual number of cases of MRSA found in Oslo increased during the period 2005-11 from 92 in 2005 to 268 in 2011, a total of 1198 cases. Of these, 224 cases (19%) were registered in nursing homes, distributed among 22 institutions, 158 residents and 66 staff, with an average of 32 cases annually (14-58 spread). Twenty-eight of 50 nursing homes had no cases of MRSA, while 159 of the cases were related to outbreaks of MRSA. Three of 20 outbreaks affected residents only. The nursing home isolates consisted of 40 different spa types, of which 160 (71%) of the isolates were clustered in three clonal complexes. The most common spa type t304 was found in 116 (52%) of the cases.

INTERPRETATION

Cases of MRSA in Oslo in total increased sharply from 2005 to 2011, while the number of cases in nursing homes was stable. It is, however, uncertain whether this reflects the actual incidence.

Staphylococcal cassette chromosome mec characterization of methicillin-resistant Staphylococcus aureus strains isolated at the military hospital of Constantine/Algeria

Staphylococcal cassette chromosome mec is a genetic mobile element that carries the gene mecA mediating the methicillin resistance in staphylococci. The aim of this study is to type the Staphylococcal cassette chromosome mec (SCCmec) in 64 non-redundant methicillin-resistant Staphylococcus aureus (MRSA) strains recovered at the military hospital of Constantine (Algeria) between 2005 and 2007. Methicillin resistance was detected by oxacillin and cefoxitin discs and PBP2a test, and then confirmed by mecA PCR. The SCCmec complex types were determined by real time PCR. The analysis showed that 50 isolates were hospital acquired (HA-MRSA) and 14 were community-acquired (CA-MRSA). SCCmec type IV and V (traditionally attributed to CA-MRSA) were harbored by both HA-MRSA and CA-MRSA, while SCCmec type I, II and III were not recorded. These findings motivate more investigations to be carried on HA-MRSA in our hospital and other national health care centers.

Co-infection of Ornithobacterium rhinotracheale with Streptococcus zooepidemicus in chickens

An outbreak of bronchial embolization with 50%-70% morbidity and 30% mortality occurred in broilers in northeast China. This highly contagious disease is characterized by the sudden onset of clinical symptoms, including dyspnea, hemorrhagic tracheal discharge, and bronchial obstruction. Subsequently, six strains of Ornithobacterium rhinotracheale (ORT) and three strains of Streptococcus zooepidemicus were isolated from the various organs and identified using biochemical tests and PCR methods. The pathogenesis of embolization in chickens is poorly understood. The current experimental study confirmed that ORT infection alone could induce a significantly fatal hemorrhagic pneumonia and high mortality in comparison with S. zooepidemicus infection. Moreover, co-infection of ORT with S. zooepidemicus could induce even higher mortality, with severe bronchial obstruction, than that observed in chickens infected with S. zooepidemicus or ORT alone. Therefore, the combination of ORT and S. zooepidemicus may be associated with the outbreak of chicken bronchial embolization. Further investigation of the pathogenesis of ORT and Streptococcus is urgently needed.

Methicillin-resistant Staphylococcus aureus containing mecC in Swedish dairy cows

Background

Hitherto, methicillin-resistant Staphylococcus aureus (MRSA) has not been detected in Swedish cattle. However, due to the report of mecC, a novel homologue to the mecA gene, there was reason to re-evaluate susceptibility results from strain collections of Staphylococcus aureus and test suspected isolates for the presence of mecC.

Findings

Bovine isolates of S. aureus with elevated minimum inhibitory concentrations of beta-lactams were retrospectively tested for presence of mecC. In four of the isolates mecC was detected.

Conclusion

In Sweden, this is the first finding of MRSA in cattle and the first detection of MRSA harbouring mecC of domestic animal origin. MRSA in animal populations has implications as a potential reservoir with risk for spread to humans. Occurrence of MRSA among Swedish cattle appears still very limited.

Meticillin-resistant Staphylococcus aureus in elderly residents of care homes: colonization rates and molecular epidemiology

BACKGROUND

Meticillin-resistant Staphylococcus aureus (MRSA) is a significant cause of mortality and morbidity in healthcare and community settings; however, there is a paucity of large-scale, longitudinal studies monitoring the occurrence of MRSA in the care home setting.

AIM

To determine the molecular epidemiology of MRSA colonizing elderly residents of care homes.

METHODS

Residents in 65 care homes in Leeds, UK, were screened for MRSA nasal colonization in four consecutive years (2006-2009). Isolates were characterized using antibiotic susceptibility testing, detection of the Panton-Valentine leucocidin (PVL) locus, accessory gene regulator allotyping, characterization of the staphylococcal cassette chromosome mec element, spa-typing and pulsed-field gel electrophoresis.

FINDINGS

MRSA was recovered from 888 nasal swabs of 2492 residents and prevalence was similar (19-22%) throughout the study. Resistance to ≥3 antibiotic classes was common (34%), but resistance to only β-lactam agents was rare (3%); no PVL-positive isolates were identified. Most isolates were related to healthcare-associated epidemic-MRSA type 15 (EMRSA-15, ST22-IV); such isolates decreased in prevalence during the study (86-72%; P < 0.0001, χ(2)-test). The remainder belonged to five different multi-locus sequence type clonal complexes (CC). Most notably, CC59 strains increased in prevalence (10-25%; P < 0.0001, χ(2)-test) and were associated with high-level mupirocin resistance.

CONCLUSIONS

The molecular epidemiology of MRSA in care homes is complex and dynamic. There was a high, consistent prevalence of MRSA nasal colonization, dominated by healthcare-associated strains. Vigilance is recommended; however, as high-level mupirocin resistance was associated with a single clonal group (CC59) that significantly increased in prevalence during the study.

Genotyping of 353 Staphylococcus aureus bloodstream isolates collected between 2004 and 2009 at a Norwegian university hospital and potential associations with clinical parameters

We analyzed 353 Staphylococcus aureus bloodstream isolates from 2004 to 2009 to identify dominant genotypes, changes over time, and associations between genotype, phenotype, and clinical parameters. The isolates were genotyped with regard to spa type and presence of Panton-Valentine leukocidin and toxic shock syndrome toxin 1-encoding genes. A high level of genetic diversity was detected. All but three isolates were methicillin sensitive. Interestingly, spa clonal complex 021 showed a weak association with higher all-cause hospital mortality.

Molecular and epidemiological evaluation of strain replacement in patients previously harboring gentamicin-resistant MRSA

Gentamicin-susceptible methicillin-resistant Staphylococcus aureus (GS-MRSA) clones have gradually replaced gentamicin-resistant MRSA (GR-MRSA) clones in many European countries. We studied molecular and epidemiological aspects of MRSA strain replacement in individual patients. All patients from whom at least 2 MRSA strains showing different gentamicin susceptibility patterns were isolated between 1996 and 2008 were retrospectively identified. Staphylococcal cassette chromosome mec (SCCmec) type and clonality between isolates were determined using molecular methods. Risk factors for individual GR-MRSA SCCmec I (prevalent clone) strain replacement with GS-MRSA non-SCCmec I types were studied in a nested case-crossover study (n = 55 patients). MRSA strain replacement was observed in 127 patients, 85 (67%) of whom were initially colonized with GR-MRSA replaced subsequently by GS-MRSA. Most GS-MRSA replacement strains (50; 59%) possessed SCCmec IV. All MRSA isolate pairs from the same patient that consisted of different gentamicin susceptibility and SCCmec types were also genotypically different. Exposure to domiciliary nursing assistance (odds ratio [OR], 8.1; 95% confidence interval [CI], 1.2 to 53.7) and high Charlson scores (OR, 7.1; 95% CI, 1.1 to 46.8) were associated with individual strain replacement. In individual patients, exogenous acquisition of a different MRSA strain was responsible for strain replacement in most cases. Domiciliary nursing assistance could be a target for specific control measures to prevent transmission of GS-MRSA in our setting.

Pragmatic management of Panton-Valentine leukocidin-associated staphylococcal diseases

Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus is associated with a broad spectrum of diseases, ranging from common uncomplicated soft tissue infections to severe diseases such as complicated soft tissue infections, extensive bone and joint infections, and necrotising pneumonia. Specialised management of infection based on the presence of PVL may not be required for mild infections, whereas it could be lifesaving in other settings. Moreover, most severe PVL diseases are recently identified entities and a 'gold standard' treatment from comparatives studies of different therapeutic options is lacking. Thus, recommendations are based on expert opinions, which are elaborated based on theory, in vitro data and analogies with other toxin-mediated diseases. In this review, we consider the potential need for specialised PVL-based management and, if required, which tools should be used to achieve optimal management.

Epidemiology and virulence insights from MRSA and MSSA genome analysis

Staphylococcus aureus is a major human pathogen responsible for a wide diversity of infections ranging from localized to life threatening diseases. From 1961 and the emergence of methicillin-resistant S. aureus (MRSA), this bacterium has shown a particular capacity to survive and adapt to drastic environmental changes and since the beginning of the 1990s it has spread worldwide. Until recently, S. aureus was considered as the prototype of a nosocomial pathogen but it has now been recognized as an agent responsible for outbreaks in the community. Several recent reports suggest that the epidemiology of MRSA is changing. Understanding of pathogenicity, virulence and emergence of epidemic clones within MRSA populations is not clearly defined, despite several attempts to identify common molecular features between strains that share similar epidemiological and/or virulence behavior. These studies included: pattern profiling of bacterial adhesins, analysis of clonal complex groups, molecular genotyping and enterotoxin content analysis. To date, all approaches failed to find a correlation between molecular determinants and clinical outcomes. We hypothesize that the capacity of the bacterium to become more invasive or virulent is determined by genetics. The utilization of massively parallel methods of analysis is therefore ideal to study the contribution of genetics. Therefore, this article focuses on the entire genome including coding sequences as well as noncoding sequences. This high resolution approach allows the monitoring micro- and macroevolution of MRSA and identification of specific genomic markers of evolution of invasive or highly virulent phenotypes.

The connection between agr and SCCmec elements of Staphylococcus aureus strains and their response to photodynamic inactivation

OBJECTIVE

The aim of this work was to analyze the presence of specific types of agr and SCCmec in Staphylococcus aureus strains and to determine the correlation between these types of genes and the response of S. aureus strains to photodynamic inactivation.

BACKGROUND

S. aureus is an important human pathogen that is still one of the most common etiological factors of nosocomial infections. The genetic factor connected with high pathogenicity of S. aureus strains is the agr locus, which encodes a molecule responsible for activation of virulence genes. The characteristic feature of strains resistant to methicillin (MRSA) is the presence of the gene determining the resistance to β-lactam antibiotics. This gene is a part of a mobile genetic element known as Staphylococcal Chromosome Cassette mec (SCCmec). Polymorphic differences in the agr locus and SCCmec cassette enable classification of strains into different groups.

MATERIALS AND METHODS

We cultured and incubated each strain with defined dose of photosensitizer (protoporphyrin diarginate). Next, strains were irradiated with a red light at a dose of 12  J/cm(2). After an 18-h incubation, the Colony Forming Units were counted and the results were analyzed statistically. Furthermore, the genetic profile of the studied strains was determined with the use of the Multiplex PCR reaction both for agr and SCCmec elements.

RESULTS

The results agreed with previous data, confirming that the response to photodynamic inactivation varies among different S. aureus strains. We also found a connection between some of the agr and SCCmec groups and the response of analyzed S. aureus strains to photoinactivation.

CONCLUSION

Unfortunately, those relations are not specific enough to determine a diagnostically important pattern, which could enable predictions of strain response to PDI. Nevertheless, we can conclude that the connection between the response of S. aureus strains to photoinactivation and the strain specific agr/SCCmec pattern could be observed.

Evaluation of molecular assays for rapid detection of methicillin-resistant Staphylococcus aureus

The diagnostic sensitivities of the BD GeneOhm and Cepheid Xpert assays were compared using culture on log-serial dilutions of well-characterized methicillin-resistant Staphylococcus aureus (MRSA) and non-MRSA strains and on nasal and groin swabs from patients with histories of MRSA carriage. The sensitivities of GeneOhm and Xpert were high at 10(3)-CFU/ml MRSA concentrations (92.3% and 96.3%, respectively) although decreased considerably (<35%) at a 1-log-lower concentration. Unexpectedly, both assays also detected select coagulase-negative staphylococci, which requires further evaluation.

Microstructuring of polymer films for sensitive genotyping by real-time PCR on a centrifugal microfluidic platform

We present a novel process flow enabling prototyping of microfluidic cartridges made out of polymer films. Its high performance is proven by implementation of a microfluidic genotyping assay testing 22 DNA samples including clinical isolates from patients infected by methicilin-resistant Staphylococcus aureus (MRSA). The microfluidic cartridges (disks) are fabricated by a novel process called microthermoforming by soft lithography (microTSL). Positive moulds are applied allowing for higher moulding precision and very easy demoulding when compared to conventional microthermoforming. High replication accuracies with geometric disk-to-disk variations of less than 1% are typical. We describe and characterise fabrication and application of microfluidic cartridges with wall thicknesses <188 microm thus enabling efficient thermocycling during real-time polymerase chain reaction (PCR). The microfluidic cartridges are designed for operation in a slightly modified commercial thermocycling instrument. This approach demonstrates new opportunities for both microfluidic developments and well-established laboratory instruments. The microfluidic protocol is controlled by centrifugal forces and divides the liquid sample parallely into independent aliquots of 9.8 microl (CV 3.4%, N = 32 wells). The genotyping assays are performed with pre-stored primers and probes for real-time PCR showing a limit of detection well below 10 copies of DNA per reaction well (N = 24 wells in 3 independent disks). The system was evaluated by 44 genotyping assays comprising 22 DNA samples plus duplicates in a total of 11 disks. The samples contained clinical samples of seven different genotypes of MRSA as well as positive and negative controls. The results are in excellent agreement with the reference in microtubes.

Genetic diagnosis of community-acquired MRSA: a multiplex real-time PCR method for Staphylococcal cassette chromosome mec typing and detecting toxin genes

Methicillin-resistant Staphylococcus aureus (MRSA) causes a wide range of infections in health care settings and community environments. In particular, community-acquired MRSA (CA-MRSA) is important for clinicians because many fatal cases in healthy populations have been reported. Staphylococcal cassette chromosome mec (SCCmec) is a mobile genetic element and carries the central determinant for broad-spectrum beta-lactam resistance encoded by the mecA gene. The emergence of MRSA is due to the acquisition and insertion of the SCCmec element into the chromosome. CA-MRSA is characterized as SCCmec type IV. Thus, we aimed to establish a novel multiplex real-time PCR method to distinguish SCCmec type, which enables us to evaluate the pathogenicity of MRSA. A total of 778 MRSA were isolated at Nagasaki University Hospital from 2000 to 2007. All isolates were subjected to minimal inhibitory concentration testing and PCR for SCCmec typing and detecting genes of toxins: tst (toxic shock syndrome toxin 1), sec (encoded enterotoxin type c), etb (exfoliative toxin type b), and lukS/F-PV (Panton-Valentine leukocidin). PCR was performed to amplify a total of 10 genes in the same run. The 667 MRSA clones detected from pus in 778 clones were classified as SCCmec type II (77.7%), type IV (19.2%), and type I (3.0%). 87.5% of SCCmec type II clone had tst and sec genes. No isolate was lukS/F-PV positive. The present study indicates the high rate of lukS/F-PV-negative SCCmec type IV in Nagasaki. Our PCR method is convenient for typing MRSA and detecting toxins in Japan.

Evaluation of chromogenic media for detection of methicillin-resistant Staphylococcus aureus

Rapid laboratory diagnosis is critical for treating, managing, and preventing methicillin-resistant Staphylococcus aureus (MRSA) infections. We evaluated and compared the potential for MRSA detection of five chromogenic media, Brilliance MRSA agar (Oxoid), ChromID (bioMérieux), MRSASelect (Bio-Rad), CHROMagar (CHROMagar Microbiology), and BBL-CHROMagar (BD Diagnostics). Media were tested with log serial dilutions (10(0) to 10(6) CFU) of pure isolates of MRSA (n = 60), non-MRSA (n = 27), and defined mixtures thereof simulating clinical samples (n = 84). Further evaluations were done on pre-enriched nasal and groin screening swabs (n = 213) from 165 hospitalized patients. Randomized samples were spiral plated on each medium and independently scored by five investigators for characteristic colonies at 24 and 48 h of incubation. Confirmatory testing of up to five putative MRSA colonies recovered from each medium was done. The cumulative average sensitivity with isolates, mixtures, and clinical samples was the highest for Brilliance MRSA agar (97%) and similar for the other four media (>or=92%). The cumulative average specificity was the highest for BBL-CHROMagar (99%), followed by MRSASelect (98%), CHROMagar (97%), ChromID (89%), and Brilliance MRSA agar (86%). All of the media detected MRSA at 10 and 1 CFU, although at these low loads, few MRSA samples harboring SCCmec type III or IV were misinterpreted as non-MRSA by investigators. False-positive results were mainly due to methicillin-resistant S. epidermidis. For an arbitrary MRSA prevalence of 5% and based on patient sample evaluations, the positive predictive values for BBL-CHROMagar and CHROMagar ( approximately 84%) were the highest. The negative predictive values of all of the media were >or=92% for MRSA prevalences ranging from 5% to 30%. In conclusion, BBL-CHROMagar and CHROMagar gave the best overall results for detection of MRSA, irrespective of the sample concentration, investigator, or incubation period.

Comparative activity of oritavancin against meticillin-resistant Staphylococcus aureus (MRSA) bloodstream isolates from Geneva University Hospital

In this study, we assessed by broth microdilution the in vitro activity of oritavancin, a semisynthetic lipoglycopeptide currently under development, against selected meticillin-resistant Staphylococcus aureus (MRSA) bloodstream isolates (n=56) from Geneva University Hospital, Switzerland, displaying a wide range of vancomycin minimum inhibitory concentrations (MICs) (0.25-4 microg/mL). The MRSA resistance phenotype was confirmed by broth microdilution (oxacillin MIC > or = 4 microg/mL) for all isolates; 89% and 100% of the tested isolates were also resistant to erythromycin and ciprofloxacin, respectively. For 53 MRSA isolates for which vancomycin MICs were in the susceptible range (0.5-2.0 microg/mL), the oritavancin MICs ranged from 0.03 microg/mL to 0.5 microg/mL. For these 53 vancomycin-susceptible isolates, the cumulative distribution of oritavancin MICs was markedly different from those of vancomycin, teicoplanin, daptomycin and linezolid MICs, yielding an oritavancin MIC for 90% of the organisms (MIC(90)) (0.25 microg/mL) that was four times lower than the MIC(90) values (1 microg/mL) of comparators. For three MRSA isolates with a vancomycin-intermediate phenotype (vancomycin MIC=4 microg/mL), oritavancin MICs (0.5-1.0 microg/mL) were 2-4-fold lower than vancomycin, teicoplanin or daptomycin MICs, but were equivalent to linezolid MICs. Pairwise comparison for each bloodstream isolate showed that oritavancin was > or =4-fold more active than vancomycin, teicoplanin and daptomycin, against 86%, 75% and 59% of all MRSA isolates, respectively.

Multiplex real-time PCR for rapid Staphylococcal cassette chromosome mec typing

Rapid identification and typing of methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) is important for understanding the molecular epidemiology and evolution of MRSA and offers many advantages for controlling transmission in both health care and community settings. We developed a rapid molecular beacon real-time PCR (MB-PCR) assay for staphylococcal cassette chromosome mec (SCCmec) typing. The design of this system is based on the established definition of SCCmec types, namely, the combination of the mec class complex with the ccr allotype. The assay consists of two multiplex panels, the combination of which results in two targets (mec class, ccr) for each SCCmec type. MB-PCR panel I targets mecA, ccrB2, mecI, and the DeltamecR1-IS1272 junction (mec class B); it can definitively identify SCCmec types II and IV. MB-PCR panel II detects ccrC, ccrB1, ccrB3, ccrB4, and the DeltamecR1-IS431 junction (mec class C2) and is therefore capable of identifying SCCmec types I, III, V, and VI in combination with panel I. The method can also detect the recently described novel SCCmec type VIII (ccrAB4 with mec class A). Our assay demonstrated 100% concordance when applied to 162 MRSA strains previously characterized by traditional SCCmec typing schemes. Four geographically and temporally diverse S. aureus collections were also successfully classified by our assay, along with 1,683 clinical isolates comprising both hospital- and community-associated MRSA and methicillin-susceptible S. aureus strains. As many as 96 isolates can be classified easily within 3 to 4 h, including DNA isolation, PCR cycling, and analysis. The assay is rapid, robust, sensitive, and cost-effective, allowing for high-throughput SCCmec typing of MRSA isolates.

Genomic analysis of an emerging multiresistant Staphylococcus aureus strain rapidly spreading in cystic fibrosis patients revealed the presence of an antibiotic inducible bacteriophage

Background

Staphylococcus aureus is a major human pathogen responsible for a variety of nosocomial and community-acquired infections. Recent reports show that the prevalence of Methicillin-Resistant S. aureus (MRSA) infections in cystic fibrosis (CF) patients is increasing. In 2006 in Marseille, France, we have detected an atypical MRSA strain with a specific antibiotic susceptibility profile and a unique growth phenotype. Because of the clinical importance of the spread of such strain among CF patients we decided to sequence the genome of one representative isolate (strain CF-Marseille) to compare this to the published genome sequences. We also conducted a retrospective epidemiological analysis on all S. aureus isolated from 2002 to 2007 in CF patients from our institution.

Results

CF-Marseille is multidrug resistant, has a hetero-Glycopeptide-Intermediate resistance S. aureus phenotype, grows on Cepacia agar with intense orange pigmentation and has a thickened cell wall. Phylogenetic analyses using Complete Genome Hybridization and Multi Locus VNTR Assay showed that CF-Marseille was closely related to strain Mu50, representing vancomycin-resistant S. aureus. Analysis of CF-Marseille shows a similar core genome to that of previously sequenced MRSA strains but with a different genomic organization due to the presence of specific mobile genetic elements i.e. a new SCCmec type IV mosaic cassette that has integrated the pUB110 plasmid, and a new phage closely related to phiETA3. Moreover this phage could be seen by electron microscopy when mobilized with several antibiotics commonly used in CF patients including, tobramycin, ciprofloxacin, cotrimoxazole, or imipenem. Phylogenetic analysis of phenotypically similar h-GISA in our study also suggests that CF patients are colonized by polyclonal populations of MRSA that represents an incredible reservoir for lateral gene transfer.

Conclusion

In conclusion, we demonstrated the emergence and spreading of a new isolate of MRSA in CF patients in Marseille, France, that has probably been selected in the airways by antibiotic pressure. Antibiotic-mediated phage induction may result in high-frequency transfer and the unintended consequence of promoting the spread of virulence and/or antibiotic resistance determinants. The emergence of well-adapted MRSA is worrying in such population chronically colonized and receiving many antibiotics and represents a model for emergence of uncontrollable super bugs in a specific niche.

Reviewers

This article was reviewed by Eric Bapteste, Pierre Pontarotti, and Igor Zhulin. For the full reviews, please go to the Reviewers' comments section.

Rapid methods for diagnosis of bloodstream infections

Direct detection technologies for pathogenic microorganisms are emerging to be applied in the diagnosis of serious bloodstream infections and infections at sterile body sites, as well as for quality control measures prior to the release of sterile blood products and to ascertain microbial safety of food. Standard blood cultures as the current gold standard for detection of bacteraemia/sepsis and other culture-based microbiological identification procedures are comparatively slow and have limited sensitivity for fastidious or slow-growing microorganisms. Rapid nucleic acid-based technologies with PCR amplification or hybridisation probes for specific pathogens, broad-range bacterial or fungal assays, flow cytometry, as well as protein-based characterisation by mass spectrometry, aim at identification of pathogenic microorganisms within minutes to hours. Interpretation of direct detection of panbacterial or panfungal nucleic acids instead of living microorganisms in blood is complex, given the risk of contamination, the ubiquitous presence of bacterial and fungal DNA, and the lack of a gold standard. Since many of the infections at sterile sites, particularly sepsis, are medical emergencies requiring immediate therapeutic responses, rapid technologies could contribute to reduction of morbidity, mortality, and of the economic burden. This review summarises the currently available data on rapid non-culture-based technologies and outlines the potential clinical usefulness in infectious disease diagnosis.

Community-acquired methicillin-resistant Staphylococcus aureus infections in two scuba divers returning from the Philippines

We describe two patients who had skin infection due to identical strains of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) after returning from the Philippines. Both patients did not share risk factors for CA-MRSA acquisition besides scuba diving. Scuba diving equipment may represent a possible new mode of acquisition of CA-MRSA.

Are methicillin-resistant Staphylococcus aureus that produce Panton-Valentine leucocidin (PVL) found among residents of care homes?

OBJECTIVES

Panton-Valentine leucocidin (PVL)-positive Staphylococcus aureus are responsible for causing skin and soft tissue infections, with the potential to cause severe invasive disease. Recently, methicillin-resistant Staphylococcus aureus (MRSA) strains that produce PVL have emerged in the community. As residents of care homes are a key group at risk of MRSA colonization and infection, we have examined the epidemiology of MRSA in three large cohorts of residents in urban care homes to establish whether PVL-positive MRSA strains are present in this setting.

METHODS

Nasal swabs (n = 3037) collected from consenting residents of 69 care homes in Leeds, UK, were screened for MRSA using chromogenic agar over three periods (June-August 2005, November-December 2006 and October-November 2007). PCR amplification was used to detect genes encoding PVL. Antibiogram profile and PFGE were also used to characterize MRSA isolates (n = 601).

RESULTS

MRSA prevalence was 21%, 20% and 19% in each cohort, respectively. The majority of the isolates were related epidemiologically to the predominant local nosocomial epidemic MRSA strain, EMRSA-15 (78%). No isolate carried the genes encoding PVL. Twelve percent of the isolates (n = 74) had increased susceptibility to non-beta-lactam agents and were distributed across 31 care homes.

CONCLUSIONS

MRSA strains that produced PVL were not found to be colonizing residents of care homes between 2005 and 2007. Continued surveillance is, however, necessary to understand the interaction between MRSA in care homes and hospitals, especially to reduce the chance that the former may amplify community-associated MRSA strains.

Prevalence of and risk factors for community-acquired methicillin-resistant and methicillin-sensitive staphylococcus aureus colonization in children seen in a practice-based research network

OBJECTIVE

We sought to define the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus nasal colonization in the St Louis pediatric population.

METHODS

Children from birth to 18 years of age presenting for sick and well visits were recruited from pediatric practices affiliated with a practice-based research network. Nasal swabs were obtained, and a questionnaire was administered.

RESULTS

We enrolled 1300 participants from 11 practices. The prevalence of methicillin-resistant S aureus nasal colonization varied according to practice, from 0% to 9% (mean: 2.6%). The estimated population prevalence of methicillin-resistant S aureus nasal colonization for the 2 main counties of the St Louis metropolitan area was 2.4%. Of the 32 methicillin-resistant S aureus isolates, 9 (28%) were health care-associated types and 21 (66%) were community-acquired types. A significantly greater number of children with community-acquired methicillin-resistant S aureus were black and were enrolled in Medicaid, in comparison with children colonized with health care-associated methicillin-resistant S aureus. Children with both types of methicillin-resistant S aureus colonization had increased contact with health care, compared with children without colonization. Methicillin-sensitive S aureus nasal colonization ranged from 9% to 31% among practices (mean: 24%). The estimated population prevalence of methicillin-sensitive S aureus was 24.6%. Risk factors associated with methicillin-sensitive S aureus colonization included pet ownership, fingernail biting, and sports participation.

CONCLUSIONS

Methicillin-resistant S aureus colonization is widespread among children in our community and includes strains associated with health care-associated and community-acquired infections.

Methicillin-resistant Staphylococcus aureus, Geneva, Switzerland, 1993-2005

Molecular characterization of methicillin-resistant Staphylococcus aureus (MRSA) strains different from those of an endemic healthcare-associated clone was conducted over 13 years in Geneva, Switzerland. We demonstrated strain diversity, including clones rarely found in Europe. Local epidemiology of community-associated MRSA is diverse and is evolving by importation and transmission of new strains.

Validation of virulence and epidemiology DNA microarray for identification and characterization of Staphylococcus aureus isolates

The human pathogen Staphylococcus aureus is isolated and characterized using traditional culture and sensitivity methodologies that are slow and offer limited information on the organism. In contrast, DNA microarray technology can provide detailed, clinically relevant information on the isolate by detecting the presence or absence of a large number of virulence-associated genes simultaneously in a single assay. We have developed and validated a novel, cost-effective multiwell microarray for the identification and characterization of Staphylococcus aureus. The array comprises 84 gene targets, including species-specific, antibiotic resistance, toxin, and other virulence-associated genes, and is capable of examining 13 different isolates simultaneously, together with a reference control strain. Analysis of S. aureus isolates whose complete genome sequences have been determined (Mu50, N315, MW2, MRSA252, MSSA476) demonstrated that the array can reliably detect the combination of genes known to be present in these isolates. Characterization of a further 43 S. aureus isolates by the microarray and pulsed-field gel electrophoresis has demonstrated the ability of the array to differentiate between isolates representative of a spectrum of S. aureus types, including methicillin-susceptible, methicillin-resistant, community-acquired, and vancomycin-resistant S. aureus, and to simultaneously detect clinically relevant virulence determinants.

Comparison of single- and multilocus sequence typing and toxin gene profiling for characterization of methicillin-resistant Staphylococcus aureus

We compared three novel methicillin-resistant Staphylococcus aureus (MRSA) genotyping methods with multilocus sequence typing (MLST) and spa typing to assess their utility for routine strain typing. The new methods were femA and nuc sequence typing and toxin gene profiling (TGP), using a multiplex-PCR-based reverse line blot assay to detect 13 pyrogenic superantigen and exfoliative toxin genes. Forty-two well-characterized MRSA strains, representing 15 MLSTs or 9 clonal clusters (CCs), were genotyped by all methods. Twenty-two spa, nine femA, and seven nuc sequence types were identified. The femA sequence types correlated exactly with CCs; nuc sequences types were less discriminatory but generally correlated well with femA types and CCs. Ten isolates contained none of 13 toxin genes; TGPs of the remainder comprised 1 to 5 toxin genes. The combination of spa typing and TGPs identified 26 genotypes among the 42 strains studied. A combination of two or three rapid, inexpensive genotyping methods could potentially provide rapid MRSA strain typing as well as useful information about clonal origin and virulence.

Panton-Valentine Leukocidin-Positive Methicillin-Resistant Staphylococcus aureus Lung Infection in Patients With Cystic Fibrosis

BACKGROUND

Panton-Valentine Leukocidin-expressing (PVL+) methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen worldwide causing fatal necrotizing pneumonias in otherwise healthy individuals but has not been described in patients with cystic fibrosis (CF). Following two cases of patients with CF admitted with lung abscesses in association with PVL+ MRSA, we examined the incidence and the clinical characteristics of MRSA acquisition in our CF patient population.

METHODS

Newly acquired MRSA isolates from patients with CF followed up at St. Louis Children's Hospital were analyzed for the presence of Panton-Valentine leukocidin coding region, clindamycin susceptibility, staphylococcal cassette chromosome (SCC) mec type, and multilocus sequence type. Medical records and pulmonary function studies at the time of MRSA isolation were reviewed.

RESULTS

MRSA isolates from 40 CF patients were available for analysis. Six children (15%) had PVL+ MRSA infection. All PVL+ organisms were clindamycin susceptible. Patients who acquired a PVL+ organism were more likely to have a focal pulmonary infiltrate on chest radiograph, including cavitary lung lesions in two patients (p = 0.04), a markedly greater decline in FEV1 at the time of MRSA detection (p = 0.01), and a significantly higher WBC count (p = 0.04) and absolute neutrophil count (p = 0.04). These patients were more likely to be admitted for IV antibiotic therapy for respiratory illnesses (p < 0.01).

CONCLUSIONS

We describe the emergence of PVL+ MRSA in our CF population in association with development of invasive lung infections including lung abscesses. Early identification and treatment of CF patients with newly acquired PVL+ MRSA may be crucial.