Correlation of penicillin Binding protein 2a detection with oxacillin resistance in Staphylococcus aureus and discovery of a novel penicillin binding protein 2a mutation

Prevalence, Mechanism, Genetic Diversity, and Cross-Resistance Patterns of Methicillin-Resistant Staphylococcus Isolated from Companion Animal Clinical Samples Submitted to a Veterinary Diagnostic Laboratory in the Midwestern United States

Methicillin-resistant Staphylococcus (MRS) is a leading cause of skin and soft tissue infections in companion animals, with limited treatment options available due to the frequent cross-resistance of MRS to other antibiotics. In this study, we report the prevalence, species distribution, genetic diversity, resistance mechanism and cross-resistance patterns of MRS isolated from companion animal (mostly dog and cat) clinical cases submitted to Iowa State University Veterinary Diagnostic Laboratory (ISU VDL) between 2012 and 2019. The majority of isolates were identified as Staphylococcus pseudintermedius (68.3%; 2379/3482) and coagulase-negative Staphylococcus (CoNS) (24.6%; 857/3482), of which 23.9% and 40.5% were phenotypically resistant to methicillin, respectively. Cross resistance to other β-lactams (and to a lesser extent to non-β-lactams) was common in both methicillin-resistant S. pseudintermedius (MRSP) and CoNS (MRCoNS), especially when oxacillin MIC was ≥4 μg/mL (vs. ≥0.5−<4 μg/mL). The PBP2a protein was detected by agglutination in 94.6% (521/551) MRSP and 64.3% (146/227) MRCoNS. A further analysis of 31 PBP2a-negative MRS isolates (all but one MRCoNS) indicated that 11 were mecA gene-positive while 20 were negative for mecA and other mec genes by PCR. The resistance to last-resort anti-staphylococcal human drugs (e.g., tigecycline, linezolid, vancomycin) among the MRS tested was none to very low. Even though genotyping indicated an overall high level of genetic diversity (87 unique PFGE patterns and 20 MLST types) among a subset of MRSP isolates tested (n = 106), certain genotypes were detected from epidemiologically connected cases at the same or different time points, suggesting persistence and/or nosocomial transmission. These results indicate a relatively high prevalence of MRS from companion animals in the Midwestern US; therefore, it is important to perform routine susceptibility testing of Staphylococcus in veterinary clinical settings for the selection of appropriate antimicrobial therapy.

Detection of Methicillin-Resistant Staphylococcus aureus Infections Using Molecular Methods

The application of molecular detection methods for bacterial pathogens has dramatically improved the outcomes of septic patients, including those with methicillin-resistant Staphylococcus aureus (MRSA) infections. Molecular methods can be applied to a variety of clinical specimens including nasal swabs, growth in blood culture bottles, and wounds. While data show that the overall accuracy of molecular tests for MRSA is high, results can be confounded by the presence of multiple staphylococcal species in a specimen, insertions and deletions of DNA in and around the Staphylococcal Cassette Chromosome mec (SCCmec) element, and point mutations in mecA. Herein, we explore the complexities of molecular approaches to MRSA detection and the instances where phenotypic methods should be pursued to resolve discrepancies between genotypic and phenotypic results.

The Genotype-to-Phenotype Dilemma: How Should Laboratories Approach Discordant Susceptibility Results?

Traditional culture-based methods for identification and antimicrobial susceptibility testing (AST) of bacteria take 2 to 3 days on average. Syndromic molecular diagnostic panels have revolutionized clinical microbiology laboratories as they can simultaneously identify an organism and detect some of the most significant antimicrobial resistance (AMR) genes directly from positive blood culture broth or from various specimen types (e.g., whole blood, cerebrospinal fluid, and respiratory specimens). The presence or absence of an AMR marker associated with a particular organism can be used to predict the phenotypic AST results to more rapidly guide therapy. Numerous studies have shown that genotypic susceptibility predictions by syndromic panels can improve patient outcomes. However, an important limitation of AMR marker detection to predict phenotype is the potential discrepancies that may arise upon performing phenotypic AST of the recovered organism in culture. The focus of this minireview is to address how clinical laboratories should interpret rapid molecular results from commercial platforms in relation to phenotypic AST. Stepwise approaches and solutions are provided to resolve discordant results between genotypic and phenotypic susceptibility results.

Mutation-Based Antibiotic Resistance Mechanism in Methicillin-Resistant Staphylococcus aureus Clinical Isolates

β-Lactam antibiotics target penicillin-binding proteins and inhibit the synthesis of peptidoglycan, a crucial step in cell wall biosynthesis. Staphylococcus aureus acquires resistance against β-lactam antibiotics by producing a penicillin-binding protein 2a (PBP2a), encoded by the mecA gene. PBP2a participates in peptidoglycan biosynthesis and exhibits a poor affinity towards β-lactam antibiotics. The current study was performed to determine the diversity and the role of missense mutations of PBP2a in the antibiotic resistance mechanism. The methicillin-resistant Staphylococcus aureus (MRSA) isolates from clinical samples were identified using phenotypic and genotypic techniques. The highest frequency (60%, 18 out of 30) of MRSA was observed in wound specimens. Sequence variation analysis of the mecA gene showed four amino acid substitutions (i.e., E239K, E239R, G246E, and E447K). The E239R mutation was found to be novel. The protein-ligand docking results showed that the E239R mutation in the allosteric site of PBP2a induces conformational changes in the active site and, thus, hinders its interaction with cefoxitin. Therefore, the present report indicates that mutation in the allosteric site of PBP2a provides a more closed active site conformation than wide-type PBP2a and then causes the high-level resistance to cefoxitin.

Ability of biofilm production and molecular analysis of spa and ica genes among clinical isolates of methicillin-resistant Staphylococcus aureus

Objective

This study aimed to evaluate the phenotypic and genotypic characterization of biofilm formation and spa and ica genes among clinical isolates of methicillin-resistant Staphylococcus aureus.

Result

This cross-sectional study was performed on 146 Staphylococcus aureus isolates from hospitalized patients in Isfahan Province Hospitals. MRSA isolates were confirmed using disk diffusion test with oxacillin disk and amplification of mecA gene by PCR assays. Ability of biofilm production was evaluated targeting the icaA and icaD genes. Of 146 Staphylococcus aureus isolates, 24 (16.4%) carried mecA genes and identified as MRSA strains. Strong ability of biofilm production was seen among 76.02% (111/146) S. aureus isolates and 87.5% (21/24) MRSA strains, respectively. Also, 75.0% (18/24) MRSA isolates carried icaA and icaD was not detected in these strains. Analysis of spa gene showed 70.83% (17/24) MRSA strains were spa positive. From which 14 and 3 strains identified with one band (150, 270, 300, 360, 400 bp) and two bands (150–300 bp), respectively. According to data obtained, the prevalence of MRSA isolates from Isfahan Province Hospitals is relatively high and a remarkable percentage of them show strong power in biofilm production. Also analysis of spa gene showed a fairly large diversity among MRSA strains.

Effects of gamma-irradiation on antibiotic resistance and diagnostic molecular markers of methicillin-resistant Staphylococcus aureus in Egyptian cancer patients

Purpose: This in-vitro study aimed to assess in 120 [40 community-acquired (CA-MRSA) & 80 hospital-acquired (HA-MRSA)] isolates from cancer patients whether the transmissible staphylococcal cassette chromosome mec (SCCmec) typing, and the Panton-Valentine leukocidin (PVL) virulence genes detection could be employed as tools for molecular diagnostic purposes to distinguish both methicillin-resistant Staphylococcus aureus (MRSA) categories in radiotherapy treated cancer patients.Materials and methods: SCCmec typing was determined by the combination of the type of the cassette chromosome recombinase genes (ccr) gene complex and the class of the methicillin resistance (mec) gene complex. Besides, a rapid slide latex agglutination test (LAT) and antibiotic resistance spectrum determination before and after irradiation were performed.Results: In the strict sense, with the effect of irradiation; the presence of SCCmec subtypes IVa (22.5% vs. 10.0%), b (47.5% vs. 25.0%), & d (7.5 vs. 2.5%) or type V (15.0% vs. 7.5%) genetic elements and PVL genes (p < .001) were not proved as a signature for CA-MRSA. While, the larger SCCmec types II, and III elements were not detected in 14, and 19 from the 38, and 36 typed HA-MRSA isolates (p < .001), respectively. Remarkable effects on class A & class B mec gene complex and type2, type 3 & type 5 ccr gene complex and an increase in agglutination reaction strength in response to gamma irradiation external stimulus were observed.Conclusions: Different heterogeneous genetic composition with upregulation mecA gene expression was detected after irradiation in the HA- MRSA studied population. CA-MRSA showed remarkable ability to acquire multi-antibiotic resistance after irradiation and propose a novel paradigm for future chemotherapy against the multi-resistant pathogens whose proliferation especially among immunocompromised cancer patients is on the increase.

Improved internal control for molecular diagnosis assays

The two principal determining steps in molecular diagnosis are the amplification and the identification steps. Accuracy of DNA amplification is primarily determined by the annealing sequence of the PCR primer to the analyte DNA. Accuracy for identification is determined either by the annealing region of a labelled probe for the real time PCR analysis, or the annealing of a sequencing primer for DNA sequencing analysis, that binds to the respective analyte (amplicon). Presently, housekeeping genes (Beta globin, GAPDH) are used in molecular diagnosis to verify that the PCR conditions are optimum, and are thus known as amplification controls [1], [2], [3], [4]. Although these genes have been useful as amplification controls, they lack the true definition of an internal control because the primers and annealing conditions are not identical to the analyte being assayed. This may result in a false negative report [5]. The IC-Code platform technology described here provides a true internal control where the internal control and analyte share identical PCR primers annealing sequences for the amplification step and identical sequencing primer annealing sequence for the identification step.

•

The analyte and internal control have the same PCR and sequencing annealing sequences.

•

This method assures for little or no false negatives and false positives due to the method’s design of using identical annealing conditions for the internal control and analyte, and by using DNA sequencing analysis for the identification step of the analyte, respectively.

•

This method also allows for a set lower limit of detection to be used by varying the amount of internal control used in the assay.

Rapid methods for detection of MRSA in clinical specimens

Antimicrobial susceptibility test methods such as disk diffusion, broth microdilution, and oxacillin screen plate require 24 h of incubation after having the organism growing in pure culture. Rapid and accurate identification of MRSA isolates is essential not only for patient care, but also for effective infection control programs to limit the spread of MRSA. In the last few years, several commercial rapid tests for detection of MRSA directly from nasal swabs and blood cultures have been developed for use in clinical laboratories. Real-time PCR and other molecular tests are gaining popularity as MRSA screening tests to identify patients who are candidates for contact precaution at the time of admission decreasing the risk for nosocomial transmission. These new methodologies have the advantage of a lower turnaround time than that of traditional culture and susceptibility testing and they are capable of detecting MRSA directly from nasal or wound swabs allowing rapid identification of colonized or infected patients. In addition, molecular methods able to detect and differentiate S. aureus and MRSA (SA/MRSA) directly from blood cultures are becoming a useful tool for rapid detection of bacteremia caused by MSSA and MRSA. This review focuses on the procedures for performing testing using rapid methods currently available for detection of MRSA directly from clinical specimens.

Genotypic resistance testing creates new treatment challenges: two cases of oxacillin-susceptible methicillin-resistant Staphylococcus aureus

Oxacillin-susceptible, mecA-positive Staphylococcus aureus isolates create a treatment challenge for the clinician. In this article, we describe two cases of bacteremia from isolates that carried the mecA gene but were susceptible to oxacillin (oxacillin-susceptible methicillin-resistant S. aureus [OS-MRSA]). DNA microarray analysis was used to characterize these isolates as a mecA-positive, clonal complex 5, pediatric strain and a mecA-positive, clonal complex 8, USA300 strain.

Evaluation of Clearview Exact PBP2a, a new immunochromatographic assay, for detection of low-level methicillin-resistant Staphylococcus aureus (LL-MRSA)

We evaluated the performance of a new immunochromatographic assay (ICA), the Clearview Exact PBP2a, for rapid detection of penicillin-binding protein 2a (PBP2a) in a challenge set of Staphylococcus aureus strains showing MICs to oxacillin of ≤16 mg/liter. The sensitivity and specificity of the ICA were 96.6% and 100%, respectively.

Methicillin and aminoglycoside resistance in Staphylococcus aureus isolates from bovine mastitis and sequence analysis of their mecA genes

Although methicillin-resistant Staphylococcus aureus (MRSA) were generally isolated from human beings; these agents were recently isolated from various animal species. It has been shown that MRSA isolates are not only resistant to beta-lactam antibiotics, but can also be resistant to the other commonly used antibiotics. In this study, 18 phenotypic methicillin resistant S. aureus isolates from bovine mastitis cases were analyzed by PCR for the presence of mecA gene encoding methicillin resistance and aac (6′)/aph(2″), aph(3′)-IIIa and ant(4′)-Ia genes encoding aminoglycoside resistance. Out of 18 S. aureus isolates (oxacillin MICs, ≥4 μg/ml), 3 were positive for mecA gene. Only one from 3 mecA positive isolates was positive for genes encoding aminoglycoside-modifying enzymes and this isolate carried aac(6′)/aph(2″) in combination with aph(3′)-IIIa gene. The aph(3′)-IIIa gene was detected in 3 isolates. These three isolates carrying the aminoglycoside-modifying enzyme genes were resistant to gentamicin, kanamycin and neomycin. The mecA gene of 3 MRSA isolates was sequenced. All three mecA genes of these isolates were identical to that found in human MRSA strains, except a one-base substitution at nucleotide position 757. From the data presented in this study, it can be concluded that MRSA isolated from bovine mastitis may be originated from human beings, but further studies are needed to investigate the possibility of zoonotic transfer of MRSA.

Rapid differentiation of methicillin-resistant and methicillin-susceptible Staphylococcus aureus by flow cytometry after brief antibiotic exposure

We noticed that methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) isolates yielded side-scatter (SSC) and fluorescence intensity (FI) differences on flow cytometry (FCM) following incubation in oxacillin broth. The purpose of this study was to determine whether MRSA and MSSA could be reliably differentiated by FCM. S. aureus isolates were incubated in oxacillin-containing Mueller-Hinton broth, stained using the FASTEST total viable organisms kit, and analyzed by FCM in the MicroPRO instrument. SSC versus FI were examined, and gates 1 and 2 were defined to encompass the majority of MSSA and MRSA signal events, respectively. A count ratio (CR) was defined as the ratio of counts in gate 2 to those in gate 1. Initially, 33 isolates were tested after 4 h of incubation for proof-of-concept. Twenty others were then tested after incubation intervals ranging from 30 min to 4 h to determine the earliest possible time for differentiation. Next, 100 separate isolates were tested to determine the best CR cutoff value. Finally, the CR was validated by using an independent cohort of 121 isolates. We noted that MRSA isolates had higher SSC and FI readings than did MSSA isolates after 2 h of incubation. The receiver-operator characteristics curve showed that a CR cutoff of 0.0445 reliably differentiated MRSA from MSSA. In the validation cohort, this cutoff had a sensitivity of 100% and a specificity of 98.7% for identifying MRSA from among S. aureus isolates, following 2 h of incubation. This study demonstrates that MRSA and MSSA can be accurately differentiated by FCM after 2 h of incubation in an oxacillin-containing liquid culture medium.

Evaluation of Bio-Rad MRSASelect agar for detection of methicillin-resistant Staphylococcus aureus directly from blood cultures

MRSASelect agar (Bio-Rad, Redmond, WA) was evaluated for its performance in detecting MRSA directly from positive blood cultures containing Gram-positive cocci in clusters. Agar plates were evaluated for the presence of pink colonies at 18 to 24 h. Results were compared to organism identification by using standard laboratory methods. Confirming coagulase on pink isolates, the sensitivity and specificity were both 99%.

Evaluation of Susceptibility Test Breakpoints Used to Predict mecA-Mediated Resistance in Staphylococcus Pseudintevmedius Isolated from Dogs

Clinical and Laboratory Standards Institute interpretive breakpoints for in vitro susceptibility tests that predict mecA-mediated oxacillin resistance in Staphylococcus pseudintermedius isolates from animals have been changed twice in the past decade. Moreover, there are no counterpart recommendations for human isolates of S. pseudintermedius. Individual medical and veterinary laboratories variably use interpretive breakpoints identical to those recommended for use with Staphylococcus aureus or identical to those recommended for use with coagulase-negative staphylococci. The purpose of the current study was to examine correlations between oxacillin disk diffusion, oxacillin gradient diffusion, oxacillin microbroth dilution, and cefoxitin disk diffusion tests used to predict mecA-mediated resistance in S. pseudintermedius and to retrospectively estimate, from disk diffusion zone diameter measurements, the prevalence and rate of increase of oxacillin resistance among canine S. pseudintermedius isolates submitted to a veterinary teaching hospital laboratory. Oxacillin disk diffusion zone diameters of ≤17 mm and oxacillin minimum inhibitory concentrations of ≥0.5 μg/ml were highly correlated with detection of mecA in canine S. pseudintermedius isolates by polymerase chain reaction. MecA-mediated resistance among S. pseudintermedius isolates from dogs increased from less than 5% in 2001 to near 30% in 2007. More than 90% of the methicillin-resistant S. pseudintermedius isolates in 2006 and 2007 were also resistant to representatives of ≥4 additional antimicrobial drug classes. Cefoxitin disk diffusion with the resistance breakpoint set at ≤24 mm significantly underestimated the presence of mecA in S. pseudintermedius.

Unusual form of oxacillin resistance in methicillin-resistant Staphylococcus aureus clinical strains

The mechanisms by which there is differential expression of resistance to oxacillin within the populations of a single strain remains to be fully understood. The purpose of this study was to evaluate and characterize 25 GOA48 methicillin-resistant Staphylococcus aureus (MRSA) oxacillin-susceptible mecA-positive strains, which were obtained by screening consecutively 832 S. aureus isolates. These 25 isolates (3% of the total strains investigated) were uniformly detected by extending the 24-h oxacillin agar screen plate to 48 h (namely, GOA48-MRSA). Twenty-two isolates tested positive for penicillin-binding protein 2a, whereas the remaining 3 isolates were inconsistently mecA positive. Inconsistent detection of mecA by polymerase chain reaction (PCR) in the mentioned 3 isolates was investigated by colony hybridization using a mecA probe (> or = 80% of colonies hybridized poorly to the probe). A PCR product that amplified the empty SCCmec insertion site (attB), present only if the element was excised, resulted positive in all 3 isolates before oxacillin exposure, whereas integrated elements were positive only for oxacillin-grown isolates. The remaining 22 strains did not reveal excision demonstrating stable mecA. We concluded that resistance to beta-lactams in MRSA-positive mecA strains susceptible to oxacillin is associated to an extreme heterogeneous expression of resistance combined in some cases to oxacillin SCCmec excision.

[Comparison of phenotypic methods with PCR to screening methicillin resistance in coagulase negative staphylococci]

THE AIM OF STUDY

Appreciation of the frequency, the level and the genetic support of methicillin resistance.

MATERIAL AND METHODS

Seventy-three strains of coagulase negative staphylococci isolated from various specimens, from January to June 2004, were studied. The phenotypic detection was carried out by disk diffusion test using oxacillin and cefoxitin disks, by the determination of oxacillin Minimal Inhibitor Concentration (E-test), by the oxacillin screening test at a concentration of 4 mug/ml and by the search of the penicillin binding protein PBP2a using the slide latex agglutination test. The results of these methods were compared to PCR of mecA gene.

RESULTS

Forty-eight strains carried mecA gene whose 30 were detected by the oxacillin disk, the cefoxitin disk, the oxacillin screening test, the slide latex agglutination test and had a MIC from 24 to 256 mug/ml. Seventeen strains were not detected by oxacillin disk but by cefoxitin disk and the slide latex agglutination test. Among these strains, 13 (76%) had oxacillin MIC from 0.5 to 1,5 mug/ml and not grew on oxacillin agar screening, while 4 (24%) had oxacillin MIC from 6 to 16 mug/ml and grew on this agar. One strain had oxacillin MIC of 0,19 mug/ml and was not detected with any phenotypic method.

CONCLUSION

The determination of oxacillin MIC, the search of the PBP2a or more simply the cefoxitin disk had permitted to detect the strains mecA gene (+) with resistant and pre-resistant phenotype but not the strain with sensible phenotype (2.1%).

Detection of mecA-mediated resistance using reference and commercial testing methods in a collection of Staphylococcus aureus expressing borderline oxacillin MICs

Phenotypic methods for detecting mecA-mediated resistance in Staphylococcus aureus include both oxacillin and cefoxitin susceptibility tests; many laboratories perform multiple tests. Conflicting oxacillin and cefoxitin susceptibility results are most likely to occur for isolates that either have reduced susceptibility to oxacillin by a non-mecA-mediated mechanism or are mecA positive but are very heteroresistant. To understand the performance of oxacillin and cefoxitin tests for such isolates, we tested 135 S. aureus isolates using either cefoxitin or oxacillin and compared the results with mecA polymerase chain reaction. These strains either expressed borderline oxacillin MICs (1-4 microg/mL) and had undetermined mecA status or were mecA positive but were not detected by oxacillin broth microdilution (BMD) or disk diffusion (DD) in original testing. For 24-h readings, performance of cefoxitin tests (sensitivity/specificity) were DD (99/100), Etest using < or =6 microg/mL as susceptible (99/98), and Phoenix MIC using < or =4 microg/mL as susceptible (98/100). Using 6 microg/mL of cefoxitin as a screen test in both BMD and agar dilution also worked well (98/98-100). Sensitivity/specificity of oxacillin methods were oxacillin agar screen (BBL: 80/86; Remel, Lenexa, KS: 85/50), DD (91/59), BMD (85/88), MicroScan (89/96), VITEK Legacy (82/93), VITEK 2 (91/73), and Phoenix, (67/96). These results suggest that a cefoxitin test can be used alone to predict mecA-mediated resistance in S. aureus.

Voltammetric study of the interaction between oxacillin sodium and cysteine in the presence and absence of Mn(II)ions in neutral buffer solution

In this study, the voltammetric behaviour of the interaction of oxacillin sodium (OXA) and OXA-cysteine (RSH) was studied by square-wave voltammetry, cyclic voltammetry in Britton-Robinson (B-R) buffer (pH 7.0). OXA gave two peaks at -0.248 and -1.224 V. For the interaction, the peak of mercurous cysteine thiolate (Hg2(SR)2) was selected. It was found that the peak currents corresponding to Hg2(SR)2 significantly decreased, while the peak potential shifted to more positive potentials upon the addition of OXA. The observed phenomena are due to the interaction of OXA with RSH on the surface of the mercury electrode. When OXA was added to the electrochemical cell along with Mn(II), new peaks at -0.146 and -0.608 V were observed. These peaks were due to the catalytic activity of OXA on the reduction of Mn(II) and could be attributed to the formation of Mn(II) complexes with different metal/ligand ratios. On the other hand, in the presence of RSH, the peak at -0.608 V vanished and a reduction peak was observed at -0.662 V. The catalytic reduction peak potential of Mn(II) at -0.662 V indicated that RSH slightly prevented the catalysis process of OXA due to their mutual interaction. .