Coagulase-negative staphylococci and the epidemiological typing of Staphylococcus epidermidis

Single-Walled Carbon Nanotube-Assisted Antibiotic Delivery and Imaging in S. epidermidis Strains Addressing Antibiotic Resistance

Although conventional antibiotics have evolved as a staple of modern medicine, increasing antibiotic resistance and the lack of antibiotic efficacy against new bacterial threats is becoming a major medical threat. In this work, we employ single-walled carbon nanotubes (SWCNTs) known to deliver and track therapeutics in mammalian cells via intrinsic near-infrared fluorescence as carriers enhancing antibacterial delivery of doxycycline and methicillin. SWCNTs dispersed in water by antibiotics without the use of toxic bile salt surfactants facilitate efficacy enhancement for both antibiotics against Staphylococcus epidermidis strain showing minimal sensitivity to methicillin. Doxycycline to which the strain did not show resistance in complex with SWCNTs provides only minor increase in efficacy, whereas the SWCNTs/methicillin complex yields up to 40-fold efficacy enhancement over antibiotics alone, suggesting that SWCNT-assisted delivery may circumvent antibiotic resistance in that bacterial strain. At the same time SWCNT/antibiotic formulations appear to be less toxic to mammalian cells than antibiotics alone suggesting that nanomaterial platforms may not restrict potential biomedical applications. The improvement in antibacterial performance with SWCNT delivery is tested via 3 independent assays-colony count, MIC (Minimal Inhibitory Concentration) turbidity and disk diffusion, with the statistical significance of the latter verified by ANOVA and Dunnett's method. The potential mechanism of action is attributed to SWCNT interactions with bacterial cell wall and adherence to the membrane, as substantial association of SWCNT with bacteria is observed-the near-infrared fluorescence microscopy of treated bacteria shows localization of SWCNT fluorescence in bacterial clusters, scanning electron microscopy verifies SWCNT association with bacterial surface, whereas transmission electron microscopy shows individual SWCNT penetration into bacterial cell wall. This work characterizes SWCNTs as novel advantageous antibiotic delivery/imaging agents having the potential to address antibiotic resistance.

Evaluation of the Variety of Plasmid Profiles in S epidermidis Isolates from Hospital Patients and Staff

Plasmid profiling was used to determine the variability of normal flora isolates of Staphylococcus epidermidis in order to evaluate the usefulness of plasmid profiling for identifying pathogens. Fifteen hospital staff members and patients repeatedly had cultures taken from the hands and nares, and multiple isolates were examined for plasmid profiles. S epidermidis isolated from the nares of 15 neonates were also examined. The total number of isolates examined for plasmid profiles was 726. Repetition of profiles was common among the different isolates from a single sampling (one swab). The frequency of re-isolating similar profiles on different days varied from 7% to 13%. Simultaneous isolation of similar profiles from nares and hands on the same individual varied from 0% to 11%, the percentage being lower for personnel. Isolation of the same plasmid profile from different individuals occurred only twice and resulted in an assignment probability of Pa = 0.002 for isolates obtained from different individuals. Significantly more isolates from nares contained plasmids (97%) compared with isolates from hands (89%).Patients who had two or more isolates of coagulase-negative staphylococci with similar profiles were judged, clinically, to have infections in 12 of 13 cases. However, the likelihood of re-isolating an S epidermidis strain with a similar plasmid profile twice from the same person at different times was sufficiently high to prevent plasmid profiling from being used as an absolute criterion for infection.

Ultrasonographic Findings in Anterior Chest Wall Abscess

Empyema necessitatis is a rare complication of empyema, in which the pleural infection spreads outside of the pleural space to involve the soft tissues of the chest wall, and is difficult to diagnose with sonography alone. In the case presented, sonography to evaluate a focal anterior chest wall pain in a patient resulted in findings consistent with an abscess and prompted additional workup. Further testing included sonography-guided aspiration and computed tomography scan to establish the diagnosis followed by surgical debridement.

Bacteriologic evidence of infection caused by coagulase-negative staphylococci in total hip replacement

Coagulase-negative staphylococci are important agents of infected hip arthroplasties, but sample contamination from the skin flora may confuse the diagnosis. Recovery of multiple identical strains has been regarded as indication of true infection. We have evaluated 29 total hip replacement operations with cultures positive for coagulase-negative staphylococci in a prospective study, 16 with > or = 3 isolates available for strain identity analysis. In 26 episodes, > or = 3 cultures were positive for coagulase-negative staphylococci, but only 19 of them had strong or intermediate clinical evidence of infection. Negative clinical evidence of infection coincided with the absence of a predominating strain according to plasmid profile analysis. A reliable identity analysis may help to rule out infection when multiple cultures are positive in patients who lack clinical evidence of infection.

Use of enzyme tests in characterization and identification of aerobic and facultatively anaerobic gram-positive cocci

The contribution of enzyme tests to the accurate and rapid routine identification of gram-positive cocci is introduced. The current taxonomy of the genera of aerobic and facultatively anaerobic cocci based on genotypic and phenotypic characterization is reviewed. The clinical and economic importance of members of these taxa is briefly summarized. Tables summarizing test schemes and kits available for the identification of staphylococci, enterococci, and streptococci on the basis of general requirements, number of tests, number of taxa, test classes, and completion times are discussed. Enzyme tests included in each scheme are compared on the basis of their synthetic moiety. The current understanding of the activity of enzymes important for classification and identification of the major groups, methods of testing, and relevance to the ease and speed of identification are reviewed. Publications describing the use of different identification kits are listed, and overall identification successes and problems are discussed. The relationships between the results of conventional biochemical and rapid enzyme tests are described and considered. The use of synthetic substrates for the detection of glycosidases and peptidases is reviewed, and the advantages of fluorogenic synthetic moieties are discussed. The relevance of enzyme tests to accurate and meaningful rapid routine identification is discussed.

Ultrastructural organization and regulation of a biomaterial adhesin of Staphylococcus epidermidis

Coagulase-negative staphylococci have emerged as important pathogens in infections associated with intravascular devices. Microbial adherence to biomaterial surfaces is a crucial step in the pathogenesis of these infections. Staphylococcal surface proteins (herein referred to as SSP-1 and SSP-2) are involved in the attachment of Staphylococcus epidermidis 354 to polystyrene. In the present study we show that the adhesin protrudes from the cell surface as a fimbria-like polymer. Furthermore, in vitro proteolytic cleavage of SSP-1 produces an SSP-2-like protein which coincides with a loss of adhesive function. SSP-1 expression is down-regulated in a phenotypical variant of S. epidermidis 354 whereas SSP-2 expression is not. These results could suggest that proteolytic cleavage is a key to the regulation of the adhesive state of S. epidermidis in vivo.

Update on clinical significance of coagulase-negative staphylococci

The clinical significance of coagulase-negative Staphylococcus species (CNS) continues to increase as strategies in medical practice lead to more invasive procedures. Hospitalized patients that are immunocompromised and/or suffering from chronic diseases are the most vulnerable to infection. Since CNS are widespread on the human body and are capable of producing very large populations, distinguishing the etiologic agent(s) from contaminating flora is a serious challenge. For this reason, culture identification should proceed to the species and strain levels. A much stronger case can be made for the identification of a CNS etiologic agent if the same strain is repeatedly isolated from a series of specimens as opposed to the isolation of different strains of one or more species. Strain identity initially can be based on colony morphology, and then one or more molecular approaches can be used to gain information on the genotype. Many of the CNS species are commonly resistant to antibiotics that are being indicated for staphylococcal infections, with the exception of vancomycin. The widespread use of antibiotics in hospitals has provided a reservoir of antibiotic-resistant genes. The main focus on mechanisms of pathogenesis has been with foreign body infections and the role of specific adhesins and slime produced by Staphylococcus epidermidis. Slime can reduce the immune response and opsonophagocytosis, thereby interfering with host defense mechanisms. As we become more aware of the various strategies used by CNS, we will be in a better position to compromise their defense mechanisms and improve treatment.

Characterization of unrelated strains of Staphylococcus schleiferi by using ribosomal DNA fingerprinting, DNA restriction patterns, and plasmid profiles

The molecular characteristics of 31 unrelated strains of Staphylococcus schleiferi isolated from 13 hospitals between 1973 and 1991 were determined by ribosomal DNA fingerprinting by using a digoxigenin-labeled DNA probe, genomic DNA restriction patterns, and plasmid profiles. Only six strains harbored one or two plasmids. DNA restriction analysis, which was carried out with five endonucleases (EcoRI, HindIII, PstI, PvuII, and ClaI), did not allow us to discriminate between isolates. Ribotyping with HindIII, ClaI, or EcoRI enzymes generated six, seven, and nine distinct patterns, respectively. With the combination ClaI-EcoRI, 13 ribotypes were obtained among the 31 strains, suggesting a relative heterogeneity within the species. Moreover, all strains shared two or three common bands, according to the endonuclease used, which were relatively specific for S. schleiferi in comparison with the ribosomal banding patterns described for other coagulase-negative staphylococci. These results illustrate that ribotyping can be used for the epidemiological investigation of S. schleiferi isolates and possibly for taxonomic analysis in this species.

Development of a phage typing system for Staphylococcus hyicus

Bacteriophages were released by 98% of 100 Staphylococcus hyicus strains studied after treatment with mitomycin C. Twenty-three phages with different lytic spectra were included in a phage typing system and used for typing S. hyicus. On a test-set of 100 epidemiologically unrelated S. hyicus strains isolated from Danish pig herds, the phages were able to type 92% of the strains, producing 16 different phage types. Reproducibility of the phage typing system after subculture of the strains and using fresh phage stock was 96%. Typability ranged from 52 to 80% when typing porcine strains originating from other countries. Although phages were isolated from porcine skin strains exclusively, the system produced phage types in S. hyicus strains of bovine origin. Ten strains of S. aureus and S. chromogens were not typable by these phages. Strains belonging to one phage type (A/B/C/W) were isolated significantly more often from piglets with exudative epidermidis than from healthy piglets. The phage typing system described appears to be a valuable tool in diagnosis of exudative epidermidis in pigs, and furthermore, might be of value in epidemiological studies of S. hyicus.

Diagnostic value of phage typing, antibiogram typing, and plasmid profiling of Staphylococcus hyicus from piglets with exudative epidermitis

A total of 989 isolates of S. hyicus were recovered from the skin of 103 piglets (9.6 isolates per piglet) with exudative epidermitis (EE), and phage typed. Phage patterns of 806 typable isolates (81%) could be divided into 44 distinct phage types. From 1 to 6 different phage types were found on individual piglets, with an average of 1.9 phage type per piglet. Antibiogram patterns of 384 isolates from 40 randomly selected piglets with EE showed a mean of 2.3 different antibiograms per investigated piglet, ranging from 1 to 6 antibiograms per piglet. Plasmid profiles of 248 S. hyicus isolates from 25 randomly selected piglets showed an average of 2.8 different plasmid profiles per piglet. Seven EE outbreaks in pig herds vaccinated with autogenous vaccine were investigated. In all these herds, strains recovered from the present outbreak differed by two or more type markers to the strains from the previous outbreak used for production of the autogenous vaccine. This finding suggest, that lack of protection might be due to the presence of other virulent types in the investigated herd than those used for production of autogenous vaccine.

Ribotype analysis of Pseudomonas pseudomallei isolates

No epidemiological typing system to differentiate among Pseudomonas pseudomallei isolates has been available. Ribotype analysis was developed and used to examine 74 clinical and 10 environmental isolates of P. pseudomallei from Thailand. Six P. pseudomallei ribotypes were identified from restriction fragment polymorphisms of EcoRI chromosomal digests. The predominant ribotype, A, was found in 59 of the isolates examined. By using patterns from hybridizations with SalI, HindIII, and PstI restriction digests, isolates of ribotype A were subdivided into a further five subtypes, giving a total of 10 differentiable P. pseudomallei types. In 23 of 34 melioidosis patients studied, multiple P. pseudomallei isolates were present. In all but one of these patients, a single ribotype of the organism was present. Isolation of two different ribotypes of P. pseudomallei from one patient, one each in sputum and urine, suggests that superinfection may have occurred. The ribotype was shown to be conserved during the course of antibiotic treatments in seven patients studied, although the antibiotic sensitivity patterns in the isolates from these patients varied. The prevalence of subtype A1 in clinical and environmental specimens suggests that this strain may be predominant in this geographical location. These results demonstrate the usefulness of the ribotyping method for epidemiological studies of P. pseudomallei.

Molecular epidemiology of Pseudomonas cepacia determined by polymerase chain reaction ribotyping

Traditional ribotyping detects genomic restriction fragment length polymorphisms by probing chromosomal DNA with rRNA. Although it is a powerful method for determining the molecular epidemiology of bacterial pathogens, technical difficulties limit its application. As an alternative, polymorphisms were sought in the 16S-23S spacer regions of bacterial rRNA genes by use of the polymerase chain reaction (PCR). Chromosomal DNA from isolates of Pseudomonas cepacia was used as a template in the PCR with oligonucleotide primers complementary to highly conserved sequences flanking the spacer regions of the rRNA genes. Length polymorphisms in the amplified DNA distinguished unrelated isolates of P. cepacia. Isolates of P. cepacia previously implicated in person-to-person transmission were shown to have identical amplification patterns. These data demonstrate the utility of this new PCR ribotyping method for determining the molecular epidemiology of bacterial species.

Ribotyping of coagulase-negative staphylococci with special emphasis on intraspecific typing of Staphylococcus epidermidis

Coagulase-negative staphylococci (CoNS), particularly Staphylococcus epidermidis, are increasingly being recognized as opportunistic pathogens. They are often multiply antibiotic resistant and can cause nosocomial outbreaks. For clinical and epidemiological reasons, accurate species identification and typing are imperative. Ribotyping, i.e., the generation of characteristic fragment patterns by hybridization of restriction endonuclease fragments of total DNA with labeled standard rRNA from Escherichia coli, has been applied to CoNS for species identification by various investigators. The present study, involving 115 randomly collected clinical isolates of CoNS, provides ambiguous evidence with respect to those findings. Eighty six S. epidermidis strains were ribotyped intraspecifically. Eleven different ribotypes were found after digestion with EcoRI, and 10 were found with HindIII. A combination of the two restriction endonucleases resulted in an increase in the discriminatory power (DP) from 14.3 to 31.6%. A combination of ribotyping with biotyping raised the DP to a maximum of 48.6%. The reproducibility of ribotyping was 100% after greater than 400 generations of growth. No correlation between methicillin resistance and certain ribotypes among the S. epidermidis strains was observed. Ribotyping is considered a useful tool for the intraspecific typing of CoNS for epidemiological purposes. The DP can be increased by the use of additional restriction endonucleases.

Investigation of nosocomial prosthetic valve endocarditis due to antibiotic-resistant Staphylococcus epidermidis

A reservoir of antibiotic-resistant Staphylococcus epidermidis strains in our cardiac surgery unit appeared to be the source of organisms responsible for three cases of early prosthetic valve endocarditis. Staphylococcus epidermidis isolates recovered from the skin of 13 patients before and after surgery were compared. All were typed by plasmid profile, antimicrobial susceptibility and slime production. The three strains from early prosthetic valve endocarditis resembled the antibiotic-resistant nosocomial strains recovered from the skin of eight patients following surgery and the environment of the operating theatres. These strains expressed resistance to oxacillin, gentamicin, kanamycin and tobramycin and most produced slime, whereas those isolated from the skin of patients at the time of admission were predominantly susceptible to antibiotics and few produced slime.

Reproducibility of Staphylococcus epidermidis plasmid profiles

The plasmid profiles of six isolates of Staphylococcus epidermidis were repetitively evaluated over an 8-month period. Each isolate was subcultured and stored at three different temperatures (-70 degrees C, -20 degrees C, and room temperature) and plasmid DNA was prepared from each subculture at 0, 1, 4, and 8 months by two different methods of plasmid extraction [using mixed alkyltrimethylammonium bromide (ATAB) or Brij 58 and deoxycholate (modified Parisi)]. Plasmid DNA bands were lost from two isolates when subcultures were kept at room temperature. This plasmid loss was confirmed by repetitive extractions and electrophoresis, as well as by restriction endonuclease analysis of the ATAB preparations. Profiles were otherwise highly related to one another, with occasional exceptions being extra or missing plasmid DNA bands of high molecular size. The latter findings were not reproducible. Plasmid DNA extracted by the modified Parisi method was not reliably digested with restriction endonuclease enzymes. We conclude that the plasmid profiles of Staphylococcus epidermidis isolates are highly reproducible as long as isolates are stored at less than or equal to -20 degrees C. Minor discrepancies in the number of plasmid DNA bands of large molecular size may occur. These are resolvable by repetitive testing or restriction endonuclease analysis of ATAB-extracted plasmid DNA preparations.

Identification of Staphylococcus species and subspecies with the MicroScan Pos ID and Rapid Pos ID panel systems

The accuracies of the MicroScan Pos ID and Rapid Pos ID panel systems (Baxter Diagnostic Inc., MicroScan Division, West Sacramento, Calif.) were compared with each other and with the accuracies of conventional methods for the identification of 25 Staphylococcus species and 4 subspecies. Conventional methods included those used in the original descriptions of species and subspecies and DNA-DNA hybridization. The Pos ID panel uses a battery of 18 tests, and the Rapid Pos ID panel uses a battery of 42 tests for the identification of Staphylococcus species. The Pos ID panel has modified conventional and chromogenic tests that can be read after 15 to 48 h of incubation; the Rapid Pos ID panel has tests that use fluorogenic substrates or fluorometric indicators, and test results can be read after 2 h of incubation in the autoSCAN-W/A. Results indicated that both MicroScan systems had a high degree of congruence (greater than or equal to 90%) with conventional methods for the species S. capitis, S. aureus, S. auricularis, S. saprophyticus, S. cohnii, S. arlettae, S. carnosus, S. lentus, and S. sciuri and, in particular, the subspecies S. capitis subsp. capitis and S. cohnii subsp. cohnii. The Rapid Pos ID panel system also had greater than or equal to 90% congruence with conventional methods for S. epidermidis, S. caprae, S. warneri subsp. 2, S. xylosus, S. kloosii, and S. caseolyticus. For both MicroScan systems, congruence with conventional methods was 80 to 90% for S. haemolyticus subsp. 1, S. equorum, S. intermedius, and S. hyicus; and in addition, with the Rapid Pos ID panel system congruence was 80 to 89% for S. capitis subsp. ureolyticus, S. warneri subsp. 1, S. hominis, S. cohnii subsp. urealyticum, and S. simulans. The MicroScan systems identified a lower percentage (50 to 75%) of strains of S. lugdunensis, S. gallinarum, S. schleiferi, and S. chromogenes, although the addition of specific tests to the systems might increase the accuracy of identification significantly.

Application of gas-liquid chromatographic analysis of cellular fatty acids for species identification and typing of coagulase-negative staphylococci

Gas-liquid chromatography (GLC) of bacterial cellular fatty acids was used to analyze 264 isolates of coagulase-negative staphylococci, of which 178 were Staphylococcus epidermidis. The presence and amounts of individual fatty acids were determined to generate fatty acid profiles for each of the seven coagulase-negative species tested. The fatty acid profiles were then analyzed by computerized correlation and cluster analysis to calculate mean correlation values between isolates belonging to the same or different species, as well as to establish cluster analysis dendrograms. These data ultimately allowed the clustering of individual samples into species-specific clusters. Species identification by the GLC clustering was highly consistent with species identification by biochemical assays; the results were similar in 92.4% of the cases. The GLC profile correlation analysis was further used to analyze multiple blood isolates from 60 patients in order to determine the usefulness of this methodology in establishing identity, as well as differences, between consecutive patient isolates. The correlation between those multiple S. epidermidis isolates determined to be identical by standard techniques (such as the antibiogram, biotype, and plasmid profile) was significantly (P less than 0.001) higher than that between random isolates of the same species. The correlation coefficient was greater than 97 for 40 (97.6%) of the 41 patients with multiple identical blood isolates, compared with less than 95 in all 19 (100.0%) patients with multiple nonidentical isolates. The successful use of the computerized GLC analysis in this study demonstrated its appropriate application for species identification and typing of coagulase-negative staphylococci.

Phosphatase activity of staphylococci is constitutive in some species and repressed by phosphates in others

The phosphatase activities of colonies of staphylococcal strains belonging to the 10 species most frequently isolated from specimens of human origin were evaluated on media with undetermined inorganic phosphate contents and on media supplemented with known amounts of phosphates. All strains of all species tested were phosphatase positive on plates that were not supplemented with inorganic phosphates when the pH of the medium was high. In media supplemented with 0.3% phosphates at low and high pH, all strains of Staphylococcus aureus, almost all strains of S. epidermidis and S. xylosus, and none of the other species tested were phosphatase positive. Thirty S. simulans strains were grown in broths at pH 7 with and without phosphates, and the phosphatase activities of the cells were assayed at pH 5.5 and 8 in the absence of phosphates. At pH 8, all strains gave a strong positive reaction when grown in the absence of phosphates and a negative reaction when grown in the presence of these salts at 0.3%. It was concluded that all the species of staphylococci tested possess phosphatase activity and that the staphylococcal phosphatases are constitutive in some species and repressed in others.

Identification of coagulase-negative staphylococci by electrophoretic profile of total proteins and analysis of penicillin-binding proteins

Analyses of total solubilized proteins and penicillin-binding proteins by sodium dodecyl sulfate-polyacrylamide gel electrophoresis were demonstrated to be accurate methods for the identification of coagulase-negative staphylococci. However, penicillin-binding protein profiles were found to be much clearer for the identification of these organisms to species level than was examination of the total solubilized proteins. By using the former technique, 13 reference strains were found to have species-specific penicillin-binding protein profiles, and 150 of 160 randomly collected clinical isolates were identified as belonging to eight of these species. A group of three clinical strains probably represents the recently described species Staphylococcus lugdunensis; the other seven clinical isolates belonging to five species remained unclassified.

Evaluation of restriction endonuclease fingerprinting of chromosomal DNA and plasmid profile analysis for characterization of multiresistant coagulase-negative staphylococci in bacteremic neonates

A procedure was developed for restriction endonuclease fingerprinting (REF) of the chromosomal DNA of coagulase-negative staphylococci. A total of 48 isolates comprising 29 Staphylococcus epidermidis and 19 Staphylococcus haemolyticus isolates from blood and mucocutaneous sites of 15 premature neonates were characterized by REF, plasmid profile (PP) analysis, antimicrobial susceptibility testing, biotyping, and slime production. On the basis of REF analysis of chromosomal DNA, the 48 coagulase-negative staphylococcal isolates were subdivided into 10 subgroups, whereas PP analysis subdivided the strains into 20 distinct subgroups. REF analysis of total DNA (i.e., chromosome plus plasmid) resulted in the same 20 subgroups as were subdivided by PP analysis. The high discriminatory power of PP analysis was associated with the variability of plasmid content in coagulase-negative staphylococcal strains isolated during the outbreak. REF patterns were found to be stable both in vitro and in vivo. Isolates carried from 2 to 10 plasmids that ranged in molecular size from 0.9 to 39.5 megadaltons. Plasmids were disseminated among the coagulase-negative staphylococci, regardless of the genetic relatedness of their chromosomal DNAs. Hence, a lack of correlation existed between the grouping of isolates by REF analysis of chromosomal DNA and the grouping by PP analysis. There were one and two distinct chromosomal patterns among 4 of 4 blood cultures and 15 of 15 mucocutaneous cultures of S. haemolyticus, respectively. In contrast, a higher proportion of distinct chromosomal patterns was found for S. epidermidis in blood cultures (7 of 11 cultures) compared with those identified for isolates in mucocutaneous cultures (6 of 18 cultures). In summary, REF analysis of chromosomal DNA, rather than total DNA, is a useful marker for epidemiological investigations of coagulase-negative staphylococci. PP analysis can also be used to provide additional epidemiological information regarding the most recent genetic events.

Temporal study of staphylococcal species on the skin of human subjects in isolation and clonal analysis of Staphylococcus capitis by sodium dodecyl sulfate-polyacrylamide gel electrophoresis

The staphylococcal skin floras of an isolated group of subjects were studied for 1 year. A wide variation in isolation patterns was found for different species. Staphylococcus intermedius, previously thought to be of veterinary origin, was found to be part of the resident flora of some subjects, and this may indicate a wider role for it in clinical infection. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) analysis of S. capitis isolates indicated persistent skin colonization at some sites; each region was colonized by only one clone of that species, although an adjacent area could be inhabited by a separate clone. Nine clonal groups were identified by SDS-PAGE; there was a degree of specialization between the groups with regard to the sites which they colonized. The interaction between species at a single site was less well defined. Noncolonizing isolates often exhibited phenotypic similarities that were lower than expected when compared with their presumed source. The results of SDS-PAGE analysis were compared with immunoblotting, antibiograms, and biotyping, and SDS-PAGE analysis was found to be a useful and practical tool for epidemiological work.

Prevalence of peritonitis-associated coagulase-negative staphylococci on the skin of continuous ambulatory peritoneal dialysis patients

The predominance of coagulase-negative staphylococci as normal skin flora is thought to be a factor in their association with episodes of peritonitis in patients undergoing continuous ambulatory peritoneal dialysis. We investigated the prevalence of peritonitis-associated strains on the skin of 28 patients undergoing peritoneal dialysis. Coagulase-negative staphylococci were the most frequently isolated organisms, comprising 47% of peritoneal dialysis fluid isolates and 59% of body site isolates. A total of 142 coagulase-negative staphylococci were speciated, tested for their antimicrobial sensitivity and slime production, and identified by phage typing and plasmid-profile analysis. Staphylococcus epidermidis was the most commonly identified species from both peritoneal dialysis fluid (73%) and body sites (53%). Multiple antibiotic resistance was common, and the greater proportion of isolates were resistant to methicillin; 63.6% of peritoneal dialysis fluid isolates and 61.7% of body-site isolates. S. haemolyticus isolates were significantly more resistant to methicillin than other species. By phage typing and plasmid-profile analysis it was shown that peritonitis was rarely caused by skin-colonizing strains. In only 3 of 14 patients were peritonitis-associated strains isolated as skin colonizers, and no patients developed peritonitis due to organisms previously isolated as skin colonizers.

Construction of a database to identify Staphylococcus species

A database was constructed for the routine identification of Staphylococcus species, isolated from man. The method comprised 15 conventional characterisation tests using substrates incorporated into agar plates and a multipoint inoculation system. The database was constructed from results of 125 reference strains and 1567 clinical isolates. In an evaluation trial, using a probability profile index generated from the database, 529 of 559 (94.6%) further clinical isolates were identified to species level. A further 20 (3.6%) gave low discrimination between two species. The proposed scheme was rapid, reliable, and inexpensive.

Characteristics of coagulase-negative staphylococci that help differentiate these species and other members of the family Micrococcaceae

One hundred reference strains and 1,240 clinical isolates representing 26 species of the family Micrococcaceae were used to evaluate the potential of tests for synergistic hemolysis, adherence to glass, pyroglutamyl-beta-naphthylamide hydrolysis, and susceptibility to a set of five antimicrobial agents for differentiating these species and strains within the species. Sixty-eight percent of the clinical isolates exhibited synergistic hemolysis; 69% of the clinical staphylococci but none of the micrococci or stomatococci were adherence positive, and 92% of the strong positive adherence reactions were produced by strains of Staphylococcus epidermidis. Strains from 15 of the species were pyroglutamyl-beta-naphthylamide positive, but this test separated Staphylococcus xylosus from other novobiocin-resistant staphylococci and Staphylococcus intermedius from other coagulase-positive species. A polymyxin B disk helped differentiate S. epidermidis from most other coagulase-negative staphylococci, and a bacitracin disk (10 U) helped differentiate Staphylococcus haemolyticus from most other novobiocin-susceptible staphylococci. All strains that were susceptible to furazolidone and resistant to Taxo A disks (bacitracin, 0.04 U; BBL Microbiology Systems, Cockeysville, Md.) were staphylococci. We observed a 91% correlation between species identification obtained with the Staph-Ident system (Analytab Products, Plainview, N.Y.) and conventional methods; but the micrococci and stomatococci were incorrectly identified as staphylococci with Staph-Ident, and several isolates of S. epidermidis were misidentified as Staphylococcus hominis because they were alkaline phosphatase negative. Both these problems can be prevented by adding the simple tests we describe to those already recommended when the Staph-Ident system is used to identify isolates of gram-positive, catalase-positive cocci.

Biotyping coagulase-negative staphylococci

The biochemical profiles obtained with Staph-Ident (Analytab Products, Plainview, N.Y.) panels were combined with the results of adherence and synergistic hemolysis tests to define biotypes among 1,064 clinical isolates representing eight species of coagulase-negative staphylococci. The 672 isolates of Staphylococcus epidermidis were aligned in 69 of 144 potential biotypes in our scheme because of 18 different biochemical profiles and the eight physiologic subtypes. Isolates of most other species were in fewer biotypes because of more uniform adherence and synergistic hemolysis data, as well as fewer biochemical profiles. Since adherence and synergistic hemolysis may prove to be related to virulence and pathogenicity, biotyping with these test results would help evaluate the reliability of adherence and synergistic hemolysis as possible indices of the clinical significance of some of these organisms. When the antimicrobial susceptibility and plasmid profiles obtained on two clusters of S. epidermidis isolates were compared with the biotyping results, one cluster was not further differentiated by plasmid profiles, but was by antimicrobial profiles; the other cluster with only two biotypes was further divided into five distinct types by plasmid profiles but was not separated at all by antimicrobial profiles.

Evaluation of the variety of plasmid profiles in S epidermidis isolates from hospital patients and staff

Plasmid profiling was used to determine the variability of normal flora isolates of Staphylococcus epidermidis in order to evaluate the usefulness of plasmid profiling for identifying pathogens. Fifteen hospital staff members and patients repeatedly had cultures taken from the hands and nares, and multiple isolates were examined for plasmid profiles. S epidermidis isolated from the nares of 15 neonates were also examined. The total number of isolates examined for plasmid profiles was 726. Repetition of profiles was common among the different isolates from a single sampling (one swab). The frequency of re-isolating similar profiles on different days varied from 7% to 13%. Simultaneous isolation of similar profiles from nares and hands on the same individual varied from 0% to 11%, the percentage being lower for personnel. Isolation of the same plasmid profile from different individuals occurred only twice and resulted in an assignment probability of Pa = 0.002 for isolates obtained from different individuals. Significantly more isolates from nares contained plasmids (97%) compared with isolates from hands (89%). Patients who had two or more isolates of coagulase-negative staphylococci with similar profiles were judged, clinically, to have infections in 12 of 13 cases. However, the likelihood of re-isolating an S epidermidis strain with a similar plasmid profile twice from the same person at different times was sufficiently high to prevent plasmid profiling from being used as an absolute criterion for infection.

Laboratory, clinical, and epidemiological aspects of coagulase-negative staphylococci

Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are increasingly important causes of nosocomial infection. Microbiologists and clinicians no longer can afford to disregard clinical isolates of coagulase-negative staphylococci as contaminants. Accurate species identification and antimicrobial susceptibility testing, in a clinically relevant time frame, are important aids in the diagnosis and management of serious coagulase-negative staphylococcal infections. Emphasis in the clinical laboratory should be placed on the routine identification of S. epidermidis and Staphylococcus saprophyticus, with identification of other species of coagulase-negative staphylococci as clinically indicated. The application of newer techniques, such as plasmid analysis and tests for slime production and adherence, contribute to our understanding of the epidemiology and pathogenesis of coagulase-negative staphylococci and may also be helpful in establishing the diagnosis of infection.

Plasmid analysis as an epidemiological tool in neurosurgical infections with coagulase-negative staphylococci

Coagulase-negative staphylococci isolated from blood or spinal fluid during a period of 1 year in a department of neurosurgery, were analysed by biotyping, antibiotic resistance pattern and plasmid profiles. Altogether 41 isolates from 19 patients were studied. About 90% of the isolates were Staphylococcus epidermidis. The antibiotic resistance pattern seemed to be closely related to antibiotic usage in the unit. Most common was resistance to penicillin (63%), trimethoprim-sulphamethoxazole (49%) and cloxacillin (39%) while resistance to gentamicin was seen in only one strain. In several cases species and antibiograms were identical in isolates from different patients. Plasmid pattern analysis could then be used for identification of different strains. In one instance, plasmid pattern and restriction enzyme analysis confirmed that two patients probably were infected by the same strain.

Antimicrobial resistance of Staphylococcus aureus: genetic basis

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Elastolytic activity among staphylococci

A total of 161 isolates of the genus Staphylococcus were evaluated for the ability to produce elastase. Elastase activity was detected only in S. epidermidis strains (sensu stricto), being absent in S. aureus isolates and other coagulase-negative staphylococci tested. The elastase elaborated by S. epidermidis isolates appeared to be an inducible enzyme whose synthesis was medium dependent.

Comparison of epidemiologic markers for Staphylococcus epidermidis

Cultures of Staphylococcus epidermidis from the eyes or nose of the same individual were compared by their antimicrobial phenotype, Staph-Ident (Analytab Products, Inc., Plainview, N.Y.) profile number, phage type, and plasmid profile to determine which parameters provide the most compelling data for their identity. None of the parameters alone provided this type of information. The most conclusive data for the identity of strains resulted when two cultures had the same long phage type and identical or similar plasmid profiles. The presence of a large, slowly migrating plasmid band(s) in a culture that agreed with its pair in all other parameters and, in all likelihood, was the same strain casts doubt in some instances on the reliability of the plasmid profile alone for strain identification in an epidemiologic study.

Rapid lysostaphin test to differentiate Staphylococcus and Micrococcus species

A rapid, simple lysostaphin lysis susceptibility test to differentiate the genera Staphylococcus and Micrococcus was evaluated. Of 181 strains from culture collections, 95 of 95 Staphylococcus strains were lysed, and 79 of 79 Micrococcus strains were not lysed. The seven Planococcus strains were resistant. Clinical isolates (890) were tested with lysostaphin and for the ability to produce acid from glycerol in the presence of erythromycin. Overall agreement between the methods was 99.2%. All clinical Micrococcus strains (43) were resistant to lysostaphin, and all clinical Staphylococcus strains (847) were susceptible. Seven of the Staphylococcus strains did not produce acid from glycerol in the presence of erythromycin. This lysostaphin test provides results in 2 h. It is easier to perform than previously described lysostaphin lysis methods. It is also more rapid and accurate than the glycerol-erythromycin test.

Naturally occurring Staphylococcus epidermidis plasmid expressing constitutive macrolide-lincosamide-streptogramin B resistance contains a deleted attenuator

A naturally occurring constitutive macrolide-lincosamide-streptogramin B (MLS) resistance plasmid, pNE131, from Staphylococcus epidermidis was chosen to study the molecular basis of constitutive expression. Restriction and functional maps of pNE131 are presented along with the nucleotide sequence of ermM, the gene which mediates constitutive MLS resistance. Sharing 98% sequence homology within the 870-base-pair Sau3A-TaqI fragment, ermM appears to be almost identical to ermC, the inducible MLS resistance determinant from S. aureus (pE194). The two genes share nearly identical sequences, except in the 5' promoter region of ermM. Constitutive expression of ermM is due to the deletion of 107 base pairs relative to ermC; the deletion removes critical sequences for attenuation, resulting in constitutive methylase expression.