Epidemiological studies of penicillin resistance in Danish Staphylococcus aureus strains in the period 1977-1990

Penicillin-susceptible Staphylococcus aureus: susceptibility testing, resistance rates and outcome of infection

BACKGROUND

Staphylococcus aureus (SA) is an important human pathogen that causes both superficial and invasive infections. Penicillin is now rarely used in the treatment of SA infections due to widespread resistance and a concern about the accuracy of existing methods for penicillin susceptibility testing. The aims of the present study were to determine the frequency of penicillin-susceptible SA isolates from blood and wound cultures in Lund, Sweden, and to evaluate methods for penicillin testing in SA. We also wanted to investigate if penicillin-susceptible isolates are associated with higher mortality.

METHODS

Hundred blood culture isolates collected 2008/2009, 140 blood culture isolates from 2014/2015, and 141 superficial wound culture strains from 2015 were examined. Penicillin susceptibility was tested with disk diffusion according to EUCAST guidelines, and results were confirmed with a cloverleaf assay and PCR amplification of the BlaZ gene. Patient data for all bacteraemia cases were extracted from medical records.

RESULTS

The disk diffusion method with assessment of both zone size and zone edge appearance had high accuracy in our study. About 57% of bacteraemia isolates from 2008/2009 were sensitive to penicillin compared to 29% in 2014/2015 (p < .0001). In superficial wound cultures, 21% were penicillin susceptible. There was no difference in co-morbidity or mortality rates between patients with penicillin resistant and penicillin sensitive SA bacteraemia.

CONCLUSION

Disk-diffusion is a simple and reliable method to detect penicillin resistance in SA, and susceptibility rates are significant. Penicillin has many theoretical advantages and should be considered in the treatment of SA bacteraemia when susceptible.

Phage typing, PCR amplification for mecA gene, and antibiotic resistance patterns as epidemiologic markers in nosocomial outbreaks of methicillin resistant Staphylococcus aureus

Staphylococcus aureus is one of the major causes of community and hospital-acquired infections. Bacteriophage considered as a major risk factor acquires S. aureus new virulence genetic elements. A total number of 119 S. aureus isolated from different specimens obtained from (RKH) were distinguished by susceptibility to 19 antimicrobial agents, phage typing, and PCR amplification for mecA gene. All of MRSA isolates harbored mecA gene, except three unique isolates. The predominant phage group is belonging to the (mixed group). Phage group (II) considered as an epidemiological marker correlated to β-lactamase hyper producer isolates. MRSA isolates indicated high prevalence of phage group (II) with highly increase for phage types (Ø3A), which were correlated to the skin. Phage types (Ø80/Ø81) played an important roll in Community Acquired Methicillin Resistant S. aureus (CAMRSA). Three outpatients MRSA isolates had low multiresistance against Bacitracin (Ba) and Fusidic acid (FD), considered as CAMRSA isolates. It was detected that group I typed all FD-resistant MSSA isolates. Phage groups (M) and (II) were found almost to be integrated for Gentamycin (GN) resistance especially phage type (Ø95) which relatively increased up to 20% in MRSA. Tetracycline (TE) resistant isolates typed by groups (II) and (III) in MSSA. Only one isolate resistant to Sulphamethoxazole/Trimethoprim (SXT) was typed by (III/V) alone in MSSA. MRSA isolates resistant to Chloramphenicol (C) and Ba were typed by all groups except (V). It could be concluded that (PERSA) S. aureus isolates from the wound that originated and colonized, and started to build up multi-resistance against the topical treatment antibiotics. In this study, some unique sporadic isolates for both MRSA and MSSA could be used as biological, molecular and epidemiological markers such as prospective tools.

Tetracycline consumption and occurrence of tetracycline resistance in Salmonella typhimurium phage types from Danish pigs

The aims of the present study were to investigate at the farm-owner level the effect of prescribed tetracycline consumption in pigs and different Salmonella Typhimurium phage types on the probability that the S. Typhimurium was resistant to tetracycline. In this study, 1,307 isolates were included, originating from 877 farm owners, and data were analyzed using logistic regression. The analysis showed that both the S. Typhimurium phage type (p < 0.0001) and an increase in tetracycline consumption (p = 0.0007) were significantly associated with tetracycline resistance. In particular, the phage type was strongly associated with tetracycline resistance. A further analysis of data from the Danish Integrated Antimicrobial Resistance Monitoring and Research Programme (DANMAP) indicates that the tetracycline-susceptible phage types only slowly become tetracycline resistant, although tetracycline consumption more than doubled at the national level from 12,000-13,000 kg of active compound in 1996-1998 to 29,000 kg of active compound in 2004. Instead, tetracycline-resistant S. Typhimurium phage types became more prevalent. This suggests that the spread of already established or new resistant clones, rather than conversion of "old" well-established susceptible clones to resistant clones by uptake of resistance genes, explains most of the increased levels of tetracycline resistance in S. Typhimurium in Danish swine production in response to increased tetracycline consumption.

Phage types and antimicrobial resistance among Danish bovine Staphylococcus aureus isolates since the 1950s

A total of 292 bovine Staphylococcus aureus isolates obtained from the 1950s (86 isolates), 1992 (107 isolates), and 2000 (99 isolates) were examined for antimicrobial susceptibility and phage typing. The same types of S. aureus (80, 52, 3A, 3A/3C, 42E, 77) were found among the isolates from all three time periods, representing 43.3% of the typeable isolates. This indicates that the Danish S. aureus population related to bovine mastitis has remained relatively unchanged over the last 50 years. The occurrence of antimicrobial resistance has remained low in Denmark in comparison to other countries in Europe.

Association between phage types and antimicrobial resistance among bovine Staphylococcus aureus from 10 countries

This study was conducted to investigate the diversity of phage types and associations between penicillin resistance and phage types among 815 Staphylococcus aureus isolates from bovine mastitis in nine European countries and USA. All isolates were examined for susceptibility to antimicrobial agents and characterised by phage typing. Penicillin resistance was found among strains from all countries with an average occurrence of 32.4% (2-71.4%). A total of 76% of isolates were identifiable by phage typing and 144 different phage types were observed. The most predominant types were phage type 29 (11% of the 815 isolates), phage type 52 (5%), and phage type 80 (5%). Phage type 95 and 29/52/52A/80 were both distributed within seven countries. In the countries with the highest occurrence of penicillin resistance a reduced diversity of phage types and phage groups was observed. Phage group III was significantly associated with penicillin resistance in contrast to phage group I (P=0.0023) and phage complex-80 (P=0.0066). This study confirms that a large number of phage types of S. aureus cause bovine mastitis, but that some types predominate. In addition, these findings could indicate that the use of penicillin in the bovine environment has selected for specific types of S. aureus in countries with a high frequency of resistance.

Trends in antimicrobial susceptibility in relation to antimicrobial usage and presence of resistance genes in Staphylococcus hyicus isolated from exudative epidermitis in pigs

From 1996 to 2001 a total of 467 Staphylococcus hyicus isolates from exudative epidermitis (EE) in pigs in Denmark were examined for susceptibility to 13 different antimicrobial agents. The presence of selected genes encoding macrolide (erm(A), erm(B) and erm(C)), penicillin (blaZ), streptogramin (vat, vga, vga(B), vat(B), vat(D) and vat(E)), streptomycin (aadE) and tetracycline resistance (tet(K), tet(L), tet(M) and tet(O)) were determined in selected isolates. The occurrence of erythromycin resistance increased from 33% in 1996 to a maximum of 62% in 1997 and decreased to 26% in 2001. Resistance to sulphametazole increased from 17% in 1996 to 30% in 1998 but has since decreased to 4% in 2001. Resistance to trimethoprim increased to 51% in 1997 and decreased to 21% in 2001. Resistance to tetracycline (21-31%) remained relatively constant during 1996-2000, but increased to 47% in 2001. Resistance to penicillin (54-75%) streptomycin (33-53%) and tetracycline (21-47%) remained relatively constant over the time investigated. All 48 penicillin resistant isolates examined contained the blaZ gene and 40 (85%) of the streptomycin resistant isolates the aadE gene. It was not possible to detect any streptogramin resistance gene in four streptogramin resistant isolates. Of the 55 erythromycin resistant isolates examined, five contained erm(A), 13 erm(B), 35 erm(C) and two both erm(A) and erm(C). The presence of erm(B) was confirmed by hybridization to plasmid profiles in all 13 PCR-positive isolates. Of 52 tetracycline resistant isolates examined, two contained tet(L), 38 tet(K) and 12 both tet(K) and tet(L).

Twelve year observation of primary and secondary antibiotic-resistant Helicobacter pylori strains in children

BACKGROUND

The effectiveness of Helicobacter pylori eradication regimens is influenced by antibiotic susceptibility of infecting strains. Data concerning antibiotic resistance in children are limited. We report the evolution of primary and secondary resistance in a series of Belgian children during the last 12 years.

PATIENTS AND METHODS

From 1989 through 2000, H. pylori gastritis was diagnosed in 569 children, and antibiotic susceptibility tests were performed in 555. Eradication, using different schemes, failed in 128 of 457 treated children. After eradication failure antibiotic susceptibility determination was performed in 87 of 128. Comparison of antibiotic susceptibility of strains isolated from the gastric body and from the antrum was performed in 238 samples.

RESULTS

Resistance to amoxicillin was not observed. The rate of primary resistance to nitroimidazole derivatives was 18.0% (101 of 555) and remained constant throughout this period, whereas primary resistance to macrolides increased from an average of 6.0% (range, 0 to 10%) before 1995 to 16.6% (range, 10 to 25%, P < 0.001) thereafter. Antibiotic consumption in Belgium, especially macrolides, did not show important fluctuations during the study period. Secondary resistance developed in 39 of 87 patients (46%). Strains isolated from different gastric locations show identical susceptibility testing in all but 5 of 238.

CONCLUSIONS

Resistance of H. pylori to macrolides increased in our pediatric population which did not appear to correlate with macrolides prescription habits in our country. After eradication failure acquired secondary resistance was observed in one-half of the patients.

Occurrence of the blaZ gene in penicillin resistant Staphylococcus aureus isolated from bovine mastitis in Denmark

Fifty-eight penicillin resistant Staphylococcus aureus isolates of known phage types from bovine mastitis in Denmark from the 1950'ties (10 isolates) and the 1990'ties (48 isolates) were tested for beta-lactamase production. Furthermore, the presence of blaZ and blaR1 and the location of blaZ was determined by PCR and hybridisation. All isolates produced beta-lactamase and contained blaZ and blaR1. The blaZ gene was located on the chromosome in 54 isolates and on plasmids of different sizes in 4 isolates. Sequence analysis of an internal region of blaZ in 2 isolates of bovine origin showed a high degree of homology to already published sequences from human isolates. BlaZ could be transferred from the 4 isolates with plasmid location whereas it was not possible to transfer blaZ from 3 isolates with chromosomal location of the gene. The blaZ gene and the blaR1 gene were located closely to each other as previously published. In contrast to observations among isolates of human origin, no correlation between penicillin resistance and phage pattern was indicated for the bovine isolates. Furthermore, in contrast to the observed shift towards increased occurrence of plasmid location of blaZ among isolates of human origin in Denmark, blaZ appears to remain predominately chromosomal located among isolates of bovine origin.

A study of phage- and ribotype patterns of Staphylococcus aureus isolated from bovine mastitis in the Nordic countries

This study was conducted to investigate the geographical distribution of phage and ribotypes of Staphylococcus aureus causing bovine mastitis in the 5 Nordic countries. A total of 403 isolates of S. aureus was isolated from 403 different dairy herds. One hundred five strains were isolated in Denmark, 81 in Finland, 17 in Iceland, 96 in Norway and 104 in Sweden. The isolates were phage typed and characterized for their EcoRI restriction fragment length polymorphisms of the genes encoding ribosomal RNA (ribotyping). A total of 351 (87%) of the 403 isolates could be typed by phages assigning them to 25 different phage types. Two to 3 different phage types predominated within each country. One type (29/52) accounted for 36% of all the isolates and was found in 4 of the countries. A total of 87 different ribotypes was found among the isolates investigated. As for phage typing 2 to 3 different types predominated within countries. However, except for one type (ribotype 1), which was commonly found in Denmark, Sweden and Finland, different ribotypes predominated within each country. The combination of phage and ribotyping assigned the isolates to 178 different types. Ninety-six percent of the isolates of ribotype 1 belonged to phage type 29/52. This combined type accounted for 17% of all the 403 isolates. These findings show that a large number of different types of S. aureus can be isolated from cases of bovine mastitis. However, few types predominate within different countries. These predominating types seem to be specific in each country, however, a single type was common for both Denmark, Sweden and Finland. This could suggest differences in the virulence or in modes of transmission of predominating and rare types of S. aureus associated with bovine mastitis.

High prescribers of antibiotics among general practitioners--relation to prescribing habits of other drugs and use of microbiological diagnostics

General practitioners' (GPs') prescriptions of antibiotics have shown large variations and may not always be rational. We analysed GPs' prescriptions and use of microbiological diagnostics in Viborg County during a 6-month period in 1992 based on Danish Health Service data. In a logistic regression model we tried to identify potential predictors for a high prescriber of antibiotics, i.e. the GPs with the highest number of prescriptions per patient (upper quartile). Two categories were calculated for the predictor variables, dividing the distribution by the median value. The most liberal GP wrote 15 times as many prescriptions for antibiotics per patient as the most restrictive GP. A strong predictor for high prescribing of antibiotics was the number of prescriptions for other drugs per patient [odds ratio (OR) 12.3, 95% CI: 2.8-54.4] after adjustment for age and sex. High use of throat swabs was a strong negative predictor of high prescribing of antibiotics (OR 0.2, 95% CI: 0.1-0.8) while high use of cultures (OR 2.4, 95% CI: 0.8-6.9) and of urinary susceptibility tests (OR 3.1, 95% CI: 1.1-9.3) were positive predictors. The GP's general attitude to pharmacotherapy seems important for antimicrobial chemotherapy, and if use of antibiotics should be reduced, targeted strategies should be aimed at high prescribers.

A comparative study of Staphylococcus aureus strains isolated from bovine subclinical mastitis during 1952-1956 and 1992

Fifty-two strains of S. aureus isolated from cases of bovine subclinical mastitis in 52 different dairy herds in Denmark, in the periods 1952 to 1956 and 1992, were compared with regard to their phage- and EcoRI ribotypes. Furthermore, susceptibility to penicillin and production of fibrinolysin were used as additional phenotypic markers. Forty-nine strains (94%) could be separated into 12 phage types. Ribotyping assigned the 52 strains to 21 different types. Both methods showed that 57% of the 1950's strains and between 38-45% of the 1992 strains belonged to 3 dominating types. The remaining strains were placed by ribotyping in 8 types occurring among the 1952-1956 strains and 10 types occurring among the 1992 strains. In 87% of the strains the results of the 2 typing methods were in accordance. However, 7 strains gave different results by the 2 methods including 2 strains with major differences. Penicillin resistance only occurred in a single genotype from the 1950's compared to 6 different genotypes among the 1992 strains.

beta-Lactamase production and genetic location in Staphylococcus aureus: introduction of a beta-lactamase plasmid in strains of phage group II

Staphylococcus aureus strains of phage group II have increased in frequency in hospital-acquired infections during recent years. A total of 184 penicillin resistant group II strains from bacteraemia cases in the years 1961-1990 were analysed for the amount of beta-lactamase produced and the location of the beta-lactamase gene. Until 1977 all strains investigated had a chromosomally located beta-lactamase gene, but since then a 21 kb beta-lactamase plasmid has increased in occurrence among group II strains, especially among those strains typable only at high phage concentrations [100 x Routine Test Dilution (RTD) and 1000 x RTD]. In 1990, 84% of the group II strains contained this plasmid. Plasmid-containing strains produced more beta-lactamase than strains without the plasmid. S. aureus strains of the 94,96 complex, which since 1984 have decreased in frequency from 18 to 9% in 1993, have remained high producers of beta-lactamase.

Epidemiology of Staphylococcus aureus bacteremia in Denmark

The number of Staphylococcus aureus bacteremia cases has increased annually in Denmark during the latest decades. This increase has occurred among older patients with hospital-acquired bacteremia. Methicillin-resistance, which earlier was a property of strains of the 83A phage-complex, has nearly disappeared, while the frequency of penicillin-resistance has increased. Today both the phage-type pattern and antibiotic resistance are nearly similar for strains from hospital-acquired and community-acquired cases. In hospitals the frequency of bacteremia after postoperative wound infections has decreased, while cases associated with intravascular catheters has increased, and these infections are now the most common cause of hospital-acquired S. aureus bacteremia. Endocarditis is most commonly found in community-acquired cases without an identified primary focus in patients between 21-50 years. Also hematogenous osteomyelitis is most common in community-acquired cases, but these infections have changed to having a high predilection for the vertebral column, and the prevalence of chronic cases has decreased.

Changing patterns among the subgroups of strains of Staphylococcus aureus of phage group II in Danish hospitals from 1961-91

During the period 1961-91 a total of 567,635 strains of Staphylococcus aureus from hospitalized patients in Denmark have been characterized according to their antibiotic resistance, site of isolation and phage type. Strains of phage group II (typed by the phages 3A, 3C, 55 and 71) have been analysed further. The occurrence of group II strains was relatively constant (approximately 16%) from 1961 until 1983. Since then the frequency of group II strains increased; in 1991 they accounted for 22.7% of all S. aureus strains isolated. Strains of group II can, on the basis of their phage types, be divided in four subgroups: 3A, 71, 71+ and the 'rest of group II'. Furthermore, within these groups strains may differ from one another in respect to their sensitivity to phages. The increased isolation of group II strains during recent years was because of an increase in strains of subgroups 71+ and the 'rest of group II strains'. In 1991 these two subgroups accounted for 89.7% of all group II strains. Furthermore, an increasing number of group II strains, 71.4% in 1991, was typable only at RTD x 100. The increase in the number of group II strains was even throughout Denmark. All four subgroups of group II have, during the observation period, become more frequently resistant to penicillin and/or tetracycline. Strains typed at 100 x RTD of subgroup 71+ and the 'rest of group II' are more frequently antibiotic resistant than the rest of the group II strains. Strains of the increasing subgroups occurred most often in abscesses.

Changing pattern of phage group II Staphylococcus aureus infections: from community to hospital

Changes in Staphylococcus aureus strains of phage group II were evaluated over a 30-year period. Strains of this group were previously known to be mainly community-acquired, to be rather sensitive to antibiotics and to occur in infections with better clinical outcome. During the period 1961 to 1990 a total of 551, 563 S. aureus strains was characterized according to antibiotic resistance, phage type and site of isolation. Clinical information was obtained on 16,781 bacteraemia cases. Strains of group II occurred until 1983 with a rather constant frequency around 16% of the S. aureus population. Since then, a constant increase in frequency has taken place and since 1990 they are the most frequently isolated phage pattern (22%). Bacteraemia caused by these strains occurs today with the same frequency in hospital and community as strains of other phage patterns. Moreover, these strains have changed from being highly susceptible, to being more resistant to penicillins and tetracycline than the rest of the population. Resistance to methicillin remained low in group II strains throughout the period (about 0.2%). Mortality rate and the proportion of patients with underlying diseases have been the same in recent years regarding group II strains as with other strains. This study indicates that the previous distinction between community-acquired and hospital-acquired S. aureus infections is no longer valid.