Suspected horse-to-human transmission of MRSA ST398

A look at staphylococci from the one health perspective

Staphylococcus aureus and other staphylococcal species are resident and transient multihost colonizers as well as conditional pathogens. Especially S. aureus represents an excellent model bacterium for the "One Health" concept because of its dynamics at the human-animal interface and versatility with respect to host adaptation. The development of antimicrobial resistance plays another integral part. This overview will focus on studies at the human-animal interface with respect to livestock farming and to companion animals, as well as on staphylococci in wildlife. In this context transmissions of staphylococci and of antimicrobial resistance genes between animals and humans are of particular significance.

Wound swabs versus biopsies to detect methicillin resistant Staphylococcus aureus in experimental equine wounds

OBJECTIVE

To compare: (1) the load and diversity of cultivatable bacterial species isolated from tissue biopsies with cultures from surface swabs, and (2) the ability of each technique to detect methicillin-resistant Staphylococcus aureus (MRSA) in a model of MRSA-infected equine wounds.

STUDY DESIGN

Experimental in vivo study.

ANIMALS

Three light-breed adult horses.

METHODS

Four 2.5 × 2.5 cm full-thickness skin wounds were created on the dorsolateral aspect of each forelimb. Five days later, each wound was inoculated with a pure culture of MRSA (ATCC 43300). One hundred microlitres of 0, 5 × 108 , 5 × 109 or 5 × 1010 colony forming units (CFU)/ml was used to inoculate each wound. Surface swabs (Levine technique) and tissue biopsy samples (3 mm punch biopsy) were obtained at 2, 7, 14, and 21 days after inoculation. Quantitative aerobic culture was performed using routine clinical techniques.

RESULTS

A similar bacterial profile was identified from the culture of each wound-sampling technique and there was moderate correlation (R = 0.49, P < .001) between the bacterial bioburdens. Agreement was fair (κ = 0.31; 95% CI, 0.129-0.505) between the sampling techniques in identification of MRSA. Methicillin-resistant Staphylococcus aureus was isolated more frequently (P = .016) from cultures of tissue biopsies (79%; 76/96) than from surface swabs (62%; 60/96).

CONCLUSION

Bacterial load and diversity did not differ between sampling techniques but MRSA was detected more often from the cultures of tissue biopsies.

CLINICAL SIGNIFICANCE

Tissue biopsy should be preferred to culture swab in wounds where MRSA is suspected.

Assessment of listing and categorisation of animal diseases within the framework of the Animal Health Law (Regulation (EU) No 2016/429): antimicrobial-resistant Staphylococcus aureus in cattle and horses

Staphylococcus aureus (S. aureus) was identified among the most relevant antimicrobial-resistant (AMR) bacteria in the EU for cattle and horses in previous scientific opinions. Thus, it has been assessed according to the criteria of the Animal Health Law (AHL), in particular criteria of Article 7 on disease profile and impacts, Article 5 on its eligibility to be listed, Annex IV for its categorisation according to disease prevention and control rules as in Article 9, and Article 8 for listing animal species related to the bacterium. The assessment has been performed following a methodology previously published. The outcome is the median of the probability ranges provided by the experts, which indicates whether each criterion is fulfilled (lower bound ≥ 66%) or not (upper bound ≤ 33%), or whether there is uncertainty about fulfilment. Reasoning points are reported for criteria with uncertain outcome. According to the assessment here performed, it is uncertain whether AMR S. aureus can be considered eligible to be listed for Union intervention according to Article 5 of the AHL (60-90% probability). According to the criteria in Annex IV, for the purpose of categorisation related to the level of prevention and control as in Article 9 of the AHL, the AHAW Panel concluded that the bacterium does not meet the criteria in Sections 1, 2 and 4 (Categories A, B and D; 1-5%, 5-10% and 10-33% probability of meeting the criteria, respectively) and the AHAW Panel was uncertain whether it meets the criteria in Sections 3 and 5 (Categories C and E, 33-90% and 60-90% probability of meeting the criteria, respectively). The animal species to be listed for AMR S. aureus according to Article 8 criteria include mainly mammals, birds, reptiles and fish.

Nasal colonization and antibiotic resistance patterns of Staphylococcus species isolated from healthy horses in Tripoli, Libya

The present study investigated the colonization rates and antimicrobial susceptibility of Staphylococcus species isolated from the nostrils of healthy horses. A nonselective laboratory approach was applied, followed by confirmation using a Phoenix automated microbiological system. Among the 92 horses included in the study, 48.9% (45/92) carried Staphylococcus species of mostly the coagulase-negative staphylococci (CoNS) type yielding 70 Staphylococcus strains. Of these strains, 37.1% (26/70; 24 CoNS and 2 coagulase-positive staphylococci; CoPS) were identified as methicillin-resistant staphylococci (MRS) expressing significant resistance to important antimicrobial classes represented mainly by subspecies of CoNS. This is the first study reporting a high prevalence of various Staphylococcus species, particularly strains of CoNS expressing multidrug resistance patterns of public health concern, colonizing healthy horses in Libya.

Antimicrobial prescribing patterns in equine ambulatory practice

Antimicrobial resistance is one of the most important public health risks facing our world today. Antimicrobials are commonly prescribed in equine veterinary medicine, but limited information exists documenting their use in practice. The goal of this study was to investigate antimicrobial prescription patterns in regards to prescription frequency, duration, drug class, clinician and affected body system in an equine ambulatory setting via retrospective analysis of billing and electronic medical records. Risk factors associated with antimicrobial prescription including the nature of the visit, submission of a culture, body system affected and clinician were assessed using multivariable regression. We found that antimicrobials were prescribed in 8.5 % of visits with a median number of 3.5 (IQR 0.8-12.2) animal-defined daily doses (ADD), defined as the number of daily doses of all antimicrobials prescribed to a patient at a single visit. Aminoglycosides were the most common class of antimicrobials prescribed and trimethoprim sulfamethoxazole was the most common drug prescribed overall. Amikacin was primarily used for patients presenting with musculoskeletal signs, and the median number of ADDs for visits where amikacin was prescribed was 1 (IQR 0.9-1.9), while the median number of antimicrobial ADDs for all other visits was 4.4 (IQR 0-14.1). Statistically significant differences in antimicrobial use patterns existed across clinicians, months, years and affected body systems. Horses presenting with ocular (OR 1199; 95 % CI 204-7,037; p < 0.001) and integumentary (OR 365; 95 % CI 87.2-1532; p < 0.001) signs were most likely to be prescribed an antimicrobial. Emergency visits (OR 5.61; 95 % CI 3.19-9.89; p < 0.001) and submission of a bacterial culture (OR 3.58; 95 % CI 2.11-6.09; p < 0.001) were associated with an increased likelihood of an antimicrobial prescription. This observational study was the first to quantitatively characterize antimicrobial use patterns in equine ambulatory practice in the United States, which is an important step needed to determine appropriateness of use and develop and evaluate antimicrobial stewardship guidelines.

Antimicrobial resistance in clinical bacterial isolates from horses in the UK

BACKGROUND

Surveillance of antimicrobial resistance (AMR) in horses is important to aid empirical treatment decisions and highlight emerging AMR threats.

OBJECTIVE

To describe the AMR patterns of common groups of bacteria from clinical submissions from horses in the UK during 2018, and to determine how this varies by sample site and type of submitting veterinary practice.

STUDY DESIGN

Prospective observational study.

METHODS

All data on bacterial culture and subsequent antimicrobial susceptibility testing (AST) collected in 2018 from six large equine diagnostic laboratories were included. Resistance patterns were analysed including resistance to 1 or 2 antimicrobial classes, multidrug resistance (MDR), extensively drug resistant (XDR), resistance to highest priority critically important antimicrobials and isolates where there was no readily available treatment for adult horses in the UK. Submitting practices were classified according to whether they treated referral cases or not (first opinion). Comparisons between proportions and resistance for each bacterial group and sample site was performed using Chi-squared (or Fisher's exact test).

RESULTS

A total of 6,018 bacterial isolates from 4,038 diagnostic submissions were included from respiratory (n = 1555), urogenital (n = 1,010), skin/hair/wound/abscess (n = 753), surgical site infection (SSI) /catheter-related-infection (CRI) /orthopaedic infections (n = 347) and unknown/'other' submissions (n = 373). There were 2,711 Gram-negative isolates and 3,307 Gram-positive isolates. Prevalence of MDR for E. coli was 31.7%, Staphylococcus spp. 25.3% and > 25% for the majority of bacterial isolates from SSI/CRI/orthopaedic submissions. For Enterococcus spp. there was no readily available treatment for adult horses in the UK in 30.2% of positive submissions. MDR was significantly higher from referral hospital than first opinion submissions for the majority of pathogens (except Actinobacillus spp. and Pasteurella spp. and β-haemolytic Streptococcus spp.).

MAIN LIMITATIONS

Since culture and susceptibility results are not systematic analyses based on harmonised methods, selection bias could impact the findings.

CONCLUSIONS

Ongoing surveillance is essential to understand emerging patterns of resistance. MDR is high in SSI/CRI/orthopaedic infections, which is important for hospital biosecurity and guiding treatment decisions. Harmonisation of diagnostic procedures and interpretation of results amongst veterinary laboratories will improve AMR surveillance and data comparison among laboratories.

A retrospective study on methicillin-resistant Staphylococcus spp. isolated from horses admitted to a Canadian veterinary teaching hospital between 2008 and 2018

The goals of this retrospective study were to: determine the frequency of methicillin-resistant Staphylococcus spp. (MRS) isolated from horses admitted to an equine veterinary teaching hospital in Quebec from 2008 to 2018, investigate the patterns of antimicrobial resistance (AMR), and evaluate the distribution of MRS and methicillin-sensitive Staphyloccocus spp. (MSS) by body site. During this period, 311 Staphylococcus spp. were isolated from 273 horses and 127 of these isolates were submitted to antimicrobial susceptibility testing. Of these 127 isolates, 24 (18.9%) were MRS, and among the S. aureus (n = 76), 19 (25%) were MRS. The odds of detecting an MRS increased (25%) each year [95% confidence interval (CI) (1% to 55%), P = 0.039]. The highest frequencies of resistance were to tetracycline and gentamicin. Among the MRS isolates, 12% were susceptible to both tetracycline and gentamicin. The most frequently sampled body sites were "soft-tissues." There was no significant difference (P = 0.93) in the body site distribution of MRS and MSS isolates.

Horses as a Crucial Part of One Health

One Health (OH) is a crucial concept, where the interference between humans, animals and the environment matters. This review article focusses on the role of horses in maintaining the health of humans and the environment. Horses' impact on environmental health includes their influence on soil and the biodiversity of animal and plant species. Nevertheless, the effect of horses is not usually linear and several factors like plant-animal coevolutionary history, climate and animal density play significant roles. The long history of the relationship between horses and humans is shaped by the service of horses in wars or even in mines. Moreover, horses were essential in developing the first antidote to cure diphtheria. Nowadays, horses do have an influential role in animal assisted therapy, in supporting livelihoods in low income countries and as a leisure partner. Horses are of relevance in the spillover of zoonotic and emerging diseases from wildlife to human (e.g., Hendra Virus), and in non-communicable diseases (e.g., post-traumatic osteoarthritis in horses and back pain in horse riders). Furthermore, many risk factors-such as climate change and antimicrobial resistance-threaten the health of both horses and humans. Finally, the horse is a valuable factor in sustaining the health of humans and the environment, and must be incorporated in any roadmap to achieve OH.

In vitro antimicrobial susceptibility of equine clinical isolates from France, 2006-2016

OBJECTIVES

This study aimed to analyse antimicrobial susceptibility evolution of equine pathogens isolated from clinical samples from 2006-2016.

METHODS

A collection of 25 813 bacterial isolates was studied, clustered according to their origins (respiratory tract, cutaneous, genital and other), and analysed for their antimicrobial susceptibility using the disk diffusion method.

RESULTS

The most frequently isolated pathogens were group C Streptococci (27.6%), Escherichia coli (20.0%), Staphylococcus aureus (7.8%), Pseudomonas aeruginosa (4.0%), Enterobacter spp. (3.4%), Klebsiella pneumoniae (2.4%), and Rhodococcus equi (1.8%). Of the isolates, 9512 were from respiratory samples (36.8%), 7689 from genital origin (29.8%), and 4083 from cutaneous samples (15.8%). Over the 11-year period, the frequency of multidrug-resistant (MDR) strains fluctuated between 6.4-20.4% for group C Streptococci and 17-37.7% for Klebsiella pneumoniae. From 2006-2009, 24.5-43.0% of Staphylococcus aureus isolates were MDR; after 2009 the level did not exceeded 27.6%. For Escherichia coli and Enterobacter spp., these levels were mostly >30.0% until 2012, but significantly decreased thereafter (22.5-26.3%).

CONCLUSIONS

This study is the first large-scale analysis of equine pathogens, by the number of samples and duration of study. The results showed high levels of MDR strains and the need to support veterinary antimicrobial stewardship to encourage proper use of antibiotics.

Equine Methicillin-Resistant Sequence Type 398 Staphylococcus aureus (MRSA) Harbor Mobile Genetic Elements Promoting Host Adaptation

Continuing introduction of multi-drug resistant, zoonotic pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) in horse clinics challenges the biosafety of employees and animal patients. This study was aimed to determine the occurrence of mobile genetic elements facilitating survival in the early stages of invasive infection in different host species, including humans and horses, in MRSA carried by equine patients admitted to a large horse clinic. A total of 341 equine patients were investigated for carriage of MRSA by hygiene screening directly at hospital admission. MRSA were further investigated by antimicrobial susceptibility testing, whole-genome sequencing and genomic composition, including virulence factors involved in immune evasion and host adaption. From a total of 340 validated specimens from equine nostrils, 3.5% yielded positive results for MRSA. All MRSA were found to be closely related belonging to sequence type (ST) 398_t011 with up to four additional antimicrobial resistances. All MRSA harbored a specific Staphylococcal Pathogenicity Island (SaPIbov5) involved in facilitating survival in ruminant and equine plasma. Moreover, a β-hemolysin (hlb) converting ΦSa3 phage encoding the human-specific Immune Evasion Cluster (IEC) was present in 72% of the isolates. An equid-specific leukotoxin encoded by a further temperate phage (Saeq1) was only rarely detected (22%). Despite the absence of β-hemolysin production for all IEC-positive ST398, a prominent hemolysis zone was demonstrable on sheep blood agar. Thus, IEC might remain undetected among the ST398 lineage, since the presence of IEC is commonly associated with reduction of hemolysis in S. aureus belonging to other genetic backgrounds. Here we describe MRSA-ST398 harboring different mobile genetic elements encoding variants of immune evasion factors and toxins previously shown to contribute to S. aureus invasive diseases in specific host species or ecologic niches. We suggest these combinations contribute to the adaptation of MRSA belonging to ST398 with respect to epidemic spread across different habitats and hosts, and may therefore confer a host “generalist” phenotype.

An epidemiologic study of antimicrobial resistance of Staphylococcus species isolated from equine samples submitted to a diagnostic laboratory

Background

Antimicrobial resistance limits traditional treatment options and increases costs. It is therefore important to estimate the magnitude of the problem so as to provide empirical data to guide control efforts. The aim of this study was to investigate the burden and patterns of antimicrobial resistance (AMR) among equine Staphylococcus samples submitted to the University of Kentucky Veterinary Diagnostic Laboratory (UKVDL) from 1993 to 2009. Retrospective data of 1711 equine Staphylococcus samples submitted to the UKVDL during the time period 1993 to 2009 were included in the study. Antimicrobial susceptibility testing, that included 16 drugs, were performed using cultures followed by the Kirby-Bauer disk diffusion susceptibility test. The proportion of resistant isolates by animal breed, species of organism, sample source, and time period were computed. Chi-square and Cochran-Armitage trend tests were used to identify significant associations and temporal trends, respectively. Logistic regression models were used to investigate predictors of AMR and multidrug resistance (MDR).

Results

A total of 66.3% of the isolates were resistant to at least one antimicrobial, most of which were Staphylococcus aureus (77.1%), while 25.0% were MDR. The highest level of resistance was to penicillins (52.9%). Among drug classes, isolates had the highest rate of AMR to at least one type of β-lactams (49.2%), followed by aminoglycosides (30.2%). Significant (p < 0.05) associations were observed between odds of AMR and horse breed, species of organism and year. Similarly, significant (p < 0.05) associations were identified between odds of MDR and breed and age. While some isolates had resistance to up to 12 antimicrobials, AMR profiles featuring single antimicrobials such as penicillin were more common than those with multiple antimicrobials.

Conclusion

Demographic factors were significant predictors of AMR and MDR. The fact that some isolates had resistance to up to 12 of the 16 antimicrobials assessed is quite concerning. To address the high levels of AMR and MDR observed in this study, future studies will need to focus on antimicrobial prescription practices and education of both practitioners and animal owners on judicious use of antimicrobials to slow down the development of resistance.

High Occurrence of Methicillin-Resistant Staphylococcus aureus in Horses at Slaughterhouses Compared with Those for Recreational Activities: A Professional and Food Safety Concern?

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in horses and its zoonotic potential is poorly understood. The objective of this study is to provide data on the prevalence and genetic characteristics of MRSA isolated from horses on farms, at racecourses, and at slaughterhouses in Italy, using standard and molecular methods. In addition, we report the prevalence of MRSA in horse handlers. Among 388 horses tested by nasal swabs, 27 (7%) were positive for MRSA ST398 (t011, t899, t1255) and ST1 (t127). The prevalence of MRSA in horses tested at slaughterhouses was significantly higher (p < 0.001) compared with those tested on farms and racecourses. Five (7%) out of 67 staff members working in close contact with horses (2 from slaughterhouse, 2 from riding stable, and 1 from racecourse) were carriers of MRSA ST398 (t011, t034) and ST1 (t127). The isolates from horses and humans carried SCCmec IVa or V and were pvl negative and pia positive. All the isolates from both horses and humans were resistant to at least two antimicrobial classes. The circulation of MRSA in horses and in humans working in close contact with them should be considered an emerging public health issue. In fact, it represents a potential risk for people who work in close contact with horses, and for horse meat consumers.

Public health risk of antimicrobial resistance transfer from companion animals

Antimicrobials are important tools for the therapy of infectious bacterial diseases in companion animals. Loss of efficacy of antimicrobial substances can seriously compromise animal health and welfare. A need for the development of new antimicrobials for the therapy of multiresistant infections, particularly those caused by Gram-negative bacteria, has been acknowledged in human medicine and a future corresponding need in veterinary medicine is expected. A unique aspect related to antimicrobial resistance and risk of resistance transfer in companion animals is their close contact with humans. This creates opportunities for interspecies transmission of resistant bacteria. Yet, the current knowledge of this field is limited and no risk assessment is performed when approving new veterinary antimicrobials. The objective of this review is to summarize the current knowledge on the use and indications for antimicrobials in companion animals, drug-resistant bacteria of concern among companion animals, risk factors for colonization of companion animals with resistant bacteria and transmission of antimicrobial resistance (bacteria and/or resistance determinants) between animals and humans. The major antimicrobial resistance microbiological hazards originating from companion animals that directly or indirectly may cause adverse health effects in humans are MRSA, methicillin-resistant Staphylococcus pseudintermedius, VRE, ESBL- or carbapenemase-producing Enterobacteriaceae and Gram-negative bacteria. In the face of the previously recognized microbiological hazards, a risk assessment tool could be applied in applications for marketing authorization for medicinal products for companion animals. This would allow the approval of new veterinary medicinal antimicrobials for which risk levels are estimated as acceptable for public health.

An Exploratory Descriptive Study of Antimicrobial Resistance Patterns of Staphylococcus Spp. Isolated from Horses Presented at a Veterinary Teaching Hospital

BACKGROUND

Antimicrobial resistant Staphylococcus are becoming increasingly important in horses because of the zoonotic nature of the pathogens and the associated risks to caregivers and owners. Knowledge of the burden and their antimicrobial resistance patterns are important to inform control strategies. This study is an exploratory descriptive investigation of the burden and antimicrobial drug resistance patterns of Staphylococcus isolates from horses presented at a veterinary teaching hospital in South Africa.

METHODS

Retrospective laboratory clinical records of 1027 horses presented at the University of Pretoria veterinary teaching hospital between 2007 and 2012 were included in the study. Crude and factor-specific percentages of Staphylococcus positive samples, antimicrobial resistant (AMR) and multidrug resistant (MDR) isolates were computed and compared across Staphylococcus spp., geographic locations, seasons, years, breed and sex using Chi-square and Fisher's exact tests.

RESULTS

Of the 1027 processed clinical samples, 12.0% were Staphylococcus positive. The majority of the isolates were S. aureus (41.5%) followed by S. pseudintermedius (14.6%). Fifty-two percent of the Staphylococcus positive isolates were AMR while 28.5% were MDR. Significant (p < 0.05) differences in the percentage of samples with isolates that were AMR or MDR was observed across seasons, horse breeds and Staphylococcus spp. Summer season had the highest (64.3%) and autumn the lowest (29.6%) percentages of AMR isolates. Highest percentage of AMR samples were observed among the Boerperds (85.7%) followed by the American saddler (75%) and the European warm blood (73.9%). Significantly (p < 0.001) more S. aureus isolates (72.5%) were AMR than S. pseudintermedius isolates (38.9%). Similarly, significantly (p < 0.001) more S. aureus (52.9%) exhibited MDR than S. pseudintermedius (16.7%). The highest levels of AMR were towards β-lactams (84.5%) followed by trimethoprim/sulfamethoxazole (folate pathway inhibitors) (60.9%) while the lowest levels of resistance were towards amikacin (14.%).

CONCLUSIONS

This exploratory study provides useful information to guide future studies that will be critical for guiding treatment decisions and control efforts. There is a need to implement appropriate infection control, and judicious use of antimicrobials to arrest development of antimicrobial resistance. A better understanding of the status of the problem is a first step towards that goal.

Nationwide molecular epidemiology of methicillin-resistant Staphylococcus aureus responsible for horse infections in France

Background

The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) isolated in horse infections is not well documented, especially in France. The aim of the study was to evaluate the prevalence of MRSA isolates in horse infections from 2007 to 2013 in France and to characterize phenotypically and genotypically this collection.

Results

Out of 1393 S. aureus horse isolates, 85 (6.1%) were confirmed to be MRSA. Interestingly, the prevalence of MRSA significantly increased from 2007–2009 to 2010–2013 (0.7 vs. 9.5%, P <0.0001). Resistance to methicillin was due to the presence of the mecA gene in 84 strains (98.8%) while one strain (1.2%) possessed the mecC gene. The vast majority of the strains (83/85, 97.6%) was resistant to at least three different classes of antibiotics. Multi-locus sequence typing (MLST) showed that MRSA strains belonged mainly since not all belong to two sequence types (STs): ST398 (53/85, 62.4%) and ST8 (28/85, 32.9%). It is worth to note that all ST398 MRSA isolates were detected in the period 2010–2013. Other molecular typing methods were also used, such SCC_mec analysis, spa typing and rep-PCR (Diversilab, bioMérieux). All these four techniques were in good agreement, with spa typing and rep-PCR being more discriminative than MLST and SCC_mec typing.

Conclusions

This study is the first epidemiological study in France with extensive characterization of MRSA isolates associated with horse infections in stud farms. It shows that there is a significant increase of MRSA prevalence between 2007 and 2013, which mainly results from the spread of ST398 clones. It also highlights the importance of horses as a potential reservoir of important antimicrobial resistance genes.

Bacterial resistance to antimicrobial agents and its impact on veterinary and human medicine

BACKGROUND

Antimicrobial resistance has become a major challenge in veterinary medicine, particularly in the context of bacterial pathogens that play a role in both humans and animals.

OBJECTIVES

This review serves as an update on acquired resistance mechanisms in bacterial pathogens of human and animal origin, including examples of transfer of resistant pathogens between hosts and of resistance genes between bacteria.

RESULTS

Acquired resistance is based on resistance-mediating mutations or on mobile resistance genes. Although mutations are transferred vertically, mobile resistance genes are also transferred horizontally (by transformation, transduction or conjugation/mobilization), contributing to the dissemination of resistance. Mobile genes specifying any of the three major resistance mechanisms - enzymatic inactivation, reduced intracellular accumulation or modification of the cellular target sites - have been found in a variety of bacteria that may be isolated from animals. Such resistance genes are associated with plasmids, transposons, gene cassettes, integrative and conjugative elements or other mobile elements. Bacteria, including zoonotic pathogens, can be exchanged between animals and humans mainly via direct contact, but also via dust, aerosols or foods. Proof of the direction of transfer of resistant bacteria can be difficult and depends on the location of resistance genes or mutations in the chromosomal DNA or on a mobile element.

CONCLUSION

The wide variety in resistance and resistance transfer mechanisms will continue to ensure the success of bacterial pathogens in the future. Our strategies to counteract resistance and preserve the efficacy of antimicrobial agents need to be equally diverse and resourceful.

Human Infections with Staphylococcus aureus CC398

Staphylococcus aureus isolates belonging to clonal cluster 398 (CC398) have emerged over the previous decade as a risk to livestock workers. Though most of the research to date has focused on colonization with these strains, a number of infections have also been documented, ranging from mild skin infections to more serious invasive infections and even death. Here, we review existing reports of human infections with CC398 and discuss their geographic distribution, general characteristics, and implications for future research. We identified 74 publications describing CC398 infections in humans in 19 different countries, suggesting this is an emerging worldwide issue.

Individual predisposition to Staphylococcus aureus colonization in pigs on the basis of quantification, carriage dynamics, and serological profiles

Previous research on Staphylococcus aureus in pigs focused on livestock-associated methicillin-resistant S. aureus (MRSA) and had a qualitative cross-sectional design. This study aimed to elucidate the frequency, load, and stability of S. aureus nasal carriage in pigs over time and investigated possible associations between carriage and immune response. Nasal swabs were collected three times weekly from 480 tagged adult pigs in 20 Danish production farms. S. aureus and MRSA were quantified on selective media by the most-probable-number method. The levels of IgG against 10 S. aureus antigens in serum were quantified in selected pigs by a Luminex assay. All the farms were positive for S. aureus and 15 for MRSA, leading to overall prevalences of persistent and intermittent carriers and noncarriers of 24, 52, and 23%, respectively. Carriage frequency and nasal loads were significantly higher on MRSA-positive farms. Logistic-regression modeling revealed the presence of individual pigs characterized by high nasal loads (>10,000 CFU per swab) and stable carriage regardless of farm- and pen-associated factors. On the other hand, the humoral response was strongly influenced by these environmental factors. The existence of a minority of shedders contributing to maintenance of S. aureus within farms opens up new perspectives on the control of MRSA in pig farming.

Impact of livestock-associated MRSA in a hospital setting

OBJECTIVES

The Netherlands is known for a stringent search and destroy policy to prevent spread of MRSA. In the hospital setting, livestock-associated MRSA (LA-MRSA) is frequently found in patients coming from the high density farming area in the south of the Netherlands. The aim of the study was to determine the contribution of LA-MRSA in the epidemiology of MRSA in cases found following the Dutch search and destroy policy.

PATIENTS AND METHODS

From two hospitals serving a population of 550,000 persons all data on MRSA cultures and subsequent control measures from 2008 and 2009 were retrospectively collected and analyzed.

RESULTS

A total of 3856 potential index patients were screened for MRSA, 373 (9.7%) were found to be positive, 292 ( 78%) LA-MRSA and 81 (22%) non-LA-MRSA respectively. No secondary cases were found among contact research in persons exposed to LA-MRSA (0/416), whereas similar contact research for non-LA-MRSA resulted in 83 (2.5%) secondary cases. LA-MRSA were rarely found to cause infections.

CONCLUSIONS

LA-MRSA is more prevalent than non-LA-MRSA in Dutch Hospitals in the South of the Netherlands. However, retrospectively studied cases show that the transmission rate for LA-MRSA was much lower than for non-LA-MRSA. This suggest that infection control practices for LA-MRSA may possibly be less stringent than for non-LA-MRSA.

Prevalence of the immune evasion gene cluster in Staphylococcus aureus CC398

The immune evasion gene cluster (IEC) is typical for Staphylococcus aureus isolated from humans but is usually absent in S. aureus isolated from animals. Previous studies have shown that methicillin resistant S. aureus (MRSA) CC398 obviously lost the IEC when evolving as livestock-associated MRSA from a human-adapted, methicillin-susceptible ancestor. This study aimed to look for the presence of IEC in MRSA from pigs and horses as well as from the colonization of humans with occupational animal contact and from infections in humans. For comparison, methicillin susceptible S. aureus (MSSA) isolates from infections in humans were included. We did not detect the IEC among 94 isolates from the nasal colonization of pigs; however, the IEC was found in 6 of 61 isolates from nosocomial infections in horses. MRSA CC398 isolates from the nasal colonization of 138 pig farmers were negative for the IEC. It was detected, however, in 4 of 69 veterinarians treating horses. Among 99 epidemiologically unrelated MRSA isolates attributed to CC398 originating from infections in humans, 19 were positive for the IEC. Only three of these isolates which also contained luk-PV were attributed to the ancestral, human-adapted subpopulation of CC398 by means of PCR for detection of canonical SNPs. A considerable proportion of LA-MRSA CC398 attributed to the animal subpopulation and originating from infections in humans had acquired the IEC; this acquisition is, however, obviously not a prerequisite to the capacity of LA-MRSA CC398 to cause infections in this host. Among 15 MSSA CC398 isolates from infections in humans, 11 contained the IEC, and of these, two were attributed to the animal subpopulation. Six isolates containing both the IEC and luk-PV were attributed to the ancestral, human subpopulation. Re-acquisition of the IEC by LA-MRSA CC398 suggests readaptation to the human host. In epidemiological surveillance, discrimination from the ancestral human subpopulation is important.

Methicillin resistant staphylococci and broad-spectrum β-lactamase producing Enterobacteriaceae in horses

The use of β-lactam antibiotics results in the selection of bacteria showing resistance toward this class of antibiotics. The review focuses on the increasing importance of methicillin resistant staphylococci and broad-spectrum β-lactamase-producing Enterobacteriaceae in horses. Diagnostic protocols that optimize accurate identification of these bacteria from both clinical samples and samples obtained from putative carrier animals are described. In addition, the opportunities and pitfalls for preventive and curative measures are discussed.

First detection of methicillin-resistant Staphylococcus aureus ST398 and Staphylococcus pseudintermedius ST68 from hospitalized equines in Spain

Eight coagulase-positive staphylococci from equines with different pathologies obtained between 2005 and 2011 were investigated. Isolates were characterized by different molecular techniques (spa-, agr-, MLST), and clonal relatedness of strains was investigated by ApaI and SmaI PFGE. Anti-microbial resistance and virulence profiles were determined. Six isolates were identified as Staphylococcus aureus, and two as Staphylococcus pseudintermedius. Of these, four isolates were methicillin-resistant S. aureus (MRSA) ST398 and one S. pseudintermedius was mecA positive and typed as ST68. One MRSA ST398 strain was isolated in 2005 and might be one of the earliest MRSA ST398 descriptions in Spain. All 5 mecA-positive strains were multidrug resistant and were isolated from hospitalized equines. Three MRSA ST398 strains carried the recently described transposon Tn559 within the chromosomal radC gene. The mecA-positive S. pseudintermedius ST68 strain was also multidrug resistant and harboured the erm(B)-Tn5405-like element. This ST68 strain presented a clear susceptible phenotype to oxacillin and cefoxitin regardless of the presence of an integral and conserved mecA gene and mecA promoter, which enhances the need for testing the presence of this gene in routine analysis to avoid treatment failures. These data reflect the extended anti-microbial resistance gene acquisition capacities of both bacterial species and evidence their pathogenic properties. The first detection of MRSA ST398 and S. pseudintermedius ST68 in horses in Spain is reported.

Methicillin-resistant staphylococci: implications for our food supply?

Food-borne intoxication, caused by heat-stable enterotoxins produced by Staphylococcus aureus, causes over 240,000 cases of food-borne illness in the United States annually. Other staphylococci commonly associated with animals may also produce these enterotoxins. Foods may be contaminated by infected food handlers during slaughter and processing of livestock or by cross-contamination during food preparation. S. aureus also causes a variety of mild to severe skin and soft tissue infections in humans and other animals. Antibiotic resistance is common in staphylococci. Hospital-associated (HA) S. aureus are resistant to numerous antibiotics, with methicillin-resistant S. aureus (MRSA) presenting significant challenges in health care facilities for over 40 years. During the mid-1990s new human MRSA strains developed outside of hospitals and were termed community-associated (CA). A few years later, MRSA was isolated from horses and methicillin resistance was detected in Staphylococcus intermedius/pseudintermedius from dogs and cats. In 2003, a livestock-associated (LA) MRSA strain was first detected in swine. These methicillin-resistant staphylococci pose additional food safety and occupational health concerns. MRSA has been detected in a small percentage of retail meat and raw milk samples indicating a potential risk for food-borne transmission of MRSA. Persons working with animals or handling meat products may be at increased risk for antibiotic-resistant infections. This review discusses the scope of the problem of methicillin-resistant staphylococci and some strategies for control of these bacteria and prevention of illness.

MRSA carriage in the equine community: an investigation of horse-caretaker couples

Equine methicillin-resistant Staphylococcus aureus (MRSA) carriage entails a risk of both equine and zoonotic transmission and infection. In Europe, CC398, the livestock-associated (LA-)MRSA is highly prevalent in horses and veterinary personnel at equine clinics. The extent of the MRSA reservoir created by healthy horses from the general population and associated health hazard for their daily caretakers is, however, unknown. This study aimed at screening healthy horse-caretaker couples from a broad range of home farms. At five equine gatherings, 166 couples were selected for MRSA screening in the anterior nares and participation in an epidemiologic survey. All MRSA isolates were subjected to genotyping and antimicrobial susceptibility testing. Only 4 humans (2.4%) and 2 of their horses (1.2%) tested MRSA positive. Within the 2 couples where both partners were positive, man and horse carried isolates belonging to identical, livestock-associated spa types (t011 and t2330) and demonstrating equal antimicrobial susceptibility patterns. For all LA-MRSA positive humans (n=3) and animals (n=2) regular (in)direct contact with the veterinary sector was reported. A significant association between the horses' carriage status and transportation to an event could not be demonstrated (P=1.00). In conclusion, outside equine clinics, the extent of the MRSA reservoir in horses and their caretakers was low. Travel to an equine gathering could not be withheld as a risk factor for equine MRSA carriage, whereas indications were found that contact with veterinary care may predispose both healthy horses and their handlers to carriage.

Are all meticillin-resistant Staphylococcus aureus (MRSA) equal in all hosts? Epidemiological and genetic comparison between animal and human MRSA

Meticillin-resistant Staphylococcus aureus (MRSA) continues to pose a major threat to human health. In animals, MRSA has become established as a veterinary pathogen in pets and horses; in livestock, it presents a concern for public health as a reservoir that can infect humans and as a source of transferrable resistance genes. Genetic analyses have revealed that the epidemiology of MRSA is different in different animal hosts. While human hospital-associated MRSA lineages are most commonly involved in pet infection and carriage, horse-specific MRSA most often represent 'traditional' equine S. aureus lineages. A recent development in the epidemiology of animal MRSA is the emergence of pig-adapted strains, such as CC398 and CC9, which appear to have arisen independently in the pig population. Recent insight into the genome structure and the evolution of S. aureus has helped to explain key aspects of these three distinct epidemiological scenarios. This nonsystematic literature review summarizes the structure and variations of the S. aureus genome and gives an overview of the current distribution of MRSA lineages in various animal species. It also discusses present knowledge about the emergence and evolution of MRSA in animals, adaptation to different host species and response to selective pressure from animal-specific environments. An improved understanding of the genetics and selective pressure that underpin the adaptive behaviour of S. aureus may be used in the future to predict new developments in staphylococcal diseases and to investigate novel control strategies required at a time of increasing resistance to antimicrobial agents.

Major families of multiresistant plasmids from geographically and epidemiologically diverse staphylococci

Staphylococci are increasingly aggressive human pathogens suggesting that active evolution is spreading novel virulence and resistance phenotypes. Large staphylococcal plasmids commonly carry antibiotic resistances and virulence loci, but relatively few have been completely sequenced. We determined the plasmid content of 280 staphylococci isolated in diverse geographical regions from the 1940s to the 2000s and found that 79% of strains carried at least one large plasmid >20 kb and that 75% of these large plasmids were 20–30 kb. Using restriction fragment length polymorphism (RFLP) analysis, we grouped 43% of all large plasmids into three major families, showing remarkably conserved intercontinental spread of multiresistant staphylococcal plasmids over seven decades. In total, we sequenced 93 complete and 57 partial staphylococcal plasmids ranging in size from 1.3 kb to 64.9 kb, tripling the number of complete sequences for staphylococcal plasmids >20 kb in the NCBI RefSeq database. These plasmids typically carried multiple antimicrobial and metal resistances and virulence genes, transposases and recombinases. Remarkably, plasmids within each of the three main families were >98% identical, apart from insertions and deletions, despite being isolated from strains decades apart and on different continents. This suggests enormous selective pressure has optimized the content of certain plasmids despite their large size and complex organization.