Surgical Site Infections Caused by Highly Virulent Methicillin-Resistant Staphylococcus aureus Sequence Type 398, China

Strong Biofilm Formation and Low Cloxacillin Susceptibility in Biofilm-Growing CC398 Staphylococcus aureus Responsible for Bacteremia in French Intensive Care Units, 2021

A prospective 3-month study carried out in 267 ICUs revealed an S. aureus nosocomial bacteremia in one admitted patient out of 110 in adult and pediatric sectors, and in one out of 230 newborns; 242 S. aureus bacteremias occurred during the study, including 7.9% MRSA-bacteremias. In one ICU out of ten, the molecular characteristics, antimicrobial susceptibility profiles and biofilm production of the strains responsible for S. aureus bacteremia were studied. Of the 53 strains studied, 9.4% were MRSA and 52.8% were resistant to erythromycin. MLST showed the predominance of CC398 (37.7% of the strains) followed by CC8 (17.0%), CC45 (13.2%) and CC30 (9.4%). The lukF/S genes were absent from our isolates and tst-1 was found in 9.4% of the strains. Under static conditions and without exposure to glucose, biofilm production was rare (9.4% of the strains, without any CC398). The percentage increased to 62.3% for strains grown in broth supplemented with 1% glucose (including 7 out of 9 CC8 and 17 out of the 20 CC398). Further study of the CC398, including whole genome sequencing, revealed (1) highly frequent patient death within seven days after CC398 bacteremia diagnosis (47.4%), (2) 95.0% of the strains producing biofilm when exposed to sub-inhibitory concentrations of cloxacillin, (3) a stronger biofilm production following exposure to cloxacillin than that observed in broth supplemented with glucose only (p < 0.001), (4) a high minimum biofilm eradication concentration of cloxacillin (128 mg/L) indicating a low cloxacillin susceptibility of biofilm-growing CC398, (5) 95.0% of the strains carrying a ϕSa-3 like prophage and its particular evasion cluster (i.e., yielding chp and scin genes), and (6) 30.0% of the strains carrying a ϕMR11-like prophage and yielding a higher ability to produce biofilm. Our results provide evidence that active surveillance is required to avoid spreading of this virulent staphylococcal clone.

New clues about the global MRSA ST398: Emergence of MRSA ST398 from pigs in Qinghai, China

This study, a part of the China national surveillance program on antimicrobial resistance in zoonotic bacteria, was to determine the phenotypic and genomic characteristics of endemic pig-associated Staphylococcus aureus ST398 strains in China. A total of 68 (48.9 %) S. aureus strains were recovered from 139 samples collected from two pig farms and one slaughterhouse in Qinghai province. Genomic characterization of All S. aureus strains was performed by WGS and their evolutionary relationships were assessed by phylogenetic analysis. Their susceptibilities to antimicrobials were determined using the broth dilution method. All S. aureus strains consisted of 41 ST398-t571 MSSA, 26 ST398-t011 MRSA and 1 ST5-t002 MRSA. Among these, ST398 was frequently identified in 67 S. aureus strains, suggesting that ST398 was a frequent source of MRSA and MSSA infections in Qinghai province and its possibility of transmission between individuals in pigs from farms and slaughterhouse. Meanwhile, Livestock-associated-MRSA ST398 in our study was establishing closely evolutionary relationships with MRSA ST 398 in Europe and Australia. The clues about closely relatedness of the global S. aureus ST398 underscore the potential public health risk of S. aureus ST398 in the pork supply chain and offer significant guidance for veterinary and human health.

Snapshot of resistance and virulence features in ESCAPE strains frequently isolated from surgical wound infections in a Romanian hospital

Background: The aim of this study was to investigate the phenotypic features (adherence, biofilm formation, virulence, antibiotic susceptibility) and the genetic background of antibiotic resistance in nosocomial ESCAPE strains consecutively isolated from surgical wound infections in hospitalized patients.

Methods: 86 bacterial strains consecutively isolated from various wound infections were analysed by their antibiotic resistance (antibiotic susceptibility testing and PCR for certain antibiotic resistance genes), virulence, biofilm formation and cellular adherence.

Results: The bacterial isolates were identified as: Enterobacterales (n = 39) including Escherichia coli (n = 9), Klebsiella pneumoniae (n = 14) Proteus mirabilis (n = 7), followed by Staphylococcus aureus (n = 26) and Enterococcus faecalis (n = 20). Compared to other isolates, S. aureus strains exhibited the highest capacity to produce soluble virulence factors and to develop biofilms in vitro, with significant differences between methicillin resistant and methicillin susceptible isolates. Among enterobacterial isolates, K. pneumoniae strains expressed the highest capacity to develop biofilms. The assessment of bacterial adherence to HeLa cells revealed that all bacterial strains adhered to the cellular substrata, showing various adherence patterns. E. faecalis strains exhibited a low soluble virulence factors profile, a lower capacity to adhere to epithelial cells and to develop biofilms.

Conclusions: The present study could contribute to the understanding of the pathology of infected wounds, depending on the etio-logical agents, providing data with positive impact on the therapeutic management of surgical wounds infections.

Emergence of livestock-associated MRSA ST398 from bulk tank milk, China

OBJECTIVES

To detect livestock-associated MRSA (LA-MRSA) ST398 from bulk tank milk in China and to determine the phenotypic and genomic characteristics of the strains.

METHODS

LA-MRSA ST398 strains were isolated from bulk tank milk samples in Shanghai and their susceptibilities to antimicrobials were determined using the broth dilution method. Genomic characterization of MRSA ST398 strains was performed by WGS and their evolutionary relationships were assessed by phylogenetic analysis.

RESULTS

Two LA-MRSA ST398 isolates were recovered from bulk tank milk samples in two geographically distant farms in China. Whole-genome analysis strongly suggested that the LA-MRSA ST398 strains were closely related to the highly virulent hospital-associated MRSA (HA-MRSA) ST398 strains in China.

CONCLUSIONS

The presence of LA-MRSA ST398 in bulk tank milk might be a serious threat to public health, highlighting the need for active surveillance of LA-MRSA in healthy cattle in China.

Erythrocyte-camouflaged biosensor for α-hemolysin detection

Without appropriate treatment, Staphylococcus aureus (S. aureus) infection can cause life-threatening diseases (e.g., meningitis, pneumonia, bacteremia, and sepsis). However, a rapid and accurate point-of-care test for the infection remains challenging. The bacterium secretes α-hemolysin (Hla), which spontaneously binds to the cell membrane of erythrocyte, and eventually lyses the cell via pore formation. Taking advantage of this phenomenon, we apply the erythrocyte membrane (EM) extracted from human whole blood as a novel bioreceptor for detecting Hla, fabricating erythrocyte-camouflaged biosensors (ECB) by coating EM onto electrochemical impedance electrodes. We verify the existence of EM on the ECB by using confocal microscopy and atomic force microscopy. We demonstrate that ECBs sensitively detect Hla spiked in phosphate buffer saline and human serum. Also, the sensor shows higher sensitivity to Hla than major blood proteins, such as human serum albumin, fibrinogen, and gamma globulin. Specifically, the signal intensities for Hla are 8.8-12.7 times higher than those in the same concentration of those blood proteins. The detection limit of the ECB for Hla is 1.9 ng/ml while the dynamic range is 0.0001-1 mg/ml. Finally, we validate the constant sensing performance of ECB with 99.0 ± 5.6% accuracy for 35 days of storage.

The Surge of Hypervirulent ST398 MRSA Lineage With Higher Biofilm-Forming Ability Is a Critical Threat to Clinics

The global increase of community-associated (CA) infections with methicillin-resistant Staphylococcus aureus (MRSA) is a major healthcare problem. Although sequence type (ST) 398 MRSA was first described as a livestock-associated (LA) lineage, human-adapted MRSA (HO-MRSA) ST398 without livestock contact has subsequently been reported from China in our previous study and other later research. The proportion of ST398 HO-MRSA has also remarkably increased in recent years in China. Based on 3878 S. aureus isolates that were collected in a general hospital between 2008 and 2018, we identified 56 ST398 HO-MRSA isolates. The four early appearing isolates of them have been sequenced by whole-genome sequencing (WGS) in our previous study. Here, by usage of WGS on the later-appearing 52 isolates and analyzing the phylogenetic dynamics of the linage, we found that 50 isolates clustered together with the former 4 isolates, making it a main clade out of MSSA clones and other MRSA clones, although ST398 HO-MRSA evolved with multiple origins. Drug resistance and virulence gene analysis based on the WGS data demonstrated that ST398 HO-MRSA main clade exhibited a similar pattern in both parts. Furthermore, they all carried a conserved variant of prophage 3 to guarantee virulence and a short SCCmec type V element of class D to maintain considerable lower methicillin resistance. Further phenotypical research verified that the epidemic HO-MRSA ST398 displayed enhanced biofilm formation ability when keeping high virulence. The dual advantages of virulence and biofilm formation in the HO-MRSA ST398 subtype promote their fitness in the community and even in the healthcare environment, which poses a serious threat in clinical S. aureus infections. Therefore, further surveillance is required to prevent and control the problematic public health impact of HO-MRSA ST398 in the future.

Livestock-Associated and Non-Livestock-Associated Staphylococcus aureus Carriage in Humans is Associated with Pig Exposure in a Dose-Response Manner

Background

The distinction between livestock-associated and human-associated methicillin-resistant Staphylococcus aureus (MRSA) has become more and more blurred. This study aimed to reveal the transmission risk of livestock-associated and non-livestock-associated S. aureus (including MRSA and multidrug-resistant S. aureus [MDRSA]) by occupational pig exposure.

Methods

A total of 591 pig-exposed workers and 1178 non-exposed workers were enrolled in this study. All nasal S. aureus isolates were tested for antibiotic susceptibility and molecular characteristics. Logistic regression models were used to examine the dose–response relationships between occupational pig exposure and S. aureus carriage.

Results

Pig-exposed workers had significantly higher carriage rates of MRSA (OR=6.29, 95% CI: 3.38~11.68) and MDRSA (OR=3.17, 95% CI: 2.03~4.96) than non-exposed workers. Notably, we found dose–response relationships between occupational pig exposure and MRSA or MDRSA carriage. Using genotypic and phenotypic markers for differentiating livestock-associated and non-livestock-associated S. aureus, we also revealed dose–response relationships occupational pig exposure and livestock-associated or non-livestock-associated S. aureus carriage.

Conclusion

Our findings provide sufficient epidemiological evidence for revealing the high transmission risk of livestock-associated S. aureus and the low transmission risk of non-livestock-associated S. aureus by occupational pig exposure.

Antibacterial and antibiofilm effects of flufenamic acid against methicillin-resistant Staphylococcus aureus

Methicillin-resistant Staphylococcus aureus (MRSA) infections are one of the most serious surgery complications, and their prevention is of utmost importance. Flufenamic acid is a non-steroid anti-inflammatory drug approved for clinical use to relieve inflammation and pain in rheumatoid arthritis patients. In this study, we explored the antibacterial efficacy of flufenamic acid and the mechanisms underlying this effect. By using minimal inhibitory concentration (MIC), time-kill, resistance induction assays, and the antibiotic synergy test, we demonstrated that flufenamic acid inhibited the growth of methicillin-resistant staphylococci and did not induce resistance when it was used at the MIC. Furthermore, flufenamic acid acted synergistically with the beta-lactam antibiotic oxacillin and did not show significant toxicity toward mammalian cells. The biofilm inhibition assay revealed that flufenamic acid could prevent biofilm formation on medical implants and destroy the ultrastructure of the bacterial cell wall. RNA sequencing and quantitative RT-PCR indicated that flufenamic acid inhibited the expression of genes associated with peptidoglycan biosynthesis, beta-lactam resistance, quorum sensing, and biofilm formation. Furthermore, flufenamic acid efficiently ameliorated a local infection caused by MRSA in mice. In conclusion, flufenamic acid may be a potent therapeutic compound against MRSA infections and a promising candidate for antimicrobial coating of implants and surgical devices.

Epidemiology and risk factors of Staphylococcus aureus CC398 bone and joint infections

Background

A particular ability of the Staphylococcus aureus clonal complex 398 (CC398) to cause bone and joint infections (BJI) remains questionable, since some studies have described high prevalence of MSSA CC398 in prosthetic joint infection (PJI) and diabetic foot ostemolyelitis (DFO). Here, we described the long-term epidemiology of CC398 among S. aureus isolated from BJI and identified risk factors associated with CC398.

Methods

We included all bone and joint samples with S. aureus-positive culture in our university hospital between January 2010 and December 2017. Logistic regression was used for univariate and multivariate analysis.

Results

We identified 124 CC398 isolates among the 958 BJI-associated S. aureus. The proportion of CC398 among S. aureus increased steadily from 4% in 2010 to 26% in 2017. Only 4 isolates of CC398 were resistant to methicillin. The distribution of BJI types due to CC398 and non CC398 isolates was similar. In multivariate analysis, age (p = 0.034, OR = 3.9), McCabe score (p = 0.005, OR = 5) and inoculation mechanism (p = 0.020, OR = 3.7) were associated with PJI-related CC398. The year of infection (p < 0.001, OR = 1.6), Charlson’s score (p = 0.001, OR = 1.5) and grade 4 (severe) of the International Working Group of the Diabetic Foot classification (p < 0.001, OR = 8.5) were associated with DFO-related CC398.

Conclusion

We highlighted here the emergence and spread of CC398-MSSA in BJI. Patients with comorbidities are at high risk of CC398 MSSA PJI and DFO. The spread of CC398 in the community and hospital settings remains unclear and further epidemiological studies are needed to identify the determinants of its success.

Prevalence and characterization of Staphylococcus aureus isolates from subclinical bovine mastitis in southern Xinjiang, China

Staphylococcus aureus is one of the major pathogens causing mastitis in dairy herds. The colonization of dairy cows and subsequent contamination of raw milk by S. aureus, especially strains exhibiting multidrug resistance and biofilm-forming and toxin-producing abilities, remains an important issue for both dairy farmers and public health. In this study, we investigated the prevalence, antimicrobial susceptibility, biofilm formation, and genetic diversity of S. aureus from subclinical bovine mastitis in dairy farms located in southern Xinjiang, China. Sixty-five isolates from 84 subclinical mastitic milk samples were identified as S. aureus. The resistance rates to penicillin, erythromycin, clindamycin, tetracycline, gentamicin, linezolid, rifampicin, quinupudin-dafupudin, ciprofloxacin, norfloxacin, and chloramphenicol were 58.5, 44.6, 40.0, 18.5, 12.3, 10.8, 9.2, 6.2, 4.6, 4.6, and 1.5%, respectively. All isolates were susceptible to cefoxitin, sulfamethoxazole-trimethoprim, and vancomycin. Isolates from farm A showed a significantly higher resistance rate to tetracycline (16.9%) than those from farm B (1.5%). The most frequently detected virulence factors were hla (96.9%, 63/65) and hlb (100.0%, 65/65). The percentage rates of the staphylococcal enterotoxin genes sea, sec, sed, seg, seh, sei, and sej in S. aureus isolates were 4.6, 33.8, 27.7, 3.1, 41.5, 41.5, and 7.7%, respectively. The percentage rate of the sec gene in isolates from farm B (30.8%) was significantly higher than that of farm A (3.1%). The percentage rates of the tsst and pvl genes in S. aureus isolates were 26.2 and 40.0%. The percentage rate of the pvl gene in isolates from farm B (32.3%) was significantly higher than that of farm A (7.7%). The adhesion molecules fnbA, fnbB, clfA, clfB, and cna were detected in 21 (32.3%), 23 (35.4%), 65 (100.0%), 65 (100.0%), and 65 (100.0%) isolates, respectively. The percentage rates of the icaA, sarA, tcaR, ccp, luxS, and sigB genes in S. aureus isolates were 69.2, 100.0, 86.2, 95.4, 84.6, and 100.0%, respectively. The fnbB and icaA genes were more frequently detected in isolates from farm A (29.2 and 40.0%, respectively) than those from farm B (6.2 and 29.2%, respectively). The luxS gene was more often found in isolates from farm B (50.8%) than those from farm A (33.8%). Using the microplate method, 61.5, 26.2, and 10.8% of the isolates showed weak, moderate, and strong biofilm-forming abilities, respectively. Different clonal complex (CC) and spa-types were identified, including CC81, CC398, CC88, CC5405, and CC5406. Importantly, in this study we report for the first time 41 new sequence types (ST) among 44 distinct ST. These results indicated high genetic diversity of S. aureus involved in subclinical bovine mastitis in southern Xinjiang, China. The results also showed that S. aureus from subclinical bovine mastitis cases in southern Xinjiang, China, were mainly resistant to β-lactams, erythromycin, and clindamycin. Also, biofilm- and adhesion-related genes, which are increasingly known as important virulence factors in the pathogenesis of S. aureus infections, were detected at a high rate. This study could help identify predominant clones and provide surveillance measures to decrease or eliminate S. aureus contamination in raw milk of dairy cows with subclinical mastitis.

Detection and phylogeny of Staphylococcus aureus sequence type 398 in Taiwan

Background

Methicillin-resistant Staphylococcus aureus (MRSA) ST398 is a livestock associated-bacterium that is most prevalent in Europe. Human-adapted MRSA ST398 was recently reported from China, but there is no data available yet for Taiwan.

Methods

To identify S. aureus ST398 isolates, we examined 6413 S. aureus isolates (5632 MRSA and 781 susceptible strains) that were collected in Taiwan between 1995 and 2017. If isolates could not be typed by pulsed-field gel electrophoresis upon Sma I digestion, we performed further characterization and complete genome sequencing.

Results

We identified 18 ST398 S. aureus isolates from 16 subjects (0.28%), including 6 sensitive and 12 resistant strains. Of these, 14 were colonizing isolates, 3 were clinical (infecting) isolates and one isolate was from a pork specimen. All 3 infecting isolates were MSSA strains identified in 2015 from two children with recurrent otitis media or sinusitis. The other 3 MSSA isolates were identified from workers handling pork (2) or pork meat (1) in 2015. The first 5 MRSA colonizing isolates were identified from residents in two nursing homes in 2012. Six MRSA isolates were identified from residents and foreign employees at a nursing home in 2016 and one MRSA from a foreign worker in 2017. Phylogenetic analysis of genome sequences indicated that all 12 local ST398 MRSA strains cluster together, human-adapted and phylogenetically related to a human MRSA strain identified in China in 2002. Two local MSSA isolates could be linked to isolates from livestock. The toxin profiles were similar for the MRSA and MSSA isolates.

Conclusions

Our results demonstrate that S. aureus ST398 was present in Taiwan in 2012 and potentially earlier. Although some isolates could be linked to livestock, most ST398 S. aureus isolates identified in Taiwan, particularly MRSA, represent human-adapted strains. Local transmission of human-adapted MRSA ST398 strains has occurred in nursing homes in Taiwan, possibly after import from China. Further surveillance is needed.

Decreasing methicillin-resistant Staphylococcus aureus (MRSA) infections is attributable to the disappearance of predominant MRSA ST239 clones, Shanghai, 2008-2017

A consistently decreasing prevalence of MRSA infections in China has been reported, however, the underlying mechanism of molecular processes responsible for this decline in MRSA infections has been poorly understood. We conducted an epidemiologic investigation to determine the dynamic changes of Staphylococcus aureus infections. A total of 3695 S. aureus isolates was recovered from 2008 to 2017, and subsequently characterized by infection types, resistance profile, and clone types. The frequency of respiratory infection decreased over the study period from 76% to 52%. The proportion of MRSA remarkably decreased (from 83.5% to 54.2%, 2008-2017) (p < .0001). The prevalence of predominant healthcare-associated MRSA (HA-MRSA) clones, ST239-t030 and ST239-t037, significantly decreased (from 20.3% to 1% and 18.4% to 0.5%, 2008-2017, respectively); both of them were replaced by the continually growing ST5-t2460 clone (from 0% to 17.3%, 2008-2017). Epidemic community-acquired MRSA (CA-MRSA) ST59 and ST398 clones also increased (from 1.0% to 5.8% and 1.8% to 10.5%, 2008-2017, respectively). These results demonstrated a significant decrease in the previously dominant HA-MRSA ST239 clones, leading to a marked decrease in the prevalence of MRSA over the past decade, and shed new light on the complex competition of S. aureus clones predominating within the health-care environment.