Presence of Pathogens and Indicator Microbes at a Non-Point Source Subtropical Recreational Marine Beach

Swimming in ocean water, including ocean water at beaches not impacted by known point sources of pollution, is an increasing health concern. This study was an initial evaluation of the presence of indicator microbes and pathogens and the association among the indicator microbes, pathogens, and environmental conditions at a subtropical, recreational marine beach in south Florida impacted by non-point sources of pollution. Twelve water and eight sand samples were collected during four sampling events at high or low tide under elevated or reduced solar insolation conditions. The analyses performed included analyses of fecal indicator bacteria (FIB) (fecal coliforms, Escherichia coli, enterococci, and Clostridium perfringens), human-associated microbial source tracking (MST) markers (human polyomaviruses [HPyVs] and Enterococcus faecium esp gene), and pathogens (Vibrio vulnificus, Staphylococcus aureus, enterovirus, norovirus, hepatitis A virus, Cryptosporidium spp., and Giardia spp.). The enterococcus concentrations in water and sand determined by quantitative PCR were greater than the concentrations determined by membrane filtration measurement. The FIB concentrations in water were below the recreational water quality standards for three of the four sampling events, when pathogens and MST markers were also generally undetectable. The FIB levels exceeded regulatory guidelines during one event, and this was accompanied by detection of HPyVs and pathogens, including detection of the autochthonous bacterium V. vulnificus in sand and water, detection of the allochthonous protozoans Giardia spp. in water, and detection of Cryptosporidium spp. in sand samples. The elevated microbial levels were detected at high tide and under low-solar-insolation conditions. Additional sampling should be conducted to further explore the relationships between tidal and solar insolation conditions and between indicator microbes and pathogens in subtropical recreational marine waters impacted by non-point source pollution.Global estimates indicate that each year more than 120 million cases of gastrointestinal disease and 50 million cases of severe respiratory diseases are caused by swimming and bathing in wastewater-polluted coastal waters (42). Swimming-related illness is attributed predominantly to exposure to microbial pathogens, which enter the water through point sources, such as sewage outfalls. Water quality at beaches may also be impacted by non-point sources, such as storm water runoff, sand resuspension, animal fecal inputs, and human bather shedding (8, 12, 22, 47, 59).The concentration of indicator microorganisms in a body of recreational water is used to estimate the health risk to bathers. These microbes serve as surrogates for microbial pathogens. Studies show that the U.S. Environmental Protection Agency (EPA)-recommended indicator microbe for marine beaches, enterococci, shows a significant correlation with illness in marine beaches impacted by point source pollution (38, 54). However, a similar correlation has not been identified at beaches impacted by non-point source pollution or subtropical marine beaches (17, 29, 38, 54).The failure to consistently demonstrate an association between enterococci and illness at non-point source beaches calls into question the ability of indicator microbes to predict the presence of pathogens. Studies conducted on the west coast of the United States have shown that indicators are often not correlated with measured pathogens at non-point source beaches (31, 32, 33, 37). Additional studies conducted in a subtropical environment, such as that of South Florida, where this study was conducted, have repeatedly shown the limited accuracy of indicator microbe standards for determining the presence of pathogens (27, 35). This lack of correlation is understandable since an indicator microbe, such as enterococci, may come from relatively low-risk sources of fecal pollution and therefore may not be related to human or other high-risk sources of fecal pollution and pathogens (9). It has also been shown in both subtropical and temperate climates that indicator bacteria can multiply in the environment, resulting in a false impression of increased microbial pollution and pathogen presence (4, 7, 19, 24, 41, 45, 57, 58). Environmental factors, such as tide, rain, and solar insolation, can also have significant and varying effects on the levels of indicator and pathogenic microbes (21, 24, 33).The lack of correlation between pathogens and indicator microbes at non-point source beaches can result in two problematic scenarios. If indicator microbes are absent and pathogens are present (false-negative scenario), regulatory monitoring may fail to identify the potential adverse health effects on bathers due to the pathogens. This problem is likely to occur since indicator bacteria are less resistant to environmental stresses and disinfection at wastewater treatment plants than certain pathogens (6, 15). However, if indicator microbes are present and pathogens are absent (false-positive scenario), there can be unnecessary economic losses due to recreational beach advisories and/or closures. A 4-month closure of Huntington Beach in 1999 due to microbial standard violations resulted in the loss of millions of dollars in tourism income to the business community and almost 2 million dollars in beach closure investigation fees (55; for a review, see reference 27).Given these two possible scenarios, the relationship between indicator microbes and pathogens under different environmental conditions at non-point source beaches representing different geographic and climatic settings should be assessed further. Investigation of this relationship would require a large sample size in order to establish possible significant associations between the various factors and targets. The objective of this study was to conduct a preliminary evaluation of the presence of indicator microbes and pathogens and the possible association between indicator microbes, pathogen measurements, and environmental conditions at a subtropical recreational marine beach in South Florida. Because of cost limitations when multiple targets, including pathogens, are screened, this study was not intended to establish a conclusive relationship between the various factors and targets but was intended to provide insight into both the presence of organisms and possible associations which should be investigated further. Such information would be useful for understanding the potential health risks to bathers from non-point sources of microbes and would also contribute to determining the appropriateness of using indicator microbes to monitor the water quality at non-point source beaches. Although previous studies have assessed the presence of either viral, protozoan, or bacterial pathogens along with indicator microbes in point or non-point source recreational beach waters (27, 33, 37, 47), to our knowledge, this is the first study to assess the presence of all three classes of pathogens (viral, protozoan, and bacterial) as well as indicator microbes at a non-point source recreational beach. This study is also the first study to sample for all these microbes in both water and sand at a non-point source recreational beach. Through analysis of the various microbes under different targeted environmental conditions, this study also included a preliminary evaluation of the sources of microbial contaminants and pathogens and the effectiveness of various analytical methods for microbe detection. The latter part of the study included a comparison of three different methods for enterococcus enumeration, as well as an innovative method for simultaneously concentrating protozoans and viruses from water samples.     

Pitfalls in Identification of Methicillin-Resistant Staphylococcus aureus

Media and techniques for in vitro testing with respect to screening for methicillin-resistant Staphylococcus aureus are discussed.     

耐甲氧西林金黄色葡萄球菌的分子流行病学研究

了解我院患者耐甲氧西林金黄色葡萄球菌（MRSA）的分子流行病学特点,为临床抗感染治疗提供依据。收集2007年1月~2008年9月我院分离的耐甲氧西林金黄色葡萄球菌共54株,采用PCR进行SCCmec基因分型、葡萄球菌A蛋白（SPA）分型,并检测杀白细胞毒素（PVL）基因,同时应用脉冲场凝胶电泳（PFGE）进行同源性分析。54株MRSA菌株SCCmec基因分型为SCCmecⅡ型17株,SCCmecⅢ型33株,SCCmecⅣ型2株,SCCmecⅤ型2株;SPA基因分型将28株归属为t030,9株为t002,8株为t037,5株为t570,2株为t437,t163和t796各1株;PVL毒素检测只有2株SCCmecⅣ型菌株阳性;PFGE证实院内MRSA感染主要为2种克隆株传播,同时还有其他型别出现。本院MRSA流行传播的SCCmec基因型主要以Ⅲ型占优势,同时发现有携带PVL毒素的CA-MRSA分离株流行,应引起密切关注。     

Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus Isolated from Australian Veterinarians

This work investigated the molecular epidemiology and antimicrobial resistance of methicillin-resistant Staphylococcus aureus (MRSA) isolated from veterinarians in Australia in 2009. The collection (n = 44) was subjected to extensive molecular typing (MLST, spa, SCCmec, dru, PFGE, virulence and antimicrobial resistance genotyping) and antimicrobial resistance phenotyping by disk diffusion. MRSA was isolated from Australian veterinarians representing various occupational emphases. The isolate collection was dominated by MRSA strains belonging to clonal complex (CC) 8 and multilocus sequence type (ST) 22. CC8 MRSA (ST8-IV [2B], spa t064; and ST612-IV [2B], spa variable,) were strongly associated with equine practice veterinarians (OR = 17.5, 95% CI = 3.3–92.5, P < 0.001) and were often resistant to gentamicin and rifampicin. ST22-IV [2B], spa variable, were strongly associated with companion animal practice veterinarians (OR = 52.5, 95% CI = 5.2–532.7, P < 0.001) and were resistant to ciprofloxacin. A single pig practice veterinarian carried ST398-V [5C2], spa t1451. Equine practice and companion animal practice veterinarians frequently carried multiresistant-CC8 and ST22 MRSA, respectively, whereas only a single swine specialist carried MRSA ST398. The presence of these strains in veterinarians may be associated with specific antimicrobial administration practices in each animal species.     

Isolation and Characterization of Methicillin-Resistant Staphylococcus aureus Strains from Louisiana Retail Meats

We investigated the prevalence of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) in 120 retail meat samples from 30 grocery stores in Baton Rouge, LA. S. aureus strains were recovered from 45.6% of pork samples and 20% of beef samples, whereas MRSA strains were isolated from six meat samples (five pork samples and one beef sample). The MRSA isolates were of two strain types (clones), one harboring Panton-Valentine leucocidin and belonging to pulsed-field gel electrophoresis type USA300 and the other one belonging to USA100.     

Occurrence and Molecular Characteristics of Methicillin-Resistant Staphylococcus aureus and Methicillin-Resistant Staphylococcus pseudintermedius in an Academic Veterinary Hospital

Recently, methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus pseudintermedius (MRSP) have been increasingly isolated from veterinarians and companion animals. With a view to preventing the spread of MRSA and MRSP, we evaluated the occurrence and molecular characteristics of each in a veterinary college. MRSA and MRSP were isolated from nasal samples from veterinarians, staff members, and veterinary students affiliated with a veterinary hospital. Using stepwise logistic regression, we identified two factors associated with MRSA carriage: (i) contact with an identified animal MRSA case (odds ratio [OR], 6.9; 95% confidence interval [95% CI], 2.2 to 21.6) and (ii) being an employee (OR, 6.2; 95% CI, 2.0 to 19.4). The majority of MRSA isolates obtained from individuals affiliated with the veterinary hospital and dog patients harbored spa type t002 and a type II staphylococcal cassette chromosome mec (SCCmec), similar to the hospital-acquired MRSA isolates in Japan. MRSA isolates harboring spa type t008 and a type IV SCCmec were obtained from one veterinarian on three different sampling occasions and also from dog patients. MRSA carriers can also be a source of MRSA infection in animals. The majority of MRSP isolates (85.2%) carried hybrid SCCmec type II-III, and almost all the remaining MRSP isolates (11.1%) carried SCCmec type V. MRSA and MRSP were also isolated from environmental samples collected from the veterinary hospital (5.1% and 6.4%, respectively). The application of certain disinfection procedures is important for the prevention of nosocomial infection, and MRSA and MRSP infection control strategies should be adopted in veterinary medical practice.Methicillin-resistant Staphylococcus aureus (MRSA) is an important cause of nosocomial infections in human hospitals. The prevalence of hospital-acquired MRSA (HA-MRSA) infection among inpatients in intensive care units (ICUs) continues to increase steadily in Japan. Recently, cases of community-acquired MRSA (CA-MRSA) have been documented in persons without an established risk factor for HA-MRSA infection (14, 32, 36, 49).There has also been an increase in the number of reports of the isolation of MRSA from veterinarians and companion animals (5, 21, 23-26, 28, 31, 34, 38, 44, 50, 51, 53). Values reported for the prevalence of MRSA among veterinary staff include 17.9% in the United Kingdom (21), 10% in Japan (38), 3.9% in Scotland (13), and 3.0% in Denmark (28). Loeffler et al. reported that the prevalence of MRSA among dog patients and healthy dogs owned by veterinary staff members was 8.9% (21). In Japan, an MRSA isolate was detected in only one inpatient dog (3.8%) and could not be detected in any of 31 outpatient dogs (38). In the United States, MRSA isolates were detected in both dog (0.1%) and cat (0.1%) patients (31). The prevalence of MRSA among healthy dogs has been reported to be 0.7% (5). Hanselman et al. suggested that MRSA colonization may be an occupational risk for large-animal veterinarians (12). Recently, Burstiner et al. reported that the frequency of MRSA colonization among companion-animal veterinary personnel was equal to the frequency among large-animal veterinary personnel (6).In addition, other methicillin-resistant coagulase-positive staphylococci (MRCPS), such as methicillin-resistant Staphylococcus pseudintermedius (MRSP) and methicillin-resistant Staphylococcus schleiferi (MRSS), isolated from dogs, cats, and a veterinarian have been reported (11, 31, 38, 40, 52). MRSP isolates have also been detected among inpatient dogs (46.2%) and outpatient dogs (19.4%) in a Japanese veterinary teaching hospital (38). In Canada, however, MRSP and MRSS isolates were detected in only 2.1% and 0.5% of dog patients, respectively (11).Methicillin-resistant staphylococci produce penicillin-binding protein 2′, which reduces their affinity for β-lactam antibiotics. This protein is encoded by the mecA gene (48), which is carried on the staphylococcal cassette chromosome mec (SCCmec). SCCmec is a mobile genetic element characterized by the combination of the mec and ccr complexes (16), and it is classified into subtypes according to differences in the junkyard regions (43). SCCmec typing can be used as a molecular tool (22, 27, 30, 33, 36, 55) for examining the molecular epidemiology of methicillin-resistant staphylococci.In this study, we investigated the occurrence and characteristics of MRCPS isolates in a veterinary hospital in order to establish the transmission route of MRCPS in a veterinary hospital and with a view to preventing the spread of MRCPS infection. In addition, we evaluated the factors associated with MRCPS. Further, as Heller et al. have reported the distribution of MRSA within veterinary hospital environments and suggested the necessity to review cleaning protocols of hospital environments (13), we also attempted to isolate MRCPS from environmental samples collected in a veterinary hospital for an evaluation of MRSA transmission cycle though environmental surfaces in the veterinary hospital.     

The Genome Sequence of a Type ST239 Methicillin-Resistant Staphylococcus aureus Isolate from a Malaysian Hospital

We report the genome sequence of a healthcare-associated MRSA type ST239 clone isolated from a patient with septicemia in Malaysia. This clone typifies the characteristics of ST239 lineage, including resistance to multiple antibiotics and antiseptics.     

Comparison of the Virulence of Methicillin-Resistant and Methicillin-Sensitive Staphylococcus aureus

The virulence of methicillin-resistant Staphylococcus aureus (MRSA) was compared with that of methicillin-sensitive S. aureus (MSSA), using 13 MRSA and 7 MSSA strains isolated from clinical specimens. The infectivity and lethality of the two groups were examined as to the inoculum required to infect 50% of guinea pigs (ID₅₀) and to kill 50% of mice (LD₅₀), respectively. The mean ID₅₀ [log₁₀ colony forming units (CFU)] for MRSA strains was 7.1 ± 0.60 standard deviation, which was 1.5 higher than that for MSSA strains (P < 0.001). The mean LD₅₀ (log₁₀ CFU) for MRSA strains was 9.0 ± 0.42, being 1.1 higher than that for MSSA strains (P = 0.001). Pretreatment of mice with cyclophosphamide decreased the mean LD₅₀ for MRSA strains more than that for MSSA strains, resulting in the difference in the mean LD₅₀ being insignificant (P = 0.502). These results indicate that MRSA is less virulent than MSSA in normal hosts, but that they are equally virulent in immunocompromised hosts. The growth of MRSA strains was much slower than that of MSSA strains in the lag phase, although their growth rates were almost the same in the exponential growth phase, suggesting that the difference in virulence between them may be at least partly due to such a difference in growth.     

Nasal Carriage of Methicillin-Resistant Staphylococcus aureus among Pediatricians in Taiwan

Background

Health care workers (HCWs) are at the interface between hospitals and communities. The survey for methicillin-resistant Staphylococcus aureus (MRSA) carriage among HCWs has mostly been conducted to investigate outbreaks or endemics. Community-associated MRSA are prevalent among children in Taiwan. We conducted this study to better understand the carriage rate of MRSA among pediatricians in non-outbreak situations in Taiwan,.

Methods

A total of 220 pediatricians from Taiwan who attended the annual meeting of Taiwan Pediatric Association in April, 2010 were recruited to participate in this study and were sampled from the nares for the detection of MRSA by polymerase chain reaction (PCR) and further by culture. The following molecular analyses were performed, including pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), typing of staphylococcal cassette chromosome mec (SCCmec) and the presence of Panton-Valentine leukocidin (PVL) genes.

Results

MRSA was detected from 15 attendees (6.8%) by PCR. MRSA-colonized attendees had a significantly lower rate (0.041) of working in the medical center, while borderline significantly higher rate of working in the Regional Hospital (p=0.056), than those without MRSA colonization. From those 15 samples, 12 MRSA isolates were identified by culture and molecularly characterized. Three PFGE patterns, two sequence types (ST 59, ST 508), and two SCCmec types (IV and V_T) were identified, respectively. Five isolates, including three carrying SCCmec types V_T, were PVL-positive. All 12 isolates were susceptible to vancomycin, teicoplanin, linezolid, fusidic acid, trimethoprim/sulfamethoxazole, and doxycyclin, and resistant to penicillin.

Conclusion/significance

Around seven percent of pediatricians in Taiwan harbored CA-MRSA in their nares.     

Transmission of Methicillin-Resistant Staphylococcus aureus CC398 from Livestock Veterinarians to Their Household Members

There are indications that livestock-associated MRSA CC398 has a reduced human-to-human transmissibility, limiting its impact on public health and justifying modified control measures. This study determined the transmissibility of MRSA CC398 from livestock veterinarians to their household members in the community as compared to MRSA non-CC398 strains. A one-year prospective cohort study was performed to determine the presence of MRSA CC398 in four-monthly nasal and oropharyngeal samples of livestock veterinarians (n  =  137) and their household members (n  =  389). In addition, a cross-sectional survey was performed to detect the presence of MRSA non-CC398 in hospital derived control patients (n  =  20) and their household members (n  =  41). Staphylococcus aureus isolates were genotyped by staphylococcal protein A (spa) typing and multiple-locus variable-number tandem repeat analysis (MLVA). Mean MRSA CC398 prevalence over the study period was 44% (range 41.6–46.0%) in veterinarians and 4.0% (range 2.8–4.7%) in their household members. The MRSA CC398 prevalence in household members of veterinarians was significantly lower than the MRSA non-CC398 prevalence in household members of control patients (PRR 6.0; 95% CI 2.4–15.5), indicating the reduced transmissibility of MRSA CC398. The impact of MRSA CC398 appears to be low at the moment. However, careful monitoring of the human-to-human transmissibility of MRSA CC398 remains important.     

Optical Mapping Reveals a Large Genetic Inversion between Two Methicillin-Resistant Staphylococcus aureus Strains

Staphylococcus aureus is a highly versatile and evolving bacterium of great clinical importance. S. aureus can evolve by acquiring single nucleotide polymorphisms and mobile genetic elements and by recombination events. Identification and location of novel genomic elements in a bacterial genome are not straightforward, unless the whole genome is sequenced. Optical mapping is a new tool that creates a high-resolution, in situ ordered restriction map of a bacterial genome. These maps can be used to determine genomic organization and perform comparative genomics to identify genomic rearrangements, such as insertions, deletions, duplications, and inversions, compared to an in silico (virtual) restriction map of a known genome sequence. Using this technology, we report here the identification, approximate location, and characterization of a genetic inversion of ∼500 kb of a DNA element between the NRS387 (USA800) and FPR3757 (USA300) strains. The presence of the inversion and location of its junction sites were confirmed by site-specific PCR and sequencing. At both the left and right junction sites in NRS387, an IS1181 element and a 73-bp sequence were identified as inverted repeats, which could explain the possible mechanism of the inversion event.Staphylococcus aureus is a gram-positive bacterium of immense clinical importance. This opportunistic pathogen is capable of causing a wide range of diseases from skin and soft-tissue infections to life-threatening bacteremia, endocarditis, and osteomyelitis (14). Approximately 75% of the S. aureus genome is composed of a core genome that is common in all strains, and 25% of the genome is composed of variable regions which can differ between different strains (4, 16, 24-26). S. aureus evolves primarily by introducing single nucleotide polymorphisms in its core genome and by acquiring mobile genetic elements (MGEs) through horizontal gene transfer. These MGEs include pathogenicity/genomic islands, plasmids, transposons, and bacteriophages that become integrated in the chromosome (4, 11, 16, 31, 32). Despite being a heterogeneous organism, genetic recombination in S. aureus is proposed to be rather rare (20, 24, 29, 35). Its clones are more likely to evolve by point mutations than by recombination events (12). The MGEs contribute to the phenotypic and genotypic diversity seen with the S. aureus population. Acquisition of the staphylococcal cassette chromosome (SCCmec) elements through site-specific recombinases has led to the epidemic of methicillin-resistant S. aureus (MRSA) strains in hospitals and communities all over the world (6, 10, 15). In recent years, the integration of arginine catabolite mobile element in the USA300 lineage of MRSA has been proposed to give the pathogen its epidemiological advantage, including traits for surviving in low-pH conditions and oxygen tension environments (11). In addition, chromosomal replacements have been observed within lineages of sequence type 34 (ST34) and ST42 (34) and ST8 and ST30 (13).Genomic rearrangements, such as inversions, have been observed with genomes of enteric bacteria, such as Salmonella enterica, Shigella flexneri, Yersinia pestis KIM, Escherichia coli (K12 and O157:H7), and group A Streptococcus pyogenes (8, 9, 18, 27, 28, 30, 37). No genomic inversions in S. aureus have been reported to date. With the use of optical mapping, large genomic rearrangements, such as inversions, that would otherwise be missed with other comparative genotyping approaches, including microarray analysis, can be identified. Optical mapping uses high-resolution restriction maps (optical maps) of a bacterial genome to determine its genomic organization (5, 21, 23, 33, 36). These optical maps can be compared to an in silico (virtual) restriction map of a known genome sequence and can be used to identify gene rearrangements and their locations. Using optical mapping in conjunction with subsequent site-specific PCR and sequencing, we report the identification, approximate location, and partial characterization of an ∼500-kb DNA element in NRS387, a USA800 strain that was found to be inverted relative to USA300FPR3757. Identification of IS1181 elements and a novel 73-bp element at both ends of the ∼500-kb element in NRS387 could suggest the possibility of an inversion event in an ancestral strain of NRS387.     

Whole-Genome Sequence of Livestock-Associated ST398 Methicillin-Resistant Staphylococcus aureus Isolated from Humans in Canada

Despite reports of high colonization rates of ST398 livestock-associated methicillin-resistant Staphylococcus aureus (LA-MRSA) among pigs and pig farmers, the incidence of LA-MRSA infection in the general population in Canada appears to be rare in comparison to that in some European countries. In this study, the complete genome sequence of a Canadian representative LA-MRSA isolate (08BA02176) from a human postoperative surgical site infection was acquired and compared to the sequenced genome of an LA-MRSA isolate (S0385) from Europe to identify genetic traits that may explain differences in the success of these particular strains in some locales.     

Isolation and Characterization of Methicillin-Resistant Staphylococcus aureus from Pork Farms and Visiting Veterinary Students

In the last decade livestock-associated methicillin-resistant S. aureus (LA-MRSA) has become a public health concern in many parts of the world. Sequence type 398 (ST398) has been the most commonly reported type of LA-MRSA. While many studies have focused on long-term exposure experienced by swine workers, this study focuses on short-term exposures experienced by veterinary students conducting diagnostic investigations. The objectives were to assess the rate of MRSA acquisition and longevity of carriage in students exposed to pork farms and characterize the recovered MRSA isolates. Student nasal swabs were collected immediately before and after farm visits. Pig nasal swabs and environmental sponge samples were also collected. MRSA isolates were identified biochemically and molecularly including spa typing and antimicrobial susceptibility testing. Thirty (30) veterinary students were enrolled and 40 pork farms were visited. MRSA was detected in 30% of the pork farms and in 22% of the students following an exposure to a MRSA-positive pork farm. All students found to be MRSA-positive initially following farm visit were negative for MRSA within 24 hours post visit. Most common spa types recovered were t002 (79%), t034 (16%) and t548 (4%). Spa types found in pork farms closely matched those recovered from students with few exceptions. Resistance levels to antimicrobials varied, but resistance was most commonly seen for spectinomycin, tetracyclines and neomycin. Non-ST398 MRSA isolates were more likely to be resistant to florfenicol and neomycin as well as more likely to be multidrug resistant compared to ST398 MRSA isolates. These findings indicate that MRSA can be recovered from persons visiting contaminated farms. However, the duration of carriage was very brief and most likely represents contamination of nasal passages rather than biological colonization. The most common spa types found in this study were associated with ST5 and expands the range of livestock-associated MRSA types.     

Cell Wall Composition and Associated Properties of Methicillin-Resistant Staphylococcus aureus Strains

Methicillin-resistant (MR) Staphylococcus aureus strains have previously been reported to be deficient in surface negative charge; this has been correlated with methicillin resistance and ascribed to a deficiency of teichoic acid at the cell surface (A. W. Hill and A. M. James, Microbios 6:157-167, 1972). Teichoic acid was present in walls of MR organisms as revealed by appreciable phosphate levels and detection of ribitol residues. Phosphate levels in walls from five MR strains (0.54 to 0.77 mumol/mg of wall) were lower than in three unrelated methicillin-sensitive (MS) strains (0.86 to 1.0 mumol/mg of wall). However, two MS strains derived from two of the MR strains had wall phosphate levels very similar to those of the MR strains. No evidence for unusual wall polymers was found. Simple deficiency of wall teichoic acid does not result in methicillin resistance since an independently isolated teichoic acid-deficient strain (0.1 mumol of phosphate per mg of wall) was not methicillin resistant. In studies of biological properties possibly related to wall teichoic acid, it was discovered that walls isolated from MR organisms grown in the presence of methicillin autolyzed more rapidly than those isolated from organisms grown in the absence of the drug. Since methicillin resistance is enhanced by NaCl and suppressed by ethylenediaminetetraacetate, the effects of these compounds on autolysis of isolated walls were studied. NaCl (1.0 M) and ethylenediaminetetraacetate (1.0 mM) inhibited the autolysis of walls isolated from MR and MS strains. An MR strain bound phage 47, 52A, and 3A only slightly less well than their respective propagating strains.     

Complete Genome Sequence of Staphylococcus aureus Strain JKD6159, a Unique Australian Clone of ST93-IV Community Methicillin-Resistant Staphylococcus aureus

Community methicillin-resistant Staphylococcus aureus (cMRSA) is an emerging issue that has resulted in multiple worldwide epidemics. We report the first complete genome sequence of an ST93-MRSA-IV clinical isolate that caused severe invasive infection and a familial outbreak of skin infection. This isolate is a representative of the most common Australian clone of cMRSA that is more distantly related to the previously sequenced genomes of S. aureus.Staphylococcus aureus is a major cause of both hospital- and community-acquired infections, with rapid emergence of antibiotic resistance, in particular methicillin resistance, adding complexity to the treatment of this organism (3). While previously a hospital problem, methicillin-resistant S. aureus (MRSA) is now being increasingly documented in healthy patients in the community, and these isolates are termed “community MRSA” (cMRSA). A number of cMRSA genomes have been sequenced; however, these are phylogenetically closely related to each other. In contrast, ST93-MRSA-IV, a unique Australian clone, is a singleton by multilocus sequence typing (MLST) eBURST analysis (4). It is now the dominant cMRSA clone in Australia and is associated with both skin infection and severe invasive infection, including necrotizing pneumonia, deep-seated abscesses, and septicemia (5, 10). JKD6159 is a representative ST93-MRSA-IV clinical isolate which caused septicemia and multifocal pulmonary and musculoskeletal abscesses in a previously well intravenous drug user and also resulted in a familial outbreak of skin infection.The genome sequence of S. aureus strain JKD6159 was determined by high-throughput whole-genome shotgun sequencing, using both Illumina GAII (Illumina, CA) and Roche GS FLX Titanium (Roche Diagnostics, Basel, Switzerland) sequencing technologies, producing approximately 164× and 32× coverage of the genome, respectively. The GS FLX Titanium reads were assembled using Newbler 2.0.01.12, resulting in 56 contigs totaling 2.8 Mbp (9). The paired GAII reads were aligned to the contigs using SHRiMP 1.3.2 to identify and correct 74 homopolymeric sequencing errors (11). Optical mapping was used to produce a high-resolution XbaI chromosome restriction map, and the contigs were ordered and oriented against this map using MapSolver 2.1.1 (Opgen). Gap closures were performed by PCR followed by Sanger sequencing of amplification products (3730S genetic analyzer sequencer; Applied Biosystems, CA). The finished sequence was validated by reference to the XbaI optical map, Roche GS FLX Titanium mate pair analysis, and Illumina paired-end-read analysis.Protein coding regions were predicted using GeneMarkS 4.6b, tRNA genes using tRNAscan-SE 1.23, and rRNA genes using RNAmmer 1.2 (2, 7, 8). Gene products were assigned using HMMER 3.0 against the Pfam database (release 23) and BLAST 2.2.23 against RefSeq Proteins (April 2010) and the Conserved Domain Database (v2.22) (1, 6). These automated analyses were followed by manual curation, including comparison with other completed S. aureus genomes.The genome of S. aureus strain JKD6159 consists of a circular 2,811,435-bp chromosome with 33% G+C content—similar to those of other staphylococci—and one circular plasmid of 20,730 bp. A total of 2,605 coding regions, 57 tRNA genes, and 5 rRNA loci were detected. Over 67% of genes were assigned to specific Clusters of Orthologous Groups (COG) Database functional groups, and 40% were assigned an enzyme classification number (12).Initial analysis of the whole-genome sequence of JKD6159 confirms that ST93-MRSA-IV is distantly related to other previously sequenced S. aureus genomes. ST93-MRSA-IV has a distinct accessory genome. There were a number of regions of difference in JKD6159 that contain coding sequences (CDS) not present in any other published S. aureus genomes. Additionally, the ssl gene cluster in JKD6159 appears distinct from other sequenced S. aureus isolates. Comparison with other S. aureus genomes also shows that although JKD6159 carries lukSF-PV (the genes encoding Panton-Valentine leukocidin), there is a relative paucity of virulence factors such as tst-1, genes encoding staphylococcal enterotoxins A to U, and the ACME locus. Further analysis of the genome is now under way to identify factors that might explain the emergence of this MRSA strain in the community.     

Healthcare Associated Infections of Methicillin-Resistant Staphylococcus aureus: A Case-Control-Control Study

Background

Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most widespread and dangerous pathogens in healthcare settings. We carried out this case-control-control study at a tertiary care hospital in Guangzhou, China, to examine the antimicrobial susceptibility patterns, risk factors and clinical outcomes of MRSA infections.

Methods

A total of 57 MRSA patients, 116 methicillin-susceptible Staphylococcus aureus (MSSA) patients and 102 S. aureus negative patients were included in this study. We applied the disk diffusion method to compare the antimicrobial susceptibilities of 18 antibiotics between MRSA and MSSA isolates. Risk factors of MRSA infections were evaluated using univariate and multivariate logistic regression models. We used Cox proportional hazards models and logistic regression analysis to assess the hospital stay duration and fatality for patients with MRSA infections.

Results

The MRSA group had significantly higher resistance rates for most drugs tested compared with the MSSA group. Using MSSA patients as controls, the following independent risk factors of MRSA infections were identified: 3 or more prior hospitalizations (OR 2.8, 95% CI 1.3–5.8, P = 0.007), chronic obstructive pulmonary disease (OR 5.9, 95% CI 1.7–20.7, P = 0.006), and use of a respirator (OR 3.6, 95% CI 1.0–12.9, P = 0.046). With the S. aureus negative patients as controls, use of a respirator (OR 3.8, 95% CI 1.0–13.9, P = 0.047) and tracheal intubation (OR 8.2, 95% CI 1.5–45.1, P = 0.016) were significant risk factors for MRSA infections. MRSA patients had a longer hospital stay duration and higher fatality in comparison with those in the two control groups.

Conclusions

MRSA infections substantially increase hospital stay duration and fatality. Thus, MRSA infections are serious issues in this healthcare setting and should receive more attention from clinicians.     

Synergism between Medihoney and Rifampicin against Methicillin-Resistant Staphylococcus aureus (MRSA)

Skin and chronic wound infections caused by highly antibiotic resistant bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) are an increasing and urgent health problem worldwide, particularly with sharp increases in obesity and diabetes. New Zealand manuka honey has potent broad-spectrum antimicrobial activity, has been shown to inhibit the growth of MRSA strains, and bacteria resistant to this honey have not been obtainable in the laboratory. Combinational treatment of chronic wounds with manuka honey and common antibiotics may offer a wide range of advantages including synergistic enhancement of the antibacterial activity, reduction of the effective dose of the antibiotic, and reduction of the risk of antibiotic resistance. The aim of this study was to investigate the effect of Medihoney in combination with the widely used antibiotic rifampicin on S. aureus. Using checkerboard microdilution assays, time-kill curve experiments and agar diffusion assays, we show a synergism between Medihoney and rifampicin against MRSA and clinical isolates of S. aureus. Furthermore, the Medihoney/rifampicin combination stopped the appearance of rifampicin-resistant S. aureus in vitro. Methylglyoxal (MGO), believed to be the major antibacterial compound in manuka honey, did not act synergistically with rifampicin and is therefore not the sole factor responsible for the synergistic effect of manuka honey with rifampicin. Our findings support the idea that a combination of honey and antibiotics may be an effective new antimicrobial therapy for chronic wound infections.     

Emergence of Community-Associated Methicillin-Resistant Staphylococcus aureus Associated with Pediatric Infection in Cambodia

Background

The incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection is rising in the developed world but appears to be rare in developing countries. One explanation for this difference is that resource poor countries lack the diagnostic microbiology facilities necessary to detect the presence of CA-MRSA carriage and infection.

Methodology and Principal Findings

We developed diagnostic microbiology capabilities at the Angkor Hospital for Children, Siem Reap, western Cambodia in January 2006 and in the same month identified a child with severe community-acquired impetigo caused by CA-MRSA. A study was undertaken to identify and describe additional cases presenting between January 2006 and December 2007. Bacterial isolates underwent molecular characterization using multilocus sequence typing, staphylococcal cassette chromosome mec (SCCmec) typing, and PCR for the presence of the genes encoding Panton-Valentine Leukocidin (PVL). Seventeen children were identified with CA-MRSA infection, of which 11 had skin and soft tissue infection and 6 had invasive disease. The majority of cases were unrelated in time or place. Molecular characterization identified two independent MRSA clones; fifteen isolates were sequence type (ST) 834, SCCmec type IV, PVL gene-negative, and two isolates were ST 121, SCCmec type V, PVL gene-positive.

Conclusions

This represents the first ever report of MRSA in Cambodia, spread of which would pose a significant threat to public health. The finding that cases were mostly unrelated in time or place suggests that these were sporadic infections in persons who were CA-MRSA carriers or contacts of carriers, rather than arising in the context of an outbreak.