Franziska Layer

A genomic portrait of the emergence, evolution and global spread of a methicillin resistant Staphylococcus aureus pandemic

The widespread use of antibiotics in association with high-density clinical care has driven the emergence of drug-resistant bacteria that are adapted to thrive in hospitalized patients. Of particular concern are globally disseminated methicillin-resistant Staphylococcus aureus (MRSA) clones that cause outbreaks and epidemics associated with health care. The most rapidly spreading and tenacious health-care-associated clone in Europe currently is EMRSA-15, which was first detected in the UK in the early 1990s and subsequently spread throughout Europe and beyond. Using phylogenomic methods to analyze the genome sequences for 193 S. aureus isolates, we were able to show that the current pandemic population of EMRSA-15 descends from a health-care-associated MRSA epidemic that spread throughout England in the 1980s, which had itself previously emerged from a primarily community-associated methicillin-sensitive population. The emergence of fluoroquinolone resistance in this EMRSA-15 subclone in the English Midlands during the mid-1980s appears to have played a key role in triggering pandemic spread, and occurred shortly after the first clinical trials of this drug. Genome-based coalescence analysis estimated that the population of this subclone over the last 20 yr has grown four times faster than its progenitor. Using comparative genomic analysis we identified the molecular genetic basis of 99.8% of the antimicrobial resistance phenotypes of the isolates, highlighting the potential of pathogen genome sequencing as a diagnostic tool. We document the genetic changes associated with adaptation to the hospital environment and with increasing drug resistance over time, and how MRSA evolution likely has been influenced by country-specific drug use regimens.

Emergence of methicillin-resistant Staphylococcus aureus (MRSA) in different animal species

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) in animals such as horses, pet animals and productive livestock has raised questions of a probable human origin and in more general of host specificity of S. aureus. Particular clonal lineages are obviously specific for humans (e.g. ST15, ST25, ST45) and other for ruminants (e.g. ST151). MRSA associated with veterinary nosocomial infections (e.g. ST8 and ST254 in horses, ST22 in small animals) very likely have their origin in health care facilities. MRSA ST398 which became first known from widespread colonization in industrially raised pigs seems to have a limited host specificity and is able to colonize and to cause infections in various hosts. Mechanisms of host adaptation and their genomic background are poorly understood so far.

Nasal Colonization of Humans with Methicillin-Resistant Staphylococcus aureus (MRSA) CC398 with and without Exposure to Pigs

Background Studies in several European countries and in North America revealed a frequent nasal colonization of livestock with MRSA CC398 and also in humans with direct professional exposure to colonized animals. The study presented here addresses the question of further transmission to non exposed humans. Methods After selecting 47 farms with colonized pigs in different regions of Germany we sampled the nares of 113 humans working daily with pigs and of their 116 non exposed family members. The same was performed in 18 veterinarians attending pig farms and in 44 of their non exposed family members. For investigating transmission beyond families we samples the nares of 462 pupils attending a secondary school in a high density pig farming area. MRSA were detected by direct culture on selective agar. The isolates were typed by means of spa-sequence typing and classification of SCCmec elements. For attribution of spa sequence types to clonal lineages as defined by multi locus sequence typing we used the BURP algorithm. Antibiotic susceptibility testing was performed by microbroth dilution assay. Results At the farms investigated 86% of humans exposed and only 4.3% of their family members were found to carry MRSA exhibiting spa-types corresponding to clonal complex CC398. Nasal colonization was also found in 45% of veterinarians caring for pig farms and in 9% of their non exposed family members. Multivariate analysis revealed that antibiotic usage prior to sampling beard no risk with respect to colonization. From 462 pupils only 3 were found colonized, all 3 were living on pig farms. Conclusion These results indicate that so far the dissemination of MRSA CC398 to non exposed humans is infrequent and probably does not reach beyond familial communities.

Genetic Classification and Distinguishing of Staphylococcus Species Based on Different Partial gap, 16S rRNA, hsp60, rpoB, sodA, and tuf Gene Sequences

ABSTRACT The analysis of 16S rRNA gene sequences has been the technique generally used to study the evolution and taxonomy of staphylococci. However, the results of this method do not correspond to the results of polyphasic taxonomy, and the related species cannot always be distinguished from each other. Thus, new phylogenetic markers for Staphylococcus spp. are needed. We partially sequenced the gap gene (∼931 bp), which encodes the glyceraldehyde-3-phosphate dehydrogenase, for 27 Staphylococcus species. The partial sequences had 24.3 to 96% interspecies homology and were useful in the identification of staphylococcal species (F. Layer, B. Ghebremedhin, W. König, and B. König, J. Microbiol. Methods 70:542-549, 2007). The DNA sequence similarities of the partial staphylococcal gap sequences were found to be lower than those of 16S rRNA (∼97%), rpoB (∼86%), hsp60 (∼82%), and sodA (∼78%). Phylogenetically derived trees revealed four statistically supported groups: S. hyicus/S. intermedius, S. sciuri, S. haemolyticus/S. simulans, and S. aureus/epidermidis. The branching of S. auricularis, S. cohnii subsp. cohnii, and the heterogeneous S. saprophyticus group, comprising S. saprophyticus subsp. saprophyticus and S. equorum subsp. equorum, was not reliable. Thus, the phylogenetic analysis based on the gap gene sequences revealed similarities between the dendrograms based on other gene sequences (e.g., the S. hyicus/S. intermedius and S. sciuri groups) as well as differences, e.g., the grouping of S. arlettae and S. kloosii in the gap-based tree. From our results, we propose the partial sequencing of the gap gene as an alternative molecular tool for the taxonomical analysis of Staphylococcus species and for decreasing the possibility of misidentification.

Rare occurrence of methicillin-resistant Staphylococcus aureus CC130 with a novel mecA homologue in humans in Germany.

MRSA CC130 containing the mecA homologue mecALGA251 were reported from the UK and from Denmark so far from cattle and humans. Here we report on 11 MRSA CC130 among a sample of 12691 isolates of human origin collected from January 2006 until June 2011. MRSA CC130 grew insufficiently on chromogernic agar plates for detection of MRSA; the agglutination test for presence of PBP2a was negative. We designed primers for specific detection of mecALGA251 as well as for concomitant detection of both, mec LGA251 and mecA. As already described, the isolates exhibited spa-types t843, t1736, and t1773. The ccrA homologue indicated the presence SCCmec XI. When subjected to further characterization by means of a commercially available microarray the isolates were negative for sak chp, and scn, and as expected positive for hla, untruncated hlb, and hld. They furthermore contained edinB, aur, slpA, slpB, slpE. From genes coding for surface and cell wall associated products the ica-operon, cap8, clfA, clfF, ebpS, fnbA, fnbB, sdrC were detected but not cna. The isolates were negative for enterotoxin genes and tst, as well as for eta, and etb; agr-type was III.

Antibiotic resistance and molecular epidemiology of Staphylococcus aureus in Nigeria

BackgroundStaphylococcus aureus is an important pathogen causing a wide range of infections in the hospital and community setting. In order to have adequate information for treatment of S. aureus infections, it is crucial to understand the trends in the antibiotic-resistance patterns. In addition, the occurrence and changes in types of S. aureus, clonal identities, and their geographic spread is essential for the establishment of adequate infection control programmes. In this study, 68 S. aureus isolates obtained from clinical and non-clinical sources in Nigeria between January and April 2009 were characterized using phenotypic and molecular methods.ResultsAll the S. aureus isolates were susceptible to teicoplanin, vancomycin, phosphomycin, fusidic acid, rifampicin, daptomycin, mupirocin, linezolid and tigecycline. Sixteen percent of the isolates were resistant to oxacillin, while 55% and 72% of isolates were resistant to tetracycline and trimethoprim/sulphamethoxazole (cotrimoxazole), respectively (Table 1). There was excellent correlation between the broth microdilution assay and detection of antibiotic resistance genes by the multiplex PCR, in the determination of S. aureus resistance to erythromycin, gentamicin, methicillin and tetracycline. A total of 28 spa types were identified in the study, and the predominant spa type among the methicillin-susceptible S. aureus (MSSA) isolates was t084 (13 isolates). The t037-ST241-SCCmecIII type was the only clone identified in Maiduguri (North-East Nigeria) while in South-West Nigeria, diversity among the MRSA isolates (t451-ST8-SCCmecV; t008-ST94-SCCmecIV; t002-ST5-SCCmecV; t064-ST8-SCCmecV) was observed. The toxin genes seh and etd were detected in isolates affiliated with clonal complexes CC1, CC80 and sequence type ST25, respectively. The proportion of PVL-positive isolates among MSSA was high (40%). Most of the PVL-positive MSSA isolates were obtained from wound infections and associated with clonal complexes CC1, CC30, CC121 and with sequence type ST152.Table 1Antibiotic resistance profile of S. aureus (MSSA and MRSA) from NigeriaNumber (%) of resistant isolates among:AntibioticMSSA(n = 57)MRSA(n = 11)Total(n = 68)Penicillin49 (86)11 (100)60 (88.2)Oxacillin0 (0)11 (100)11 (16.2)Teicoplanin0 (0)0 (0)0 (0)Vancomycin0 (0)0 (0)0 (0)Gentamicin1 (1.8)9 (81.8)10 (14.7)Tetracycline27 (47.4)11 (100)38 (55.9)Ciprofloxacin12 (21.1)8 (72.7)20 (29.4)Moxifloxacin0 (0)7 (63.6)7 (10.3)Trimethoprim/sulfamethoxazole39 (68.4)10 (90.9)49 (72.1)Phosphomycin0 (0)0 (0)0 (0)Fusidic acid0 (0)0 (0)0 (0)Erythromycin2 (3.5)6 (54.5)8 (11.8)Clindamycin0 (0)6 (54.5)6 (8.8)Rifampicin0 (0)0 (0)0 (0)Daptomycin0 (0)0 (0)0 (0)Mupirocin0 (0)0 (0)0 (0)Linezolid0 (0)0 (0)0 (0)Tigecycline0 (0)0 (0)0 (0)ConclusionsThe use of phenotypic and molecular methods provided useful information on antibiotic resistance and molecular diversity of S. aureus in Nigeria. The high proportion of PVL-positive MSSA isolates affiliated to various clonal complexes and detected in all the health institutions is a major concern, both as a source of severe infections and as a potential reservoir that could lead to the emergence of PVL-positive MRSA. This study presents the first baseline information on the nature of the antibiotic resistance genes from S. aureus isolates in Nigeria. There is the need to curtail the spread and establishment of MRSA and PVL-positive MSSA clones in Nigerian health care institutions.

Comparative Study Using Various Methods for Identification of Staphylococcus Species in Clinical Specimens

ABSTRACT Coagulase-negative staphylococci (CNS) play a predominant role in nosocomial infections. Rapid, reliable identification of these organisms is essential for accurate diagnosis and prompt effective treatment of these infections. Quite recently, the VITEK 2 g-positive (gram-positive [GP]) identification card (bioMérieux) has been redesigned for greater accuracy in the identification of gram-positive cocci. We compared the BD Phoenix (Becton Dickinson) and VITEK 2 (bioMérieux) automated microbiology systems, using their respective update version cards, and the API ID32 STAPH test. The glyceraldehyde-3-phosphate dehydrogenase (gap) gene-based T-RFLP (terminal restriction fragment length polymorphism) method was used for verifying the results. In total, 86 clinical isolates of CNS and 27 reference strains were analyzed. The results show that for identification of CNS, the automated identification methods using the newest VITEK 2 and BD Phoenix identification cards are comparable. However, API ID32 STAPH revealed more correct results compared to both automated microbiology systems. Despite the increased performance of the phenotypic automated identification systems compared to the former versions, molecular methods, e.g., the gap-based T-RFLP method, still show superior accuracy in identifying Staphylococcus species other than Staphylococcus aureus.

MRSA Transmission on a Neonatal Intensive Care Unit: Epidemiological and Genome-Based Phylogenetic Analyses

Background Methicillin-resistant Staphylococcus aureus (MRSA) may cause prolonged outbreaks of infections in neonatal intensive care units (NICUs). While the specific factors favouring MRSA spread on neonatal wards are not well understood, colonized infants, their relatives, or health-care workers may all be sources for MRSA transmission. Whole-genome sequencing may provide a new tool for elucidating transmission pathways of MRSA at a local scale. Methods and Findings We applied whole-genome sequencing to trace MRSA spread in a NICU and performed a case-control study to identify risk factors for MRSA transmission. MRSA genomes had accumulated sequence variation sufficiently fast to reflect epidemiological linkage among individual patients, between infants and their mothers, and between infants and staff members, such that the relevance of individual nurses’ nasal MRSA colonization for prolonged transmission could be evaluated. In addition to confirming previously reported risk factors, we identified an increased risk of transmission from infants with as yet unknown MRSA colonisation, in contrast to known MRSA-positive infants. Conclusions The integration of epidemiological (temporal, spatial) and genomic data enabled the phylogenetic testing of several hypotheses on specific MRSA transmission routes within a neonatal intensive-care unit. The pronounced risk of transmission emanating from undetected MRSA carriers suggested that increasing the frequency or speed of microbiological diagnostics could help to reduce transmission of MRSA.

Insufficient discriminatory power of MALDI-TOF mass spectrometry for typing of Enterococcus faecium and Staphylococcus aureus isolates.

MALDI-TOF mass spectrometry (MALDI-TOF MS) is increasingly used as a reliable technique for species identification of bacterial pathogens. In this study we investigated the question of whether MALDI-TOF MS can be used for accurate sub-differentiation of strains and isolates of two important nosocomial pathogens Enterococcus faecium and Staphylococcus aureus. For this purpose, a selection of 112 pre-characterized E. faecium isolates (clonal complexes CC2, CC5, CC9, CC17, CC22, CC25, CC26, CC92 altogether 52 multilocus sequence types) and 59 diverse S. aureus isolates (mostly methicillin resistant; CC5, CC8, CC22, CC30, CC45, CC398) were studied using a combination of MALDI-TOF MS and advanced methods of spectral data analysis. The strategy of MS data evaluation included manual peak inspection on the basis of pseudo gel views, unsupervised hierarchical cluster analysis and supervised artificial neural network (ANN) analysis. We were capable of differentiating patterns of hospital-associated E. faecium isolates (CC17) from other strains of E. faecium with 87% accuracy, but failed to identify lineage-specific biomarker peaks. For S. aureus pattern analyses we were able to confirm a number of signals described in previous studies, but often failed to identify biomarkers that would allow a consistent and reliable identification of phylogenetic lineages, clonal complexes or sequence types. Hence, the discriminatory power of MALDI-TOF MS was found to be insufficient for reliably sub-differentiating E. faecium and S. aureus isolates to the level of distinct clones or clonal complexes, such as assessed by MLST. Further, a comparison between peak patterns of susceptible and resistant isolates did not identify statistically relevant marker peaks linked to glycopeptide resistance determinants (vanA, vanB) in E. faecium, or the methicillin resistance determinant (mecA) in S. aureus.

Heterogeneity of Methicillin-Susceptible Staphylococcus aureus Strains at a German University Hospital Implicates the Circulating-Strain Pool as a Potential Source of Emerging Methicillin-Resistant S. aureus Clones

ABSTRACT Recently, we demonstrated rapid dissemination of different methicillin-resistant Staphylococcus aureus (MRSA) clones at the Institute for Microbiology at the University of Magdeburg (B. Ghebremedhin, W. König, and B. König, Eur. J. Clin. Microbiol. Infect. Dis. 24:388-398, 2005). The majority of them harbored the readily transmissible mec cassette type IV. Thus, theoretically, methicillin-susceptible Staphylococcus aureus (MSSA) might capture the mecA gene from circulating MRSA, or MRSA strains might catch mobile toxin genes from MSSA. Therefore, we characterized MSSA strains circulating at the University Hospital in Magdeburg. Among a total of 84 MSSA strains under study, about 40% possessed the tst (toxic shock syndrome toxin) gene and up to four additional enterotoxin genes. tst-positive MSSA strains belonged to all known agr groups (I to IV) and to 14 different spa types (t008, t012, t015, t019, t024, t056, t065, t127, t133, t162, t271, t287, t399, and t400), and they were classified by multilocus sequence typing (MLST) as ST1, ST8, ST30, ST39, ST45, ST101, ST121, ST395, and ST426. In contrast, simultaneously circulating MRSA strains (n = 24) harbored in general two or three genes of the enterotoxin gene cluster, and the tst-positive MRSA isolates belonged to the well-known epidemic types ST22, ST45, and ST228 and were classified as spa types t001, t028, and t032. From our results, one may conclude that the pool of circulating MSSA strains is an important parameter with regard to the epidemiology of hospital- and community-acquired MRSA clones and their potential virulence.