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Background\ud Methicillin resistant Staphylococcus aureus (MRSA) bacteria cause serious, often healthcare-associated infections and are frequently highly resistant to diverse antibiotics. Multiple MRSA clonal complexes (CCs) have evolved independently and countries have different prevalent CCs. It is unclear when and why the dominant CC in a region may switch.\ud \ud Methods\ud We developed a mathematical deterministic model of MRSA CC competing for limited resource. The model distinguishes ‘standard MRSA’ and multidrug resistant sub-populations within each CC, allowing for resistance loss and transfer between same CC bacteria. We first analysed how dynamics of this system depend on growth-rate and resistance-potential differences between CCs, and on their resistance gene accumulation. We then fit the model to capture the longitudinal CC dynamics observed at a single UK hospital, which exemplified the UK-wide switch from mainly CC30 to mainly CC22.\ud \ud Results\ud We find that within a CC, gain and loss of resistance can allow for co-existence of sensitive and resistant sub-populations. Due to more efficient transfer of resistance at higher CC density, more drug resistance can accumulate in the population of a more prevalent CC. We show how this process of density dependent competition, together with prevalence disruption, could explain the relatively sudden switch from mainly CC30 to mainly CC22 in the UK hospital setting. Alternatively, the observed hospital dynamics could be reproduced by assuming that multidrug resistant CC22 evolved only around 2004.\ud \ud Conclusions\ud We showed how higher prevalence may advantage a CC by allowing it to acquire antimicrobial resistances more easily. Due to this density dependence in competition, dominance in an area can depend on historic contingencies; the MRSA CC that happened to be first could stay dominant because of its high prevalence advantage. This then could help explain the stability, despite frequent stochastic introductions across borders, of geographic differences in MRSA CC.

Bacteriophage (“phage”) are both predators and evolutionary drivers for bacteria, notably contributing to the spread of antimicrobial resistance (AMR) genes by generalised transduction. Our current understanding of the dual nature of this relationship is limited. We used an interdisciplinary approach to quantify how these interacting dynamics can lead to the evolution of multi-drug resistant bacteria. We co-cultured two strains of Methicillin-resistantStaphylococcus aureus, each harbouring a different antibiotic resistance gene, with 80α generalized transducing phage. After a growth phase of 8h, bacteria and phage surprisingly coexisted at a stable equilibrium in our culture, the level of which was dependent on the starting concentration of phage. We detected double-resistant bacteria as early as 7h, indicating that transduction of AMR genes had occurred. We developed multiple mathematical models of the bacteria and phage relationship, and found that phage-bacteria dynamics were best captured by a model in which the phage burst size decreases as the bacteria population reaches stationary phase, and where phage predation is frequency-dependent. We estimated that one in every 108new phage generated was a transducing phage carrying an AMR gene, and that double-resistant bacteria were always predominantly generated by transduction rather than by growth. Our results suggest a shift in how we understand and model phage-bacteria dynamics. Although rates of generalised transduction could be interpreted as too rare to be significant, they are sufficient to consistently lead to the evolution of multi-drug resistant bacteria. Currently, the potential of phage to contribute to the growing burden of AMR is likely underestimated.

Objectives: Horizontal gene transfer of antimicrobial resistance (AMR) genes between clinical isolates via transduction is poorly understood. MRSA are opportunistic pathogens resistant to all classes of antimicrobial agents but currently no strains are fully drug resistant. AMR gene transfer between Staphylococcus aureus isolates is predominantly due to generalized transduction via endogenous bacteriophage, and recent studies have suggested transfer is elevated during host colonization. The aim was to investigate whether exposure to sub-MIC concentrations of antimicrobials triggers bacteriophage induction and/or increased efficiency of AMR gene transfer. Methods: Isolates from MRSA carriers were exposed to nine antimicrobials and supernatants were compared for lytic phage particles and ability to transfer an AMR gene. A new technology, droplet digital PCR, was used to measure the concentration of genes in phage particles. Results: All antibiotics tested induced lytic phage and AMR gene transduction, although the ratio of transducing particles to lytic particles differed substantially for each antibiotic. Mupirocin induced the highest ratio of transducing versus lytic particles. Gentamicin and novobiocin reduced UV-induced AMR transduction. The genes carried in phage particles correlated with AMR transfer or lytic particle activity, suggesting antimicrobials influence which DNA sequences are packaged into phage particles. Conclusions: Sub-inhibitory antibiotics induce AMR gene transfer between clinical MRSA, while combination therapy with an inhibiting antibiotic could potentially alter AMR gene packaging into phage particles, reducing AMR transfer. In a continually evolving environment, pathogens have an advantage if they can transfer DNA while lowering the risk of lytic death.

Bacteria in the genus Staphylococcus are important targets for phage therapy due to their prevalence as pathogens and increasing antibiotic resistance. Here we review Staphylococcus outer surface features and specific phage resistance mechanisms that define the host range, the set of strains that an individual phage can potentially infect., Bacteria in the genus Staphylococcus are important targets for phage therapy due to their prevalence as pathogens and increasing antibiotic resistance. Here we review Staphylococcus outer surface features and specific phage resistance mechanisms that define the host range, the set of strains that an individual phage can potentially infect. Phage infection goes through five distinct phases: attachment, uptake, biosynthesis, assembly, and lysis. Adsorption inhibition, encompassing outer surface teichoic acid receptor alteration, elimination, or occlusion, limits successful phage attachment and entry. Restriction-modification systems (in particular, type I and IV systems), which target phage DNA inside the cell, serve as the major barriers to biosynthesis as well as transduction and horizontal gene transfer between clonal complexes and species. Resistance to late stages of infection occurs through mechanisms such as assembly interference, in which staphylococcal pathogenicity islands siphon away superinfecting phage proteins to package their own DNA. While genes responsible for teichoic acid biosynthesis, capsule, and restriction-modification are found in most Staphylococcus strains, a variety of other host range determinants (e.g., clustered regularly interspaced short palindromic repeats, abortive infection, and superinfection immunity) are sporadic. The fitness costs of phage resistance through teichoic acid structure alteration could make staphylococcal phage therapies promising, but host range prediction is complex because of the large number of genes involved, and the roles of many of these are unknown. In addition, little is known about the genetic determinants that contribute to host range expansion in the phages themselves. Future research must identify host range determinants, characterize resistance development during infection and treatment, and examine population-wide genetic background effects on resistance selection.

Background\ud Concern exists that frequent use of topically-applied fusidic acid (FA) and chlorhexidine (CHX) for canine pyoderma is driving clinically relevant resistance, despite rare description of FA and CHX genetic resistance determinants in canine-derived staphylococci. This study aimed to determine minimum inhibitory concentrations (MICs) and investigate presence of putative resistance determinants for FA and CHX in canine-derived methicillin-resistant (MR) and -susceptible (MS) staphylococci. Plasmid-mediated resistance genes (fusB, fusC, fusD, qacA/B, smr; PCR) and MICs (agar dilution) of FA and CHX were investigated in 578 staphylococci (50 MR S. aureus [SA], 50 MSSA, 259 MR S. pseudintermedius [SP], 219 MSSP) from Finland, U.S.A., North (NUK) and South-East U.K. (SEUK) and Germany. In all isolates with FA MIC ≥64 mg/L (n = 27) fusA and fusE were amplified and sequenced.\ud \ud Results\ud FA resistance determinants (fusA mutations n = 24, fusB n = 2, fusC n = 36) were found in isolates from all countries bar U.S.A. and correlated with higher MICs (≥1 mg/L), although 4 SP isolates had MICs of 0.06 mg/L despite carrying fusC. CHX MICs did not correlate with qacA/B (n = 2) and smr (n = 5), which were found in SEUK SA, and SP from NUK and U.S.A.\ud \ud Conclusions\ud Increased FA MICs were frequently associated with fusA mutations and fusC, and this is the first account of fusB in SP. Despite novel description of qacA/B in SP, gene presence did not correlate with CHX MIC. Selection pressure from clinical use might increase prevalence of these genetic determinants, but clinical significance remains uncertain in relation to high skin concentrations achieved by topical therapy.

Transmission of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus pseudintermedius (MRSP) between people and pets, and their co-carriage, are well-described. Potential exchange of antimicrobial resistance (AMR) genes amongst these staphylococci was investigated in vitro through endogenous bacteriophage-mediated transduction. Bacteriophages were UV-induced from seven donor isolates of canine (MRSP) and human (MRSA) origin, containing tet(M), tet(K), fusB or fusC, and lysates filtered. Twenty-seven tetracycline- and fusidic acid- (FA-) susceptible recipients were used in 122 donor-recipient combinations (22 tetracycline, 100 FA) across 415 assays (115 tetracycline, 300 FA). Bacteriophage lysates were incubated with recipients and presumed transductants quantified on antimicrobial-supplemented agar plates. Tetracycline resistance transduction from MRSP and MRSA to methicillin-susceptible S. pseudintermedius (MSSP) was confirmed by PCR in 15/115 assays. No FA-resistance transfer occurred, confirmed by negative fusB/fusC PCR, but colonies resulting from FA assays had high MICs (&ge, 32 mg/L) and showed mutations in fusA, two at a novel position (F88L), nine at H457[Y/N/L]. Horizontal gene transfer of tetracycline-resistance confirms that resistance genes can be shared between coagulase-positive staphylococci from different hosts. Cross-species AMR transmission highlights the importance of good antimicrobial stewardship across humans and veterinary species to support One Health.

Background Staphylococcus argenteus and Staphylococcus schweitzeri, previously known as divergent Staphylococcus aureus clonal lineages, have been recently established as novel, difficult-to-delimit, coagulase-positive species within the S. aureus complex. Methicillin-resistant strains of S. argenteus are known from Australia and the UK. Knowledge of their epidemiology, medical significance and transmission risk is limited and partly contradictory, hampering definitive recommendations. There is mounting evidence that the pathogenicity of S. argenteus is similar to that of ‘classical' S. aureus, while as yet no S. schweitzeri infections have been reported. Aim To provide decision support on whether and how to distinguish and report both species. Sources PubMed, searched for S. argenteus and S. schweitzeri. Content This position paper reviews the main characteristics of both species and draws conclusions for microbiological diagnostics and surveillance as well as infection prevention and control measures. Implications We propose not distinguishing within the S. aureus complex for routine reporting purposes until there is evidence that pathogenicity or clinical outcome differ markedly between the different species. Primarily for research purposes, suitably equipped laboratories are encouraged to differentiate between S. argenteus and S. schweitzeri. Caution is urged if these novel species are explicitly reported. In such cases, a specific comment should be added (i.e. ‘member of the S.aureus complex') to prevent confusion with less- or non-pathogenic staphylococci. Prioritizing aspects of patient safety, methicillin-resistant isolates should be handled as recommended for methicillin-resistant Staphylococcus aureus (MRSA). In these cases, the clinician responsible should be directly contacted and informed by the diagnosing microbiological laboratory, as they would be for MRSA. Research is warranted to clarify the epidemiology, clinical impact and implications for infection control of such isolates.

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Investigation of Staphylococcus aureus outbreaks, and particularly those due to methicillin-resistant S. aureus (MRSA) in hospitals, can identify infection reservoirs and prevent further colonization and infection. During outbreaks, S. aureus genomes develop single nucleotide polymorphisms (SNPs), small genetic rearrangements, and/or acquire and lose mobile genetic elements (MGE) encoding resistance and virulence genes. Whole genome sequencing (WGS) is the most powerful method for discriminating between related isolates and deciding which are involved in an outbreak. Isolates with only minor variations are detectable and can identify MRSA transmission routes and identify reservoirs. Some patients may carry 'clouds' of related isolates, and this has consequences for how we interpret the data from outbreak investigations. Different clones of MRSA are evolving at different rates, influencing their typability. S. aureus genome variation reveals the importance of antibiotic resistance in the long term evolution of successful hospital clones, contributing to strategies to prevent the spread of successful MRSA clones.

Staphylococcus aureus is a major human pathogen, and is targeted by the host innate immune system. In response, S. aureus genomes encode dozens of secreted proteins that inhibit complement, chemotaxis and neutrophil activation resulting in successful evasion of innate immune responses. These proteins include immune evasion cluster proteins (IEC; Chp, Sak, Scn), staphylococcal superantigen-like proteins (SSLs), phenol soluble modulins (PSMs) and several leukocidins. Biochemical studies have indicated that genetic variants of these proteins can have unique functions. To ascertain the scale of genetic variation in secreted immune evasion proteins, whole genome sequences of 88 S. aureus isolates, representing 25 clonal complex (CC) lineages, in the public domain were analysed across 43 genes encoding 38 secreted innate immune evasion protein complexes. Twenty-three genes were variable, with between 2 and 15 variants, and the variants had lineage-specific distributions. They include genes encoding Eap, Ecb, Efb, Flipr/Flipr-like, Hla, Hld, Hlg, Sbi, Scin-B/C and 13 SSLs. Most of these protein complexes inhibit complement, chemotaxis and neutrophil activation suggesting that isolates from each S. aureus lineage respond to the innate immune system differently. In contrast, protein complexes that lyse neutrophils (LukSF-PVL, LukMF, LukED and PSMs) were highly conserved, but can be carried on mobile genetic elements (MGEs). MGEs also encode proteins with narrow host-specificities arguing that their acquisition has important roles in host/environmental adaptation. In conclusion, this data suggests that each lineage of S. aureus evades host immune responses differently, and that isolates can adapt to new host environments by acquiring MGEs and the immune evasion protein complexes that they encode. Cocktail therapeutics that targets multiple variant proteins may be the most appropriate strategy for controlling S. aureus infections.

Healthcare-associated (HA) meticillin-resistant Staphylococcus aureus (MRSA) clone CC22 SCCmecIV (EMRSA-15) has recently overtaken CC30/ST36 SCCmecII (EMRSA-16) as the dominant clone in UK hospitals. CC22 SCCmecIV shows greater fitness than CC30 SCCmecII, although both are successful global pathogens. The aim of this study was to test whether mobile genetic elements (MGEs), specifically SCCmec and large plasmids encoding resistance genes, are a burden and contribute to this fitness difference. Thirty-nine clinical isolates of MRSA and meticillin-sensitive S. aureus from lineages CC30 and CC22 with a variety of antibiotic resistance genes were grown in the absence of antibiotics. A range of relative fitness measures were used to compare clinical isolates with and without SCCmecII and SCCmecIV. The same fitness measures were used to compare eight isolates with and without naturally occurring large antibiotic resistance plasmids carrying gentamicin resistance (determined by microarray) and an isolate with an introduced plasmid. Growth rate, competitive ability during co-culture and survival after desiccation were then compared. Carriage of SCCmecII contributed to the reduced fitness of CC30 MRSA. However, we found no evidence of a fitness cost due to carriage of SCCmecIV in CC22, or large antibiotic resistance plasmids in CC30 or multiple resistances in both lineages. In conclusion, many large MGEs are not a fitness burden. Surprisingly, lineage background was the most important determinant of fitness. Our results suggest CC22 SCCmecIV will remain a successful healthcare-associated clone, and resistance to meticillin and gentamicin is likely to be maintained even in the absence of antibiotic pressure.

In many parts of the world, MRSA are responsible for a high proportion of S. aureus infections in patients in contact with healthcare. Molecular studies have shown this is due to one or more MRSA clones that have become endemic in each hospital or healthcare facility, resulting in hospital- or healthcare-associated MRSA (HA-MRSA). The infection rate and clones responsible for HA-MRSA can vary substantially in different geographical locations. Molecular methods have allowed clones to be categorized, as well as the opportunity to track the evolution and spread of clones in healthcare settings and around the world. The genomes of HA-MRSA isolates belonging to the same clonal group can show dramatic variability particularly in the carriage of mobile genetic elements (MGEs) encoding virulence and resistance genes. HA-MRSA are potentially resistant to all classes of antibiotics, although individual isolates that are fully drug resistant are not reported. The incidence of fluoroquinolone resistance in HA-MRSA is remarkably high, suggesting use of this class of antibiotics as well as the β-lactams contributes to the selection and success of HA-MRSA clones in the hospital setting.

International audience; The evolution of meticillin-resistant Staphylococcus aureus (MRSA) from meticillin-susceptible S. aureus has been a result of the accumulation of genetic elements under selection pressure from antibiotics. The traditional classification of MRSA into healthcare-associated MRSA (HA-MRSA) and community-associated MRSA (CA-MRSA) is no longer relevant as there is significant overlap of identical clones between these groups, with an increasing recognition of human infection caused by livestock-associated MRSA (LA-MRSA). Genomic studies have enabled us to model the epidemiology of MRSA along these lines. In this review, we discuss the clinical relevance of genomic studies, particularly whole-genome sequencing, in the investigation of outbreaks. We also discuss the blurring of each of the three epidemiological groups (HA-MRSA, CA-MRSA and LA-MRSA), demonstrating the limited relevance of this classification. © 2016 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.

The Type I DNA restriction–modification (RM) systems of Staphylococcus aureus are known to act as a significant barrier to horizontal gene transfer between S. aureus strains belonging to different clonal complexes. The livestock-associated clonal complexes CC133/771 and CC398 contain Type I RM systems not found in human MRSA strains as yet but at some point transfer will occur. When this does take place, horizontal gene transfer of resistance will happen more easily between these strains. The reservoir of antibiotic resistance, virulence and host-adaptation genes present in livestock-associated MRSA will then potentially contribute to the development of newly evolving MRSA clones. The target sites recognised by the Type I RM systems of CC133/771 and CC398 were identified as CAG(N)5RTGA and ACC(N)5RTGA, respectively. Assuming that these enzymes recognise the methylation state of adenine, the underlined A and T bases indicate the unique positions of methylation. Target methylation points for enzymes from CC1 were also identified. The methylation points for CC1-1 are CCAY(N)5TTAA and those for CC1-2 are CCAY(N)6 TGT with the underline indicating the adenine methylation site as confirmed recently by Monk et al. (2015) (MBio 6:e00308–15, 2015), which finally clears up the ambiguity noted previously (Roberts et al. 2013, Nucleic Acids Res 41:7472–7484) for the half sites containing two adenine bases.

Staphylococcus aureus clonal complex 398 (CC398) isolates colonize livestock and can spread to human contacts. Genetic analysis of isolates epidemiologically associated with human-to-human, but not livestock, transmission in multiple countries and continents identified a common clade that was negative for tet (M) and positive for bacteriophage ϕ3. Another group of human-to-human-transmitted isolates belonged to the common livestock-associated clade but had acquired a unique ϕ7 bacteriophage.

Meticillin-resistant Staphylococcus aureus (MRSA) nasal carriage on admission to hospital remains one of the most important risk factors for subsequent infection. Identification of high risk groups for MRSA carriage is vital for the success of infection control programmes. Veterinary staff may be one such risk group but little is known about pet owners and the role of contact with infected pets. As part of a UK-wide case-control study investigating risk factors for MRSA infection in dogs and cats between 2005 and 2008, 608 veterinary staff and pet owners in contact with 106 MRSA and 91 meticillin-susceptible S. aureus (MSSA)-infected pets were screened for S. aureus nasal carriage. Laboratory isolation and characterisation included salt broth enrichment, standard and automated microbiological tests, demonstration of the S. aureus-specific thermonuclease gene (nuc) and of mecA, and polymerase chain reaction-based lineage characterisation. MRSA carriage was 12.3% in veterinarians attending MRSA-infected animals and 7.5% in their owners. In the MSSA control group, MRSA carriage was 4.8% in veterinary staff and 0% in owners. Veterinary staff carried MRSA more frequently than owners (odds ratio: 2.33; 95% confidence interval: 1.10-4.93). All MRSA from humans and all but one animal MRSA were CC22 or CC30, typical for hospital MRSA in the UK. This study indicates for the first time an occupational risk for MRSA carriage in small animal general practitioners. Veterinary staff and owners of MRSA-infected pets are high risk groups for MRSA carriage despite not having direct hospital links. Strategies to break the cycle of MRSA infection must take these potential new reservoirs into account. © 2009 The Hospital Infection Society.

Analysis of methicillin-resistant Staphylococcus aureus (MRSA) characterized as USA300 by pulsed-field gel electrophoresis identified two distinct clones. One was similar to community-associated USA300 MRSA (ST8-IVa, t008, and Panton-Valentine leukocidin positive). The second (ST8-IVa, t024, and PVL negative) had different molecular characteristics and epidemiology, suggesting independent evolution. We recommend spa typing and/or PCR to discriminate between the two clones.

To facilitate mode of action studies on antibacterial inhibitors of early-stage cell wall biosynthesis (CWB), we determined the transcriptional response of Staphylococcus aureus to depletion/inhibition of enzymes in this pathway by DNA microarray analysis. We identified a transcriptional signature distinct from that previously observed following exposure to inhibitors of late-stage CWB.

Staphylococcus aureus is a commensal and pathogen of several mammalian species, particularly humans and cattle. We aimed to (i) identify S. aureus genes associated with host specificity, (ii) determine the relatedness of human and animal isolates, and (iii) identify whether human and animal isolates typically exchanged mobile genetic elements encoding virulence and resistance genes. Using a well-validated seven-strain S. aureus microarray, we compared 56 UK S. aureus isolates that caused infection in cows, horses, goats, sheep and a camel with 161 human S. aureus isolates from healthy carriers and community acquired infections in the UK. We had previously shown that human isolates are clustered into ten dominant and a few minor lineages, each with unique combinations of surface proteins predicted to bind to human proteins. We found that the animal-associated S. aureus clustered into ten lineages, with 61 % assigned to four lineages, ST151, ST771, ST130 and ST873, that were unique to animals. The majority of bovine mastitis was caused by isolates of lineage ST151, ST771 and ST97, but a few human lineages also caused mastitis. S. aureus isolated from horses were more likely to cluster into human-associated lineages, with 54 % of horse-associated S. aureus assigned to the human clusters CC1, CC8 and CC22; along with the presence of some multi-drug resistant strains, this suggests a human origin. This is the most comprehensive genetic comparison of human versus animal S. aureus isolates conducted, and because we used a whole-genome approach we could estimate the key genes with the greatest variability that are associated with host specificity. Several genes conserved in all human isolates were variable or missing in one or more animal lineages, including the well-characterized lineage specific genes fnbA, fnbB and coa. Interestingly, genes carried on mobile genetic elements (MGEs) such as chp, scn and sak were less common in animal S. aureus isolates, and bap was not found. There was a lot of MGE variation within lineages, and some evidence that exchange of MGEs such as bacteriophage and pathogenicity islands between animal and human lineages is feasible, but there was less evidence of antibiotic resistance gene transfer on the staphylococcal cassette chromosomes (SCC) or plasmids. Surprisingly, animal lineages are closely related to human lineages and only a handful of genes or gene combinations may be responsible for host specificity.

In 1932, Philip N. Panton and his colleagues, as they studied bacterial toxins at the London Hospital, could not have anticipated the scientific revolution coming in microbial genomics. It is ironic, then, that some of the genes encoding those toxins Panton and colleagues discovered well before the midpoint in the 20th century would now be contributing to our knowledge of how bacterial pathogens arise and evolve [2]. Even then, the work of these toxin hunters was specific enough to suggest that some of the toxins, in light of their cellular targets, were separate entities. Their term, “staphylococcal toxin,” included the various toxigenic effects produced by staphylococcal “constituents” that were either hemolytic (hemolysins), necrotic when injected subcutaneously (necrotoxins), destructive for phagocytes when staphylococcal suspensions were diluted 1:16 (leukocidins), or fatal for rabbits after intravenous injection (lethal toxin) [1]. In the early 1930s, there were no therapeutic antimicrobials and no penicillin resistance in staphylococci, let alone the resistance to semisynthetic penicillins introduced some 30 years later [3]. For that reason, in the early part of the last century, the ultimate intent of staphylococcal research was to develop specific antisera against suspected toxins in an attempt to counter the ineffective therapy of the vaccines of the era, which were composed primarily of bacterial debris [4]. It is likely that many of the early isolates of Staphylococcus aureus contained the genes (lukS-PV and lukF-PV) that encode the most important leukocidin, appropriately named “Panton-Valentine leukocidin” (PVL) [5]. In fact, there were reports of antitoxins being used efficaciously to treat staphylococcal infections [4], but those studies did not continue. Monoclonal antibodies to some of the MSCRAMMs (microbial surface components recognizing adhesive matrix molecules), on the other hand, have shown new promise for immune-based therapy [6]. Conversely, the exact role played by leukocidins such as PVL in the pathogenesis of staphylococcal infection remains controversial [7]. PVL-containing S. aureus continues to cause severe necrotizing communityacquired pneumonia [8], and PVL has been shown to be sufficient to cause necrotizing pneumonia when administered to mice [9]. In 2006, an extraordinary finding was reported concerning the spread in the community of a predominant strain of methicillin-resistant S. aureus (MRSA) termed “USA300,” which displayed an easily identifiable pattern when analyzed by pulsed-field gel electrophoresis (PFGE) and elaborated PVL [10]. The “USA” designations originally published in 2003 derived from the most common PFGE patterns of US isolates of MRSA [11]. USA300 isolates arose primarily from outbreaks in correctional institutions, among athletic teams, and in nurseries [12]. Oxacillin (methicillin) resistance had historically been linked to multiple resistance determinants housed within a large, complex mobile genetic element termed “staphylococcal chromosome cassette” (SCCmec) [13]. In contrast, community-associated MRSA (CA-MRSA) isolates such as USA 300 usually contained a smaller, truncated SCCmec [14]. Community strains containing SCCmec Received 16 August 2007; accepted 16 August 2007; electronically published 4 January 2008. Potential conflicts of interest: J.F.J. has served as a consultant to Cubist, bioMerieux, and Gilead; has in the past received research funding from Merck; and has participated in speakers’ bureaus with Pfizer, Cubist, and Bayer. J.A.L. has received grant support from Enzon Pharmaceuticals. Reprints or correspondence: Dr. Joseph F. John, 109 Bee St. (14), Charleston, SC 29401 (joseph.john2@va.gov). The Journal of Infectious Diseases 2008; 197:175– 8 © 2007 by the Infectious Diseases Society of America. All rights reserved. 0022-1899/2008/19702-0001$15.00 DOI: 10.1086/524693 E D I T O R I A L C O M M E N T A R Y

Multilocus sequence typing (MLST) and multi-strain microarray analysis have shown that most human Staphylococcus aureus strains belong to ten dominant clonal complexes (CCs) or lineages, each with unique surface architecture. Meticillin-resistant S. aureus (MRSA) strains currently belong to six of these lineages (CC1, CC5, CC8, CC22, CC30 and CC45), each of which has independently acquired mobile genetic elements (MGEs) carrying antibiotic resistance genes. MLST and microarrays are expensive and time consuming methods for routine determination of S. aureus lineage. A restriction-modification (RM) test has now been developed that is rapid, simple, inexpensive and accurately determines lineage of hospital-acquired MRSA. The RM test is based on three PCRs for hsdS gene variants, as hsdS genes likely control the independent evolution of S. aureus lineages. The RM test correctly identified 102 MRSA isolates as belonging to one of the six lineages/CCs. Real-time MRSA typing can be used to identify and track changes in local MRSA outbreaks, and provide support for targeting infection control strategies. Simple and accurate typing methods will also support large scale epidemiological studies, and could lead to greater understanding of the carriage, spread and virulence of different MRSA lineages.

Objectives MRSA is a major antimicrobial resistance (AMR) pathogen. The reservoir of infecting isolates is colonization, which is the site of evolutionary selection. The aim was to identify if AMRs in colonizing MRSA populations diversified and potential mechanisms of resistance gene transfer in vivo. Methods Nasal swabs from 38 MRSA carriers admitted to hospital were plated and 20 individual colonies from each patient tested for phenotypic antibiotic susceptibility and genetically for lineage, carriage of four prophages and three plasmid families. Free bacteriophages were detected in swabs as well as their capacity for transducing resistance genes. Results Nine (24%) patients carried phenotypic AMR variants and 24 (63%) carried prophage and plasmid variants. If a single colony was selected for testing, the probability of detecting all AMR in that patient was 87%. Sixty-four different AMR and mobile genetic element (MGE) profiles were detected, mostly in the MRSA CC22 background (where CC stands for clonal complex), with up to 8 profiles per patient. Nearly half of the patients carried detectable free bacteriophages and phages successfully transduced resistance genes between laboratory and patient isolates in vitro. WGS showed MRSA core genomes were stable, while AMR and MGEs varied. Conclusions ‘Clouds’ of MRSA variants that have acquired or lost AMR and MGEs are common in nasal colonizing populations and bacteriophages may play an important role in gene transfer. Accurate estimation of AMR and genetic variability has implications for diagnostics, epidemiology, antimicrobial stewardship and understanding the evolutionary selection of AMR in colonizing populations.

SRH, SDB JP and MTGH were supported by Wellcome Trust grant 098051. LYH was funded by the National Medical Research Council Singapore. SP is funded by the UKCRC Translational Infection Research Initiative, and the NIHR Cambridge Biomedical Research Centre. Background In the past decade, several countries have seen gradual replacement of endemic multi-resistant healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA) with clones that are more susceptible to antibiotic treatment. One example is Singapore, where MRSA ST239, the dominant clone since molecular profiling of MRSA began in the mid-1980s, has been replaced by ST22 isolates belonging to EMRSA-15, a recently emerged pandemic lineage originating from Europe. Results We investigated the population structure of MRSA in Singaporean hospitals spanning three decades, using whole genome sequencing. Applying Bayesian phylogenetic methods we report that prior to the introduction of ST22, the ST239 MRSA population in Singapore originated from multiple introductions from the surrounding region; it was frequently transferred within the healthcare system resulting in a heterogeneous hospital population. Following the introduction of ST22 around the beginning of the millennium, this clone spread rapidly through Singaporean hospitals, supplanting the endemic ST239 population. Coalescent analysis revealed that although the genetic diversity of ST239 initially decreased as ST22 became more dominant, from 2007 onwards the genetic diversity of ST239 began to increase once more, which was not associated with the emergence of a sub-clone of ST239. Comparative genomic analysis of the accessory genome of the extant ST239 population identified that the Arginine Catabolic Mobile Element arose multiple times, thereby introducing genes associated with enhanced skin colonization into this population. Conclusions Our results clearly demonstrate that, alongside clinical practice and antibiotic usage, competition between clones also has an important role in driving the evolution of nosocomial pathogen populations. Publisher PDF

The capacity for intracellular survival within phagocytes is likely a critical factor facilitating the dissemination of Staphylococcus aureus in the host. To date, the majority of work on S. aureus -phagocyte interactions has focused on neutrophils and, to a lesser extent, macrophages, yet we understand little about the role played by dendritic cells (DCs) in the direct killing of this bacterium. Using bone marrow-derived DCs (BMDCs), we demonstrate for the first time that DCs can effectively kill S. aureus but that certain strains of S. aureus have the capacity to evade DC (and macrophage) killing by manipulation of autophagic pathways. Strains with high levels of Agr activity were capable of causing autophagosome accumulation, were not killed by BMDCs, and subsequently escaped from the phagocyte, exerting significant cytotoxic effects. Conversely, strains that exhibited low levels of Agr activity failed to accumulate autophagosomes and were killed by BMDCs. Inhibition of the autophagic pathway by treatment with 3-methyladenine restored the bactericidal effects of BMDCs. Using an in vivo model of systemic infection, we demonstrated that the ability of S. aureus strains to evade phagocytic cell killing and to survive temporarily within phagocytes correlated with persistence in the periphery and that this effect is critically Agr dependent. Taken together, our data suggest that strains of S. aureus exhibiting high levels of Agr activity are capable of blocking autophagic flux, leading to the accumulation of autophagosomes. Within these autophagosomes, the bacteria are protected from phagocytic killing, thus providing an intracellular survival niche within professional phagocytes, which ultimately facilitates dissemination.

Staphylococcus aureus is a persistent resident of the human nose in 20% of the population and intermittently carried by another 60% (16). Most carriers harbor a single strain (2). S. aureus is a common cause of minor skin and wound infections, but only rarely causes severe community-acquired invasive infections such as bacteremia, endocarditis, and osteomyelitis. In contrast, S. aureus is the most common cause of hospital-acquired infection, which often occurs in association with breaches of the skin and mucous membranes in the immunocompromised host (14). Hundreds of S. aureus virulence factors and putative virulence genes have been described, including those involved in adherence to human tissue, evasion of the immune response, toxin secretion, and regulation of virulence gene expression (29). Specific toxins have also been described that play a pivotal role in toxin-mediated disease such as toxic shock syndrome (toxic shock syndrome toxin-1, encoded by tst; enterotoxins B and C, encoded by seb, sec) (5), scalded skin syndrome (exfoliative toxins A and B, encoded by eta, etb) (19), food poisoning (enterotoxin A, encoded by sea) (5), and more recently hemolytic pneumonia and skin and soft tissue infection (Panton Valentine leukocidin [PVL], encoded by the lukS-PV and lukF-PV genes) (20). Many of these genes are variably present as a result of being carried on mobile genetic elements (MGE) (22). However, critical to the development of targeted or preventive strategies is the elucidation of which if any of these genes are important in invasive infection. An important isolate collection associated with community-acquired invasive disease or carriage by healthy donors in the Oxford, United Kingdom, region (7) has been examined using multilocus sequence typing (MLST) (6), in which fragments of seven housekeeping genes were amplified and sequenced. Unique alleles at the seven loci were given an allelic number, and the allelic profile (string of seven integers) was used to define sequence type (ST) for each isolate. Isolates with an identical profile were considered to be clonal, and those with at least five of seven matching genes were considered to belong to the same clonal cluster (CC). Isolates clustered into 10 major CCs, none of which were associated with invasive disease (7). This argued against the presence of virulent genotypes but did not exclude the possibility that one or more variable genes were overrepresented in the invasive-isolate group. This possibility was examined during a study that defined the presence or absence of 33 putative virulence genes in this isolate collection using PCR (27). Seven genes were found to be present more commonly in invasive isolates, including eta and those encoding fibronectin binding protein A (fnbA), collagen binding protein (cna), serine-aspartate repeat containing protein E (sdrE), staphylococcal enterotoxin J (sej), gamma-hemolysin (hlg), and intracellular adhesin (ica). This suggested there were differences between isolates that did not correlate with lineage. It also suggested that some isolates are potentially more virulent than others. Each S. aureus isolate is thought to carry hundreds of variable genes including many putative virulence determinants. The first S. aureus comparative-genomics studies using a microarray (covering 92% of the genes found in the S. aureus COL genome) estimated that 22% of the S. aureus genome was variable (8). Many of the variable genes are known or putative virulence and resistance genes carried on MGE, and these elements are likely to transfer horizontally among staphylococci (see reference 22 for a review). The accumulation of such MGE may result in the emergence of “superbugs” that are increasingly resistant and virulent (22). The whole-genome sequencing of seven isolates of S. aureus (1, 10, 12, 18; www.genome.ou.edu/staph.html) has allowed us to design, print, and validate a multistrain PCR product S. aureus microarray carrying PCR products for every gene identified from these projects, probably the most comprehensive microarray of its kind (33). Here we describe the use of the seven-strain S. aureus microarray to investigate the Oxford collection of community-acquired S. aureus isolates. The aims were to identify which regions of the S. aureus genome vary, investigate gene distribution in a typical S. aureus population, and perform a comprehensive search for differences between invasive and carriage isolates.

Staphylococcus aureus is an important nosocomial and community-acquired pathogen. Its genetic plasticity has facilitated the evolution of many virulent and drug-resistant strains, presenting a major and constantly changing clinical challenge. We sequenced the ≈2.8-Mbp genomes of two disease-causing S. aureus strains isolated from distinct clinical settings: a recent hospital-acquired representative of the epidemic methicillin-resistant S. aureus EMRSA-16 clone (MRSA252), a clinically important and globally prevalent lineage; and a representative of an invasive community-acquired methicillin-susceptible S. aureus clone (MSSA476). A comparative-genomics approach was used to explore the mechanisms of evolution of clinically important S. aureus genomes and to identify regions affecting virulence and drug resistance. The genome sequences of MRSA252 and MSSA476 have a well conserved core region but differ markedly in their accessory genetic elements. MRSA252 is the most genetically diverse S. aureus strain sequenced to date: ≈6% of the genome is novel compared with other published genomes, and it contains several unique genetic elements. MSSA476 is methicillin-susceptible, but it contains a novel Staphylococcal chromosomal cassette (SCC) mec -like element (designated SCC 476 ), which is integrated at the same site on the chromosome as SCC mec elements in MRSA strains but encodes a putative fusidic acid resistance protein. The crucial role that accessory elements play in the rapid evolution of S. aureus is clearly illustrated by comparing the MSSA476 genome with that of an extremely closely related MRSA community-acquired strain; the differential distribution of large mobile elements carrying virulence and drug-resistance determinants may be responsible for the clinically important phenotypic differences in these strains.

Objectives MDR methicillin-resistant Staphylococcus pseudintermedius (MRSP) strains have emerged rapidly as major canine pathogens and present serious treatment issues and concerns to public health due to their, albeit low, zoonotic potential. A further understanding of the genetics of resistance arising from a broadly susceptible background of S. pseudintermedius is needed. Methods We sequenced the genomes of 12 S. pseudintermedius isolates of varied STs and resistance phenotypes. Results Nine distinct clonal lineages had acquired either staphylococcal cassette chromosome (SCC) mec elements and/or Tn5405-like elements carrying up to five resistance genes [aphA3, sat, aadE, erm(B), dfrG] to generate MRSP, MDR methicillin-susceptible S. pseudintermedius and MDR MRSP populations. The most successful and clinically problematic MDR MRSP clones, ST68 SCCmecV(T) and ST71 SCCmecII-III, have further accumulated mutations in gyrA and grlA conferring resistance to fluoroquinolones. The carriage of additional mobile genetic elements (MGEs) was highly variable, suggesting that horizontal gene transfer is frequent in S. pseudintermedius populations. Conclusions Importantly, the data suggest that MDR MRSP evolved rapidly by the acquisition of a very limited number of MGEs and mutations, and that the use of many classes of antimicrobials may co-select for the spread and emergence of MDR and XDR strains. Antimicrobial stewardship will need to be comprehensive, encompassing human medicine and veterinary disciplines to successfully preserve antimicrobial efficacy.

Staphylococci that can cause disease in humans are Staphylococcus aureus, S. epidermidis, S. haemolyticus, S. saprophyticus, S. hominis, S. warneri, S. lugdunensis, S. schleiferi subsp. schleiferi, S. capitis subsp. ureolyticus, and S. simulans. This chapter briefly discusses the often complex biology of the organism before the genomic insights determined from the sequence. One of the most valuable tools that can arise from whole genome sequences are whole-genome microarrays. A study on core variable genes revealed new information about the S. aureus genome and its evolution. S. haemolyticus are generally more resistant to antiobiotics than other staphylococci, and it could be that they accumulate more of these genes than other species. As the methods for classifying strains into dominant types become more widespread, further epidemiological patterns and associations between certain lineages, toxins, and the infections they cause are being considered. Unlike the genomic islands in other staphylococci that are often associated with virulence, the arginine catabolism mobile element (ACME) island is associated with drug resistance. Each of the sequenced staphylococcal genomes carries genes common to all other sequenced staphylococci, genes specific to particular species, genes specific to particular lineages, and mobile genetic elements (MGEs).

Sugars promote the growth of S. aureus, a key bacterium in respiratory infections. We used an airway epithelial-bacterial co-culture model to examine the effect raising basolateral sugar concentration on the apical growth of S. aureus and the role of the epithelium in limiting this effect. S. aureus addition on the apical surface of H441 monolayers led to enhanced paracellular 14C-L-glucose flux across the epithelium. S. aureus growth was significantly increased by elevating basolateral glucose or fructose concentrations (p < 0.05, n = 5). A S. aureus strain in which the fructose specific permease (fruA) had been disrupted (NE768), exhibited significantly reduced growth in the presence of fructose compared to glucose, in both isolated culture (p < 0.001, n = 3) and in epithelial-bacterial co-culture (after 7h; p < 0.05, n = 5). S. aureus JE2 (parent strain) growth in co-culture was greater in fructose than glucose, despite similar growth rates in isolated culture. This correlated with the reduced rate of ...

The Staphylococcus aureus gene for toxic shock toxin (tst) is carried by a 15 kb mobile pathogenicity island, SaPI1, that has an intimate relationship with temperate staphylococcal phage 80alpha. During phage growth, SaPI1 is excised from its unique chromosomal site, attC, replicates autonomously, interferes with phage growth, and is efficiently encapsidated into special small phage heads commensurate with its size. Upon transfer to a recipient organism, SaPI1 integrates at attC by means of a self-coded integrase. One or more phage functions are required for excision, autonomous replication and encapsidation of the element and, thus, the overall relationship between SaPI1 and 80alpha is similar to that between coliphages P4 and P2. Among other staphylococcal phages tested, only phi13 interacts with SaPI1, inducing excision but not replication or transfer of the element.

Staphylococcus aureus strains often carry in their genomes virulence genes that are not found in all strains and that may be carried on discrete genetic elements. Strains also differ in that they carry one of four classes of an accessory gene regulator ( agr ) locus, an operon that regulates virulence factor expression and that has been proposed to be a therapeutic target. To look at their distribution among hospital strains, we investigated 38 methicillin-sensitive S. aureus isolates, classifying the isolates by agr class and screening them for the presence and restriction fragment length polymorphisms (RFLPs) of 12 core and 14 accessory virulence genes. Twenty-three (61%) were agr class I, 10 (26%) were agr class II, and 5 (13%) were agr class III. None were agr class IV. The S. aureus strains had distinguishable RFLP profiles, although clusters of isolates with clearly related core gene profiles were found among our strains, including all five agr class III strains, two sets of six strains within agr class I, and six strains within agr class II. Within these clusters there was evidence of horizontal acquisition and/or loss of multiple accessory virulence genes. Furthermore, two isolates from the same patient were identical except for the presence of the sea gene, indicating that movement of mobile elements may occur in vivo. Several strong correlations with the carriage of virulence genes between strains were seen, including a positive correlation between tst and agr class III and negative correlations between tst and lukE-splB and between lukE-splB and seg-sei . This suggests that the core genome or the presence of accessory genetic elements within a strain may influence acquisition and loss of other elements encoding virulence genes.

A putative operon encoding a probable zinc-responsive regulatory element (zur) and components of an ABC-type transporter (mreA mreB) have been characterized in Staphylococcus aureus. The zur gene was inactivated but apparently this did not alter Zn2+ uptake. Expression of mreAB zur is at a low level under a range of ion conditions. To allow inducible expression of the operon, a construct was made placing it under the control of the IPTG-inducible Pspac promoter. Using this approach, it was shown that zur is able to repress expression of the entire operon in a Zn2+-dependent manner, and that mreA and mreB are likely to be involved in high-affinity ion uptake. zur has no apparent role in pathogenicity in a lesion model of S. aureus infection.

Staphylococcus aureus of sequence type 398 has emerged in Europe, North America and Asia, and has typically been associated with livestock and their human contacts. We analysed two Panton–Valentine leukocidin (PVL)-negative t034-ST398 isolates from humans in contact with pigs and two t034-ST398 PVL-positive isolates from two unrelated, adopted Chinese children, using multistrain microarrays to determine genomic variability between the two sets of isolates. The ST398 isolates clearly belong to the same lineage when compared to other clonal lineages. However, the four isolates cluster into two distinct groups corresponding to differences in epidemiology based on mobile genetic elements and resistance patterns, suggesting that the two groups are epidemiologically distinct.

Why do we need a vaccine? Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of infection in hospitals and incidence is linked in the public’s mind with hospital cleanliness. In the UK, MRSA causes approximately 7000 cases of bacteremia every year, with a mortality rate of approximately 25%. It probably causes 10–20-times more infections that are not reported, predominantly wound infections and those associated with intravascular access devices. But MRSA is only the tip of the iceberg. The real problem is S. aureus itself, which causes another 11,000 bacteremias with only a slightly lower mortalilty rate. Again, an enormous number of unreported infections also occur. It is well documented that the UK has one of the highest incidences of MRSA per S. aureus infection in Europe (40%); however, it is difficult to know how to interpret this information since we don’t know the incidence of S. aureus infections in other countries. Ideally, S. aureus infections are treated with flucloxacillin, but MRSA are resistant and treated with vancomycin. The first cases of fully vancomycin-resistant MRSA have recently been described. Although several new antimicrobials have been released or are due for release, resistance is already described. Not only do we rely on antimicrobials for treatment, but we are heavily dependent on them for prophylaxis, so that as resistant strains evolve we expect to see infection rates increase. Recent high profile attempts to improve infection control strategies to reduce MRSA incidence in the UK have largely been ineffective. Not only is S. aureus a problem in hospitals, but MRSA strains carrying genes for the Panton–Valentine leukodicin (PVL) are spreading through healthy populations, particularly in the USA [1]. They cause increasing numbers of severe skin and soft tissue infections, as well as fatal hemolytic pneumonia and shock. High-risk groups are those in the military, sports teams, prisoners, intravenous drug users and children. A vaccine to S. aureus infection would therefore be a useful therapeutic and commercially very attractive. However, it is not obvious who should receive a vaccine, especially when tackling hospital infection. Heathcare workers may be a logical step, although this is unlikely to prevent spread of S. aureus via unwashed hands. Immunocompromised patients often respond poorly to vaccines. Colonized patients may be attractive targets, yet few hospitals routinely screen patients on admission to determine who are the carriers, and thus they are rarely offered prophylactic antibiotics that might be just as effective as a vaccine. Despite these limitations, several companies have invested heavily in S. aureus vaccine research.

A limited number of Methicillin-resistant Staphylococcus aureus (MRSA) clones are responsible for MRSA infections worldwide, and those of different lineages carry unique Type I restriction-modification (RM) variants. We have identified the specific DNA sequence targets for the dominant MRSA lineages CC1, CC5, CC8 and ST239. We experimentally demonstrate that this RM system is sufficient to block horizontal gene transfer between clinically important MRSA, confirming the bioinformatic evidence that each lineage is evolving independently. Target sites are distributed randomly in S. aureus genomes, except in a set of large conjugative plasmids encoding resistance genes that show evidence of spreading between two successful MRSA lineages. This analysis of the identification and distribution of target sites explains evolutionary patterns in a pathogenic bacterium. We show that a lack of specific target sites enables plasmids to evade the Type I RM system thereby contributing to the evolution of increasingly resistant community and hospital MRSA.

Background Diabetes is a risk factor for respiratory infection, and hyperglycaemia is associated with increased glucose in airway surface liquid and risk of Staphylococcus aureus infection.\ud \ud Objectives To investigate whether elevation of basolateral/blood glucose concentration promotes airway Staphylococcus aureus growth and whether pretreatment with the antidiabetic drug metformin affects this relationship.\ud \ud Methods Human airway epithelial cells grown at air–liquid interface (±18 h pre-treatment, 30 μM–1 mM metformin) were inoculated with 5×105 colony-forming units (CFU)/cm2 S aureus 8325-4 or JE2 or Pseudomonas aeruginosa PA01 on the apical surface and incubated for 7 h. Wild-type C57BL/6 or db/db (leptin receptor-deficient) mice, 6–10 weeks old, were treated with intraperitoneal phosphate-buffered saline or 40 mg/kg metformin for 2 days before intranasal inoculation with 1×107 CFU S aureus. Mice were culled 24 h after infection and bronchoalveolar lavage fluid collected.\ud \ud Results Apical S aureus growth increased with basolateral glucose concentration in an in vitro airway epithelia–bacteria co-culture model. S aureus reduced transepithelial electrical resistance (RT) and increased paracellular glucose flux. Metformin inhibited the glucose-induced growth of S aureus, increased RT and decreased glucose flux. Diabetic (db/db) mice infected with S aureus exhibited a higher bacterial load in their airways than control mice after 2 days and metformin treatment reversed this effect. Metformin did not decrease blood glucose but reduced paracellular flux across ex vivo murine tracheas.\ud \ud Conclusions Hyperglycaemia promotes respiratory S aureus infection, and metformin modifies glucose flux across the airway epithelium to limit hyperglycaemia-induced bacterial growth. Metformin might, therefore, be of additional benefit in the prevention and treatment of respiratory infection.

Methicillin-resistant Staphylococcus aureus (MRSA) CC22 SCCmecIV is a successful hospital-associated (HA-) MRSA, widespread throughout the world, and now the dominant clone in UK hospitals. We have recently shown that MRSA CC22 is a particularly fit clone, and it rose to dominance in a UK hospital at the same time as it began acquiring an increased range of antibiotic resistances. These resistances were not accumulated by individual CC22 isolates, but appear to shuffle frequently between isolates of the MRSA CC22 population. Resistances are often encoded on mobile genetic elements (MGEs) that include plasmids, transposons, bacteriophage and S. aureus pathogenicity islands (SaPIs). Using multi-strain whole genome microarrays, we show that there is enormous diversity of MGE carried within a MRSA CC22 SCCmecIV population, even among isolates from the same hospital and time period. MGE profiles were so variable that they could be used to track the spread of variant isolates within the hospital. We exploited this to show that the majority of patients colonised with MRSA at hospital admission that subsequently became infected were infected with their own colonising isolate. Our studies reveal MGE spread, stability, selection and clonal adaptation to the healthcare setting may be key to the success of HA-MRSA clones, presumably by allowing rapid adaptation to antibiotic exposure and new hosts.

Objectives: The majority of HA-MRSA infections are caused by endogenous infection and by only a small number of clones. The reasons for the success of some clones over others are unknown. Methods: We investigated the evolution of an MRSA population from a large, acute-care teaching hospital in London, UK over a 10 year period. MRSA incidence and antibiotic prescribing were correlated with changes in resistance genes and prevalence of clonal groups. Results: Three clones caused the majority of infections, CC30 SCCmecII (EMRSA-16), CC22 SCCmecIV (EMRSA15) and ST239 SCCmecIII. Clones that were multidrug resistant were selected for, and CC22 became dominant once it acquired a wide range of extra resistance genes. CC22 MRSA was also the fittest clone in an independent growth assay and a competition assay, and had a greater ability to survive desiccation. No individual isolate was fully drug resistant, and there was evidence of substantial horizontal gene transfer (HGT) as well as resistance gene loss within the clonal groups. The exception was fluoroquinolone resistance, which was rarely lost by any of the dominant hospital clones, suggesting that this resistance contributes to selection and survival of HA-MRSA. In support of this, a decrease in hospital-wide ciprofloxacin (a fluoroquinolone) prescribing was strongly associated with an overall decrease in MRSA infection. Conclusion: Our data suggest successful HA-MRSA clones such as CC22 SCCmecIV are resistant to fluoroquinolones as well as fitter and able to acquire, but not necessarily accumulate, resistance to a wide range of additional antibiotics.

Bacterial adhesion is a crucial step in colonization of the skin. In this study, we investigated the differential adherence to human and pig corneocytes of six Staphylococcus aureus strains belonging to three human-associated [ST8 (CC8), ST22 (CC22) and ST36(CC30)] and two pig-associated [ST398 (CC398) and ST433(CC30)] clonal lineages, and their colonization potential in the pig host was assessed by in vivo competition experiments. Corneocytes were collected from 11 humans and 21 pigs using D-squame® adhesive discs, and bacterial adherence to corneocytes was quantified by a standardized light microscopy assay. A previously described porcine colonization model was used to assess the potential of the six strains to colonize the pig host. Three pregnant, S. aureus-free sows were inoculated intravaginally shortly before farrowing with different strain mixes [mix 1) human and porcine ST398; mix 2) human ST36 and porcine ST433; and mix 3) human ST8, ST22, ST36 and porcine ST398] and the ability of individual strains to colonize the nasal cavity of newborn piglets was evaluated for 28 days after birth by strain-specific antibiotic selective culture. In the corneocyte assay, the pig-associated ST433 strain and the human-associated ST22 and ST36 strains showed significantly greater adhesion to porcine and human corneocytes, respectively (p

Background Staphylococcus aureus is major human and animal pathogen. Plasmids often carry resistance genes and virulence genes that can disseminate through S. aureus populations by horizontal gene transfer (HGT) mechanisms. Sequences of S. aureus plasmids in the public domain and data from multi-strain microarrays were analysed to investigate (i) the distribution of resistance genes and virulence genes on S. aureus plasmids, and (ii) the distribution of plasmids between S. aureus lineages. Results A total of 21 plasmid rep gene families, of which 13 were novel to this study, were characterised using a previously proposed classification system. 243 sequenced plasmids were assigned to 39 plasmid groups that each possessed a unique combination of rep genes. We show some resistance genes (including ermC and cat) and virulence genes (including entA, entG, entJ, entP) were associated with specific plasmid groups suggesting there are genetic pressures preventing recombination of these genes into novel plasmid groups. Whole genome microarray analysis revealed that plasmid rep, resistance and virulence genes were associated with S. aureus lineages, suggesting restriction-modification (RM) barriers to HGT of plasmids between strains exist. Conjugation transfer (tra) complex genes were rare. Conclusion This study argues that genetic pressures are restraining the spread of resistance and virulence genes amongst S. aureus plasmids, and amongst S. aureus populations, delaying the emergence of fully virulent and resistant strains.

Whole-genome analysis by 62-strain microarray showed variation in resistance and virulence genes on mobile genetic elements (MGEs) between 40 isolates of methicillin-resistant Staphylococcus aureus (MRSA) strain CC22- SCCmecIV but also showed (i) detection of two previously unrecognized MRSA transmission events and (ii) that 7/8 patients were infected with a variant of their own colonizing isolate.

A methicillin-resistant Staphylococcus aureus (MRSA) clone known as ST398 has emerged as a major cause of acute infections in individuals who have close contact with livestock. More recently, the emergence of an animal-independent ST398 methicillin-sensitive S. aureus (MSSA) clone has been documented in several countries. However, the limited surveillance of MSSA has precluded an accurate assessment of the global spread of ST398 and its clinical relevance. Here we provide evidence that ST398 is a frequent source of MSSA infections in northern Manhattan and is readily transmitted between individuals in households. This contrasts with the limited transmissibility of livestock-associated ST398 (LA-ST398) MRSA strains between humans. Our whole-genome sequence analysis revealed that the chromosome of the human-associated ST398 MSSA clone is smaller than that of the LA-ST398 MRSA reference strain S0385, due mainly to fewer mobile genetic elements (MGEs). In contrast, human ST398 MSSA isolates harbored the prophage φ3 and the human-specific immune evasion cluster (IEC) genes chp and scn. While most of the core genome was conserved between the human ST398 MSSA clone and S0385, these strains differed substantially in their repertoire and composition of intact adhesion genes. These genetic changes were associated with significantly enhanced adhesion of human ST398 MSSA isolates to human skin keratinocytes and keratin. We propose that the human ST398 MSSA clone can spread independent of animal contact using an optimized repertoire of MGEs and adhesion molecules adapted to transmission among humans., IMPORTANCE Staphylococcus aureus strains have generally been considered to be species specific. However, cross-species transfers of S. aureus clones, such as ST398 methicillin-resistant S. aureus (MRSA), from swine to humans have been reported. Recently, we observed the emergence of ST398 methicillin-susceptible S. aureus (MSSA) as a colonizing strain of humans in northern Manhattan. Here we report that ST398 is a frequent cause of MSSA infections in this urban setting. The ST398 MSSA clone was readily transmitted within households, independent of animal contact. We discovered that human ST398 MSSA genomes were smaller than that of the LA-ST398 strain S0385 due to fewer mobile genetic elements. Human and LA-ST398 strains also differed in their composition of adhesion genes and their ability to bind to human skin keratinocytes, providing a potential mechanism of S. aureus host adaptation. Our findings illustrate the importance of implementing molecular surveillance of MSSA given the evidence for the rapid and clinically undetected spread of ST398 MSSA.

Staphylococcus aureus is a major cause of human and animal infections. Bacteriophage are a class of mobile genetic element (MGE) that carry virulence genes and disseminate them horizontally, including Panton–Valentine leukocidin (PVL), the immune evasion cluster (IEC) associated with human specificity, and enterotoxin A the major toxin associated with food poisoning. S. aureus isolates group into major clonal complex (CC) lineages that largely evolve independently due to possession of different restriction–modification (RM) systems. We aimed to better understand the horizontal and vertical transmission dynamics of virulence and resistance genes by bacteriophage by using (i) bioinformatic approaches to analyze bacteriophage genomes from the first 79 sequenced S. aureus isolates and (ii) S. aureus microarrays to analyze the distribution of bacteriophage and virulence genes in S. aureus isolates from a broader range of lineages. The distribution of eight bacteriophage families was highly variable but lineage associated. Nevertheless, there was evidence of frequent acquisition and loss and not just vertical transmission. Most bacteriophage genes were dispensable, and extensive mosaicism was seen. Surprisingly, virulence genes were tightly associated with specific phage families. This data suggests S. aureus bacteriophage evolve rapidly, and the horizontal gene transfer (HGT) of virulence genes encoded by bacteriophage is restricted by bacteriophage family and the lineage of the host bacterium, delaying the evolution of fully resistant and virulent strains.

This article reviews recent findings on the global epidemiology of healthcare-acquired/ associated (HA), community-acquired/ associated (CA) and livestock-associated (LA) meticillin-resistant Staphylococcus aureus (MRSA) and aims to reach a consensus regarding the harmonisation of typing methods for MRSA. MRSA rates continue to increase rapidly in many regions and there is a dynamic spread of strains across the globe. HA-MRSA is currently endemic in hospitals in most regions. CA-MRSA clones have been spreading rapidly in the community and also infiltrating healthcare in many regions worldwide. To date, LA-MRSA is only prevalent in certain high-risk groups of workers in direct contact with live animals. CA-MRSA and LA-MRSA have become a challenge for countries that have so far maintained low rates of MRSA. These evolutionary changes have resulted in MRSA continuing to be a major threat to public health. Continuous efforts to understand the changing epidemiology of S. aureus infection in humans and animals are therefore necessary, not only for appropriate antimicrobial treatment and effective infection control but also to monitor the evolution of the species. The group made several consensus decisions with regard to harmonisation of typing methods. A stratified, three-level organisation of testing laboratories was proposed: local; regional; and national. The functions of, and testing methodology used by, each laboratory were defined. The group consensus was to recommend spa and staphylococcal cassette chromosome mec (SCCmec) typing as the preferred methods. Both are informative in defining particular strain characteristics and utilise standardised nomenclatures, making them applicable globally. Effective communication between each of the different levels and between national centres was viewed as being crucial to inform and monitor the molecular epidemiology of MRSA at national and international levels. (C) 2011 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.