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BackgroundInvasive infections caused by Staphylococcus aureus have high clinical and epidemiological relevance. It is therefore important to monitor the S. aureus trends using suitable methods.AimThe study aimed to describe the trends of bloodstream infections (BSI) caused by meticillin-resistant S. aureus (MRSA) and meticillin-susceptible S. aureus (MSSA) in the European Union (EU) and the European Economic Area (EEA).MethodsAnnual data on S. aureus BSI from 2005 to 2018 were obtained from the European Antimicrobial Resistance Surveillance Network (EARS-Net). Trends of BSI were assessed at the EU/EEA level by adjusting for blood culture set rate (number of blood culture sets per 1,000 days of hospitalisation) and stratification by patient characteristics.ResultsConsidering a fixed cohort of laboratories consistently reporting data over the entire study period, MRSA percentages among S. aureus BSI decreased from 30.2% in 2005 to 16.3% in 2018. Concurrently, the total number of BSI caused by S. aureus increased by 57%, MSSA BSI increased by 84% and MRSA BSI decreased by 31%. All these trends were statistically significant (p < 0.001).ConclusionsThe results indicate an increasing health burden of MSSA BSI in the EU/EEA despite a significant decrease in the MRSA percentage. These findings highlight the importance of monitoring antimicrobial resistance trends by assessing not only resistance percentages but also the incidence of infections. Further research is needed on the factors associated with the observed trends and on their attributable risk.

Background: Mandatory notification of invasive methicillin-resistant Staphylococcus aureus (MRSA) infections was introduced for laboratories in Germany in 2009. The aims were to support local health authorities (LHAs) in their mandate to prevent and control infections in hospitals and to improve population-based nationwide surveillance of healthcare associated infections. We evaluated the MRSA surveillance system to assess whether its aims were met and to identify areas for improvement., Methods: Using the updated guidelines for evaluating public health surveillance systems by the Centers for Disease Control and Prevention we assessed the attributes simplicity, timeliness, data quality, acceptability, and usefulness. In 2016/2017 we interviewed staff in LHAs, state health authorities (SHAs), and laboratories and analyzed surveillance data of cases notified between 2009 and 2016., Results: We interviewed 10% of LHAs (n = 38), 63% of SHAs (n = 10), 5 selected laboratories and analyzed information on 27,706 notified MRSA cases. LHAs reported that on receiving notifications from laboratories they contacted hospitals for clinical information, which was time-consuming and complicated as physicians were hard to reach or refused to answer questions, citing doctor-patient confidentiality. LHAs suggested reducing the amount of information collected as some clinical information was unnecessary for implementing control measures. LHAs stated that they received notifications on time, however surveillance data analysis showed some delay. Data completeness exceeded 90% for most variables, however it was only 68% and 80% for dates of disease onset and hospital admission respectively making it impossible to discriminate between hospital and community acquired infections in half of the cases. The surveillance system was well accepted by half of the interviewees. A third however stated that the benefits of the surveillance system were outweighed by the work associated with it. The majority rated the system to be useful for recognizing trends in the MRSA incidence and the ability to check up on infection control measures in hospitals., Conclusions: The surveillance system proved to be useful by fulfilling its aims. It was timely, acceptable and provided complete data for most variables. However, the system was complicated; ensuring that only relevant variables are reported could simplify the system without losing any of its usefulness.

Background: Recent analysis of trends of non-invasive infections with methicillin resistant Staphylococcus aureus (MRSA), of trends of MRSA infections in outpatient settings and of co-resistance profiles of MRSA isolates are scarce or lacking in Germany., Methods: We analysed data from the Antimicrobial Resistance Surveillance Network (ARS). We included in the analysis the first isolate of S. aureus per patient and year, which had a valid test result for oxacillin resistance and which was not a screening sample. We limited the analysis to isolates from facilities, which contributed to ARS for all six years between 2010 and 2015. We compared the proportion of methicillin resistance among S. aureus isolates by calendar year using Chi-square and Fisher's exact test. We corrected for multiple testing using the Bonferroni correction. We stratified the analysis by sample type including various non-invasive sample types and by type of care (e.g. hospital versus outpatient clinic). We also analysed the non-susceptibility of MRSA to selected antibiotics., Results: The analysis included 148,561 S. aureus isolates. The distribution of these isolates by sex, age, region, sample type, clinical speciality and type of care remained relatively stable over the six years analysed. The proportion of MRSA among S. aureus isolates decreased continuously from 16% in 2010 to 10% in 2015. This decrease was seen for all types of care and for the majority of sample types, including the outpatient clinic (12 to 8%), as well as blood culture (19 to 9%), urine samples (25 to 15%), swabs (14 to 9%), respiratory samples (22 to 11%) and lesions (15 to 10%). The non-susceptibility of MRSA isolates to tobramycin (47 to 32%), ciprofloxacin (95 to 89%), moxifloxacin (94 to 84%), clindamycin (80 to 71%) and erythromycin (81 to 72%) declined markedly, but it increased for tetracyclines (6 to 9%) and gentamicin (3 to 6%). Non-susceptibility of MRSA to linezolid, teicoplanin, tigecycline and vancomycin remained rare., Conclusion: This analysis indicates that the incidence of MRSA infections declined in a variety of settings in Germany between 2010 and 2015 and that the co-resistance profiles of MRSA isolates changed markedly.

This study reports on the emergence of linezolid-resistant coagulase-negative staphylococci (CoNS) containing the multiresistance gene cfr in veal calves and pigs, as well as in humans exposed to these animals. CoNS (Staphylococcus auricularis, Staphylococcus cohnii, Staphylococcus lentus, Staphylococcus kloosii, Staphylococcus sciuri, Staphylococcus simulans), but not Staphylococcus aureus, carrying the gene cfr were detected in samples of 12 out of 52 calves at three farms which had a history of florfenicol use. Nasal swabs from 10 humans living on these farms were negative for cfr-carrying staphylococci. Nasal swabs taken from 142 calves at 16 farms in the same area that did not use florfenicol were also negative for cfr-carrying staphylococci. 14 cfr-carrying CoNS (S. kloosii, S. saprophyticus, S. simulans) were detected in three of eight conventional pig farms investigated. One of 12 humans living on these farms harboured a cfr-carrying S. cohnii. Among the nasal swabs taken from 169 veterinarians from all over Germany, four (2.3%) were positive for cfr-carrying CoNS (three S. epidermidis, one S. saprophyticus), and three (1.1%) of 263 contact persons of this group also harboured cfr-carrying CoNS (one S. epidermidis, two S. saprophyticus). In vitro conjugation of cfr by filter mating to S. aureus 8325-4 was possible for 10 of 34CoNS and the cfr gene was associated with plasmids of 38-40kb. Moreover, a total of 363 humans of a German municipal community were investigated for nasal carriage of cfr-carrying staphylococci to get an idea whether such isolates are disseminated as nasal colonizers in non-hospitalized humans in the community, were all negative., (Copyright © 2016 Elsevier B.V. All rights reserved.)

There are only few data on the persistence and transmission of methicillin resistant Staphylococcus aureus (MRSA) of the clonal complex (CC) 398 among veterinarians and their household members. We therefore investigated the long-term colonisation with MRSA CC398 among participants of veterinary conferences in Germany in 2008/2009 and their household members. Forty-five initially MRSA CC398 positive and 180 initially MRSA CC398 negative conference participants were included in a longitudinal study. These persons and their household members were tested for nasal colonisation in 2011, 2012 and 2014. Of 31 continuously tested and initially MRSA CC398 positive participants only 8 (26%) were colonized with MRSA CC398at all 4 time points, 4 (13%) of them consistently with the same spa type. Among initially MRSA CC398 negative participants, 13 (7%) were tested MRSA CC398 positive at least once during the follow-up period. Data for household members at least at one time point were available for 185 households. Of these 21 (11%) households had one or more household member who tested positive for MRSA CC398at least once. The odds of household members to be MRSA CC398 positive was 12 times higher (95% confidence interval 4-37) when the conference participant tested MRSA CC398 positive in 2008/2009. This association remained strong when household members working in veterinary medicine or livestock farms were excluded. In summary, these data suggest that colonisation with MRSA CC398 is partially transient and that household members of MRSA CC398 colonized persons are at an increased risk of colonisation with MRSA CC398., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Outbreaks of Staphylococcus aureus are common in neonatal intensive care units (NICUs). Usually they are documented for methicillin-resistant strains, while reports involving methicillin-susceptible S. aureus (MSSA) strains are rare. In this study we report the epidemiological and molecular investigation of an MSSA outbreak in a NICU among preterm neonates. Infection control measures and interventions were commissioned by the Local Public Health Authority and supported by the Robert Koch Institute. To support epidemiological investigations molecular typing was done by spa-typing and Multilocus sequence typing; the relatedness of collected isolates was further elucidated by DNA SmaI-macrorestriction, microarray analysis and bacterial whole genome sequencing. A total of 213 neonates, 123 healthcare workers and 205 neonate parents were analyzed in the period November 2011 to November 2012. The outbreak strain was characterized as a MSSA spa-type t021, able to produce toxic shock syndrome toxin-1 and Enterotoxin A. We identified seventeen neonates (of which two died from toxic shock syndrome), four healthcare workers and three parents putatively involved in the outbreak. Whole-genome sequencing permitted to exclude unrelated cases from the outbreak and to discuss the role of healthcare workers as a reservoir of S. aureus on the NICU. Genome comparisons also indicated the presence of the respective clone on the ward months before the first colonized/infected neonates were detected., (Copyright © 2015 Elsevier GmbH. All rights reserved.)

Voluntary surveillance systems in Germany suggest a recent decline in the incidence of infections (subsequent to at least 2010) with meticillin-resistant Staphylococcus aureus (MRSA) from various types of specimens and settings. We asked whether this decline is reflected by data from the mandatory national surveillance system for invasive MRSA infections. Our analysis is based on the population in Germany in 2010 to 2014. Cases were identified from passive reporting by microbiological laboratories of the diagnosis of MRSA from blood culture or cerebrospinal fluid. Respective clinical data were subsequently added to the notification. We calculated risk ratios (RR) between consecutive years, stratifying cases by sex, age and federal state of residence. The national incidence increased from 4.6 episodes per 100,000 persons in 2010 to 5.6 in 2012 (2011 vs 2010: RR: 1.13, 95% confidence interval (CI): 1.08-1.18; 2012 vs 2011: RR: 1.08, 95% CI: 1.04-1.13). It stagnated at 5.4 per 100,000 in 2013 (RR: 0.97, 95% CI: 0.93-1.01) before declining to 4.8 in 2014 (RR: 0.88, 95% CI: 0.84-0.91). This trend was observed in most, but not all federal states and strata of sex and age groups. Only 204 of 20,679 (1%) episodes of infection were notified as belonging to an outbreak. Our analysis corroborates previous findings that the incidence of invasive MRSA infections in Germany may be declining.

Methicillin-resistant Staphylococcus aureus (MRSA) causes colonization and infection both in animals and humans. In Germany, cases of MRSA colonization among humans, w+hich affect 0.5-1.5% of the general population and 1.0-2.5% of patients at hospital admission, are still mostly associated with previous healthcare contact and defined epidemic clonal lineages. However, MRSA is also distributed in livestock production in Germany, mostly without causing infections in the animals. These MRSA predominantly belong to the clonal complex (CC) 398, but also to CC9 and CC97. Zoonotic transmission of MRSA CC398 from livestock to humans occurs predominantly in people with occupational livestock contact. Spread of MRSA CC398 to household members of these persons is also frequently observed, but dissemination in the general population is limited so far However, especially in areas with intensive livestock husbandry, about 20-38% of MRSA CC398 cases among humans cannot be epidemiologically linked to direct livestock contact, indicating other transmission pathways. MRSA CC398 currently causes about 2% of all human MRSA infections (wound infections, pneumonia, sepsis) in Germany, but up to 10% in regions characterized by a high density of livestock-farming. The burden of MRSA in companion animals was demonstrated to range between 3.6-9.4% within wound samples obtained from dogs, cats and horses, respectively. In contrast to livestock and horses, MRSA distributed in pet animals are mostly associated with MRSA clonal lineages that are also prevalent in human healthcare facilities. Overall, zoonotic exchange of MRSA between humans and animals has relevant impact on the epidemiology of MRSA in Germany.

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.

In 2007, the Robert Koch Institute established the infrastructure for the national Antimicrobial Resistance Surveillance (ARS) system. Laboratories submit data of routine susceptibility testing of clinical samples from hospitals as well as from outpatient care settings in a standardized format to the Robert Koch Institute for central processing. The database for the period 2008-2011 comprises data of about 1.3 million samples from patients in hospital care and almost 800,000 samples from outpatients. Based on SIR interpretations of susceptibility, the trends of methicillin resistance of Staphylococcus aureus (MRSA) and cefotaxime non-susceptibility as an indicator of extended-spectrum beta-lactamases (ESBL) of Escherichia coli and Klebsiella pneumoniae were analyzed for four care settings or categories: hospital care, outpatient care, intensive care units, and isolates from blood cultures. After constant high levels of above 20%, the proportion of MRSA isolates showed a decline for the first time from 2010 to 2011 in hospital care overall, in intensive care units as well as in blood cultures; in outpatient care, MRSA proportions of about 13% were observed. Within the observed period, non-susceptibility to cefotaxime as an indicator of ESBL in E. coli showed an increasing trend in hospital care at a level above 10% in intensive care units, while cefotaxime non-susceptibility in K. pneumoniae was more frequent but without any trend. In outpatient care, the proportions of cefotaxime non-susceptibility increased year by year in both species resulting in nearly a doubling to 6%.

Data from the German Antibiotic Resistance Surveillance system (ARS) and statutory notification of methicillin-resistant Staphylococcus aureus (MRSA) in blood cultures are presented. ARS is a voluntary laboratory-based surveillance system providing resistance data of all clinical pathogens and sample types from hospitals and ambulatory care. Statutory notification includes MRSA detected in blood and cerebrospinal fluid by microbiological laboratories. Resistance data from 2008 to 2010 and MRSA-bacteraemia incidences from 2010 are presented. From 2008 to 2010, resistance data from 70,935 Staphylococcus aureus isolates were transferred to the national health institution. MRSA proportions in hospitals and outpatient care account for 19.2% and 10.6%, respectively. In hospital care high proportions of MRSA were found in nephrological, geriatric, neurological general wards and surgical ICUs (49.4%, 45.8%, 34.2%, and 27.0%, respectively), while in community outpatient care urological practices (29.2%) account for the highest values. In both healthcare settings urinary tract samples stand out with high proportions of MRSA (hospitals, 32.9%; outpatients, 20.5%). In 2010, 3900 cases of MRSA bacteraemia were reported, accounting for an incidence of MRSA bacteraemia of 4.8/100,000 inhabitants/year. Stratification by federal states shows considerable regional differences (range, 1.0-8.3/100,000 inhabitants/year). Vulnerable areas in hospitals and outpatient care have been pointed out as subjects for further inquiries.

Background: Since the relationship between dogs and their owners has changed, and dogs moved from being working dogs to family members in post-industrial countries, we hypothesized that zoonotic transmission of opportunistic pathogens like coagulase positive staphylococci (CPS) is likely between dogs and their owners., Methodology/principal Findings: CPS- nasal carriage, different aspects of human-to-dog relationship as well as potential interspecies transmission risk factors were investigated by offering nasal swabs and a questionnaire to dog owners (108) and their dogs (108) at a dog show in 2009. S. aureus was found in swabs of 20 (18.5%) humans and two dogs (1.8%), and spa types which correspond to well known human S. aureus lineages dominated (e.g. CC45, CC30 and CC22). Multilocus sequence typing (MLST) of the two canine strains revealed ST72 and ST2065 (single locus variant of ST34). Fifteen dogs (13.9%) and six owners (5.6%) harboured S. pseudintermedius, including one mecA-positive human isolate (MRSP). Pulsed field gel electrophoresis (PFGE) revealed that one dog/owner pair harboured indistinguishable S. pseudintermedius- isolates of ST33. Ten (48%) of the 21 S. pseudintermedius-isolates showed resistance towards more than one antimicrobial class. 88.9% of the dog owners reported to allow at least one dog into the house, 68.5% allow the dog(s) to rest on the sofa, 39.8% allow their dogs to come onto the bed, 93.5% let them lick their hands and 52.8% let them lick their face. Bivariate analysis of putative risk factors revealed that dog owners who keep more than two dogs have a significantly higher chance of being colonized with S. pseudintermedius than those who keep 1-2 dogs (p<0.05)., Conclusions/recommendations: In conclusion, CPS transmission between dog owners and their dogs is possible. Further investigation regarding interspecies transmission and the diverse adaptive pathways influencing the epidemiology of CPS (including MRSA and MRSP) in different hosts is needed.

Nosocomial infections with methicillin-resistant Staphylococcus aureus (MRSA) account for increased morbidity, mortality and healthcare costs in critically ill patients worldwide. The intensive care unit (ICU) component of the German surveillance system for nosocomial infections (Krankenhaus-Infektions-Surveillance-System, KISS) has been supplemented with a module targeting the surveillance of multiresistant pathogens [Multiresistente Erreger (MRE)-KISS] in order to account for the increasing burden of antibiotic-resistant bacteria. The aim of this study was to assess the association between structural and organizational characteristics of ICUs and the number of nosocomial MRSA cases. Data were derived from routine data collected in the frame of the national surveillance system of nosocomial infections (ICU- and MRE-KISS) from January 2007 to December 2008 and from a questionnaire inquiring about structure and process parameters. One hundred and forty ICUs performing active screening have been included. Process parameters such as isolation of MRSA patients, decolonization procedures and introduction of MRSA alert systems have been implemented by the majority of the ICUs, whereas the application mode of screening procedures and pre-emptive isolation measures is heterogeneous. Multivariable analysis using negative binominal regression models shows that a stay on a medical ICU has a protective effect (incidence rate ratio, 0.42; 95% confidence interval, 0.24-0.74; p = 0.003), whereas the imported MRSA incidence is significantly associated with the number of nosocomial MRSA cases (incidence rate ratio, 1.74; 95% confidence interval, 1.23-2.45; p = 0.002). Structure and process parameters do not show any effect. ICU type and imported MRSA incidence should be considered for benchmarking between hospitals., (2010 The Authors. Clinical Microbiology and Infection; 2010 European Society of Clinical Microbiology and Infectious Diseases.)

In an asylum seeker centre in Schleswig-Holstein, a resident was diagnosed with furuncle caused by a Panton-Valentine leukocidine (PVL)-positive community-acquired meticillin-resistant Staphylococcus aureus (CA-MRSA). As a result of active case finding, 232 of 427 persons (54% of all residents) were screened for MRSA and two further PVL-positive CA-MRSA cases were identified

Some of the clinically most menacing nosocomial pathogens are Methicillin-resistent Staphylococcus aureus (MRSA) and Vancomycin-resistent Enterococcus (VRE). During the last years both pathogens showed dramatic increases in colonization and infection rates in Germany. This study covers all patients positively tested for MRSA and VRE in a German University Hospital from 1999-2005. About 1,179 MRSA cases and 116 VRE cases have been reported. VRE was significantly associated with less infection, female gender, more death and higher nosocomial acquisition than MRSA. While MRSA rates increased impressively from 1999 to 2005 VRE rates decreased clearly. Assuming that compliance with hygienic measures is similar in dealing with MRSA and VRE it is quite unclear why these two major pathogens differ so much in their trends. One possibility is that the MRSA problem has been caused by an increasing share of nonnosocomially acquired MRSA.

In the last few years, a dramatic increase of Methicillin-resistant Staphylococcus aureus (MRSA) detection in German hospitals can be recognized. Under this enormous pressure it is very important for infection control teams to assess the epidemiologic situation correctly. Therefore, a prospective multicenter hospital-based surveillance of MRSA cases was executed in four university hospitals with 1017-1333 beds in Germany. Routine surveillance data were recorded of all patients with MRSA isolates from clinical samples or screening cultures. Patients had been colonized or infected with MRSA during their hospital stay. In 2002 between 183 and 291 MRSA cases were treated in the respective hospitals (between 0.53 and 0.96 MRSA cases per 1000 patient days). Of these, 44.4% were MRSA infections. The most frequent type of MRSA infections were wound infections (56.9%) followed by pneumonia (21.0%) and bloodstream infections (15.1%). Of the infected patients 51.5% were already infected at admission. The median duration of isolation of MRSA patients in private rooms was between 11 and 16 days. Altogether 21,665 isolation days were observed in four hospitals; this means 1.52% of all patient days. On average, 9.0% of roommates were identified as MRSA carriers. Due to the high percentage of imported cases, the four university hospitals introduced a general screening for MRSA at admission in all ICUs and some further departments as well as an automatic alert system for readmitted patient with MRSA during their last hospital stay.