Abstract
The distinction between healthcare-associated MRSA (HA-MRSA) and community-associated MRSA (CA-MRSA) infections has become increasingly blurred. We assessed the molecular characterization and antimicrobial resistance profile for MRSA isolates from blood. Most of all (81.9%) isolates are related to known HA-MRSA and CA-MRSA epidemic lineages, such as, USA300, USA400, USA600, USA800 and USA1100. This is the first multicenter study in Rio de Janeiro.
Keywords:
MRSA; MLST; USA800; USA400; USA1100
Over the years, the distinction between healthcare-associated MRSA (HA-MRSA) and community-associated MRSA (CA-MRSA) has become increasingly blurred, with a growing number of reports indicating that CA-MRSA strains are spread in hospital settings and replacing traditional HA-MRSA strains, including in Brazil.11 Lima DF, Brazão NBV, Folescu TW, et al. Panton-Valentine leukocidin (PVL) gene carriage among Staphylococcus aureus strains with SCCmec types I, II, IV, and V recovered from cystic fibrosis pediatric patients in Brazil. Diagn Microbiol Infect Dis. 2014;78:59-62.,22 Schuenck RP, Nouér SA, Winter CO, et al. Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2009;64:434-441. HA-MRSA strains typically have a multidrug-resistant phenotype, whereas CA-MRSA strains are often susceptible to a variety of non-β-lactam antimicrobials.11 Lima DF, Brazão NBV, Folescu TW, et al. Panton-Valentine leukocidin (PVL) gene carriage among Staphylococcus aureus strains with SCCmec types I, II, IV, and V recovered from cystic fibrosis pediatric patients in Brazil. Diagn Microbiol Infect Dis. 2014;78:59-62. On the other hand, this resistance pattern is changing in the last decade. Thus, some HA-MRSA isolates are susceptible to many non-β-lactam antibiotics, including the isolates related USA800 clone, for example.11 Lima DF, Brazão NBV, Folescu TW, et al. Panton-Valentine leukocidin (PVL) gene carriage among Staphylococcus aureus strains with SCCmec types I, II, IV, and V recovered from cystic fibrosis pediatric patients in Brazil. Diagn Microbiol Infect Dis. 2014;78:59-62.,33 Teixeira MM, Araújo MC, Silva-Carvalho MC, et al. Emergence of clonal complex 5 (CC5) methicillin-resistant Staphylococcus aureus (MRSA) isolates susceptibleto trimethoprim-sulfamethoxazole in a Brazilian hospital. Braz J Med Biol Res. 2012;45:637-643. The in vitro antimicrobial susceptibility to clindamycin and/or sulfamethoxazole/trimethoprim is a relevant characteristic described in strains with SCCmec IV.22 Schuenck RP, Nouér SA, Winter CO, et al. Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2009;64:434-441. The genotyping of Brazilian MRSA isolates allowed a better understanding of the dissemination patterns of the epidemic clones, such as, typically HA-MRSA and CA-MRSA.44 Rozenbaum R, Silva-Carvalho MC, Souza RR, et al. Molecular characterization of methicillin-resistant Staphylococcus aureus disseminated in a home care system. Infect Control Hosp Epidemiol. 2006;27:1041-1050. The known virulence factor the exoprotein Panton-Valentine leucocidin (PVL) is traditionally seen in CA-MRSA,55 Boyle-Vavra S, Daum RS. Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine leukocidin. Lab Invest. 2007;87:3-9. however it has already been identified in methicillin-susceptible S. aureus and some rare HA-MRSA isolates.11 Lima DF, Brazão NBV, Folescu TW, et al. Panton-Valentine leukocidin (PVL) gene carriage among Staphylococcus aureus strains with SCCmec types I, II, IV, and V recovered from cystic fibrosis pediatric patients in Brazil. Diagn Microbiol Infect Dis. 2014;78:59-62.,66 Demir T, Coplu N, Bayrak H, et al. Panton-Valentine leucocidin gene carriage among Staphylococcus aureus strains recovered from skin and soft tissue infections in Turkey. J Antimicrob Chemother. 2012;67:837-840. The increasing number of reported infections caused by CA-MRSA strains in Brazil justifies the use of surveillance studies to help in understanding how these strains arrive and circulate in healthcare settings.22 Schuenck RP, Nouér SA, Winter CO, et al. Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2009;64:434-441. Furthermore, recently, Rossi and colleagues77 Rossi F, Diaz L, Wollam A, et al. Transferable vancomycin resistance in a community-associated MRSA lineage. N Engl J Med. 2014;370:1524-1531. reported a case of a Brazilian patient with a bloodstream infection caused by USA 300-related isolate, designated BR-VRSA, that acquired the vanA gene cluster during antibiotic therapy becoming resistant to vancomycin.
The present study analyzed the genetic background and resistance profile of MRSA isolates recovered from blood between March 2011 and May 2012. The inclusion criterium for the MRSA isolates studied here was the presence of susceptibility to the non-β-lactam antibiotics trimethoprim-sulfamethoxazole and/or clindamycin. The 61 MRSA blood isolates were collected from patients in five hospitals (H) in Rio de Janeiro, Brazil: H1 (n = 11; 18.1%), H2 (n = 14; 22.9%), H3 (n = 16; 26.2%), H4 (n = 7; 11.5%) and H5 (n = 13; 21.3%), the last one is a pediatric unit. Using disk diffusion test,88 Frei CR, Miller ML, Lewis JS, et al. Trimethoprim-sulfamethoxazole or clindamycin for community-associated MRSA (CA-MRSA) skin infections. J Am Board Fam Med. 2010;23:714-719. all MRSA isolates selected displayed high percentage of susceptibility to non-β-lactams.22 Schuenck RP, Nouér SA, Winter CO, et al. Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2009;64:434-441.,88 Frei CR, Miller ML, Lewis JS, et al. Trimethoprim-sulfamethoxazole or clindamycin for community-associated MRSA (CA-MRSA) skin infections. J Am Board Fam Med. 2010;23:714-719. The following resistance rates was observed: 59.0% for clindamycin (CLI), 78.7% for erythromycin (ERI) and 60.6% for ciprofloxacin (CIP). Lower resistance rates were observed for chloramphenicol (CLO), 19.7%; gentamicin (GEN), 16.4%; rifampicin (RIF), 8.2%; tetracycline (TET), 11.5%; trimethoprim-sulfamethoxazole (SUT) and linezolid (LIN), 4.9%. Resistance to three or more non-β-lactam antibiotics was observed in 55.7% of the total isolates and only in H3 was observed strains resistant to SUT. None of the isolates were resistant to vancomycin (VAN) by MIC determination,99 Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. Approved standards M100-S25. Wayne, PA, USA: CLSI; 2015. with a concentration ranging from 0.25 to 2 µg/mL. The majority of MRSA isolates (n = 45/73.8%) showed MIC of 1.0 µg/mL, following by MIC of 2.0 µg/mL (n = 14/22.9%). SCCmec types were carried out by multiplex PCR analysis that generated a specific amplification pattern, that includes SCCmec types I, II, III, IV and V, as previously described.1010 Boye K, Bartels MD, Andersen IS, Moller JA, Westh H. A new multiplex PCR for easy screening of methicillin-resistant Staphylococcus aureus SCCmec types I–V. Clin Microbiol Infect. 2007;13:725-727. A total of two (3.3%) MRSA isolates contained SCCmec I, 58 (95.1%) SCCmec IV and one (1.6%) harbored SCCmec II element. Two isolates that containing SCCmec IV, all SCCmec I and II exhibited multidrug resistance (resistance to three or more classes of non-β-lactam antimicrobial drugs). Molecular characterization based on multilocus sequence typing (MLST)1111 Enright MC, Day NP, Davies CE, Peacock SJ, Spratt BG. Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J Clin Microbiol. 2000;38:1008-1015. identified 9 STs previously described among MRSA isolates (ST1, ST5, ST8, ST12, ST30, ST45, ST105, ST435, ST1635). Three new STs (ST3163, ST3164 and ST3165) and three new allelic arrangements were identified and added to the mlst.net database. MLST results showed that most of the isolates (81.9%) belonged to known epidemic lineages. The lineages related with the clones USA800/Pediatric (ST5, SCCmec IV), USA400/MW2/WA-1 (ST1, SCCmec IV), USA1100/OSPC (ST30, SCCmec IV), USA300/USA300-LV (ST8, SCCmec IV), UK EMRSA-3/Cordobes/Chilean (ST5, SCCmec I), USA600/Berlin (ST45, SCCmec IV) and USA100/NYJ (ST5, SCCmec II) were observed in approximately 27.8%, 26.2%, 18%, 3.3%, 3.3%, 1.6% and 1.6% of isolates, respectively. HA-MRSA and CA-MRSA isolates typically found in Brazil, related to USA800 and USA400, respectively, were identified in all hospitals (at least two isolates/hospital). Isolates related to the Oceania Southwest Pacific clone (OSPC/USA1100) were also observed in all hospitals, except H4. Beside, one isolate (new ST3165) belonged to the same clonal complex as OSPC (CC30) was found in the H4 (Table 1). PCR-amplification product1212 Al-Talib H, Yean CY, Al-Khateeb A, et al. A pentaplex PCR assay for the rapid detection of methicillin-resistant Staphylococcus aureus and Panton-Valentine Leucocidin. BMC Microbiol. 2009;9:113. compatible with the PVL genes lukS and lukF was detected in 11 (18%) of the MRSA blood isolates. Those genes were related to MRSA harboring SCCmec IV. Looking at the epidemic lineage, PVL gene was found in isolates related to OSPC (n = 8/72.7%).
Characteristics and identification of 61 MRSA isolates from five hospitals in Rio de Janeiro city.
In recent years, many authors have reported the presence of typically CA-MRSA strains circulating in healthcare environments,22 Schuenck RP, Nouér SA, Winter CO, et al. Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2009;64:434-441. including Brazil.1313 Ribeiro A, Coronado AZ, Silva-Carvalho MC, et al. Detection and characterization of international community-acquired infections by methicillin-resistant Staphylococcus aureus clones in Rio de Janeiro and Porto Alegre cities causing both community- and hospital-associated diseases. Diagn Microbiol Infect Dis. 2007;59:339-345.,1414 Rozenbaum R, Sampaio MG, Batista GS, et al. The first report in Brazil of severe infection caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Braz J Med Biol Res. 2009;42:756-760. The rising frequency of CA-MRSA has several implications in nosocomial infections. CA-MRSA isolates are recognized as presenting a higher spectrum of susceptible to non-β-lactam antibiotics when compared with HA-MRSA. However, vancomycin remains first-choice antibiotic therapy for serious infections.66 Demir T, Coplu N, Bayrak H, et al. Panton-Valentine leucocidin gene carriage among Staphylococcus aureus strains recovered from skin and soft tissue infections in Turkey. J Antimicrob Chemother. 2012;67:837-840. The increase use of this late antimicrobial drug is directly related to the emergence of vancomycin-intermediate (VISA), vancomycin-resistant (VRSA) and varied multidrug-resistant MRSA isolates around the world.1515 Dhand A, Sakoulas G. Reduced vancomycin susceptibility among clinical Staphylococcus aureus isolates (‘the MIC Creep'): implications for therapy. F1000 Med Rep. 2012;4:1-11.,1616 Filleron A, Chiron R, Reverdy ME, et al. Staphylococcus aureus with decreased susceptibility to glycopeptides in cystic fibrosis patients. J Cyst Fibros. 2011;10:377-382. In the present study, resistance to vancomycin was not detected; however a MIC creep phenomenon is suggested by the high percentage of samples showing a vancomycin MIC ≥ 1.0 µg/mL.1515 Dhand A, Sakoulas G. Reduced vancomycin susceptibility among clinical Staphylococcus aureus isolates (‘the MIC Creep'): implications for therapy. F1000 Med Rep. 2012;4:1-11. The highest MIC detected was 2 µg/mL and was observed in 22.9% of the isolates. Several authors have reported that treatment with vancomycin eventually fails among patients with MRSA bloodstream infections which presented a vancomycin MIC > 1 µg/mL.1717 Lodise TP, Graves J, Evans A, et al. Relationship between vancomycin MIC and failure among patients with methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Antimicrob Agents Chemother. 2008;52:3315-3320. Recently, a VRSA strain was isolated from a blood culture in a Hospital in São Paulo city, Brazil, in which the patient had previously been treated with vancomycin.77 Rossi F, Diaz L, Wollam A, et al. Transferable vancomycin resistance in a community-associated MRSA lineage. N Engl J Med. 2014;370:1524-1531. A report from Rossi and colleagues77 Rossi F, Diaz L, Wollam A, et al. Transferable vancomycin resistance in a community-associated MRSA lineage. N Engl J Med. 2014;370:1524-1531. emphasizes the value of effective surveillance on the MIC levels of vancomycin, as well as the importance of quick response by the clinical microbiology laboratory informing the medical team on the specific vancomycin MIC. Due to the inclusion criteria used in this study, most of the MRSA isolates exhibited SCCmec type IV (95.1%). Differently, Caiaffa-Filho1818 Caiaffa-Filho HH, Cunha PA, et al. Methicillin-resistant Staphylococcus aureus carrying SCCmec type II was more frequent than the Brazilian endemic clone as a cause of nosocomial bacteremia. Diagn Microbiol Infect Dis. 2013;76:518-520. studying MRSA blood isolates from Brazilian patients, showed a high frequency of MRSA carrying SCCmec type II. The largest cassettes (I, II and III) enhance the survival abilities of MRSA when in hospital settings. However, it is believed that the smaller cassettes (particularly the IV) promote evolutionary advantages in spreading by horizontal transfer of this element, enabling the increase of CA-MRSA in hospitals.1919 Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275-286. Thus CA-MRSA SCCmec IV frequently show competitive advantages compared with multidrug-resistant strains (HA-MRSA).2020 Pardo L, Vola M, Macedo-Viñas M, et al. Community-associated methicillin-resistant Staphylococcus aureus in children treated in Uruguay. J Infect Dev Ctries. 2013;7:10-16. Several factors seem to contribute to these adaptive advantages of CA-MRSA isolates, such as the toxin PVL production.55 Boyle-Vavra S, Daum RS. Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine leukocidin. Lab Invest. 2007;87:3-9.,1919 Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275-286. The presence of PVL genes among the isolates characterized as CA-MRSA have been uneven, with percentages of positivity varying from 27 to 75%.1919 Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis. 2005;5:275-286.,2121 Brauner J, Hallin M, Deplano A, et al. Community-acquired methicillin-resistant Staphylococcus aureus clones circulating in Belgium from 2005 to 2009: changing epidemiology. Eur J Clin Microbiol Infect Dis. 2013;46:344-349. In this study, 11 (18%) isolates were positive to PVL genes and all contained SCCmec IV.
Non multidrug-resistant MRSA isolates carrying SCCmec IV have already been identified in Brazilian hospitals, with patterns similar to USA100, USA300, USA400, USA800 and USA1100 clones,44 Rozenbaum R, Silva-Carvalho MC, Souza RR, et al. Molecular characterization of methicillin-resistant Staphylococcus aureus disseminated in a home care system. Infect Control Hosp Epidemiol. 2006;27:1041-1050.,1313 Ribeiro A, Coronado AZ, Silva-Carvalho MC, et al. Detection and characterization of international community-acquired infections by methicillin-resistant Staphylococcus aureus clones in Rio de Janeiro and Porto Alegre cities causing both community- and hospital-associated diseases. Diagn Microbiol Infect Dis. 2007;59:339-345.,1414 Rozenbaum R, Sampaio MG, Batista GS, et al. The first report in Brazil of severe infection caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Braz J Med Biol Res. 2009;42:756-760.,2222 Caboclo RMF, Cavalcante FS, Iorio NLP, et al. Methicillin-resistant Staphylococcus aureus in Rio de Janeiro hospitals: dissemination of the USA400/ST1 and USA800/ST5 SCCmec type IV and USA100/ST5 SCCmec type II lineages in a public institution and polyclonal presence in a private one. Am J Infect Control. 2013;41:21-26.,2323 Gelatti LC, Bonamigo RR, Inoue FM. Community-acquired methicillin-resistant Staphylococcus aureus carrying SCCmec type IV in southern Brazil. Rev Soc Bras Med Trop. 2013;46:34-38. however, two isolates, in this study related to USA1100 and USA400, showed multidrug resistance profiles.
The emergence of MRSA clones related to USA400 and USA800 was previously described in Rio de Janeiro in only two hospitals,2222 Caboclo RMF, Cavalcante FS, Iorio NLP, et al. Methicillin-resistant Staphylococcus aureus in Rio de Janeiro hospitals: dissemination of the USA400/ST1 and USA800/ST5 SCCmec type IV and USA100/ST5 SCCmec type II lineages in a public institution and polyclonal presence in a private one. Am J Infect Control. 2013;41:21-26. and more recently, MRSA related to USA400, isolated from blood, was described associated with infective endocarditis in Rio de Janeiro.2424 Damasco PV, Cavalcante FS, Chamon RC, et al. The first case report of non-nosocomial healthcare-associated infective endocarditis due to methicillin-resistant Staphylococcus aureus USA400 in Rio de Janeiro, Brazil. Infection. 2013;41:851-854. This multicenter data indicate that these MRSA lineages are still circulating in the Brazilian healthcare settings.
In Brazil the most common lineage of CA-MRSA is related to OSPC, especially causing community associated infections.1313 Ribeiro A, Coronado AZ, Silva-Carvalho MC, et al. Detection and characterization of international community-acquired infections by methicillin-resistant Staphylococcus aureus clones in Rio de Janeiro and Porto Alegre cities causing both community- and hospital-associated diseases. Diagn Microbiol Infect Dis. 2007;59:339-345.,2323 Gelatti LC, Bonamigo RR, Inoue FM. Community-acquired methicillin-resistant Staphylococcus aureus carrying SCCmec type IV in southern Brazil. Rev Soc Bras Med Trop. 2013;46:34-38.,2525 Evangelista SS, de Oliveira AC. Community-acquired methicillin-resistant Staphylococcus aureus: a global problem. Rev Bras Enferm. 2015;68:136-143. In this study, eleven isolates (18%) were related to this clone. The presence of isolates related to OSPC clone has already been described in hospitalized patients in two hospitals in Rio de Janeiro,1414 Rozenbaum R, Sampaio MG, Batista GS, et al. The first report in Brazil of severe infection caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Braz J Med Biol Res. 2009;42:756-760.,2222 Caboclo RMF, Cavalcante FS, Iorio NLP, et al. Methicillin-resistant Staphylococcus aureus in Rio de Janeiro hospitals: dissemination of the USA400/ST1 and USA800/ST5 SCCmec type IV and USA100/ST5 SCCmec type II lineages in a public institution and polyclonal presence in a private one. Am J Infect Control. 2013;41:21-26. however, few studies described severe infections by these CA-MRSA from blood,1414 Rozenbaum R, Sampaio MG, Batista GS, et al. The first report in Brazil of severe infection caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Braz J Med Biol Res. 2009;42:756-760.,2626 Ramundo MS, Beltrame CO, Botelho AM, et al. A unique SaeS allele overrides cell-density dependent expression of saeR and lukSF-PV in the ST30-SCCmecIV lineage of CA-MRSA. Int J Med Microbiol. 2016;:. while in the other case the OSPC related isolate was collected from wound.2222 Caboclo RMF, Cavalcante FS, Iorio NLP, et al. Methicillin-resistant Staphylococcus aureus in Rio de Janeiro hospitals: dissemination of the USA400/ST1 and USA800/ST5 SCCmec type IV and USA100/ST5 SCCmec type II lineages in a public institution and polyclonal presence in a private one. Am J Infect Control. 2013;41:21-26. Here, OSPC related isolates were observed in most of the studied hospitals, though, if one considers the clonal complex (CC30), then, we can infer the spread of these MRSA genetically related to OSPC clone in all hospitals. In Uruguay, a Brazilian neighboring country, replacement of HA-MRSA by CA-MRSA in hospital settings have been described, where the most common CA-MRSA isolates recovered from invasive and superficial infection diseases are related to the OSPC clone.2020 Pardo L, Vola M, Macedo-Viñas M, et al. Community-associated methicillin-resistant Staphylococcus aureus in children treated in Uruguay. J Infect Dev Ctries. 2013;7:10-16.
In the present study, isolates related to USA300, UK EMRSA-3 and USA100 were rarely observed. However, a USA300-related isolate has also been identified in one hospital in Rio de Janeiro from a pneumonia case.1313 Ribeiro A, Coronado AZ, Silva-Carvalho MC, et al. Detection and characterization of international community-acquired infections by methicillin-resistant Staphylococcus aureus clones in Rio de Janeiro and Porto Alegre cities causing both community- and hospital-associated diseases. Diagn Microbiol Infect Dis. 2007;59:339-345.
MRSA belonging to the lineage USA100/ST5-MRSA-II was observed just in one hospital. This lineage has also been observed in blood samples in Brazil, highlighting that one of these reports describes two isolates of S. aureus resistant to daptomycin.2727 Cavalcante FS, Ferreira DC, Chamon RC, et al. Daptomycin and methicillin-resistant Staphylococcus aureus isolated from a catheter-related bloodstream infection: a case report. BMC Res Notes. 2014;25:759. In Brazil, to the best of our knowledge, there are few reports of USA600/ST45-MRSA-IV isolates, which were collected from skin infection case and from catheter.2323 Gelatti LC, Bonamigo RR, Inoue FM. Community-acquired methicillin-resistant Staphylococcus aureus carrying SCCmec type IV in southern Brazil. Rev Soc Bras Med Trop. 2013;46:34-38.,2828 Andrade-Figueiredo M, Leal-Balbino TC. Clonal diversity and epidemiological characteristics of Staphylococcus aureus: high prevalence of oxacillin-susceptible mecA-positive Staphylococcus aureus (OS-MRSA) associated with clinical isolates in Brazil. BMC Microbiol. 2016;16:115.
The epidemic clone UK MRSA-3 (ST5-MRSA-I) traditionally classified as HA-MRSA is distributed in Europe and Latin America, including Brazil.33 Teixeira MM, Araújo MC, Silva-Carvalho MC, et al. Emergence of clonal complex 5 (CC5) methicillin-resistant Staphylococcus aureus (MRSA) isolates susceptibleto trimethoprim-sulfamethoxazole in a Brazilian hospital. Braz J Med Biol Res. 2012;45:637-643.,2929 Becker AP, Santos O, Castrucci FM, et al. First report of methicillin-resistant Staphylococcus aureus Cordobes/Chilean clone involved in nosocomial infections in Brazil. Epidemiol Infect. 2012;140:1372-1375.,3030 Stefani S, Chung DR, Lindsay JA, et al. Methicillin-resistant Staphylococcus aureus (MRSA): global epidemiology and harmonisation of typing methods. Int J Antimicrob Agents. 2012;39:273-282. Using the phenotypic criteria established in this screening, we could identify an isolate related to this clone in our collection of MRSA blood. Recently our group described the presence of this clone in respiratory secretions of cystic fibrosis patients in Rio de Janeiro.11 Lima DF, Brazão NBV, Folescu TW, et al. Panton-Valentine leukocidin (PVL) gene carriage among Staphylococcus aureus strains with SCCmec types I, II, IV, and V recovered from cystic fibrosis pediatric patients in Brazil. Diagn Microbiol Infect Dis. 2014;78:59-62. Until now, there is no report of UK-MRSA-3 in bloodstream infections in Brazil. In conclusion, a number of different international clones, displaying lower level of antimicrobial resistance to non-β lactams, are circulating in different Rio de Janeiro hospitals causing bloodstream infections; including MRSA lineages that are not frequently observed in our country. Thus, we recommend a surveillance including a larger number of MRSA blood isolates, from different Rio de Janeiro hospitals, in order to expose the real picture of the antimicrobial susceptibility profiles found among MRSA isolates, which can significantly vary depending on the dominant lineages present in the studied hospitals.
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1
These authors have equally contributed for this study.
Acknowledgments
We thank the personnel at the microbiology laboratories of the participant hospitals for their generous collaboration in sending us the MRSA blood isolates. This work was supported by the Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro.
References
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1Lima DF, Brazão NBV, Folescu TW, et al. Panton-Valentine leukocidin (PVL) gene carriage among Staphylococcus aureus strains with SCCmec types I, II, IV, and V recovered from cystic fibrosis pediatric patients in Brazil. Diagn Microbiol Infect Dis 2014;78:59-62.
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2Schuenck RP, Nouér SA, Winter CO, et al. Polyclonal presence of non-multiresistant methicillin-resistant Staphylococcus aureus isolates carrying SCCmec IV in health care-associated infections in a hospital in Rio de Janeiro, Brazil. Diagn Microbiol Infect Dis. 2009;64:434-441.
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3Teixeira MM, Araújo MC, Silva-Carvalho MC, et al. Emergence of clonal complex 5 (CC5) methicillin-resistant Staphylococcus aureus (MRSA) isolates susceptibleto trimethoprim-sulfamethoxazole in a Brazilian hospital. Braz J Med Biol Res 2012;45:637-643.
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4Rozenbaum R, Silva-Carvalho MC, Souza RR, et al. Molecular characterization of methicillin-resistant Staphylococcus aureus disseminated in a home care system. Infect Control Hosp Epidemiol 2006;27:1041-1050.
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5Boyle-Vavra S, Daum RS. Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine leukocidin. Lab Invest. 2007;87:3-9.
-
6Demir T, Coplu N, Bayrak H, et al. Panton-Valentine leucocidin gene carriage among Staphylococcus aureus strains recovered from skin and soft tissue infections in Turkey. J Antimicrob Chemother. 2012;67:837-840.
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7Rossi F, Diaz L, Wollam A, et al. Transferable vancomycin resistance in a community-associated MRSA lineage. N Engl J Med 2014;370:1524-1531.
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8Frei CR, Miller ML, Lewis JS, et al. Trimethoprim-sulfamethoxazole or clindamycin for community-associated MRSA (CA-MRSA) skin infections. J Am Board Fam Med. 2010;23:714-719.
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9Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. Approved standards M100-S25 Wayne, PA, USA: CLSI; 2015.
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10Boye K, Bartels MD, Andersen IS, Moller JA, Westh H. A new multiplex PCR for easy screening of methicillin-resistant Staphylococcus aureus SCCmec types I–V. Clin Microbiol Infect 2007;13:725-727.
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11Enright MC, Day NP, Davies CE, Peacock SJ, Spratt BG. Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J Clin Microbiol 2000;38:1008-1015.
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12Al-Talib H, Yean CY, Al-Khateeb A, et al. A pentaplex PCR assay for the rapid detection of methicillin-resistant Staphylococcus aureus and Panton-Valentine Leucocidin. BMC Microbiol. 2009;9:113.
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13Ribeiro A, Coronado AZ, Silva-Carvalho MC, et al. Detection and characterization of international community-acquired infections by methicillin-resistant Staphylococcus aureus clones in Rio de Janeiro and Porto Alegre cities causing both community- and hospital-associated diseases. Diagn Microbiol Infect Dis. 2007;59:339-345.
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14Rozenbaum R, Sampaio MG, Batista GS, et al. The first report in Brazil of severe infection caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Braz J Med Biol Res 2009;42:756-760.
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15Dhand A, Sakoulas G. Reduced vancomycin susceptibility among clinical Staphylococcus aureus isolates (‘the MIC Creep'): implications for therapy. F1000 Med Rep 2012;4:1-11.
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16Filleron A, Chiron R, Reverdy ME, et al. Staphylococcus aureus with decreased susceptibility to glycopeptides in cystic fibrosis patients. J Cyst Fibros 2011;10:377-382.
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17Lodise TP, Graves J, Evans A, et al. Relationship between vancomycin MIC and failure among patients with methicillin-resistant Staphylococcus aureus bacteremia treated with vancomycin. Antimicrob Agents Chemother. 2008;52:3315-3320.
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18Caiaffa-Filho HH, Cunha PA, et al. Methicillin-resistant Staphylococcus aureus carrying SCCmec type II was more frequent than the Brazilian endemic clone as a cause of nosocomial bacteremia. Diagn Microbiol Infect Dis. 2013;76:518-520.
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19Zetola N, Francis JS, Nuermberger EL, Bishai WR. Community-acquired methicillin-resistant Staphylococcus aureus: an emerging threat. Lancet Infect Dis 2005;5:275-286.
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20Pardo L, Vola M, Macedo-Viñas M, et al. Community-associated methicillin-resistant Staphylococcus aureus in children treated in Uruguay. J Infect Dev Ctries 2013;7:10-16.
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21Brauner J, Hallin M, Deplano A, et al. Community-acquired methicillin-resistant Staphylococcus aureus clones circulating in Belgium from 2005 to 2009: changing epidemiology. Eur J Clin Microbiol Infect Dis. 2013;46:344-349.
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22Caboclo RMF, Cavalcante FS, Iorio NLP, et al. Methicillin-resistant Staphylococcus aureus in Rio de Janeiro hospitals: dissemination of the USA400/ST1 and USA800/ST5 SCCmec type IV and USA100/ST5 SCCmec type II lineages in a public institution and polyclonal presence in a private one. Am J Infect Control. 2013;41:21-26.
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23Gelatti LC, Bonamigo RR, Inoue FM. Community-acquired methicillin-resistant Staphylococcus aureus carrying SCCmec type IV in southern Brazil. Rev Soc Bras Med Trop 2013;46:34-38.
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24Damasco PV, Cavalcante FS, Chamon RC, et al. The first case report of non-nosocomial healthcare-associated infective endocarditis due to methicillin-resistant Staphylococcus aureus USA400 in Rio de Janeiro, Brazil. Infection. 2013;41:851-854.
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25Evangelista SS, de Oliveira AC. Community-acquired methicillin-resistant Staphylococcus aureus: a global problem. Rev Bras Enferm. 2015;68:136-143.
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26Ramundo MS, Beltrame CO, Botelho AM, et al. A unique SaeS allele overrides cell-density dependent expression of saeR and lukSF-PV in the ST30-SCCmecIV lineage of CA-MRSA. Int J Med Microbiol 2016;:.
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Publication in this collection
Apr-Jun 2017