Evidence for a continuum of decreased vancomycin susceptibility in unselected Staphylococcus aureus clinical isolates

Some Staphylococcus aureus isolates have glycopeptide minimal inhibitory concentrations (MICs) in the susceptible range but have subpopulations that grow on >or=4 microg/mL vancomycin. Clinical laboratory methods for determining susceptibility have proven to be inadequate for detecting these strains. Among methicillin-resistant S. aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) clinical isolates, 149 (66.2%) of 225 and 17 (56.6%) of 30, respectively, grew on brain-heart infusion (BHI) medium containing 2 microg/mL vancomycin; 17 (7.5%) of the MRSA and 2 (6.6%) of the MSSA isolates grew on BHI screening plates containing 4 microg/mL vancomycin. One isolate grew on plates containing 6 microg/mL vancomycin. This isolate escaped detection by routine testing but had a vancomycin MIC of 6 microg/mL when tested in BHI medium. This isolate also had decreased Triton X-100-induced autolysis and killing when incubated in broth media containing vancomycin, properties accorded to glycopeptide-intermediate S. aureus isolates. These observations suggest that glycopeptide-intermediate-like S. aureus isolates are circulating undetected and that a continuum of decreased susceptibility exists in unselected isolates.     

Concomitant high-level vancomycin and penicillin resistance in clinical isolates of enterococci.

Enterococci are important nosocomial pathogens among which resistance to multiple antibiotics is being recognized with increasing frequency. We characterized three clinical isolates from three New York City hospitals that demonstrated concomitant resistance to vancomycin (one VanA, two VanB phenotypes) and high-level resistance to penicillin. Two Enterococcus faecium strains were intrinsically highly resistant to penicillin and showed very low affinity for penicillin of penicillin-binding protein 5. Unlike previously described glycopeptide-resistant enterococci, these strains were not hypersusceptible to beta-lactam agents after vancomycin induction, and combinations of penicillin and vancomycin were not synergistic against them. A third isolate, Enterococcus faecalis, produced beta-lactamase. Two of the three strains were also highly resistant to all aminoglycosides. Emergence of concomitant high-level resistance to multiple antibiotic classes among enterococci considerably narrows the therapeutic options for treatment of infections due to these opportunistic pathogens.     

Investigation of infective endocarditis clinical isolates of methicillin resistant Staphylococcus aureus non-responsive to vancomycin

Methicillin resistant Staphylococcus aureus (MRSA) is one of the most important strains which induce hospital and post-operative infection. In cases of infective endocarditis in which VCM was not efficacious, MRSA strains were chronologically isolated at three different times and examined with the following parameters: minimum inhibitory concentration (MIC), fractional inhibitory concentration (FIC) index, Mu 3 agar, population analysis, pulse field gel electropholesis (PFGE). The PFGE banding patterns of the three MRSA isolates were the same, therefore, it was concluded that the same strain of MRSA was selected for reduced susceptibility. A pattern of Mu 3 and Mu 50 was demonstrated under population analysis.     

Activity of vancomycin and teicoplanin against clinical isolates of Staphylococcus aureus in the period 1994-1999

Since the emergence of the methicillin-resistant S. aureus (MRSA) in the 1960's, glycopeptides (Vancomycin and Teicoplanin) has been the drugs of choice and commonly the sole antimicrobial agents available for the treatment of serious MRSA and other Gram-positive infections. The emergence of S. aureus with intermediate vancomycin-resistance after 1997 threatens to return us to the era before the development of the antibiotics. Prevention of the further spread of S. aureus strains with intermediate and eventually with full glycopeptide resistance requires enhanced laboratory methods to detect resistance. A total of 361 S. aureus clinical isolates (177 MRSA and 184 MSSA) obtained from 1994 to 1999 in eleven Bulgarian hospitals located in geographically distinct areas of the country were enrolled in the study. Minimal inhibitory concentrations of Vancomycin and Teicoplanin were determined by agar-dilution method according to NCCLS recommendations. MIC50 and MIC90 for Vancomycin were 0.7 and 1 mg/ml, and for Teicoplanin--0.5 and 0.9 microgram/ml. All staphylococcal isolates showed sensitivity to Vancomycin and Teicoplanin. MICs of both glicopeptides against MRSA and MSSA did not differ significantly.     

Emergence of vancomycin resistance during therapy against methicillin-resistant Staphylococcus aureus in a burn patient--importance of low-level resistance to vancomycin.

OBJECTIVES: Staphylococcus aureus with low-level resistance to vancomycin (VLSA) which could develop into vancomycin-resistant S. aureus (VRSA) is most important. However, VLSA is difficult to detect by standard laboratory methods. We describe here improved methods to detect VLSA. METHODS: Three methicillin-resistant S. aureus (MRSA) strains, designated Fu6, Fu10, and Fu18, were sequentially isolated from the burn wound site of a patient, during vancomycin therapy. The properties of these strains were compared with those of reference strains Mu3 and Mu50 (previous resistant isolates from other patients). RESULTS: The isolated strains, Fu10 and Fu18, had identical phenotypes and genotypes. The vancomycin resistance of Fu10 was equivalent to that of strain Mu3, whereas Fu18 had much higher vancomycin resistance than Fu10 and Mu3, although reaching the level of Mu50. Fu18 showed similar growth to Mu50 on gradient gels and on Mu3 medium. CONCLUSIONS: Our data indicate that the VLSA developed vancomycin resistance during exposure to vancomycin in vivo. The population analysis of tested VLSA and vancomycin intermediately resistant S. aureus (VISA) indicates that a penem at relatively low concentrations induced a significant increase in the number of vancomycin-resistant subpopulations. Furthermore, we confirmed that gradient gel analysis and Mu3 medium are simple and useful methods for the detection of VLSA judged as VSSA by its conventional MIC alone.     

Determining of antibiotic resistance profile in Staphylococcus aureus isolates

ObjectiveTo determine the pattern of antibiotic resistance among Staphylococcus aureus (S. aureus) isolates from clinical specimens and to identify community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) in specimens that have been collected from patients referring to one of the hospitals of Ahvaz.MethodsS. aureus isolates from a hospital in Ahvaz were screened for resistance to various antibiotics including methicillin. The susceptibility of the isolates was determined by Kirby-Bauer disc diffusion method. The MRSA was also treated with ethidium bromide to find the origin of resistance.ResultsAmong the bacterial isolates, all of 11 S. aureus were resistant to methicillin and cefixime, 2 were resistant to ciprofloxacine, 6 were resistant to tetracycline and the reminder were sensitive or intermediate to other antibiotics. The treated isolates were reminded resistant to methicillin and this suggested that the plasmid was not the origin of resistance in these isolates.ConclusionsThese results showed that infection due to MRSA is widespread in Ahvaz and with respect to the spread of vancomycin resistance among MRSA and appearance of overwhelming infections. It is necessary to identify continuously the profile of antibiotic resistance among S. aureus isolates in other regions and finding appropriate antibiotic for infection control and eradication.     

Antimicrobial resistance and underlying mechanisms in Staphylococcus aureus isolates

Objective: To investigate the antimicrobial susceptibility of 97 clinical Staphylococcus aureus(S. aureus) strains against 14 antimicrobials and corresponding resistance mechanisms.Methods: The antimicrobial susceptibility of the isolates was determined using a disk diffusion method and antimicrobial resistance genes were screened by polymerase chain reaction. Mutations responsible for ciprofloxacin and rifampicin resistance were investigated by polymerase chain reaction and DNA sequencing.Results: All isolates were found to be susceptible to vancomycin. Various rates of resistance to penicillin(83.5%), ampicillin(77.3%), erythromycin(63.9%), tetracycline(16.5%), amoxicillin/clavulanic acid(16.5%), ciprofloxacin(15.5%), trimethoprim/sulfamethoxazole(15.5%), oxacillin(13.4%), fusidic acid(12.4%), rifampin(6.2%), clindamycin(6.2%), gentamicin(6.2%) and mupirocin(5.2%) were determined. In addition,different combinations of resistance genes were identified among resistant isolates.Ciprofloxacin resistant isolates had mutations in codon 84(Ser84 Leu) and 106(Gly106 Asp) in the gyr A gene. Mutations in grl A were mostly related to Ser80 Phe substitution. Leu466 Ser mutation in the rpo B gene was detected in all rifampin resistant isolates. All methicillin resistant S. aureus isolates were SCCmec type V.Conclusions: In conclusion, it was determined that the isolates were resistant to different classes of antimicrobials at varying rates and resistance was mediated by different genetic mechanisms. Therefore, continuous monitoring of resistance in S. aureus strains is necessary to control their resistance for clinically important antimicrobials.     

Microbiological characterization of clinical isolates of Staphylococcus epidermidis

As a result of recent development in medical practice including use of new antimicrobial agents, coagulase-negative Staphylococci (CNS) that were once considered nonpathogenic contaminants have captured attention as causes of disease. The 43 clinical isolates of Staphylococcus epidermidis sensu stricto and 7 isolates of S. epidermidis from the medical staffs were characterized with regard to (1) their biochemical profiles, (2) slime productivity, (3) beta-lactamase productivity and (4) plasmid patterns. Most of the isolates have an identical biochemical profile code. The slime production was observed in the 9 strains isolated from pleural effusions or the tubes used for pleural drainage. These strains had a similar antimicrobial susceptibility profile that are commonly seen in multi-resistant strains of methicillin-resistant Staphylococcus aureus (MRSA). In addition, most of these strains produced beta-lactamase. For the plasmid profiling, we selected 12 isolates that possessed 5 distinct antimicrobial susceptibility profiles. Upon agarose gel electrophoresis, 8 isolates were shown to possess a 1.9 kb plasmid. These 8 isolates had resistance against tobramycin (TOB) and erythromycin (EM). Emergence of S. epidermidis as causes of disease will increasingly necessitate the detailed microbiological characterization of the clinical isolates.     

Antimicrobial resistance in clinical isolates of Staphylococcus aureus from hospital and community sources in southern Jamaica.

OBJECTIVES: In this study, we assessed the antimicrobial susceptibility patterns and prevalence of methicillin resistance among Staphylococcus aureus isolates from hospital and community sources in southern Jamaica. METHODS: Eighty isolates of S. aureus obtained from hospital and community-based patients with staphylococcal infections were collected, and antimicrobial susceptibilities were determined by disk diffusion. RESULTS: While all specimens yielded isolates, multidrug-resistant isolates were obtained only from urine, high vaginal swab, abscess aspirate, and catheter tip samples. The overall prevalence of methicillin-resistant S. aureus (MRSA) was 23%. The proportions of MRSA isolated from hospital sources (18/39) and community sources were 46% and 0%, respectively (p<0.05). The pattern of antibiotic susceptibility of S. aureus differed significantly between MRSA and methicillin-susceptible (MSSA) isolates. For MRSA isolates, multiple-drug resistance was common and only few antibiotics were active against these isolates. However, no MRSA was resistant to vancomycin. Except for penicillin and to some extent co-trimoxazole (trimethoprim-sulfamethoxazole), most MSSA isolates were susceptible to nearly all antimicrobial agents used in this study. CONCLUSIONS: This is the first report of MRSA from this region of Jamaica. Because methicillin resistance is associated with multiple-drug resistance in S. aureus, it is imperative that surveillance initiatives be focused on both the hospital and community in order to monitor and limit the spread of this organism.     

Phenotypic detection of constitutive and inducible clindamycin resistance in clinical isolates of Staphylococcus aureus and coagulase negative Staphylococcus on routine susceptibility plate

Increasing frequency of methicillin resistant Staphylococcus aureus infections and changing patterns in antimicrobial resistance have led to renewed interest in the use of macrolidelincosamide-streptogramin antibiotics. However therapy may fail either due to constitutive or inducible resistance. This study was undertaken to detect different phenotypes including inducible clindamycin resistance in clinical isolates of Staphylococcus aureus and coagulase negative Staphylococcus. Four hundred sixty five Staphylococcus aureus and 84 coagulase negative Staphylococci isolated from different clinical specimens were included in the study. On routine susceptibility testing plate clindamycin (2 microg) disk was placed at a distance of 15mm towards the centre from a peripherally placed erythromycin (15 microg) disk. Fisher exact test was used for statistical analysis. Out of 465 Staphylococcus aureus isolates, 237 (50.96%) were methicillin sensitive (MSSA) and 228 (49.03%) methicillin resistant (MLS(B)c).Over all 118 (25.37%) isolates showed constitutive resistance (MLS(B)c), 70 (15.05%) inducible clindamycin resistance, 143 (30.75%) MS(B) phenotype and 134 (28.81%) were susceptible to both erythromycin as well as clindamycin. Constitutive and inducible resistance to clindamycin were significantly higher in MRSA than MSSA (P=0.0000 and 0.0001 respectively). Out of 84 isolates of coagulase negative Staphylococci, 43 (51.19%) were methicillin sensitive (MSCNS) and 41(48.80%) methicillin resistant (MRCNS). Constitutive MLS(B) resistance was detected in 32 (38.09%), inducible clindamycin resistance 10 (11.90%), MS(B) phenotype 27 (32.14%) and 15 (17.85%) were susceptible to both erythromycin and clindamycin. Performing D test on a routine susceptibility plate saves material, manpower and time as inducible resistance can be reported simultaneously along with other susceptibility results.     

The emergence of mupirocin resistance among clinical isolates of methicillin-resistant Staphylococcus aureus in Trinidad: a first report

The objective of the study was to investigate the trend of mupirocin resistance among methicillin-resistant Staphylococcus aureus (MRSA) in Trinidad. No premarketing susceptibility surveillance was ever done following the introduction of mupirocin in 1986. A total of 188 MRSA strains recovered over a 2-year period from various body sites were tested for mupirocin resistance via the disc diffusion method. The major sources of MRSA were surgical site infections (74.0%) and bloodstream infections (8.0%). High-level and low-level mupirocin resistance were detected in 26.1 and 44.1% of MRSA stains, respectively. Resistances to other non-beta-lactam antibiotics were also high. Ninety-eight percent of all MRSA were resistant to erythromycin. This was followed by resistance rates of 96.8, 95.2, 94.1, 93.6, and 93.1%, for gentamicin, ciprofloxacin, amikacin and tobramycin, co-trimoxazole, and tetracycline, respectively. No MRSA strains were found to be resistant to vancomycin, linezolid, and quinupristin-dalfopristin. The study showed that mupirocin resistance among Trinidadian MRSA strains was relatively high compared to that seen in other countries. Because of the increasing prevalence of MRSA at the San Fernando General Hospital (SFGH) and the apparently increasing resistance to mupirocin, frequent monitoring of MRSA susceptibility patterns and infection control initiatives may be helpful in reducing the incidence of MRSA with a concomitant decrease in mupirocin resistance. This report is the first after 20 years of continuous use of the drug at the SFGH.     

耐甲氧西林金黄色葡萄球菌检出动态及对万古霉素的耐药性变迁

目的 观察耐甲氧西林金黄色葡萄球菌(MRSA)在临床标本中的检出动态及对万古霉素的耐药性变化趋势。方法 检测1966年～2001年各年度各种临床标本中MRSAR的分离率，测量万古霉素对MRSA的抑菌环直径大小。结果 1996～2000年5年内MRSA检出率有逐年上升趋势，2001年通过筛查MRSA携带者并采取消毒隔离措施后，2001年MRSA检出率为32．1％，与2000年(45．9％)、1999年检出率(38．5％)比较明显降低，与1998年(30．2％)接近。随着时间推移，各年度MRSA对万古霉素的抑菌圈直径逐年减小。结论 通过筛查MRSA携带者并采取严格的消毒隔离措施，可使MRSA的检出率下降。MRSA对万古霉素的敏感程度在逐年降低。     

Reporting antimicrobial susceptibilities and phenotypes of resistance to vancomycin in vancomycin-resistant Enterococcus spp. clinical isolates: A nationwide proficiency study

IntroductionThe ability of Spanish microbiology laboratories to (a) determine antimicrobial susceptibility (AS), and (b) correctly detect the vancomycin resistance (VR) phenotype in vancomycin-resistant Enterococcus spp. (VRE) was evaluated.MethodsThree VRE isolates representing the VanA (E. faecium), VanB (E. faecium) and VanC (E. gallinarum) VR phenotypes were sent to 52 laboratories, which were asked for: (a) AS method used; (b) MICs of ampicillin, imipenem, vancomycin, teicoplanin, linezolid, daptomycin, ciprofloxacin, levofloxacin and quinupristin–dalfopristin, and high-level resistance to gentamicin and streptomycin; (c) VR phenotype.Results(a) The most frequently used system was MicroScan; (b) according to the system, the highest percentage of discrepant MICs was found with gradient strips (21.3%). By antimicrobial, the highest rates of discrepant MICs ranged 16.7% (imipenem) to 0.7% (linezolid). No discrepant MICs were obtained with daptomycin or levofloxacin. Mayor errors (MEs) occurred with linezolid (1.1%/EUCAST) and ciprofloxacin (5.0%/CLSI), and very major errors (VMEs) with vancomycin (27.1%/EUCAST and 33.3%/CLSI) and teicoplanin (5.7%/EUCAST and 2.3%/CLSI). For linezolid, ciprofloxacin, and vancomycin, discrepant MICs were responsible for these errors, while for teicoplanin, errors were due to a misassignment of the clinical category. An unacceptable high percentage of VMEs was obtained using gradient strips (14.8%), especially with vancomycin, teicoplanin and daptomycin; (c) 86.4% of the centers identified VanA and VanB phenotypes correctly, and 95.0% the VanC phenotype.ConclusionMost Spanish microbiology laboratories can reliably determine AS in VRE, but there is a significant percentage of inadequate interpretations (warning of false susceptibility) for teicoplanin in isolates with the VanB phenotype.     

Vancomycin resistance of clinical isolates of lactobacilli

Strains of lactobacilli were cultured from two patients with clinical evidence of infection. Each isolate was found to be highly resistant to vancomycin but inactivation of the antibiotic could not be demonstrated. Lactobacillus isolates should be regarded as potential pathogens. Reliable vancomycin susceptibility testing is required since susceptibility among Gram-positive bacteria in general should not be assumed.     

Emergence of clinical isolates of Staphylococcus aureus resistant to gentamicin and correlation of resistance with bacteriophage type.

A total of 623 clinical isolates of Staphylococcus aureus were tested for sensitivity to antibiotics by the disk diffusion method and were bacteriophage typed. The emergence of isolates resistant to gentamicin was noted. Eighteen percent of the isolates from patients on surgical services were resistant to gentamicin; 83% of these resistant strains were phage type 95. Five percent of the isolates from patients on services other than surgical were resistant to gentamicin, and 61% of these gentamicin-resistant strains were phage type 94, 96. Physicians are urged to be aware of the possible emergence of such strains with epidemic potential.