bj newcomer resident seminar july 7, 2011. brief history of mrsa index case characterization of...
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BJ NewcomerResident Seminar
July 7, 2011
Brief history of MRSA Index case Characterization of LA-MRSA MRSA ST398
• Pigs• Cattle• Foodstuffs• Zoonotic potential www.ashleyhardin.wordpress.com
Gram (+), A-T rich cocci Coagulase positive Most important human Staph. species 1 of 3 major veterinary Staph.
pathogens• Cellulitis• Osteomyelitis• Pododermatitis• MASTITIS
www.randstarteam.blogspot.com
MRSA contains mecA which conveys methicillin resistance
mecA encodes for penicillin-binding protein (PBP2a)
PBPs normally present in membrane
PBP2a decreasedaffinity for β-lactams
Penicillin binding protein
Nestorovich E M et al. PNAS 2002;99:9789-9794
First isolated in UK hospital 1961 1970 – Emerged in U.S. Most prevalent nosocomial infection
• Hospital-acquired MRSA (HA-MRSA) In 2005: 278,000 cases
• ~95,000 serious infections• ~20,000 deaths
www.freewebs.com
Most early HA-MRSA belonged to only 5 CC’s
Possessed larger SCCmec types (I-III)• Afford resistance to most clinically available abx
Risk factors• Prolonged abx therapy• Prolonged hospitalization• ICU care• Surgical procedures
Common cause of:• Wound dehiscence• Thrombophlebitis• UTI’s
www.brettwilliams.wordpress.com
Mid 1990’s MRSA infections increasingly documented in non-hospitalized patients• Community-acquired MRSA
(CA-MRSA) Most possess smaller
SCCmec types (IV, V)• Greater suscept. to common
abx Distinct genetic lineage
from HA-MRSA Certain strains toxigenic
• Panton-Valentine leukocidin (PVL)
• Phenol-soluble modulin (PSM)
1972 – MRSA first isolated from livestock• Mastitic cow in Belgium• Concluded isolate was of human origin
1990’s - increased isolation from companion animals• Coincided with increase of CA-MRSA
www.webweaver.nu
July 2004: MRSA cultured from routine pre-op screening in 6 month old girl • No history of traveling, hospital admission
Repeated decolonization attempts unsuccessful
Parents subsequently found to be colonized
Voss, A, et al. Emerg Infect Dis. 2005 Dec;11(12):1965-6.
www.flickr.com
Family lived on farm and raised pigs Nov 2004 – pigs tested
• Initially, nares of 10 pigs cultured - All MRSA negative
• Subsequently, 30 perineal cultures- 1 MRSA positive culture
Identical strain in pigs, child, and parents
www.clker.com/clipart-29067.htmlVoss, A, et al. Emerg Infect Dis.
2005 Dec;11(12):1965-6.
Jan 2005 – 2nd pig farmer found colonized• Different region
Feb 2005 – Son of swine veterinarian colonized
Admitted to hospital, nurse colonized Veterinarian colonized
No clinical signswww.stealstreet.com
Regional farmer’s meeting
26 pig farmers screened – throat and nares
6/26 (23%) MRSA colonized
Frequency >760x higher than Dutch population
www.cutcaster.comVoss, A, et al. Emerg Infect Dis.
2005 Dec;11(12):1965-6.
Pulsed-field gel electrophoresis (PFGE)• Digestion with restriction endonuclease
(SmaI)• Separation of DNA fragments by electric
pulses• Current gold standard
Pulsed-field gel electrophoresis (PFGE)• Digestion with restriction endonuclease
(SmaI)• Separation of DNA fragments by electric
pulses• Current gold standard
www.bio.davidson.edu/courses/genomics/method/pulse_field.html
Multi-locus sequence typing (MLST)• Sequencing of 7 housekeeping genes• Grouped into clonal complexes (CC)
spa-typing – Staphylococcal protein A gene (spa)• Profile of repeats within gene
SCCmec typing• mec complex – contains mecA gene• ccr complex – responsible for mobility
Non-typeable by standard PFGE Almost all strains in CC398 (ST398) General absence of PVL and other
virulence factors Virulence/resistance obtained through
mobile genetic elements (MGE’s)• Staphylococcal chromosomal cassette (SCC)• Plasmids via bacteriophages (transduction)
Conjugative plasmids, transformation, transposons and staphylococcal pathogenicity islands (SaPIs) uncommon
Five SCCmec types based on differences in mecA and ccrC genes
www.staphylococcus.net
Types I-III often larger, common in HA-MRSA
Types IV, V more common in CA-MRSA
Type IV predominates in human medicine
MRSA ST398: type Vwww.staphylococcus.net
38 kb type V SCCmec mecA – confers methicillin resistance The ccrC gene encodes recombinase
• Relatively stable
Schijffelen et al. BMC Genomics 2010, 11:376
GENE FUNCTION/PHENOTYPE
ampA Apramycin resistance
blaZ β-lactam resistance
cfr multiple-antibiotic resistance
copA copper resistance
dfrG trimethoprim resistance
dfrK trimethoprim resistance
erm (A) macrolide/lincosamide resistance
erm(C) macrolide/lincosamide resistance
erm(B) macrolide/lincosamide resistance
erm(T) macrolide/lincosamide resistance
fexAchloramphenicol/florfenicol
resistance
mecA methicillin resistance
tet(K) tetracycline resistance
tet(L) tetracycline resistance
tet(M) tetracycline resistance
vga(A) virginiamycin resistance
vga(C) virginiamycin resistance
Plasmids form accessory genome
Convey resistance or virulence
Lacking from most MRSA ST398 isolates
Multiple-abx resistance• Tetracyclines – always• Macrolides,
lincosamides, etc• +/- fluoroquinolones
Predominant MRSA strain in swine• Other recent reports limited to human strains
Most reports from Europe• The Netherlands• Germany• Belgium
Limited reports elsewhere
• Canada• Singapore• USA
www.netherlands.world-guides.com
Carriage rates vary considerably• 10% in Denmark (n=100)• 24.9% in Canada (n=285)• ~40% in The Netherlands, Germany
Farm prevalence• 66% in Denmark (n=3)• 45% in Canada (n=20)• 68% in Belgium (n=50)
Study differences• 81% vs 23% MRSA (+) farms in The Netherlands
www.prlog.org
Survey of 2 production systems in IA, IL• Comprise ~90,000 animals
Nasal swabs from 299 swine, 20 workers MRSA prevalence
• 49% in swine (147/299)• 45% in workers (9/20)
MRSA (+) only on Farm A• 70% in swine (147/209)• 64% in workers (9/14)
Smith, TC, et al, PLoS One. 2009;4(1):e4258www.needalittleadvice.com
Isolates tested by PFGE• Non-typeable by smaI, typeable by EagI
MLST revealed clonal isolates• Not related to common IA isolates• MRSA ST398
Isolates PVL negative Workers and swine apparently unaffected
www.thepigpage.com
Early Belgian study (Willems, 2007) : • risk for piglets > sows or fattening pigs
Canadian study (Weese, et al, 2009) :• Low prevalence in piglets (<10%)• Prevalence peaked at 64% (42 d)• Dropped to 41% at study end (70 d)
Other studies show no effect
www.thisisstaffordshire.co.uk
Similar results in USA study
Smith, TC, et al, PLoS One. 2009;4(1):e4258
LA-MRSA first detected in mastitic milk Few published reports of MRSA (+)
cattle• MRSA (+) milk/nasal swab samples in France (Alves, et al., 2009)
MRSA ST398 found in mastitic milk in S. Korea (Lee 2006, Moon 2007)
• Quarter level prevalence very low (<0.2%)
www.farmville.wikia.com
MRSA ST398 never detected in US milk 357 isolates of S. aureus from 24 NC
dairy herds (Anderson, et al., 2006)
• No MRSA isolates Comprehensive study by NAHMS 2009 (Virgin, et al., 2009)
542 bulk milk tank samples (17 states)
• No MRSA
www.scientificamerican.com
Due to elaboration of enterotoxins• Symptoms generally mild• Often undiagnosed
One report of MRSA food poisoning (Jones, et al., 2002)
• Contaminated coleslaw• Isolate from hospital origin
No reports of LA-MRSA food intoxication
www.mylot.com
MRSA ST398 never detected in US food
Spain survey (Lozano,
et al., 2009):• 318 raw meat
samples• Chicken, pork, veal,
lamb, poultry, rabbit, game
• 2 MRSA ST398 (+) samples: pork and veal www.venere.com
Dutch survey (de Boer, et al., 2009):• 2217 raw meat samples• beef, pork, veal, lamb/mutton, chicken,
turkey, fowl and game • Incidence highest in poultry and veal• Also found in turkey, lamb and sheep meat
www.thefreedictionary.com
Apparent capacity to transfer with close animal contact• Especially swine workers
Also demonstrated in veal farming• Lone report of LA-MRSA carriage
Unknown mechanism No increased risk for dairy/beef farmers
www.Ft.com
Pig health conference in Denmark Nasal/throat swab from 272
registrants 34 (12.5%) MRSA (+) from 9
countries• 31/34 MRSA ST398
Wulf, et al., Clin Microbiol Infect. 2008 Jan;14(1):29-34
www.bacontoday.com
Survey of US Veterinary Teaching Hosp.
70 S. aureus isolates, 9/70 MRSA 9 (+)’s: 4 EQ, 4 CN, 1 FE No MRSA ST398
Prevalent colonizer of swine • Less common in other livestock
Poor host specificity• Capable of transfer to humans• Higher prevalence in livestock workers
Reports of associated disease rare Potential to acquire virulence or resistance factors
www.clker.com
Veterinary University of Austria• 140 swabs of wounds/incisions • 25 (+) MRSA, 7 MRSA ST398• All contracted after admission
Faculty of Vet Medicine, Ghent University• 110 horses screened• 12 (+) MRSA ST398• 1 infected wound
www.itstrulyrandom.com
Cultured from foot ulcer (The Netherlands 2008)• 5 other patients
colonized• No pig or cattle
contact 3687 MRSA isolates
– Canadian D-labs (2010)• 5 MRSA ST398
samples• No livestock contact
12 yr old Spanish girl• Skin lesion (2010)• Near pig farm• 2 types isolated
Croatian pig farmer bitten on arm (2008)• Complicated soft
tissue infection
www.northernvirginiamag.com