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Coexistence of Panton-Valentine leukocidin-positive and -negative community-associated methicillin-resistant Staphylococcus aureus USA400 sibling strains in a large Canadian health-care region.

https://arctichealth.org/en/permalink/ahliterature159491
Source
J Infect Dis. 2008 Jan 15;197(2):195-204
Publication Type
Article
Date
Jan-15-2008
Author
Kunyan Zhang
Jo-Ann McClure
Sameer Elsayed
Jonathan Tan
John M Conly
Author Affiliation
Centre for Antimicrobial Resistance, Calgary Health Region/Calgary Laboratory Services/University of Calgary, Calgary, Alberta, Canada. kzhang@ucalgary.ca
Source
J Infect Dis. 2008 Jan 15;197(2):195-204
Date
Jan-15-2008
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Bacterial Toxins - genetics - metabolism
Canada - epidemiology
Community-Acquired Infections - epidemiology - microbiology
Cross Infection - epidemiology - microbiology
Electrophoresis, Gel, Pulsed-Field
Exotoxins - genetics - metabolism
Female
Genotype
Humans
Leukocidins - genetics - metabolism
Male
Methicillin Resistance
Middle Aged
Phenotype
Random Amplified Polymorphic DNA Technique
Staphylococcal Infections - epidemiology - microbiology
Staphylococcus aureus - classification - drug effects - genetics - isolation & purification
Abstract
Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) strains often carry the Panton-Valentine leukocidin (PVL) genes. However, the specific role that PVL plays in the epidemiological features and pathogenesis of CA-MRSA infections has remained undefined and controversial. Conducting a retrospective study on a natural population of MRSA clinical isolates recovered from community and hospital patients in a large Canadian health-care region during a 6-year period, we identified the coexistence of 2 USA400 (a major clonal group of CA-MRSA) sibling strains with and without PVL genes. Polymerase chain reaction and sequence analysis indicated that the PVL-carrying prophage phiSa2mw was present in PVL(+) but absent in PVL(-) USA400 isolates. These strains shared identical genotypic and phenotypic properties and similar clinical characteristics. This study provides direct evidence that PVL genes are not necessarily the key determinants associated with the increasing dissemination of CA-MRSA strains, suggesting that the genomic milieu may play a greater role in this regard.
Notes
Comment In: J Infect Dis. 2008 Jan 15;197(2):179-8218173362
PubMed ID
18173361 View in PubMed
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Community-acquired methicillin-resistant Staphylococcus aureus, Finland.

https://arctichealth.org/en/permalink/ahliterature190112
Source
Emerg Infect Dis. 2002 Jun;8(6):602-7
Publication Type
Article
Date
Jun-2002
Author
Saara Salmenlinna
Outi Lyytikäinen
Jaana Vuopio-Varkila
Author Affiliation
Department of Microbiology, National Public Health Institute, Helsinki, Finland. saara.salmenlinna@ktl.fi
Source
Emerg Infect Dis. 2002 Jun;8(6):602-7
Date
Jun-2002
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Bacteriophage Typing
Child
Child, Preschool
Community-Acquired Infections - drug therapy - epidemiology - transmission
DNA, Bacterial - chemistry - genetics
Disease Transmission, Infectious
Electrophoresis, Gel, Pulsed-Field
Female
Finland - epidemiology
Humans
Infant
Male
Methicillin Resistance
Middle Aged
Retrospective Studies
Ribotyping
Staphylococcal Infections - drug therapy - epidemiology - transmission
Staphylococcus aureus - classification - drug effects - genetics
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is no longer only hospital acquired. MRSA is defined as community acquired if the MRSA-positive specimen was obtained outside hospital settings or within 2 days of hospital admission, and if it was from a person who had not been hospitalized within 2 years before the date of MRSA isolation. To estimate the proportion of community-acquired MRSA, we analyzed previous hospitalizations for all MRSA-positive persons in Finland from 1997 to 1999 by using data from the National Hospital Discharge Register. Of 526 MRSA-positive persons, 21% had community-acquired MRSA. Three MRSA strains identified by phage typing, pulsed-field gel electrophoresis, and ribotyping were associated with community acquisition. None of the strains were multiresistant, and all showed an mec hypervariable region hybridization pattern A (HVR type A). None of the epidemic multiresistant hospital strains were prevalent in nonhospitalized persons. Our population-based data suggest that community-acquired MRSA may also arise de novo, through horizontal acquisition of the mecA gene.
Notes
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PubMed ID
12023917 View in PubMed
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Community-associated methicillin-resistant Staphylococcus aureus, Canada.

https://arctichealth.org/en/permalink/ahliterature174258
Source
Emerg Infect Dis. 2005 Jun;11(6):844-50
Publication Type
Article
Date
Jun-2005
Author
Michael R Mulvey
Laura MacDougall
Brenda Cholin
Greg Horsman
Melanie Fidyk
Shirley Woods
Author Affiliation
National Microbiology Laboratory, Winnipeg, Manitoba, Canada. michael_mulvey@phac-aspc.gc.ca
Source
Emerg Infect Dis. 2005 Jun;11(6):844-50
Date
Jun-2005
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Anti-Bacterial Agents - pharmacology
Bacterial Proteins - genetics
Bacterial Toxins
Child
Communicable Diseases, Emerging - epidemiology - microbiology
Community-Acquired Infections - epidemiology - microbiology
Exotoxins
Humans
Leukocidins - genetics
Methicillin Resistance
Microbial Sensitivity Tests
Middle Aged
Saskatchewan - epidemiology
Soft Tissue Infections - epidemiology - microbiology
Staphylococcal Infections - epidemiology - microbiology
Staphylococcal Skin Infections - epidemiology - microbiology
Staphylococcus aureus - classification - drug effects - genetics
Abstract
A total of 184 methicillin-resistant Staphylococcus aureus (MRSA) strains were collected from patients who sought treatment primarily for skin and soft tissue infections from January 1, 1999, to March 31, 2002, in east-central Saskatchewan, Canada. Molecular subtyping analysis using pulsed-field gel electrophoresis showed 2 major clusters. Cluster A (n = 55) was composed of a multidrug-resistant MRSA strain associated with a long-term care facility and was similar to the previously reported nosocomial Canadian epidemic strain labeled CMRSA-2. Cluster B (n = 125) was associated with cases identified at community health centers and was indistinguishable from a community-associated (CA)-MRSA strain identified previously in the United States (USA400). Cluster B remained susceptible to a number of classes of antimicrobial agents and harbored the lukF-PV and lukS-PV toxin genes. Over 50% of both clonal groups displayed high-level resistance to mupirocin. This is the first report of the USA400 strain harboring the lukF-PV and lukS-PV toxin genes in Canada.
Notes
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PubMed ID
15963278 View in PubMed
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Comparative genomics of Canadian epidemic lineages of methicillin-resistant Staphylococcus aureus.

https://arctichealth.org/en/permalink/ahliterature164196
Source
J Clin Microbiol. 2007 Jun;45(6):1904-11
Publication Type
Article
Date
Jun-2007
Author
Sara Christianson
George R Golding
Jennifer Campbell
Michael R Mulvey
Author Affiliation
National Microbiology Laboratory, Winnipeg, Manitoba R3E 3R2, Canada.
Source
J Clin Microbiol. 2007 Jun;45(6):1904-11
Date
Jun-2007
Language
English
Publication Type
Article
Keywords
Bacterial Proteins - genetics
Canada - epidemiology
Community-Acquired Infections - epidemiology - microbiology
Cross Infection - epidemiology - microbiology
Disease Outbreaks
Electrophoresis, Gel, Pulsed-Field
Genome, Bacterial
Genomics
Humans
Methicillin Resistance
Staphylococcal Infections - epidemiology - microbiology
Staphylococcus aureus - classification - drug effects - genetics
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) is a pathogen that has disseminated throughout Canadian hospitals and communities. Pulsed-field gel electrophoresis of over 9,300 MRSA isolates obtained from the Canadian Nosocomial Infection Surveillance Program has identified 10 epidemic strain types in Canada (CMRSA1 to CMRSA10). In an attempt to determine specific genetic factors that have contributed to their high prevalence in community and/or hospital settings, the genomic content of representative isolates for each of the 10 Canadian epidemic types was compared using comparative genomic hybridizations. Comparison of the community-associated Canadian epidemic isolates (CMRSA7 and CMRSA10) with the hospital-associated Canadian epidemic isolates revealed one open reading frame (ORF) (SACOL0046) encoding a putative protein belonging to a metallo-beta-lactamase family, which was present only in the community-associated Canadian epidemic isolates. A more restricted comparison involving only the most common hospital-associated Canadian epidemic isolates (CMRSA1 and CMRSA2) with the community-associated Canadian epidemic isolates did reveal additional factors that might be contributing to their prevalence in the community and hospital settings, which included ORFs encoding potential virulence factors involved in capsular biosynthesis, serine proteases, epidermin, adhesion factors, regulatory functions, leukotoxins, and exotoxins.
Notes
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PubMed ID
17428941 View in PubMed
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The decline of the impetigo epidemic caused by the epidemic European fusidic acid-resistant impetigo clone: an 11.5-year population-based incidence study from a community in Western Norway.

https://arctichealth.org/en/permalink/ahliterature262687
Source
Scand J Infect Dis. 2014 Dec;46(12):832-7
Publication Type
Article
Date
Dec-2014
Author
Sverre Rørtveit
Dag Harald Skutlaberg
Nina Langeland
Guri Rortveit
Source
Scand J Infect Dis. 2014 Dec;46(12):832-7
Date
Dec-2014
Language
English
Publication Type
Article
Keywords
Adult
Anti-Bacterial Agents - therapeutic use
Cohort Studies
Drug Resistance, Bacterial
Epidemics
Female
Fusidic Acid - therapeutic use
Humans
Impetigo - epidemiology - microbiology
Incidence
Male
Middle Aged
Molecular Typing
Norway - epidemiology
Staphylococcus aureus - classification - drug effects - genetics - isolation & purification
Abstract
From around the year 2000, Northern Europe experienced a rise in impetigo caused by Staphylococcus aureus resistant to fusidic acid. A single clone of S. aureus was found to be the bacterial pathogen involved in the impetigo outbreak in Norway, Sweden, the UK and Ireland, termed 'the epidemic European fusidic acid-resistant impetigo clone' (EEFIC). We have followed the incidence of impetigo during the years 2001-2012 based on all patients in general practice in the island community of Austevoll, Western Norway. We previously reported a marked decline of impetigo incidence in Austevoll, from 0.0260 cases per person-year in 2002 to 0.0038 in 2009. This article explores indications of an end to the impetigo epidemic caused by the EEFIC clone.
All four general practitioners (GPs) in the community (mean population = 4400) were asked to diagnose impetigo in a uniform way and to take bacterial specimens from all impetigo cases. Phenotypic characteristics of specimen bacteria were determined for the whole period and molecular analyses were performed on isolates in the period 2008-2012.
We observed a further decline in incidence of impetigo in Austevoll in the study period. The proportion of fusidic acid-resistant S. aureus isolates decreased during the period 2002-2012, with a mean of 80% in the epidemic years of 2002-2004, 55% in 2005-2009, and 6% in 2010-2012. In total, 44 S. aureus isolates from impetigo were subject to molecular analyses in the period 2008-2012, and 11 were found to be related to the EEFIC. All EEFIC isolates were found in 2008-2009, with no new isolates in 2010-2012.
There is an apparent end to the impetigo epidemic related to the EEFIC in this population in Western Norway.
Notes
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PubMed ID
25229166 View in PubMed
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Detection and characterisation of SCCmec remnants in multiresistant methicillin-susceptible Staphylococcus aureus causing a clonal outbreak in a Swedish county.

https://arctichealth.org/en/permalink/ahliterature134420
Source
Eur J Clin Microbiol Infect Dis. 2012 Feb;31(2):141-7
Publication Type
Article
Date
Feb-2012
Author
M. Lindqvist
B. Isaksson
C. Grub
T Ã? Jonassen
A. Hällgren
Author Affiliation
Department of Infection Control, Linköping University Hospital, Linköping, Sweden. maria.m.lindqvist@lio.se
Source
Eur J Clin Microbiol Infect Dis. 2012 Feb;31(2):141-7
Date
Feb-2012
Language
English
Publication Type
Article
Keywords
Anti-Bacterial Agents - pharmacology
Bacterial Typing Techniques
DNA Transposable Elements - genetics
Disease Outbreaks
Drug Resistance, Multiple, Bacterial
Humans
Methicillin - pharmacology
Methicillin Resistance - genetics
Methicillin-Resistant Staphylococcus aureus - genetics
Microbial Sensitivity Tests
Polymerase Chain Reaction
Sequence Analysis, DNA
Staphylococcal Infections - epidemiology - microbiology
Staphylococcus aureus - classification - drug effects - genetics
Sweden - epidemiology
Abstract
The purpose of this study was to investigate if multiresistant methicillin-susceptible Staphylococcus aureus (MR-MSSA) causing a clonal outbreak in �stergötland County, Sweden, were derived from methicillin-resistant S. aureus (MRSA) by carrying remnants of SCCmec, and, if so, to characterise this element. A total of 54 MSSA isolates with concomitant resistance to erythromycin, clindamycin and tobramycin from 49 patients (91% clonally related, spa type t002) were investigated with the BD GeneOhm MRSA assay and real-time polymerase chain reaction (PCR) targeting the SCCmec integration site/SCCmec right extremity junction. DNA sequencing of one isolate representing the MR-MSSA outbreak clone was performed by massive parallel 454 pyrosequencing. All isolates that were part of the clonal outbreak carried SCCmec remnants. The DNA sequencing revealed the carriage of a pseudo-SCC element 12 kb in size, with a genomic organisation identical to an SCCmec type ?? element, except for a 41-kb gap. This study demonstrates the presence of a pseudo-SCC element resembling SCCmec type II among MR-MSSA, suggesting possible derivation from MRSA. The presence of SCCmec remnants should always be considered when SCCmec typing is used for MRSA detection, and may not be suitable in locations with a high prevalence of MR-MSSA, since this might give a high number of false-positive results.
PubMed ID
21590357 View in PubMed
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Dissemination of community-acquired methicillin-resistant Staphylococcus aureus clones in northern Norway: sequence types 8 and 80 predominate.

https://arctichealth.org/en/permalink/ahliterature174947
Source
J Clin Microbiol. 2005 May;43(5):2118-24
Publication Type
Article
Date
May-2005
Author
Anne-Merethe Hanssen
Aina Fossum
Jarle Mikalsen
Dag S Halvorsen
Geir Bukholm
Johanna U Ericson Sollid
Author Affiliation
Department for Microbiology and Virology, Faculty of Medicine, Institute of Medical Biology, University of Tromsø, N-9037 Tromsø, Norway. annemh@fagmed.uit.no
Source
J Clin Microbiol. 2005 May;43(5):2118-24
Date
May-2005
Language
English
Publication Type
Article
Keywords
Community-Acquired Infections - epidemiology - microbiology - transmission
Humans
Methicillin Resistance
Microbial Sensitivity Tests
Molecular Epidemiology - methods
Norway - epidemiology
Phylogeny
Serotyping
Staphylococcal Infections - epidemiology - microbiology - transmission
Staphylococcus aureus - classification - drug effects - genetics - isolation & purification
Abstract
Increasing frequencies of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) strain isolation have been reported from many countries. The overall prevalence of MRSA in Norway is still very low. MRSA isolates (n = 67) detected between 1995 and 2003 in northern Norway were analyzed by pulsed-field gel electrophoresis, multilocus sequence typing, and staphylococcal cassette chromosome mec (SCCmec) typing. Sixty-seven isolates were associated with 13 different sequence types. Two successful MRSA clones predominated. Sequence type 8 (ST8) (40%) and ST80 (19%) containing SCCmec type IV were detected in hospitals and communities in different geographic regions during a 7-year period. In general, there was a low level of antimicrobial resistance. Only 26% of the isolates were multiresistant. International epidemic clones were detected. The frequent findings of SCCmec type IV (91%) along with heterogeneous genetic backgrounds suggest a horizontal spread of SCCmec type IV among staphylococcal strains in parallel with the clonal spread of successful MRSA strains.
Notes
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PubMed ID
15872230 View in PubMed
Less detail

Emergence and characterization of community-associated methicillin-resistant Staphyloccocus aureus infections in Denmark, 1999 to 2006.

https://arctichealth.org/en/permalink/ahliterature91458
Source
J Clin Microbiol. 2009 Jan;47(1):73-8
Publication Type
Article
Date
Jan-2009
Author
Larsen A R
Stegger M.
Böcher S.
Sørum M.
Monnet D L
Skov R L
Author Affiliation
Statens Serum Institut, National Center for Antimicrobials and Infection Control, Artillerivej 5 (B.47/204), 2300 Copenhagen S, Denmark.
Source
J Clin Microbiol. 2009 Jan;47(1):73-8
Date
Jan-2009
Language
English
Publication Type
Article
Keywords
Age Factors
Bacterial Toxins - genetics
Bacterial Typing Techniques
Cluster analysis
Community-Acquired Infections - epidemiology - microbiology - transmission
DNA Fingerprinting
DNA, Bacterial - genetics
Denmark - epidemiology
Exotoxins - genetics
Family Health
Leukocidins - genetics
Methicillin-Resistant Staphylococcus aureus - classification - drug effects - genetics - isolation & purification
Microbial Sensitivity Tests
Soft Tissue Infections - epidemiology - microbiology
Staphylococcal Skin Infections - epidemiology - microbiology - transmission
Abstract
The epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) infections has changed worldwide. From being strictly nosocomial, MRSA is now frequently found as a community-associated (CA) pathogen. Denmark has been a low-prevalence country for MRSA since the mid-1970s but has in recent years experienced an increasing number of CA-MRSA cases. The aim of this study was to describe the emergence of CA-MRSA infections in Denmark. All Danish MRSA specimens and corresponding clinical data from 1999 to 2006 were investigated. Isolates were analyzed by antibiotic resistance and molecular typing and were assigned to clonal complexes (CC). Clinical data were extracted from discharge summaries and general practitioners' notes, from which assessments of community association were made for all infected cases. CA-MRSA cases constituted 29.4% of all MRSA infections (n = 1,790) and an increasing proportion of the annual numbers of MRSA infections during the study period. CA-MRSA was associated with a young age, skin and soft tissue infections, and non-Danish origin. Transmission between household members was frequently reported. Molecular typing showed >60 circulating clones, where 89.4% of the isolates belonged to five CC (CC80, CC8, CC30, CC5, and CC22), 81.2% carried staphylococcal cassette chromosome mec IV, and 163/244 (69.4%) were positive for Panton-Valentine leukocidin. Clinical and microbiological characteristics indicated that import of MRSA occurs frequently. Resistance to > or =3 antibiotic classes was observed for 48.8% of the isolates. The emergence of CA-MRSA in Denmark was caused by diverse strains, both well-known and new CA-MRSA strains. The results suggest multiple introductions of MRSA as an important source for CA-MRSA infections in Denmark.
PubMed ID
18971362 View in PubMed
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Epidemiological typing of methicillin-resistant Staphylococcus aureus (MRSA): spa typing versus pulsed-field gel electrophoresis.

https://arctichealth.org/en/permalink/ahliterature151074
Source
Scand J Infect Dis. 2009;41(6-7):433-9
Publication Type
Article
Date
2009
Author
Sara Melin
Sara Haeggman
Barbro Olsson-Liljequist
Maria Sjölund
Peter A Nilsson
Barbro Isaksson
Sture Löfgren
Andreas Matussek
Author Affiliation
Department of Clinical Microbiology, Division of Laboratory Medicine, County Hospital Ryhov, Jönköping, Sweden.
Source
Scand J Infect Dis. 2009;41(6-7):433-9
Date
2009
Language
English
Publication Type
Article
Keywords
Bacterial Toxins - genetics
Electrophoresis, Gel, Pulsed-Field - methods
Endemic Diseases
Exotoxins - genetics
Genes, Bacterial
Humans
Leukocidins - genetics
Methicillin-Resistant Staphylococcus aureus - classification - drug effects - genetics - isolation & purification
Microbial Sensitivity Tests
Molecular Epidemiology - methods
Sequence Analysis, DNA - methods
Staphylococcal Infections - epidemiology - microbiology
Staphylococcal Protein A - genetics
Sweden - epidemiology
Abstract
Molecular methods based on sequencing, such as spa typing, have facilitated epidemiological typing of bacterial isolates compared to the gold standard pulsed-field gel electrophoresis (PFGE), a technically more demanding method. We studied methicillin-resistant Staphylococcus aureus (MRSA) in 4 Swedish counties from 2003 through 2005, and compared spa typing and PFGE results to epidemiological data. Of 280 MRSA isolates, 91 were from sporadic cases and 189 were associated with 35 outbreaks. A total of 50 spa types and 74 PFGE patterns were detected. 60 (21%) of the MRSA isolates carried the Panton-Valentine leukocidin (PVL) genes. 12 of the PVL-positive MRSA were healthcare associated. 25 of the spa types and 31 of the PFGE patterns were associated with outbreaks. In 1 of the outbreaks we found isolates with different but closely related spa types, and in 6 of the outbreaks we observed isolates with different but related PFGE patterns. In this low-endemic setting, with outbreaks limited in time and place, we found spa typing to be a useful tool for epidemiological typing of MRSA, due to its rapidity, accessibility, ease of use, and standardized nomenclature.
PubMed ID
19431050 View in PubMed
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Epidemiology of European community-associated methicillin-resistant Staphylococcus aureus clonal complex 80 type IV strains isolated in Denmark from 1993 to 2004.

https://arctichealth.org/en/permalink/ahliterature87264
Source
J Clin Microbiol. 2008 Jan;46(1):62-8
Publication Type
Article
Date
Jan-2008
Author
Larsen A R
Böcher S.
Stegger M.
Goering R.
Pallesen L V
Skov R.
Author Affiliation
Statens Serum Institut, National Center for Antimicrobials and Infection Control, Artillerivej 5 (B.47/204), 2300 Copenhagen S, Denmark. arl@ssi.dk
Source
J Clin Microbiol. 2008 Jan;46(1):62-8
Date
Jan-2008
Language
English
Publication Type
Article
Keywords
Adolescent
Adult
Aged
Aged, 80 and over
Anti-Bacterial Agents - pharmacology
Child
Child, Preschool
Cross Infection - epidemiology - microbiology - transmission
DNA Fingerprinting
DNA, Bacterial - genetics
Denmark - epidemiology
Electrophoresis, Gel, Pulsed-Field
Family Health
Genotype
Humans
Infant
Infant, Newborn
Methicillin Resistance
Microbial Sensitivity Tests
Middle Aged
Sequence Analysis, DNA
Soft Tissue Infections - epidemiology - microbiology - transmission
Staphylococcal Infections - epidemiology - microbiology - transmission
Staphylococcal Protein A - genetics
Staphylococcal Skin Infections - epidemiology - microbiology - transmission
Staphylococcus aureus - classification - drug effects - genetics - isolation & purification
Travel
Abstract
In Europe, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have been caused predominantly by isolates belonging to the "European CA-MRSA" clone (sequence type 80, staphylococcal cassette chromosome mec type IV). In this study, the epidemiology of European CA-MRSA was investigated on a nationwide scale, covering the period from 1993 to 2004. Denmark has been a low-prevalence country regarding MRSA since the mid-1970s but has experienced an increase in the number of new MRSA cases in recent years. Our results show that European CA-MRSA contributed to this increase. The isolates primarily caused skin and soft tissue infections (SSTIs) in patients outside hospitals, and transmission between household members was the predominant mode of spread. Although some of the isolates were found in hospitalized patients, nosocomial transmission seemed likely in only one instance, pointing to endogenous infections as an important factor. Compared to the CA-MRSA clone most common in the United States (USA300), the European CA-MRSA clone seems less well adapted to persist in hospital environments. Patients with a recent history of travel or family relation to the Mediterranean or Middle East were highly overrepresented. The epidemiological data indicated that the European CA-MRSA isolates were introduced into Denmark on multiple occasions, paralleled by an increasing level of genetic diversity of the isolates found during the study period. European CA-MRSA has previously been described as a rather uniform clone. However, we found pronounced, diverse pulsed-field gel electrophoresis subtypes, staphylococcal protein A gene (spa) types, and susceptibility patterns.
PubMed ID
17989197 View in PubMed
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