Antibiotic resistance and molecular typing of clinical Staphylococcus aureus isolates from Malaysian military hospital

Abstract

Objective: To determine the antibiotic resistance profile (ARP) of Staphylococcus ( S.) aureus isolates and molecular typing of the methicillin-resistant S. aureus (MRSA) isolates from Tuanku Mizan Armed Forces Hospital (TMAFH), Kuala Lumpur. Methods: The ARP and presence of the pvl gene were determined for 209 S. aureus isolates from clinical specimens. Of these, 123 were methicillin-susceptible S. aureus (MSSA) isolates and 86 were MRSA isolates. All MRSA isolates were characterized using SCC mec typing and spa typing. Descriptive analysis was performed to compare the demographic data with the phenotypic and genotypic variables of the S. aureus isolates. Results: No vancomycin-intermediate and -resistant S. aureus (VISA and VRSA, respectively) were detected among the study isolates. The MSSA isolates showed low resistance rates to all tested antibiotics, were commonly invasive (28/42, 66.7%), and mostly harboured pvl (35/42, 83.3%). Meanwhile, MRSA isolates showed high resistance to penicillin (86/86, 100%), ampicillin (86/86, 100%), sulbactam/ampicillin (86/86, 100%), cefuroxime (81/86, 94.19%), cefoperazone (76/86, 88.37%), azithromycin (56/86, 65.12%), and erythromycin (54/86, 62.79%). The majority of MRSA isolates were of SCC mec type IVh (65/86, 75.58%), spa type t032 (55/85, 63.95%), and grouped into spaCC-t022 (66/85, 77.65%). The t032 type was found to be associated with resistance traits to azithromycin and erythromycin (P<0.05). We also found several spa types that are typically associated with hospital-, community-, and livestock-associated MRSA co-existing in our MRSA population. Conclusions: This study reflected the consistent absence of VISA and VRSA and corroborated the clonal shifting of MRSA isolates in the Malaysian MRSA isolates.

Keywords

Staphylococcus aureus / Methicillin-resistant Staphylococcus aureus / spa typing / SCCmec typing / Antibiotic resistance

References

[1] Shakrin NNSM, Junaidi NSSA, Huri MFD, Rahmat F, Ahmad NA, Kamarudin AZ, et al. Antibiotic susceptibility profiles of Staphylococcus aureus in Hospital Angkatan Tentera Tuanku Mizan (HATTM), Malaysia: A preliminary study. Zulfaqar J Def Sci Eng Tech 2021; 4(2):108-116.

[2] Klein S, Hannesen J, Zanger P, Heeg K, Boutin S, Nurjadi D. Entry of Panton-Valentine Leukocidin-positive Methicillin-resistant Staphylococcus aureus into the hospital: Prevalence and population structure in Heidelberg, Germany 2015-2018. Sci Rep 2020; 10(1):13243.

[3] Ruscio FD, Guzzetta G, Bjørnholt JV, Leegaard TM, Moen AEF, Merler S, et al. Quantifying the transmission dynamics of mrsa in the community and healthcare settings in a low-prevalence country. Proc Natl Acad Sci USA 2019; 116(29):14599-14605.

[4] Zhang K, McClure JA, Elsayed S, Louie T, Conly JM. Novel multiplex PCR assay for simultaneous identification of community-associated methicillin-resistant Staphylococcus aureus strains USA300 and USA400 and detection of mecA and Panton-Valentine Leukocidin genes, with discrimination of Staphylococcus aureus. J Clin Microbiol 2008; 46(3):1118-1122.

[5] Ghaznavi-Rad E, Nor Shamsudin M, Sekawi Z, van Belkum A, Neela V. A simplified multiplex PCR assay for fast and easy discrimination of globally distributed Staphylococcal cassette chromosome mec types in methicillin-resistant Staphylococcus aureus. J Med Microbiol 2010; 59(10):1135-1139.

[6] Harmsen D, Claus H, Witte W, Claus H, Turnwald D, Vogel U. Typing of methicillin-resistant. Society 2003; 41(12):5442-5448.

[7] Sit PS, Teh CSJ, Idris N, Sam IC, Syed Omar SF, Sulaiman H, et al. Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection and the molecular characteristics of MRSA bacteraemia over a two-year period in a tertiary teaching hospital in Malaysia. BMC Infect Dis 2017; 17(1):1-14.

[8] Jennifer Curry CA, Usn M, Jason Maguire CD, Fraser J, Tribble DR, Deiss RG, et al. Prevalence of Staphylococcus aureus colonization and risk factors for infection among military personnel in a shipboard setting. Mil Med 2016; 181(6):524-529. doi:10.7205/MILMED-D-15-00274.

[9] Michael Washington MA, Usa M, Willie Agee III CA, Kajiura L, Staege CM, Uyehara CF, et al. An analysis of Staphylococcus aureus infections at a military medical center using the PLEX-ID combined Polymerase Chain Reaction-Mass spectrometry system. Mil Med 2014; 179(4):445-450.

[10] Amran F, Hashim R, Rashid FA, Zamri HF, Amdan NAN, Ali MRM, et al. National antibiotic resistance surveillance report 2020. Ministry of Health Malaysia, 2020.

[11] Sit PS, Teh CSJ, Idris N, Sam IC, Syed Omar SF, Sulaiman H, et al. Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection and the molecular characteristics of mrsa bacteraemia over a two-year period in a tertiary teaching hospital in Malaysia. BMC Infect Dis 2017; 17(1):1-14.

[12] Hamzah AMC, Yeo CC, Puah SM, Chua KH, Rahman NIA, Abdullah FH, et al. Tigecycline and inducible clindamycin resistance in clinical isolates of methicillin-resistant Staphylococcus aureus from Terengganu, Malaysia. J Med Microbiol 2019; 68(9):1299-1305.

[13] Landrum ML, Neumann C, Cook C, Chukwuma U, Ellis MW, Hospenthal DR, et al. Epidemiology of Staphylococcus aureus blood and skin and soft tissue infections in the US military health system, 2005-2010. JAMA 2012; 308(1):50-59.

[14] Ko JH, Moon SM. Evaluation of methicillin-resistance rates among community-associated Staphylococcus aureus infections in korean military personnel. J Korean Med Sci 2018; 33(39):1-6.

[15] Hashim R, Rashid FA, Zamri HF, Amdan NAN, Ali MRM, Noor AM. National antibiotic resistance surveillance report 2019. Ministry of Health Malaysia, 2019.

[16] Jones SU, Chua KH, Chew CH, Yeo CC, Abdullah FH, Othman N, et al. spa diversity of methicillin-resistant and -susceptible Staphylococcus aureus in clinical strains from Malaysia: A high prevalence of invasive European spa-type t032. Peer J 2021; 9:e11195.

[17] Kanjilal S, Abdul Sater MR, Thayer M, Lagoudas GK, Kim S, Blainey PC, et al. Trends in antibiotic susceptibility in Staphylococcus aureus in Boston, Massachusetts, from 2000 to 2014. J Clin Microbiol 2018; 56(1):1-9.

[18] Bariman MH, Mahmoud MIAM, binti Hamzah HA. Phenotypic and genotypic characterization, and detection of PVL encoding gene in methicillin resistant Staphylococcus aureus strains isolated from patients admitted to a tertiary hospital in Kuantan, Malaysia. Int Med J Malaysia 2019; 18(2):87-94.

[19] Guthrie JL, Teatero S, Hirai S, Fortuna A, Rosen D, Mallo GV, et al. Genomic epidemiology of invasive methicillin-resistant Staphylococcus aureus infections among hospitalized individuals in Ontario, Canada. J Infect Dis 2020; 222(12):2071-2081.

[20] Sukri A, Saat MNF, Yusof NAM, Zin NM, Rachman ARA. Differences in antibiotic resistance profiles of methicillin-susceptible and -resistant Staphylococcus aureus isolated from the teaching hospital in Kuala Lumpur, Malaysia. J Appl Biol Biotechnol 2021; 9(4):98-103.

[21] Jin Y, Zhou W, Zhan Q, Chen Y, Luo Q, Shen P, et al. Genomic epidemiology and characterisation of penicillin-sensitive Staphylococcus aureus isolates from invasive bloodstream infections in China: An increasing prevalence and higher diversity in genetic typing be revealed. Emerg Microbes Infect 2022; 11(1):326-336.

[22] Hamzah AMC, Yeo CC, Puah SM, Chua KH, Chew CH. Staphylococcus aureus infections in Malaysia: A review of antimicrobial resistance and characteristics of the clinical isolates, 1990-2017. Antibiotics 2019; 8(3):1990-2017.

[23] Niek WK, Teh CSJ, Idris N, Thong KL, Ponnampalavanar S. Predominance of ST22-MRSA-IV clone and emergence of clones for methicillin-resistant Staphylococcus aureus clinical isolates collected from a tertiary teaching hospital over a two-year period. Jpn J Infect Dis 2019; 72(4):228-236.

[24] Yuan W, Liu J, Zhan Y, Wang L, Jiang Y, Zhang Y, et al. Molecular typing revealed the emergence of pvl-positive sequence type 22 methicillin-susceptible Staphylococcus aureus in Urumqi, Northwestern China. Infect Drug Resist 2019; 12:1719.

[25] Aung MS, Zi H, Nwe KM, Maw WW, Aung MT, Min WW, et al. Drug resistance and genetic characteristics of clinical isolates of staphylococci in Myanmar: High prevalence of PVL among methicillin-susceptible Staphylococcus aureus belonging to various sequence types. New Microbes New Infect 2016; 10:58-65.

[26] Jaiswal R, Garg A, Tripathi P, Venkatesh V. Epidemiology of Panton Valentine Leukocidin in clinical Staphylococcus aureus isolates - A prospective study at a tertiary care centre in North India. Clin Epidemiol Glob Health 2022; 15:101006.

[27] Ahmad NI, Yean Yean C, Foo PC, Mohamad Safiee AW, Hassan SA. Prevalence and association of panton-valentine leukocidin gene with the risk of sepsis in patients infected with methicillin resistant Staphylococcus aureus. J Infect Public Health 2020; 13(10):1508-1512.

[28] Qu M da, Kausar H, Smith S, Lazar PG, Kroll-Desrosiers AR, Hollins C, et al. Epidemiological and clinical features of Panton-Valentine Leukocidin positive Staphylococcus aureus bacteremia: A case-control study. PLoS One 2022; 17(3):e0265476.

[29] Nichol KA, Adam HJ, Golding GR, Lagacé-Wiens PRS, Karlowsky JA, Hoban DJ, et al. Characterization of MRSA in Canada from 2007 to 2016. J Antimicrob Chemother 2019; 74(Supplement_4):iv55-iv63.

[30] Ismail MAH, Kamarudin N, Samat MNA, Rahman RMFRA, Saimun S, Tan TL, et al. Methicillin-resistant Staphylococcus aureus (MRSA) clonal replacement in a malaysian teaching hospital: Findings from an eight-year interval molecular surveillance. Antibiotics 2021; 10(3):320.

[31] Hsu LY, Harris SR, Chlebowicz MA, Lindsay JA, Koh TH, Krishnan P, et al. Evolutionary dynamics of methicillin-resistant Staphylococcus aureus within a healthcare system. Genome Biol 2015; 16(1):1-13.

[32] Cuny C, Layer F, Werner G, Harmsen D, Daniels-Haardt I, Jurke A, et al. State-wide surveillance of antibiotic resistance patterns and spa types of methicillin-resistant Staphylococcus aureus from blood cultures in North Rhine-Westphalia, 2011-2013. Clin Microbiol Infect 2015; 21(8):750-757.

[33] Votintseva AA, Fung R, Miller RR, Knox K, Godwin H, Wyllie DH, et al. Prevalence of Staphylococcus aureus protein A (spa) mutants in the community and hospitals in Oxfordshire. BMC Microbiol 2014; 14(1):1-11.

[34] Ho WY, Choo QC, Chew CH. Predominance of three closely related methicillin-resistant Staphylococcus aureus clones carrying a unique ccrC-positive SCCmec type III and the emergence of spa t304 and t690 SCCmec type IV pvl+ MRSA isolates in Kinta Valley, Malaysia. Microbial Drug Resistance 2017; 23(2):215-223.

[35] Möllers M, von Wahlde MK, Schuler F, Mellmann A, Böing C, Schwierzeck V, et al. Outbreak of MRSA in a Gynecology/Obstetrics Department during the COVID-19 pandemic: A cautionary tale. Microorganisms 2022; 10(4):689.

[36] Chamon RC, Ribeiro S da S, da Costa TM, Nouér SA, dos Santos KRN. Complete substitution of the Brazilian endemic clone by other methicillin-resistant Staphylococcus aureus lineages in two public hospitals in Rio de Janeiro, Brazil. Braz J Infect Dis 2017; 21(2):185-189.

[37] Nurjadi D, Fleck R, Lindner A, Schäfer J, Gertler M, Mueller A, et al. Import of community-associated, methicillin-resistant Staphylococcus aureus to Europe through skin and soft-tissue infection in intercontinental travellers, 2011-2016. Clin Microbiol Infect 2019; 25(6):739-746.

[38] Earls MR, Kinnevey PM, Brennan GI, Lazaris A, Skally M, O’Connell B, et al. The recent emergence in hospitals of multidrug-resistant community-associated sequence type 1 and spa type t127 methicillin-resistant Staphylococcus aureus investigated by whole-genome sequencing: Implications for screening. PLoS One 2017; 12(4):1-17. doi: 10.1371/JOURNAL.PONE.0175542.

[39] Hashemizadeh Z, Hadi N, Mohebi S, Kalantar-Neyestanaki D, Bazargani A. Characterization of SCCmec, spa types and Multi Drug Resistant of methicillin-resistant Staphylococcus aureus isolates among inpatients and outpatients in a referral hospital in Shiraz, Iran. BMC Res Notes 2019; 12(1):1-6.

[40] Merla C, Kuka A, Petazzoni G, Postiglione U, Zatelli M, Gaiarsa S, et al. Livestock-associated methicillin-resistant Staphylococcus aureus in inpatients: A snapshot from an Italian hospital. J Glob Antimicrob Resist 2022; 30:10-15.

[41] Singh-Moodley A, Lowe M, Mogokotleng R, Perovic O. Diversity of SCCmec elements and spa types in South African Staphylococcus aureus mecA-positive blood culture isolates. BMC Infect Dis 2020; 20(1):1-12.