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Journal of Clinical Microbiology, October 2008, p. 3514-3516, Vol. 46, No. 10
0095-1137/08/$08.00+0     doi:10.1128/JCM.00966-08
Copyright © 2008, American Society for Microbiology. All Rights Reserved.

Genetic Lineages of Community-Associated Methicillin-Resistant Staphylococcus aureus in Kuwait Hospitals{triangledown}

E. E. Udo,1* F. G. O'Brien,2 N. Al-Sweih,1 Bobby Noronha,1 B. Matthew,1 and W. B. Grubb2

Department of Microbiology, Faculty of Medicine, Kuwait University, Safait 13110, Kuwait,1 Gram-Positive Bacteria Typing and Research Unit, Molecular Genetics Research Unit, School of Biomedical Sciences, Curtin University of Technology, Perth, Australia2

Received 20 May 2008/ Returned for modification 29 June 2008/ Accepted 7 July 2008


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ABSTRACT
 
Twenty-six community-associated methicillin-resistant Staphylococcus aureus (CAMSRA) isolates were characterized by pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) and screened for accessory gene regulator (agr), capsular polysaccharide (cap), and Panton-Valentine leucocidin (PVL) genes. They exhibited five PFGE patterns (types A to E). The majority were PFGE type A (12 isolates) or type B (8 isolates). MLST showed that PFGE type A isolates belonged to sequence type 80 (ST80), while the PFGE type B isolates were ST30. The ST80 and ST30 clones contained agr allotype 3, cap type 8, and PVL. The results showed that two internationally recognized CAMRSA clones are dominant in Kuwait hospitals.


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TEXT
 
Methicillin-resistant Staphylococcus aureus (MRSA) was initially associated with large health care facilities such as teaching hospitals, nursing homes, and long-term care facilities (1) but have now appeared in community settings (3, 9, 10, 12, 14, 15). These MRSA strains, described as community-acquired or community-associated MRSA (CAMRSA), were initially isolated from individuals residing in remote communities with no access to health care centers (9, 12, 14). However, they are now increasingly isolated from patients in health care environments (9, 10, 12). CAMRSA strains are characterized by their susceptibility to a wide range of non-beta-lactam antibiotics, low methicillin MICs, and the carriage of the type IV or V staphylococcal cassette chromosome mec (SCCmec) element. In contrast health care-associated MRSA strains are usually multiresistant to non-beta-lactam antibiotics and contain type I, II, or III SCCmec elements (1, 13).

The genotype distribution of CAMRSA differs in different geographical regions. Recent reports show that, while the USA300 CAMRSA clone (sequence type 8 [ST8] MRSA, SCCmec type IV [ST8-SCCmec-IV]) is dominant in the United States (10), the ST80-SCCmec-IV and ST30-SCCmec-IV clones are dominant in Europe (3, 15) and the ST30-SCCmec-IV clone is dominant in New Zealand, the southwest Pacific islands, and Singapore (4, 11).

CAMRSA isolates obtained in Kuwait hospitals were previously characterized by antibiotic resistance patterns and SCCmec typing (13), but their sequence types were not determined. Consequently, it was not possible to ascertain whether the CAMRSA strains isolated in Kuwait hospitals constituted indigenous or imported internationally recognized clones. The aim of this study was to determine the genetic lineages and the accessory gene regulator (agr) and capsular polysaccharide (cap) types of CAMRSA strains obtained from patients in Kuwait hospitals to ascertain their relatedness to CAMRSA clones isolated elsewhere. This is important because the population of Kuwait includes a large component of expatriate workers from different countries, which consequently provides opportunities for the dissemination of international bacterial clones.

A total of 26 CAMRSA isolates previously characterized on the basis of SCCmec typing were selected for this study. They were among 1,457 MRSA isolates submitted to the MRSA Reference Laboratory for typing and were isolated between July 2001 and October 2003. They were from 7 outpatients and 19 inpatients in seven hospitals (Table 1). Only one patient was an expatriate worker from the Philippines. The rest were Kuwait nationals. They represented five pulsed-field gel electrophoresis (PFGE) patterns commonly encountered among CAMRSA strains in these hospitals (Fig. 1). Their susceptibility to antibiotics and SCCmec types were described previously (13). The fusidic acid-resistant isolates were investigated for the carriage of the fusidic acid resistance determinant far-1 by PCR as described previously (15), and fusidic acid MICs were determined using the Etest. SCCmec subtyping was performed by the method of Zhang et al. (16) and included WBG8318 (8) as a control for SCCmec type V. The subtypes were assigned based on the sizes of the amplified products (16). The agr (7) and cap (6) types were determined by PCR using primers and protocols described previously. The detection of genes for agr types I, II, III, and IV was performed by PCR using the primers and conditions described by Lina et al. (6). The Panton-Valentine leucocidin (PVL) genes lukS-PV and lukF-PV were detected by PCR using primers described previously (5), with WBG10049 (8) as a positive control. Multilocus sequence typing (MLST) was done as described previously (2).


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  		TABLE 1. Characteristics of CAMRSA isolates


Figure 1
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  		FIG. 1. PFGE of representative CAMRSA isolates. Lane 1, PFGE type A, ST80; lane 2, PFGE type A1, ST80; lane 3, PFGE type A2, ST80; lane 4, PFGE type B, ST30; lane 5, PFGE type B1, ST30; lane 6, PFGE type C, ST8; lane 7, PFGE type C1, ST6; lane 8, PFGE type C2, ST8; lane 9, PFGE type D, ST5; lane 10, PFGE type E, ST361; lane M, molecular size marker.

All 26 isolates expressed low-level methicillin resistance (MIC: 8 to 32 µg/ml) (13) and were resistant to the agents shown in Table 1. The fusidic acid MIC for all fusidic acid-resistant isolates was 8 mg/liter, and each of these isolates yielded a 900-kb amplified product in PCR experiments, consistent with carriage of the far-1 gene (15). All 26 isolates belonged to SCCmec type IV (13). However, subtyping using the method of Zhang et al. (16) indicated that two isolates were SCCmec type IVa and one isolate was SCCmec type IVc (Table 1). None was SCCmec type V. All PFGE type A isolates were SCCmec type IV, whereas those with SCCmec subtypes IVa and IVc had PFGE pattern B or C. All PFGE type A and B isolates were agr type III and cap type 8. The rest exhibited different agr and cap types.

MLST revealed seven sequence types. Ten (38.5%) isolates were ST80, and 8 isolates (30.8%) were ST30. The rest belonged to ST8 (2 isolates, 7.7%), ST5 (2 isolates, (7.7%), ST728 (2 isolates, 7.7%), or ST6 or ST361 (1 isolate each) (Table 1).

The application of MLST to type CAMRSA isolated in Kuwait hospitals has helped define their relationship to isolates obtained in other countries. It identified two sequence types, ST80 and ST30, as the dominant CAMRSA clones in Kuwait hospitals. Both sequence types constituted 76.9% of the isolates from six of the seven hospitals with CAMRSA, establishing their dominance in these hospitals. The other clones were isolated less frequently. Our ST80 isolates contained genes for PVL, belonged to agr type III, and had type 8 capsular polysaccharide. Furthermore, they contained far-1-mediated fusidic acid resistance similar to that of the ST80 MRSA IV clone isolated in Germany and other European countries (3, 15). The ST30 MRSA IV clone in this study was similar to the ST30 isolates from Singapore in their susceptibility to non-beta-lactam agents, but, whereas the majority of ST30 isolates from Singapore were SCCmec type IVc (4), only one of our ST30 isolates was SCCmec type IVc. indicating that internationally recognized clones of CAMRSA are dominant in Kuwait hospitals. These CAMRSA clones could have been introduced into Kuwait hospitals by Kuwaiti nationals following medical treatment abroad or by expatriate workers from countries where these clones are common. Although there were no records of overseas travel for any of the Kuwait nationals, many Kuwait patients do seek medical treatment abroad.


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ACKNOWLEDGMENTS
 
This study was supported by Kuwait University Research Administration grant MI 03/01.

LSBFG Precision Genomics, Department of Clinical Immunology and Immunogenetics, Royal Perth Hospital, Perth, Western Australia, Australia, performed DNA sequencing.


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FOOTNOTES
 
* Corresponding author. Mailing address: Department of Microbiology, Faculty of Medicine, Kuwait University, P.O. Box 24923, Safat 13110, Kuwait. Phone: (965) 498 6773. Fax: (965) 533 2719. E-mail: EDET{at}hsc.edu.kw Back

{triangledown} Published ahead of print on 16 July 2008. Back


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REFERENCES
 
    1
  1. Chambers, H. F. 2001. The changing epidemiology of Staphylococcus aureus. Emerg. Infect. Dis. 7:178-182.[Medline]
    2. 2
  2. Enright, M. C., N. P. J. Day, C. E. Davies, S. J. Peacock, and B. G. Spratt. 2000. Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J. Clin. Microbiol. 38:1008-1015.[Abstract/Free Full Text]
    3. 3
  3. Fang, H., G. Hedin, G. Li, and C. E. Nord. 2008. Genetic diversity of community-associated methicillin-resistant Staphylococcus aureus in southern Stockholm, 2000-2005. Clin. Microbiol. Infect. 14:370-376.[CrossRef][Medline]
    4. 4
  4. Hsu, L. Y., Y. L. Koh, N. L. Chlebicka, T. Y. Tan, P. Krishnan, R. T. P. Lin, N. Tee, T. Barkham, and T. H. Koh. 2006. Establishment of ST30 as the predominant clonal type among community associated methicillin-resistant Staphylococcus aureus isolates in Singapore. J. Clin. Microbiol. 44:1090-1093.[Abstract/Free Full Text]
    5. 5
  5. Lina, G., Y. Piemont, F. Godail-Gamot, M. Bes, M.-O. Peter, V. Gauduchon, F. Vandenesch, and J. Etienne. 1999. Involvement of Panton-Valentine leukocidin producing Staphylococcus aureus in primary skin infections and pneumonia. Clin. Infect. Dis. 29:1128-1132.[CrossRef][Medline]
    6. 6
  6. Lina, G., F. Boutite, A. Tristan, M. Bes, J. Etienne, and F. Vandenesch. 2003. Bacterial competition for human nasal cavity colonization: role of staphylococcal agr alleles. Appl. Environ. Microbiol. 69:18-23.[Abstract/Free Full Text]
    7. 7
  7. Moore, P. C. L., and J. A. Lindsay. 2001. Genetic variation among hospital isolates of methicillin-sensitive Staphylococcus aureus: evidence for horizontal transfer of virulence genes. J. Clin. Microbiol. 39:2760-2767.[Abstract/Free Full Text]
    8. 8
  8. O'Brien, F. G., G. W. Coombs, J. C. Pearson, K. J. Christiansen, and W. B. Grubb. 2005. Type V staphylococcal cassette chromosome mec in community staphylococci from Australia. Antimicrob. Agents Chemother. 49:5129-5132.[Abstract/Free Full Text]
    9. 9
  9. O'Brien, F. G., J. W. Pearman, M. Gracey, T. V. Riley, and W. B. Grubb. 1999. Community strains of methicillin-resistant Staphylococcus aureus involved in a hospital outbreak. J. Clin. Microbiol. 37:2858-2862.[Abstract/Free Full Text]
    10. 10
  10. Seybold, U., E. V. Kourbatova, J. G. Johnson, S. J. Halvosa, Y. F. Wang, M. D. King, S. M. Ray, and H. M. Blumberg. 2006. Emergence of community-associated methicillin-resistant Staphylococcus aureus USA300 genotype as a major cause of healthcare-associated blood stream infections. Clin. Infect. Dis. 42:647-656.[CrossRef][Medline]
    11. 11
  11. Smith, J. M. B., and G. M. Cook. 2005. A decade of community MRSA in New Zealand. Epidemiol. Infect. 133:899-904.[CrossRef][Medline]
    12. 12
  12. Stemper, M., S. K. Shukla, and K. D. Reed. 2004. Emergence and spread of community-associated methicillin-resistant Staphylococcus aureus in rural Wisconsin, 1989-1999. J. Clin. Microbiol. 42:5673-5680.[Abstract/Free Full Text]
    13. 13
  13. Udo, E. E., N. Al-Sweih, and B. Noronha. 2006. Characterisation of non-multiresistant methicillin-resistant Staphylococcus aureus (including EMRSA-15) in Kuwait hospitals. Clin. Microbiol. Infect. 12:262-269.[CrossRef][Medline]
    14. 14
  14. Udo, E. E., J. W. Pearman, and W. B. Grubb. 1993. Genetic analysis of community isolates of methicillin-resistant Staphylococcus aureus in Western Australia. J. Hosp. Infect. 25:157-165.
    15. 15
  15. Witte, W., C. Braulke, C. Cuny, B. Strommenge, G. Werner, D. Heuck, U. Jappe, C. Wendt, H. J. Linde, and D. Harmsen. 2005. Emergence of methicillin-resistant Staphylococcus aureus with Panton-Valentine leukocidin in central Europe. Eur. J. Clin. Microbiol. Infect. Dis. 24:1-5.[CrossRef][Medline]
    16. 16
  16. Zhang, K., J. A. McClure, S. Elsayed, T. Louie, and J. M. Conly. 2005. Novel PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus. J. Clin. Microbiol. 43:5026-5033.[Abstract/Free Full Text]

Journal of Clinical Microbiology, October 2008, p. 3514-3516, Vol. 46, No. 10
0095-1137/08/$08.00+0     doi:10.1128/JCM.00966-08
Copyright © 2008, American Society for Microbiology. All Rights Reserved.




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