Reports of the emergence of novel MRSA strains bearing mecALGA251, discussed in Eli’s excellent post, were published just as I finished a pro-con session at ASM on the use of culture versus PCR for clinical detection of MRSA. I pointed to the ongoing evolution of MRSA as a drawback to existing PCR methods, and included reference to the "empty cassette variants" that I previously discussed.
Because I think the "empty cassette" or "mecA dropout" story is instructive here. When the orfX-based assays were initially released, the published data described a very low incidence of these variants (in the case of the "mecA dropouts", isolates of MSSA that tested positive by the GeneOhm-GeneXpert-BD test...the opposite problem we see with the mecALGA251 isolates, which are MRSA that test negative....). So the potential problem was minimized, mainly for lack of good data and an assumption that clinical labs wouldn't run across these strains very often. Of course, some labs (including ours) did run across them quite often (“empty cassette variants” constitute almost 8% of our positive tests, a finding we'll soon publish (manuscript "in press" at JCM)).
Similarly, we are going to hear about how rare these mecALGA251 isolates are, how clinical labs are not likely to run across them, the tests still perform well, etc., etc. But how will we know when we start running across them? Of the hundreds of labs doing MRSA nares screening by PCR, how many are doing culture in parallel (not just on positives, but on negatives as well)? Of the labs that do only culture, how many are also doing confirmatory mecA PCR and following up on any phenotypic MRSA that test PCR negative?
More to come on this topic, and what is says about the future of PCR testing for MDRO detection, in future posts...