Staphylococcus aureus continues to evolve: MRSA without mec edition

I just returned from a wonderful MRSA conference this past week where I enjoyed learning about how European countries are handling antimicrobial use in livestock and the emergence of potential human pathogens like livestock-associated MRSA. Perhaps I will post further thoughts on the conference later in the week.  However, I just saw this new report in JAC on a novel resistance mechanism in S. aureus, so first things first.

It is known that hyper beta-lactamase producing strains of S. aureus exist and that some strains have chromosomal mutations and resultant modified penicillin binding proteins. These strains can have phenotypic methicillin resistance while lacking the mecA (or mec C) gene. Thus, they can evade detection by genotypic methods and the underlying mechanisms can be missed by phenotypic methods, as Dan nicely described here.

There is now a report by Xiaoliang Ba and colleagues that describes four clinical S. aureus isolates that were found to be MRSA but lacked mec A or mec C. The strains were from clinical wound infections and deposited in the Scottish MRSA Reference Lab. They belonged to sequence types 1, 15 (two isolates) and 8. Three strains were resistant to oxacillin, cefoxitin and PCN by ETest and disc diffusion and the fourth isolate was at the oxacillin Etest breakpoint, while three were beta-lactamase producers. Whole genome sequencing confirmed that none contained a mec-like sequence and that beta-lactamase production was not mediating the resistance. Interestingly they found similar single amino acid substitutions across sequence types in PBP1, PBP2 and PBP3 suggesting independent evolution of the same trait (homoplasy).

The authors acknowledge that their targeted search of the genomes could have missed other possible mechanisms of resistance in these isolates. I would add that this was in four isolates out of an unreported denominator, so we don't know the magnitude of the clinical impact yet. What we can say is that our surveillance techniques had better keep up with S. aureus. Unfortunately, it seems to be just as good at evolving away from our prevention methods as it does our antibiotics.

Obligatory S. aureus image courtesy of wikipedia

Addendum: For further insight, scroll down to read Dan's comment on this study

Always playing catch-up

Reports of the emergence of novel MRSA strains bearing mecA_LGA251, 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 mecA_LGA251 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 mecA_LGA251 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...

Super Sneaky MRSA (but only if you use PCR)

Lost in the din of our Rice Crispies or even the E. Coli outbreak in Europe, are a couple papers out of UK/Denmark and Ireland reporting novel mecA containing MRSA in human and bovine populations.  The concern here, of course, is that in many centers these novel MRSA strains would be missed by static PCR tests, which is what actually happened in these reports. 

The report out of Ireland discusses two clinical MRSA isolates that were PBP2a-positive but mecA negative by conventional mecA PCR - ie they were called MSSA by GeneXpert. The first strain was isolated from a 64-year old in a Dublin acute care hospital, while the second was isolated from an 85 year-old in a South-East Ireland regional hospital. Evaluation determined that these strains contained a novel SCCmec element (Similar to SCCmec XI) with divergent mecA, mecI, mecRI, blaZ and ccr genes.

In the second report, investigators out of England noticed bovine MRSA strains which tested negative after standard PCR tests for mecA. They determined that they contained a novel mecA homologue, mecALGA251. They then searched collections in Scotland, England and Denmark for similar strains and 51 human isolates with the same mecALGA251. 14 of 25 from London, 12 of 16 from Glasgow and 24 of 32 clinical strains from Copenhagen contained the novel mecA. One human strain dated back to 1975, although detection increased substantially between 2007 and 2010. 54% (13/24) of the bovine isolates were also positive. The distribution of cattle and human isolates in England is shown above.

The authors of this paper suggest that new PCR primers will solve the problem. It is true that it will solve this particular problem, but is it a good long term solution?  Do we think MRSA evolution will stop here? Also, they suggest that dairy cows could be a reservoir of infection, but I would think that humans could also be the reservoir.

What this suggests to me is that if you isolate/decolonize patients using a static PCR for mecA, it is not surprising to me that other novel strains could emerge.  Hand hygiene would not be so easily circumvented, nor would simpler culture-based microbiology methods.

Hopefully our resident microbiologist Dan will chime in too...

UK and Denmark report: Garcia-Alvarez et al. Lancet ID June 3, 2011

Ireland report: Shore AC et al. AAC, June 2, 2011

Tara Smith's take can be found here and Scientific American's report by Katherine Harmon here