The Staphylococci

Gram-positive, cluster-forming coccus

nonmotile, nonsporeforming facultative anaerobe
fermentation of glucose produces mainly lactic acid
catalase positive
coagulase positive
golden yellow colony on agar
normal flora of humans found on nasal passages, skin and mucous membranes
pathogen of humans, causes a wide range of suppurative infections, as well as food poisoning and toxic
shock syndrome

Staphylococci are Gram-positive spherical bacteria that occur in microscopic clusters resembling grapes.
Bacteriological culture of the nose and skin of normal humans invariably yields staphylococci. S. aureus
colonizes mainly the nasal passages, but it may be found regularly in most other anatomical locales. S
epidermidis is an inhabitant of the skin.

Staphylococcus aureus forms a fairly large yellow colony on rich medium, S. epidermidis has a relatively
small white colony. S. aureus is often hemolytic on blood agar; S. epidermidis is non hemolytic.
Staphylococci are facultative anaerobes that grow by aerobic respiration or by fermentation that yields
principally lactic acid. The bacteria are catalase-positive and oxidase-negative. S. aureus can grow at a
temperature range of 15 to 45 degrees and at NaCl concentrations as high as 15 percent. Nearly all strains
of S. aureus produce the enzyme coagulase: nearly all strains of S. epidermidis lack this enzyme. S. aureus
should always be considered a potential pathogen; most strains of S. epidermidis are nonpathogenic and
may even play a protective role in their host as normal flora. Staphylococcus epidermidis may be a
pathogen in the hospital environment.

NOTE: Catalase Test

A colony is placed on a glass slide. A drop of 3% hydrogen peroxide is added. The catalase- producing
organism catalyzes the breakdown of H2O2 to oxygen and water. O2 is released as bubbles. The catalase
test is used to differentiate Staphylococcus sp. from Streptococcus sp. Staphylococcus sp. are positive for
catalase production. Streptococcus sp. are negative for catalase production

NOTE: Coagulase Test

Add a generous loopful of the organism to be tested to a tube of citrated rabbit plasma. Thoroughly
homogenize the inoculum with the loop and incubate the tube at 37o C for one to four hours. Examine the
tube at 30 minute to hourly intervals for the first couple of hours for the presence of a clot by tipping the
tube gently on its side. A test that shows any degree of clotting within 24 hours is considered coagulase
positive

NOTE: Fermentation of Mannitol

Mannitol Salt Agar (MSA) is a selective and differential medium. The high concentration of salt (7.5%)
selects for members of the genus Staphylococcus, since they can tolerate high saline levels. Organisms
from other genera may grow, but they typically grow very weakly.
MSA also contains the sugar mannitol and the pH indicator phenol red. If an organism can ferment
mannitol, an acidic byproduct is formed that will cause the phenol red in the agar to turn yellow. Most
pathogenic staphylococci, such as Staphylococcus aureus, will ferment mannitol. Most non-pathogenic
staphylococci will not ferment mannitol.

Staphylococci are perfectly spherical cells about 1 micrometer in diameter. They grow in clusters because
staphylococci divide in two planes. The configuration of the cocci helps to distinguish staphylococci from
streptococci, which are slightly oblong cells that usually grow in chains (because they divide in one plane
only).

Pathogenesis of S. aureus infections

Staphylococcus aureus causes a variety of suppurative (pus-forming) infections and toxinoses in humans. It
causes superficial skin lesions such as boils, styes and furunculosis; more serious infections such as
pneumonia, mastitis, phlebitis, meningitis, and urinary tract infections; and deep-seated infections, such as
osteomyelitis and endocarditis.

S. aureus is a major cause of hospital acquired (nosocomial) infection of surgical wounds and infections
associated with indwelling medical devices.

S. aureus causes food poisoning by releasing enterotoxins into food, and toxic shock syndrome by release
of superantigens into the blood stream.

S. aureus expresses many potential virulence factors:

1) surface proteins that promote colonization of host tissues;

(2) invasins that promote bacterial spread in tissues (leukocidin, kinases, hyaluronidase);

(3) surface factors that inhibit phagocytic engulfment (capsule, Protein A);

(4) biochemical properties that enhance their survival in phagocytes (carotenoids, catalase production);

(5) immunological disguises (Protein A, coagulase, clotting factor); and

(6) membrane-damaging toxins that lyse eukaryotic cell membranes (hemolysins, leukotoxin, leukocidin;

(7) exotoxins that damage host tissues or otherwise provoke symptoms of disease (, TSST)

(8) inherent and acquired resistance to antimicrobial agents.

Human staphylococcal infections are frequent, but usually remain localized at the portal of entry by the
normal host defenses. The portal may be a hair follicle, but usually it is a break in the skin which may be a
minute needle-stick or a surgical wound. Foreign bodies, including sutures, are readily colonized by
staphylococci, which may makes infections difficult to control. Another portal of entry is the respiratory
tract. Staphylococcal pneumonia is a frequent complication of influenza. The localized host response to
staphylococcal infection is inflammation, characterized by an elevated temperature at the site, swelling, the
accumulation of pus, and necrosis of tissue. Around the inflamed area, a fibrin clot may form, walling off
the bacteria and leukocytes as a characteristic pus-filled boil or abscess. More serious infections of the skin
may occur, such as furuncles or impetigo. Localized infection of the bone is called osteomyelitis. Serious
consequences of staphylococcal infections occur when the bacteria invade the blood stream. A resulting
septicemia may be rapidly fatal; a bacteremia may result in seeding other internal abscesses, other skin
lesions, or infections in the lung, kidney, heart, skeletal muscle or meninges.

Adherence to Host Cell Proteins

S. aureus cells express on their surface proteins that promote attachment to host proteins such as laminin
and fibronectin that form the extracellular matrix of epithelial and endothelial surfaces. In addition, most
strains express a fibrin/fibrinogen binding protein (clumping factor) which promotes attachment to blood
clots and traumatized tissue. Most strains of S. aureus express both fibronectin and fibrinogen-binding
proteins. In addition, an adhesin that promotes attachment to collagen has been found in strains that cause
osteomyelitis and septic arthritis. Interaction with collagen may also be important in promoting bacterial
attachment to damaged tissue where the underlying layers have been exposed.

Invasion

The invasion of host tissues by staphylococci apparently involves the production of a huge array of
extracellular proteins, some of which may occur also as cell-associated proteins

Membrane-damaging toxins

aplha-toxin (alpha-hemolysin) The best characterized and most potent membrane-damaging toxin of S.
aureus is alpha-toxin. It is expressed as a monomer that binds to the membrane of susceptible cells.
Subunits then oligomerize to form heptameric rings with a central pore through which cellular contents
leak.

In humans, platelets and monocytes are particularly sensitive to alpha-toxin. Susceptible cells have a
specific receptor for alpha-toxin which allows the toxin to bind causing small pores through which
monovalent cations can pass. The mode of action of alpha hemolysin is likely by osmotic lysis.

ß-toxin is a sphingomyelinase which damages membranes rich in this lipid. The classical test for ß-toxin is
lysis of sheep erythrocytes. The majority of human isolates of S. aureus do not express ß-toxin. A lysogenic
bacteriophage is known to encode the toxin.

Leukocidin is a multicomponent protein toxin produced as separate components which act together to
damage membranes. Leukocidin forms a hetero-oliogmeric transmembrane pore composed of four LukF
and four LukS subunits, thereby forming an octameric pore in the affected mwembrane. Leukocidin is
hemolytic, but less so than alpha hemolysin.
Only 2% of all of S. aureus isolates express leukocidin, but nearly 90% of the strains isolated from severe
dermonecrotic lesions express this toxin, which suggests that it is an important factor in necrotizing skin
infections.

Coagulase and clumping factor

Coagulase is an extracellular protein which binds to prothrombin in the host to form a complex called
staphylothrombin. The protease activity characteristic of thrombin is activated in the complex, resulting in
the conversion of fibrinogen to fibrin. Coagulase is a traditional marker for identifying S aureus in the
clinical microbiology laboratory. However, there is no overwhelming evidence that it is a virulence factor.

Staphylokinase

Many strains of S aureus express a plasminogen activator called staphylokinase. This factor lyses
fibrin.The genetic determinant is associated with lysogenic bacteriophages. A complex formed between
staphylokinase and plasminogen activates plasmin-like proteolytic activity which causes dissolution of
fibrin clots.

Other extracellular enzymes

S. aureus can express proteases, a lipase, a deoxyribonuclease (DNase) and a fatty acid modifying enzyme
(FAME). The first three probably provide nutrients for the bacteria, and it is unlikely that they have
anything but a minor role in pathogenesis. However, the FAME enzyme may be important in abscesses,
where it could modify anti-bacterial lipids and prolong bacterial survival.

Avoidance of Host Defenses

S. aureus expresses a number of factors that have the potential to interfere with host defense mechanisms.
This includes both structural and soluble elements of the bacterium.

Capsular Polysaccharide

The majority of clinical isolates of S aureus express a surface polysaccharide of either serotype 5 or 8. This
has been called a microcapsule because it can be visualized only by electron microscopy unlike the true
capsules of some bacteria which are readily visualized by light microscopy. S. aureus strains isolated from
infections express high levels of the polysaccharide but rapidly lose the ability when cultured in the
laboratory. The function of the capsule in virulence is not entirely clear. Although it does impede
phagocytosis in the absence of complement, it also impedes colonization of damaged heart valves, perhaps
by masking adhesins.

Protein A

Protein A is a surface protein of S. aureus which binds IgG molecules by their Fc region. In serum, the
bacteria will bind IgG molecules in the wrong orientation on their surface which disrupts opsonization and
phagocytosis. Mutants of S. aureus lacking protein A are more efficiently phagocytosed in vitro, and
mutants in infection models have diminished virulence.
Leukocidin

S. aureus can express a toxin that specifically acts on polymorphonuclear leukocytes. Phagocytosis is an
important defense against staphylococcal infection so leukocidin should be a virulence factor.

Exotoxins

S. aureus can express several different types of protein toxins which are probably responsible for symptoms
during infections Some will lyse erythrocytes, causing hemolysis, but it is unlikely that hemolysis is a
relevant determinant of virulence in vivo. Leukocidin causes membrane damage to leukocytes, but is not
hemolytic.

Systemic release of aplha-toxin causes septic shock, while enterotoxins and TSST-1 are superantigens that
may cause toxic shock. Staphylococcal enterotoxins cause emesis (vomiting) when ingested and the
bacterium is a leading cause of food poisoning.

The exfoliatin toxin causes the scalded skin syndrome in neonates, which results in widespread blistering
and loss of the epidermis. There are two antigenically distinct forms of the toxin, ETA and ETB. The toxins
have esterase and protease activity and apparently target a protein which is involved in maintaining the
integrity of the epidermis.

Superantigens: enterotoxins and toxic shock syndrome toxin and their diseases

STAPHYLOCOCCAL FOOD POISONING

S. aureus secretes two types of toxin with superantigen activity, enterotoxins, of which there are six
antigenic types (named SE-A, B, C, D, E and G), and toxic shock syndrome toxin (TSST-1). Enterotoxins
cause diarrhea and vomiting when ingested and are responsible for staphylococcal food poisoning.

Staphylococcal food poisoning is a gastrointestinal illness. It is caused by eating foods contaminated with
toxins produced by Staphylococcus aureus . The most common way for food to be contaminated with
Staphylococcus is through contact with food workers who carry the bacteria or through contaminated milk
and cheeses. Staphylococcus is salt tolerant and can grow in salty foods like ham. As the bacteria multiplies
in food, it produces toxins that can cause illness. Staphylococcal toxins are resistant to heat and cannot be
destroyed by cooking. Foods at highest risk of contamination with Staphylococcus aureus and subsequent
toxin production are those that are made by hand and require no cooking. Some examples of foods that
have caused staphylococcal food poisoning are sliced meat, puddings, some pastries and sandwiches.

Signs and symptoms

Staphylococcal toxins are fast acting, sometimes causing illness in as little as 30 minutes. Symptoms
usually develop within one to six hours after eating contaminated food. Patients typically experience
several of the following: nausea, vomiting, stomach cramps, and diarrhea. The illness is usually mild and
most patients recover after one to three days. In a small minority of patients the illness may be more severe.
Lab diagnosis of S. aureus food poisoning

Toxin-producing Staphylococcus aureus can be identified in stool or vomit, and toxin can be detected in
food items. Diagnosis of staphylococcal food poisoning in an individual is generally based only on the
signs and symptoms of the patient. Testing for the toxin-producing bacteria or the toxin is not usually done
in individual patients. Testing is usually reserved for outbreaks involving several persons.

Treatment

Supportive

Antibiotics are not useful in treating this illness. The toxin is not affected by antibiotics.

Patients with this illness are not contagious. Toxins are not transmitted from one person to another.

TOXIC SHOCK SYNDROME

TSST-1 is expressed systemically and is the cause of toxic shock syndrome (TSS). When expressed
systemically, enterotoxins can also cause toxic shock syndrome. In fact, enterotoxins B and C cause 50% of
non-menstrual cases of TSS. TSST-1 is weakly related to enterotoxins, but it does not have emetic activity.
TSST-1 is responsible for 75% of TSS, including all menstrual cases. TSS can occur as a sequel to any
staphylococcal infection if an enterotoxin or TSST-1 is released systemically and the host lacks appropriate
neutralizing antibodies.

Superantigens stimulate T cells non-specifically without normal antigenic recognition . Up to one in five T
cells may be activated, whereas only 1 in 10,000 are stimulated during a usual antigen presentation.
Cytokines are released in large amounts, causing the symptoms of TSS. Superantigens bind directly to class
II major histocompatibility complexes of antigen-presenting cells outside the conventional antigen-binding
grove. This complex recognizes only the Vb element of the T cell receptor. Thus any T cell with the
appropriate Vb element can be stimulated, whereas normally, antigen specificity is also required in binding.

SIGNS AND SYPMTOMS

The Centers for Disease Control and Prevention (CDC) criteria for the diagnosis of staphylococcal TSS are
as follows:

• Fever, hypotension, and rash (as defined above)

• Involvement of 3 or more organ systems
• Absence of serologic evidence of Rocky Mountain spotted fever, leptospirosis, measles, hepatitis
B, antinuclear antibody, positive Venereal Disease Research Laboratory (VDRL) test results, and
antibodies at Monospot testing
Prodromal period of 2-3 days followed by:

Pain at site of infection (most common symptom of streptococcal TSS)

Fever and/or chills

Nausea and/or vomiting

Profuse watery diarrhea with abdominal pain

Lightheadedness and/or syncope

Myalgias and/or arthralgias

Pharyngitis and/or headache

Confusion (more common with staphylococcal TSS than with streptococcal TSS)

At physical examination, findings may include the following:

Fever higher than 102°F

Hypotension - Systolic BP less than 90 mm Hg or orthostatic decrease in systolic BP

of 15 mm Hg

Skin findings

o Diffuse rash, occasionally patchy and erythematous, with

desquamation occurring approximately 1-2 weeks later
o Rash initially appearing on trunk, spreading to arms and legs, and
involving palms and soles

Signs of multiorgan involvement

o Physical findings associated with ventricular arrhythmias, renal

failure, or hepatic failure
o Disseminated intravascular coagulation (DIC)
o Acute respiratory distress syndrome
o Necrotizing fasciitis and/or myositis
o Altered consciousness (CNS involvement)
o Mucosal inflammation (eg, vaginitis, conjunctivitis, pharyngitis)

Lab Studies

• The CBC may reveal leukocytosis (77% of cases) with , mild anemia with
abnormal cells on smears, and/or thrombocytopenia.
• Electrolyte levels may indicate hyponatremia, hypokalemia, hypocalcemia
out of proportion to hypoalbuminemia, hypophosphatemia, and
 hyperbilirubinemia (76% of cases), an elevated aspartate aminotransferase
(SGOT) level (75% of cases), and an elevated alanine aminotransferase
(SGPT) level (50% of cases).
• Coagulation studies may reveal an elevated activated partial thromboplastin
time (aPTT) (46% of cases) and fibrin split products. Fibrinogen levels and
prothrombin times (PTs) usually are normal.
• Azotemia and/or acute tubular necrosis may be present.
• Urinalysis may reveal sterile pyuria, myoglobinuria, and red cell casts.
• toxin
Exfoliatin Creatine
(ET)kinase levels may indicate rhabdomyolysis (63% of cases).
• ABG findings may indicate metabolic acidosis secondary to hypotension
and/or
The exfoliatin hypoxia.
toxin, associated with scalded skin syndrome, causes separation within the epidermis,
between• theCulture
living layers and the superficial
all potentially infected sitesdead(including
layers. The separation
blood). More is through
than 50% ofthe stratum granulosum
of the epidermis. This
patients is probably
with why TSS
streptococcal healing occurs
have with little
a positive bloodscarring
culture although the risks of fluid loss and
result. Recent
secondary infections are suggested
studies have increased. that
Staphylococcal exfoliative
early and definitive toxin Bcan
diagnosis hasbebeen
madeshown
by to specifically
cleave desmoglein 1, athe
observing cadherin that of
expansion is found
TSS-1inreactive
desmosomes in the epidermis.
V beta2-positive T-cell receptors
in peripheral blood mononuclear cells.
Staphylococcal scalded skin syndrome (SSS) or Ritter Disease
Imaging Studies
Scalded skin syndrome is a skin infection characterized by damage to the skin, with marked shedding
(exfoliation).
• AItchest
usually affects infants
radiograph may showand evidence
children under therespiratory
of acute age of 5. distress
syndrome or pulmonary edema.
Scalded•skinRadiographs
syndrome isoffound most commonly
the infected in infants
site may show and very
soft-tissue young children.
swelling.
• An echocardiogram may show wall-motion abnormality suggestive of toxic
SIGNSANDcardiomyopathy.
SYMPTOMS
• A CT scan should be obtained if the diagnosis is in question. Findings
fever should be normal in TSS.

redness of the skin (erythema) which spreads to cover most of the body
TREATMENT

Fluid resuscitation

Crystalloids may be administered. As much as 10-20 L/d often is necessary.

Some authors suggest that colloids may decrease the risk of pulmonary edema.

Oxygen therapy
skin slips off with gentle pressure leaving wet red areas (Nikolsky sign)
Administer supplemental oxygen therapy to maximize tissue oxygenation and to
correct hypoxia and/or acidosis.
large areas of skin peel or fall away (exfoliation or desquamation)

painful skin
Assisted ventilation may be required if acute respiratory distress syndrome develops.
LAB EXAMS
Hyperbaric oxygen therapy has been used in necrotizing soft-tissue infections, but the
• Complete
benefit blood counthas not been proven.
of this intervention
• cultures of the skin and throat (often yield staphylococci)
• skin
Cardiac biopsy (done
monitoring only
should beinperformed,
rare cases with
where diagnosis
treatment ofishigh-grade
in question, such as when the skin
arrhythmias.
condition may be due to a drug reaction known as toxic epidermal necrolysis or TEN)
A•Foley
Serum electrolytes
catheter should be placed to monitor urine output (assess adequacy of
resuscitation).
TREATMENT
Tampons and packing materials, if present, should be removed.
• Patients need fluid rehydration, topical wound care similar to the care for thermal burns, and
parenteral
For patients withantibiotics to cover S aureus.
menstruation-related TSS, irrigation of vagina with isotonic sodium
• Consideration
chloride must be given forsolution
solution or povidone-iodine the sharply increasing
has been rates of community-acquired S aureus
advocated.
infection (CA-MRSA).
 • Fluid rehydration is initiated with Lactated Ringer solution at 20 cc/kg initial bolus. Repeat the
initial bolus as clinically indicated followed by maintenance therapy with consideration for fluid
losses from exfoliation of skin being similar to a burn patient.
• Topical wound care should begin with saline, followed by topical antibiotic ointment.
• Cultures from the exfoliated sites as well as nose, throat, and other potential sites of the original
focus of infection should be performed.
• A chest radiograph should be considered to rule out pneumonia as the original focus of infection.
• Steroids are not indicated at this time.

Healing begins in about 10 days following treatment.

The prognosis is usually excellent. A full recovery is expected.

Possible Complications

• severe bloodstream infection (septicemia)

• fluid regulation problems causing dehydration or electrolyte imbalance
• poor temperature control (in young infants)
• spread to deeper skin infection (cellulitis)

The disorder may not be preventable. Prompt treatment of any staphylococcus infection
may be helpful.

COAGULASE-NEGATIVE STAPHYLOCOCCUS

S. epidermidis accounts for all 75% of clinical isolates, and this relates to its abundance in the skin of
normal persons. Other species include:

S, haemolyticus

S. hominis

S. capitis

S. saprophyticus

The emergence of these species as pathogens refelects the increased use of implants such as CSF shunts, IV
lines, cardiac valves, pacemakers, artificial joints, urinary catheters and the increasing number of severely
debilitated patients in the hospitals.

They are morphologically similar to S.aureus, however they form white colonies, and are coagulase
negative.
Diseases caused:

Prosthetic valve endocarditis

Meningitis

Peritonitis

UTI in pregnant women(S. saprophyticus)

Treatment is with Vancomycin, if not resistant. S. saprophyticus responds to trimethoprim or to quinolones.

Staphylococcus epidermidis

In contrast to S. aureus, little is known about mechanisms of pathogenesis of S. epidermidis infections.

Adherence is obviously a crucial step in the initiation of foreign body infections. Bacteria-plastic
interactions are probably important in colonization of catheters, and a polysaccharide adhesion (PS/A) has
been identified. In addition, when host proteins deposit on the implanted device S. epidermidis will bind to
fibronectin.

A characteristic of many pathogenic strains of S. epidermidis is the production of a slime resulting in

biofilm formation. The slime is predominantly a secreted teichoic acid, normally found in the cell wall of
the staphylococci. This ability to form a biofilm on the surface of a prosthetic device is probably a
significant determinant of virulence for these bacteria.

Resistance of Staphylococci to Antimicrobial Drugs

Hospital strains of S. aureus are usually resistant to a variety of different antibiotics. A few strains are
resistant to all clinically useful antibiotics except vancomycin, and vancomycin-resistant strains are
increasingly-reported. The term MRSA refers to Methicillin resistant Staphylococcus aureus. Methicillin
resistance is widespread and most methicillin-resistant strains are also multiply resistant.

A plasmid associated with vancomycin resistance has been detected in Enterococcusfaecalis which can be
transferred to S. aureus in the laboratory, and it is speculated that this transfer may occur naturally (e.g. in
the gastrointestinal tract). In addition, S. aureus exhibits resistance to antiseptics and disinfectants, such as
quaternary ammonium compounds, which may aid its survival in the hospital environment.

S aureus responded to the introduction of antibiotics by the usual bacterial means to develop drug
resistance:

(1) mutation in chromosomal genes followed by selection of resistant strains and

(2) acquisition of resistance genes as extrachromosomal plasmids, transducing particles, transposons, or

other types of DNA inserts.

Host Defense against Staphylococcal Infections

Phagocytosis is the major mechanism for combatting staphylococcal infection. Antibodies are produced
which neutralize toxins and promote opsonization. However, the bacterial capsule and protein A may
interfere with phagocytosis. Biofilm growth on implants is also impervious to phagocytosis. Staphylococci
may be difficult to kill after phagocytic engulfment because they produce catalase which neutralize singlet
oxygen and superoxide which are primary phagocytic killing mechanisms within the phagolysosome.

Treatment

Hospital acquired infection is often caused by antibiotic resistant strains (MRSA) and can only be treated
with vancomycin or an alternative. Until recently, infections acquired outside hospitals have been treated
with penicillinase-resistant ß-lactams. However, many of the community acquired (CA) Staphylococcal
infections are now methicillin resistant. Particularly in Georgia, Texas, and California, the prevalence of
CA-MRSA is widespread.

OTHER DISEASE CAUSED BY STAPHYLOCOCCI

boils and pimples (folliculitis)
pneumonia
septicemia
osteomyelitis
surgical wound infections

MRSA AND VRSA

Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacteria that is resistant to certain

antibiotics. These antibiotics include methicillin and other more common antibiotics such as oxacillin,
penicillin and amoxicillin. Staph infections, including MRSA, occur most frequently among persons in
hospitals and healthcare facilities (such as nursing homes and dialysis centers) who have weakened
immune systems.

MRSA infections that occur in otherwise healthy people who have not been recently (within the past year)
hospitalized or had a medical procedure (such as dialysis, surgery, catheters) are known as community-
associated (CA)-MRSA infections. These infections are usually skin infections, such as abscesses, boils,
and other pus-filled lesions

Methicillin-resistant Staphylococcus aureus (MRSA) has become a prevalent nosocomial pathogen in the
United States. In hospitals, the most important reservoirs of MRSA are infected or colonized patients.
Although hospital personnel can serve as reservoirs for MRSA and may harbor the organism for many
months, they have been more commonly identified as a link for transmission between colonized or infected
patients.
 The main mode of transmission of MRSA is via hands (especially health care workers' hands) which may
become contaminated by contact with a) colonized or infected patients, b) colonized or infected body sites
of the personnel themselves, or c) devices, items, or environmental surfaces contaminated with body fluids
containing MRSA.

Approximately 10% of S. aureus isolates in the United States are susceptible to penicillin. However, many
S. aureus strains, while resistant to penicillin, remain susceptible to penicillinase-stable penicillins, such as
oxacillin and methicillin. Strains that are oxacillin and methicillin resistant, historically termed methicillin-
resistant S. aureus (MRSA), are resistant to all ß-lactam agents, including cephalosporins and carbapenems.
Hospital-associated MRSA isolates often are multiply resistant to other commonly used antimicrobial
agents, including erythromycin, clindamycin, and tetracycline, while community-associated MRSA isolates
are often resistant only to ß-lactam agents and erythromycin. Since 1996, MRSA strains with decreased
susceptibility to vancomycin (minimum inhibitory concentration [MIC], 8-16 μg/ml) and strains fully
resistant to vancomycin (MIC ≥ 32 μg/ml) have been reported .

FEATURES OF MRSA

1. Pathogenicity.
MRSA have many virulence factors that enable them to cause disease in normal hosts. For
example, MRSA are frequent causes of healthcare-associated bloodstream and catheter-related
infections. MRSA are also an emerging cause of community-associated infections, especially skin
and soft tissue infections and necrotizing pneumonia.
2. Limited treatment options.
Vancomycin and two newer antimicrobial agents, linezolid and daptomycin, are among the drugs
that are used for treatment of severe healthcare-associated MRSA infections. Although some
strains remain susceptible to trimethoprim/sulfamethoxazole, gentamicin, or rifampin, these drugs
are not typically used as first-line agents. Because of the rapid emergence resistance to rifampin,
this drug should never be used as a single agent to treat MRSA infections.

3. MRSA are transmissible.

An MRSA outbreak can occur when one strain is transmitted to other patients or close contacts of
the infected persons in the community. Often this occurs when a patient or health-care worker is
colonized with an MRSA strain (i.e., carries the organism but shows no clinical signs or symptoms
of infection) and, through contact, spreads the strain to another person. Handwashing and
screening patients for MRSA should be performed to decrease transmission and reduce the number
of patients infected with MRSA.

Lab EXAMS

The cefoxitin disk screen test, the latex agglutination test for PBP2a, or a plate containing 6 μg/ml of
oxacillin in Mueller-Hinton agar supplemented with NaCl (4% w/v; 0.68 mol/L) as alternative methods of
testing for MRSA.

Accurate detection of oxacillin/methicillin resistance can be difficult due to the presence of two
subpopulations (one susceptible and the other resistant) that may coexist within a culture of staphylococci .
All cells in a culture may carry the genetic information for resistance, but only a small number may express
the resistance in vitro. This phenomenon is termed heteroresistance and occurs in staphylococci resistant to
penicillinase-stable penicillins, such as oxacillin.

Cells expressing heteroresistance grow more slowly than the oxacillin-susceptible population and may be
missed at temperatures above 35°C. This is why it is recommended incubating isolates being tested against
oxacillin, methicillin, or nafcillin at 33-35° C (maximum of 35°C) for a full 24 hours before reading .

Additional tests to detect oxacillin/methicillin resistance

Nucleic acid amplification tests, such as the polymerase chain reaction (PCR), can be used to detect the
mecA gene, which mediates oxacillin resistance in staphylococcus.

mecA gene involved in the mechanism of resistance

Staphylococcal resistance to oxacillin/methicillin occurs when an isolate carries an altered penicillin-

binding protein, PBP2a, which is encoded by the mecA gene. The new penicillin-binding protein binds
beta-lactams with lower avidity, which results in resistance to this class of antimicrobial agents.

Methicillin is no longer commercially available in the United States. Oxacillin maintains its activity during
storage better than methicillin and is more likely to detect heteroresistant strains. However, cefoxitin is an
even better inducer of the mecA gene and disk diffusion tests using cefoxitin give clearer endpoints and are
easier to read than tests with oxacillin.

If oxacillin is tested, why are the isolates called “MRSA” instead of “ORSA”?

When resistance was first described in 1961, methicillin was used to test and treat infections caused by S.
aureus. However, oxacillin, which is in the same class of drugs as methicillin, was chosen as the agent of
choice for testing staphylococci in the early 1990s. . The acronym MRSA is still used by many to describe
these isolates because of its historic role.

VISA and VRSA

VISA and VRSA are specific types of antimicrobial-resistant staph bacteria. While most staph bacteria are
susceptible to the antimicrobial agent vancomycin some have developed resistance. VISA and VRSA
cannot be successfully treated with vancomycin because these organisms are no longer susceptibile to
vancomycin

Staph bacteria are classified as VISA or VRSA based on laboratory tests. Laboratories perform tests to
determine if staph bacteria are resistant to antimicrobial agents that might be used for treatment of
infections. For vancomycin and other antimicrobial agents, laboratories determine how much of the agent it
requires to inhibit the growth of the organism in a test tube. The result of the test is usually expressed as a
minimum inhibitory concentration (MIC) or the minimum amount of antimicrobial agent that inhibits
bacterial growth in the test tube. Therefore, staph bacteria are classified as VISA if the MIC for
vancomycin is 4-8µg/ml, and classified as VRSA if the vancomycin MIC is >16µg/ml.
Persons that developed VISA and VRSA infections had several underlying health conditions (such as
diabetes and kidney disease), previous infections with methicillin-resistant Staphylococcus aureus
(MRSA), tubes going into their bodies (such as intravenous [IV] catheters), recent hospitalizations, and
recent exposure to vancomycin and other antimicrobial agents.

TREATMENT

There are limited treatment options for VISA/VRSA infections. Some possible options include rifampin,
gentamicin, imipenem, chloramphenicol, trimethoprim-sulfamethoxazole, and tetracycline.

PREVENTION

Use of appropriate infection control practices (such as wearing gloves before and after contact with
infectious body substances and adherence to hand hygiene) by healthcare personnel can reduce the spread
of VISA and VRSA.

VISA and VRSA are types of antibiotic-resistant staph bacteria. Therefore, as with all staph bacteria, spread
occurs among people having close physical contact with infected patients or contaminated material like
bandages. Therefore, persons having close physical contact with infected patients while they are outside of
the healthcare setting should:

(1) keep their hands clean by washing thoroughly with soap and water,

(2) avoid contact with other people’s wounds or material contaminated from wounds