Accepted Manuscript

Title: Methicillin-resistant Staphylococcus aureus (MRSA)

and methicillin-resistant Staphylococcus pseudintermedius
(MRSP) among employees and in the environment of a small
animal hospital

Authors: Andrea T. Feßler, Riccarda Schünemann, Kristina

Kadlec, Vivian Hensel, Julian Brombach, Jayaseelan
Murugaiyan, Gerhard Oechtering, Iwan A. Burgener, Stefan
Schwarz

PII: S0378-1135(18)30144-5
DOI: https://doi.org/10.1016/j.vetmic.2018.06.001
Reference: VETMIC 7987

To appear in: VETMIC

Received date: 1-2-2018

Revised date: 9-5-2018
Accepted date: 4-6-2018

Please cite this article as: Feßler AT, Schünemann R, Kadlec K, Hensel
V, Brombach J, Murugaiyan J, Oechtering G, Burgener IA, Schwarz S,
Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant
Staphylococcus pseudintermedius (MRSP) among employees and in the
environment of a small animal hospital, Veterinary Microbiology (2018),
https://doi.org/10.1016/j.vetmic.2018.06.001

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 Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-

resistant Staphylococcus pseudintermedius (MRSP) among employees

and in the environment of a small animal hospital

Short title: MRSA and MRSP in a small animal hospital

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Andrea T. Feßlera,b,*, Riccarda Schünemannc,1, Kristina Kadleca,

Vivian Hensela, Julian Brombacha,b, Jayaseelan Murugaiyand, Gerhard Oechteringc,

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Iwan A. Burgenere, Stefan Schwarza,b

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Institute of Farm Animal Genetics, Friedrich-Loeffler-Institut (FLI), Neustadt-Mariensee,
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Germany
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b
Institute of Microbiology and Epizootics, Centre for Infection Medicine, Department of
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Veterinary Medicine, Freie Universität Berlin, Berlin, Germany

c
Department of Small Animal Medicine, University of Leipzig, Leipzig, Germany
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d
Institute of Animal Hygiene and Environmental Health, Freie Universität Berlin, Berlin,

Germany
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e
Department of Small Animals and Horses, Small Animal Clinic, VetMedUni Vienna,
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Vienna, Austria
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* Corresponding author: Tel.: +49-30-838-63074. Fax: +49-30-838-451851.

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E-mail address: andrea.fessler@fu-berlin.de

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present address: Kleintierspezialisten Augsburg, Max-Josef-Metzger-Str. 9, Augsburg,

Germany
Highlights

 MRSA and MRSP were found among employees and the environment of a small
animal clinic
 All but one of the MRSA isolates and all MRSP isolates were multiresistant
 Related MRSA and MRSP isolates were observed among employees and the clinic
environment pointing towards transmission

Abstract

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The aim of the study was to investigate methicillin-resistant Staphylococcus aureus (MRSA)

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and methicillin-resistant Staphylococcus pseudintermedius (MRSP) among employees of a

small animal hospital and the hospital environment. In total, 96 swabs from employees and 73

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swabs from the clinic environment were investigated. Cation-adjusted-Mueller-Hinton broth
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(CAMHB) + 6.5 % NaCl was used for enrichment before plating on Mueller-Hinton (MH) agar
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with 2 % NaCl and 0.25 mg/L oxacillin. The staphylococcal species was determined using
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MALDI-TOF MS. The isolates were subjected to mecA-PCR, macrorestriction analysis, and

antimicrobial susceptibility testing. MRSA were present in five nasal swabs of the 55
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employees tested and in six environmental samples, MRSP in two employees (nasal and hand
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swabs, each) and in three environmental samples. All isolates harboured mecA. Susceptibility

testing revealed that all but one of the isolates were multiresistant. All isolates were resistant to
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β-lactams and fluoroquinolones. All but one of the isolates were resistant to macrolides and
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lincosamides. A single MRSA was resistant to gentamicin. All MRSP were resistant to

trimethoprim/sulfamethoxazole and non-susceptible to gentamicin. One isolate was also

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resistant to tetracycline. Macrorestriction analysis revealed three main SmaI patterns for MRSA

and two main SmaI patterns for MRSP. All environmental isolates were found in areas of high

people and animal traffic such as dog ward areas, waiting and triage rooms. The finding of

indistinguishable MRSA or MRSP among employees and in the environment of the small
animal clinic suggests the possibility of transfer of these bacteria between humans, animals,

and the hospital environment.

Key words: colonization, contamination, molecular typing, antimicrobial resistance

1. Introduction

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In human and veterinary medicine, methicillin-resistant staphylococci (MRS) are an

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increasing problem. While methicillin-resistant Staphylococcus aureus (MRSA) are commonly

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found in humans and a wide variety of animals (Monecke et al., 2011; Kadlec et al., 2012;

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Grema et al., 2015; Lozano et al., 2016; Bi et al., 2018), colonization and infections with

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methicillin-resistant Staphylococcus pseudintermedius (MRSP) are more prevalent and also
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more clinically relevant than MRSA among dogs and cats (Hanselman et al., 2009; Walther et
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al., 2012). Transfer of S. aureus and S. pseudintermedius between humans and their pets have
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been already described (Hanselman et al., 2009; Nienhoff et al., 2009; Walther et al., 2012).

Paul et al. (2011) found that veterinarians being colonized with MRSP might point
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towards an animal-to-human transmission. In comparison, Nienhoff et al. (2009) could show

two cases of human-to-animal transmission, in which dogs were colonized or infected by

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MRSA originating from their owners. Moreover, MRS can also be present in the veterinary
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staff (Ishihara et al., 2010; Weiß et al., 2013; Walter et al., 2016) from which they can spread
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into the veterinary clinical environment. MRSA and MRSP are often multiresistant to

antimicrobial agents and thus, can often survive well in an environment, such as a veterinary
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hospital, where diseased animals that might carry and excrete MRSA and/or MRSP are present

and antimicrobial agents are used. Since there is an exchange of MRSA and MRSP in both

directions between humans and animals, in which the environment can be also involved, it is

important to screen veterinarians and the hospital environment for the presence of such
pathogens. This will allow to gain additional information about possible transmission routes

and to design preventive measures for further spreading of MRS within veterinary hospitals.

The aim of the present study was to investigate the presence of MRS among employees

and in the environment of a small animal hospital with particular reference to MRSA and

MRSP.

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2. Materials and methods

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2.1. Sampling

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During June and July 2012, samples were taken from employees and the environment of a small

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animal hospital in Germany. The human samples were provided on a voluntary basis and after

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informed consent. The study was approved by the ethical commission of the Medical Faculty
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of the University Leipzig (Az.: 392-12-05112012). The employees were asked for two swabs,
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a nasal swab and a hand swab. The swabs were taken randomly throughout the working day,
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with most of them taken in the early afternoon. The nasal swab was taken by the employee her-

/himself after a short instruction, the hand swab was taken by the person in charge of the
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sampling (R.S.). For the hand swab, several fingers and the palm were wiped with the swab.

Swabs were only taken if the employee had not disinfected her/his hands within the last couple
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of minutes. In total, 41 people provided both nasal and hand swabs, whereas only nasal swabs
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were provided by 12 and only hand swabs were provided by two persons, resulting in a total of
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96 human swabs. Moreover, 73 swabs were taken from the clinical environment and included

door handles, telephones, keyboards, clippers, clean blankets, soap dispensers, and the floor
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among others (Table S1). These were taken systematically throughout the entire three floors of

the building. All door handles in rooms with high people and/or animal traffic were sampled.

Telephones, keyboards, tables, and floors of all treatment and ward rooms, as well as animal

cages, technical and treatment devices such as ultrasound and anesthesia machines, and

anything with potential animal contact were also sampled. Samples were collected between 8
am and 3 pm, with most samples taken in the afternoon, before the major cleaning of the day

took place (which usually started at around 4 pm).

2.2. Isolation and identification of the staphylococcal isolates

The swabs were incubated overnight in Mueller-Hinton broth with 6.5 % NaCl at 37°C

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as an enrichment step for staphylococci, where the high sodium chloride concentration should

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inhibit the growth of the commensal flora. An aliquot of this suspension was plated on Mueller-

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Hinton agar plates supplemented with 2 % sodium chloride and 0.25 mg/L oxacillin and

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incubated over night at 37°C. Suspicious colonies were subcultured and the species

identification was carried out using MALDI-TOF MS as described elsewhere (Murugaiyan et

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al. 2014). In brief, a freshly cultured microbial colony was directly transferred onto the MALDI
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target plate (MSP 96 target polished steel plate; Bruker Daltonics, Bremen, Germany), dried
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and overlaid with 1.0 µl of saturated α-cyano-4-hydroxycinnamic acid matrix solution (in 50%
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Acetonitrile and 0. 25% tri fluroacetic acid). The MALDI measurements were carried out using
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Microflex LT instrument via MBT Compass Explorer 4.1 software (Bruker Daltonics, Bremen,

Germany). The similarity of the measured spectra to the database reference entries expressed
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as log score value in the range of 0-3 is utilised for species identification. Cut-off values

recommended by the manufacturer were followed to deduce ‘highly probable species

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identification’ (score ≥2.3), ‘secure genus identification and probable species identification’

(score 2.0-2.29), ‘probable genus identification’ (score 1.7-1.99) and ‘no reliable identification’
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(score 0-1.69).

2.3. Antimicrobial susceptibility testing and detection of resistance genes

Antimicrobial susceptibility testing was performed by broth microdilution according to

CLSI standards (CLSI, 2015, 2016). Custom-made microtiter plate panels (MCS Diagnostics,
Swalmen, The Netherlands) were used and susceptibility to 20 antimicrobial agents was

determined. The panels included β-lactams (oxacillin, imipenem), quinolones/fluoroquinolones

(ciprofloxacin, enrofloxacin, marbofloxacin, nalidixic acid), aminoglycosides (gentamicin,

neomycin, streptomycin), tetracyclines (tetracycline, doxycycline), macrolides (erythromycin,

tilmicosin, tulathromycin, tylosin), lincosamides (clindamycin, pirlimycin), a phenicol

(florfenicol), a pleuromutilin (tiamulin) and the combination trimethoprim/sulfamethoxazole.

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The respective resistance genes were tested according to previously described PCR assays.

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These included the methicillin resistance genes mecA (Merlino et al., 2002) and mecC (Cuny

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et al., 2011), the macrolide resistance genes erm(A) (Amezaga and McKenzie, 2006), erm(B)

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(Jensen et al., 1999), erm(C) (primers: erm(C)_1: 5’-ATCTTTGAAATCGGCTCAGG-3’;

erm(C)_2: 5’-CAAACCCGTATTCCACGATT-3’, PCR conditions: 94°C – 1min, 30x [94°C

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– 1min, 55°C – 1min, 72°C – 1min], 72°C – 7min; amplicon size: 259 bp), and erm(T) (Feßler
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et al., 2010), the tetracycline resistance genes tet(K) and tet(L) (Pang et al., 1994), the
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aminoglycoside resistance genes aacA-aphD and aadD (Hauschild et al., 2007), and the
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trimethoprim resistance genes dfrG (primers: dfrG_fw: 5’-TCCCAAGGACTGGGAATATG-

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3’, dfrG_rv: 5’-CCCTTTTTGGGCAAATACCT-3’; PCR conditions: 94°C – 2min, 30x [94°C

– 1min, 53°C – 1min, 72°C – 1min], 72°C – 5min; amplicon size: 498bp) and dfrK (Kadlec and
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Schwarz, 2009).
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2.4 Molecular typing

The MRSA and MRSP isolates were subjected to spa typing with the respective species-
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specific primers (Harmsen et al., 2003; Moodley et al., 2009). Macrorestriction analysis was

performed for the MRSA and MRSP isolates according to the Harmony protocol developed for

S. aureus (Murchan et al., 2003) with a running time reduced by 10 % for each block, resulting

in 20 h 42 min (compared to 23 h in the original protocol). The first-block switch time was 5 to

15 s for 9 h, and the second-block switch time was 15 to 60 s for 11 h 42 min. Multi-locus
sequence typing (MLST) was performed for two selected MRSA isolates

(https://pubmlst.org/saureus/). Macrorestriction patterns differing in up to three bands indicated

that the isolates are closely related while patterns with four to six bands difference were

considered as related and named with the same letter and an additional number. Band patterns

differing in six or more bands, indicating unrelated isolates, were indicated by different letters

(Tenover et al. 1995). It should be noted that a single point mutation at the SmaI restriction site

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commonly results in three bands difference between two strains (Tenover et al. 1995).

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3. Results and discussion

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3.1. Isolation of the staphylococcal isolates and species identification
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After the enrichment step and the selective plating on Mueller-Hinton agar supplemented
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with 2 % sodium chloride and 0.25 mg/L oxacillin, the obtained colonies were considered as
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putative methicillin-resistant staphylococci, based on their morphology. Suspicious colonies

were subjected to MALDI-TOF-MS analysis for confirmation of the species S. aureus and
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S. pseudintermedius (Murugaiyan et al., 2014). In total, S. aureus isolates were identified in 22

samples with methicillin-resistant isolates being found in 11 samples: five samples from
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employees and six from the environment (Table 1). The reason that not all of the S. aureus
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isolates selected on Mueller-Hinton agar supplemented with 2 % sodium chloride and 0.25
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mg/L oxacillin were MRSA can be explained by the different breakpoints used for detection of

methicillin resistance among S. aureus (resistant ≥ 4 mg/L) and S. pseudintermedius (resistant

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≥ 0.5 mg/L) (CLSI, 2015). Therefore, some methicillin-susceptible S. aureus (MSSA) can still

grow under these selective conditions, whereas methicillin-susceptible S. pseudintermedius are

inhibited. Putative methicillin-resistant S. pseudintermedius were detected in four samples from

employees and three samples from the environment.

3.2. Antimicrobial resistance properties

Eleven S. aureus isolates were resistant to oxacillin with MICs of ≥ 16 mg/L and carried

the methicillin resistance gene mecA. Five isolates were obtained from human nasal samples

(persons 1-5) and six from the hospital environment (Table 1). All MRSA isolates displayed

additional resistance properties, such as resistance to fluoroquinolones. All but one of the

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isolates were resistant to macrolides and lincosamides and harboured either the macrolide-

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lincosamide-streptogramin B resistance genes erm(A) (n=9) or erm(C) (n=1). The single isolate

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with the erm(C) gene was also resistant to gentamicin and harboured the resistance gene aacA-

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aphD. The only isolate not being resistant to macrolides and lincosamides was classified as

intermediate to erythromycin and proved to be negative in all erm gene PCRs applied. Three of
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the five isolates obtained from humans showed the same resistance pheno- and genotype as the
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isolates from the clinical environment (Tab. 1). The MRSA isolates differed only slightly in
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their PFGE patterns (Tab.1, Fig. 1). The detected resistance genes are also commonly found in
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staphylococci including MRSA CC398 from livestock (Feßler et al., 2010; Kadlec et al., 2012).
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Seven S. pseudintermedius isolates were classified as MRSP, based on their resistance to

oxacillin (MICs ≥ 16 mg/L) and the presence of the mecA gene. Four isolates were obtained
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from human samples: two people had MRSP detected in both their nose and hand samples (F

and G). Three isolates were obtained from the environment (Tab. 1). All isolates were
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additionally resistant to macrolides and lincosamides, fluoroquinolones and the combination

trimethoprim/sulfamethoxazole and were classified as resistant or intermediate to gentamicin.

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The macrolide/lincosamide resistance correlates with the presence of the erm(B) gene in all

isolates. This finding is also in accordance with other studies describing erm(B) as common

among MRSP (Kadlec et al., 2010, 2016; Kadlec and Schwarz, 2012; Perreten et al., 2010).

However, one isolate harboured an additional erm(C) gene. The finding of more than one erm

gene present in a single isolate is common among MRSA CC398 (Kadlec et al., 2012), but has
not yet been reported for MRSP. The trimethoprim resistance gene dfrG was present in all

isolates. This is in accordance with other studies, finding the dfrG gene most frequently in

MRSP (Kadlec et al., 2012). The reduced susceptibility to gentamicin correlates with the

presence of the aacA-aphD gene that was detected in all MRSP isolates. This gene has

previously been detected in S. pseudintermedius and was detected in 88.3 % of the canine and

91.7 % of feline MRSP from Europe and North America (Kadlec and Schwarz, 2012). One

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isolate was also resistant to tetracyclines and harboured the resistance gene tet(K), which is in

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accordance with previous findings (Kadlec and Schwarz, 2012). The MRSP isolates found in

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the nose and the hand sample of each of the two persons showed the same resistance pheno-

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and genotype (Tab. 1). In comparison, the isolates from the environment differed slightly in

their characteristics from each other and from the isolates obtained from the employees.
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3.3. Molecular characterization of the isolates
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The spa typing of the MRSA isolates revealed three different spa types, with spa type
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t003 (26-17-20-17-12-17-17-16) being present in nine and the spa types t002 (26-23-17-34-17-
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20-17-12-17-16) and t1625 (26-23-13-23-31-29-17-31-29-17-25-17-25-16) being present in

single isolates both from human samples (Tab. 1). The spa types t002 and t003 might be related,
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since t003 could have developed from t002 by the loss of three repeats (23-17-34) and a

duplication of repeat 17, whereas t1625 differs distinctly. The spa types t002 and t003 are
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commonly associated with CC5 MRSA, with ST5-MRSA-II being endemic among humans

(Monecke et al., 2011; http://spa.ridom.de/frequencies.shtml, last assessed 29.04.2018). Two

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MRSA isolates (persons 2 and 3) with spa type t003 were subjected to MLST and revealed

ST225 (https://pubmlst.org/saureus/). ST225 is a common hospital-associated MRSA clone in

Germany and was the second most common in MRSA blood stream infections from 25

European countries (Grundmann et al., 2014). The macrorestriction analysis using SmaI as

restriction enzyme revealed three different main patterns (Figure 1a). The most common main
pattern A had a subpattern A1, which was present in four isolates. All isolates belonging to the

main pattern A had spa type t003, while the patterns B and C were associated with the spa types

t002 and t1625, respectively (Tab. 1). The latter two isolates had also different resistance

patterns. These findings point towards a MRSA clone with spa type t003, pattern A/A1 and

resistance to β-lactams, macrolides, lincosamides and fluoroquinolones circulating in the clinic.

These isolates originated from persons 2, 3 and 4.

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The spa typing of the MRSP isolates revealed two different spa types, namely t02 (r01-

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r02-r03-r03-r03-r06-r05) and t06 (r01-r02-r03-r03-r06-r05) (Tab. 1). When having a look at the

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repeats, it can be seen that these spa types only differ in the number of the r03 repeat, which is

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present as duplicate in t06 and as triplicate in t02. The spa type t02 was previously identified in

eleven MRSP from European cats (Kadlec et al., 2012) and was also common among canine
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MRSP in Europe (Perreten et al., 2012). In this multicentre study, spa type t02 was found in
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69.9 % of the isolates including 84.6% of all 78 European isolates, whereas only two of 24
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isolates originating from North America had this spa type (Perreten et al., 2012). In contrast,
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spa type t06 was seen in most of the North American MRSP isolates (19 of 24, 79.1%) (Perreten
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et al., 2012). In the present study, the spa type t02 was seen in the samples of one employee and

in the environmental samples, whereas t06 was present in the other employee’s sample (Tab.
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1). The SmaI macrorestriction revealed two different main patterns with up to two subpatterns

each. Interestingly, the PFGE main patterns of the MRSP did not match with the spa types (Tab.
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1, Figure 1b). Moreover, the isolates with spa type t06 from person 6 and the environmental

isolates with spa type t02 belonged to the same main pattern. The isolates from person 7 had
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the same characteristics (Tab. 1), but the PFGE subpatterns E and E1, for the nose and hand

sample, respectively. It should be noted, that the patterns D and E are completely unrelated to

the patterns A to C from S. aureus, since these PFGE patterns were analysed for each species

separately.
3.4 Localization of MRS isolates within the hospital and possible transmission

MRSA were detected among five employees in nasal swabs only, whereas MRSA was

not detected in the respective hand swabs of these persons. In comparison, MRSP isolates were

found in the nasal and hand swabs of two employees. This results in an MRSA carriage rate of

9.1 % of the employees tested and 9.6 % of the nasal samples investigated. This MRSA carriage

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rate is similar to the 10 % carriage rate found by Sasaki and colleagues (2007) in a veterinary

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teaching hospital in Japan. Isihara and coworkers (2010) also found comparable resistance rates

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of 8.9% among the employees and 11.0 % among people “affiliated with the veterinary

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hospital”. In comparison, Heller and colleagues (2009) found a lower MRSA prevalence of

3.1 % among the employees of a small animal hospital in Scotland. Loeffler and coworkers
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(2005) revealed a comparably high MRSA prevalence of 19.9 % in a small animal hospital in
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the UK. Screening people attending an international conference, Hanselman and colleagues
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(2006) found 7.0 % (23/345) of the veterinarians and 12.0% (4/34) of the technicians being
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MRSA-positive, whereas Moodley and colleagues (2008) found a lower MRSA prevalence of
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3.8 % among Danish veterinary practitioners sampled at conferences, which might be due to a

comparably low MRSA prevalence in Denmark.

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The environmental MRSA isolates were found in the dog ward areas, dog treatment

rooms and a single one identified from the laundry cart sample. The MRSP isolates were found
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on the floor or the hospital’s waiting area, the clippers in a triage room and a table of the

intensive care unit (ICU). All of these locations are high traffic areas with many dogs,
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employees, students and clients moving around. Interestingly, the MRSA isolates from the three

employees 2, 3 and 4 and the environmental samples from the floor, doors, a table, keyboards

and a laundry cart, belonged to the same spa type t003, exhibited the two related

macrorestriction patterns A and A1 and shared the same resistance properties. These findings

point towards a transmission of these MRSA isolates within the hospital.

 Among the MRSP isolates, the same characteristics were found among the hand and nose

samples from person 6. These isolates had spa type t06, which is related to spa type t02 that has

been found in isolates from the waiting room floor and clippers of the triage room as well as

the table in the ICU. All these MRSP isolates had related PFGE patterns D, D1 or D2.

Moreover, all but one isolate from the ICU table with additional tetracycline resistance, were

resistant to β-lactams, macrolides, lincosamides, fluoroquinolones and showed an intermediate

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or resistant phenotype to gentamicin. All isolates harboured the respective resistance genes

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mecA, erm(B), dfrG and aacA-aphD. Interestingly, the isolate from the clippers of the triage

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room carried an additional erm(C) gene, which could be possibly explained by the acquisition

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of a small plasmid. As described for MRSA transferred between humans and animals (Nienhoff

et al., 2009), a possible transfer of S. pseudintermedius between humans and animals is

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supported by the study by Lozano and colleagues (2017) where indistinguishable isolates were
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detected among humans and dogs indicating a transmission from dogs to humans. Robb and
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coworkers (2017) identified S. pseudintermedius as the causative agent of a severe skin

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infection of a dog owner in Scotland. However, clinical S. pseudintermedius infections among

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humans are still rare (Lozano et al., 2017, Robb et al. 2017). Ishiara and colleagues (2010)

revealed MRSP carriage rates of 3.1 % for the employees of a veterinary clinic and 3.9 % of
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people “affiliated with the veterinary hospital”. Also Sasaki and coworkers (2007) found a

single S. pseudintermedius isolate (5 %) among 20 employees tested in a veterinary teaching

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hospital in Japan. These values are in accordance with our MRSP prevalence of 3.6 % among

55 employees tested.
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It is noteworthy that no MRS isolates were found around the surgical theatres or in the

surgical and anesthesia preparation areas. Furthermore, no isolates were found in the office

area. This indicates that a) cleaning and disinfection protocols as well as minimization of traffic

in the surgical theatres and preparation areas in this hospital are appropriate and b) lower traffic

areas such as offices are less likely to be contaminated. It should be noted, that MRS isolates
were found around dog ward areas and points toward focusing on increased disinfection

measures in areas of high traffic (people and animals).

4. Conclusions

The presence of MRSA and MRSP isolates among employees of a small animal hospital

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and in the hospital environment points towards a risk for transmission of these pathogens

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between humans and animals, while the contaminated environment might serve as a vector.

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Molecular typing methods such as spa typing and macrorestriction analysis can give

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information regarding the genetic relationship of the isolates and thereby help to investigate

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transmission routes. Minimization of people and animal traffic could be one valid measure to
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reduce transmission of MRS. Installation and regular monitoring of appropriate cleaning and
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disinfection protocols is important in order to reduce the risk of MRS transmission within the
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hospital environment, especially in areas of high traffic. These protocols may also include

testing and if necessary decolonization of veterinary personnel. Screening of patients for MRS
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carrier status on admission could be another tool to reduce introduction of MRS to a hospital.

This, however, requires the application of fast and reliable tests for MRS as recently described
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(Seidel et al. 2017).

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Conflict of interest
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None to declare.

Funding
This work was funded by the German Federal Ministry of Education and Research (BMBF)

through the German Aerospace Center (DLR), grant number MedVet-Staph II (01KI1301D)

and since 2017 by the Federal Ministry of Education and Research (BMBF) under project

number 01KI1727D as part of the Research Network Zoonotic Infectious Diseases.

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Acknowledgements

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The authors thank Marita Meurer and Regina Ronge for excellent technical assistance.

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Figure 1:
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SmaI-macrorestriction patterns of the MRSA (a) and MRSP (b) isolates
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M = marker (SmaI digested S. aureus NCTC 8325), (n) = nose, (h) = hand
A
M
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E PT
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A
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Table 1: Characteristics of the MRSA and MRSP isolates

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Origin Species spa PFGE Resistance phenotype Resistance genotype
type pattern

N
Person 1 (nose) S. aureus t002 B BLA-ML-FQ-GEN mecA, erm(C), aacA-aphD

A
Person 2 (nose) S. aureus t003 A1 BLA-ML-FQ mecA, erm(A)

M
Person 3 (nose) S. aureus t003 A BLA-ML-FQ mecA, erm(A)
Person 4 (nose) S. aureus t003 A BLA-ML-FQ mecA, erm(A)
Person 5 (nose)
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S. aureus t1625 C BLA-(ERY)-FQ mecA
Floor S. aureus t003 A BLA-ML-FQ mecA, erm(A)
Door 1 S. aureus t003 A BLA-ML-FQ mecA, erm(A)
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Door 2 S. aureus t003 A1 BLA-ML-FQ mecA, erm(A)

Table S. aureus t003 A1 BLA-ML-FQ mecA, erm(A)
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Keyboards S. aureus t003 A BLA-ML-FQ mecA, erm(A)

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Laundry cart S. aureus t003 A1 BLA-ML-FQ mecA, erm(A)

Person 6 (nose) S. pseudintermedius t06 D1 BLA-ML-FQ-SXT-(GEN) mecA, erm(B), dfrG, aacA-aphD
A

Person 6 (hand) S. pseudintermedius t06 D1 BLA-ML-FQ-SXT-(GEN) mecA, erm(B), dfrG, aacA-aphD

Person 7 (nose) S. pseudintermedius t02 E BLA-ML-FQ-SXT-GEN mecA, erm(B), dfrG, aacA-aphD
Person 7 (hand) S. pseudintermedius t02 E1 BLA-ML-FQ-SXT-GEN mecA, erm(B), dfrG, aacA-aphD
Table ICU S. pseudintermedius t02 D2 BLA-ML-FQ-SXT-(GEN)-TET mecA, erm(B), dfrG, aacA-aphD, tet(K)
Waiting room floor S. pseudintermedius t02 D BLA-ML-FQ-SXT-GEN mecA, erm(B), dfrG, aacA-aphD
 R I
SC
Clippers triage room S. pseudintermedius t02 D BLA-ML-FQ-SXT-GEN mecA, erm(B), erm(C), dfrG, aacA-aphD
BLA = β-lactams, FQ = fluoroquinolones, GEN = gentamicin, ML = macrolides, lincosamides, SXT = trimethoprim/sulfamethoxazole, TET = tetracycline,

U
brackets indicate an intermediate phenotype

N
A
M
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E PT
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A