Incidence and spa-types of penicillin-susceptible bacteremic

Staphylococcus aureus isolates in southern Sweden 2014

F Resman1,2, J Tham1, J Thegerström2 ,F Månsson1, J Ahl1 and K Riesbeck1,2
Phone:+46 40331000
Infectious Diseases Research Unit, Dept. of Clinical sciences, Malmö, Lund University, Sweden1, Clinical microbiology, Dept of Translational Medicine, Malmö, Lund University, Sweden2 fredrik.resman@med.lu.se

Objective Results Results, continued

To determine the incidence and population structure of penicillin-
susceptible Staphylococcus aureus in southern Sweden in 2014 as
well as the specificity of different screening methods.
A total of 293 separate cases of S. aureus bacteremia occurred in the catchment area during the
study period. From these, 277 isolates could be retrieved and confirmed as S. aureus. Of these
isolates 96 met screening criteria of potential penicillin-susceptible isolate according to our
screening method. Of these isolates, 90 (32.5%) isolates were confirmed as penicillinase-PCR
negative, a number distinctly higher than expected.
Spa-typing revealed that even though there were scattering across clonal complexes, most penicillin-
susceptible S. aureus could be assigned to a limited number of clonal clusters (5). While some
common clinical clusters were not represented at all, other clonal clusters were highly represented, as
shown in the BURP (Based Upon Repeat Pattern) below. The most common individual spa-type was
t002 (12% of PSSA).

The performance of different screening tests for penicillin-susceptibility in our study BURP with rough clonal clusters (6) of spa-types1 of penicillin-susceptible S. aureus
Background
SCREENING False
Resistant (n) Susceptible (n) Specificity CC246
Benzylpenicillin has a treatment advantage over cloxacillin against methicillin-susceptible TEST susceptible (n)
Staphylococcus aureus (MSSA) that do not produce a penicillinase, with superior efficacy (1) Nitrocefin test 1391 1381 48 83% CC015
(providing longer T>MIC using normal antibiotic dosing regimes) and safety (fewer side effects). Such CC084 CC002
isolates have, however, been uncommon regardless of MRSA prevalence and routine methods of E-test PcG
≤0,125
1771 1001 10 96% CC024
identifying the subgroup, such as chromogenic cephalosporins, are not deemed reliable since the
penicillinase is inducible. Due to this, S. aureus susceptibility to penicillin has not been routinely Disk diffusion
assessed in Sweden in the past decades. Reports from neighboring regions suggest rates of
penicillin-susceptible S. aureus of approximately 20% (2). In the present study, we aimed to determine
PcG (1U) zone 1861,3 911 2 99%
the incidence of penicillin-susceptible S. aureus in southern Sweden as well as the specificity of ≥26mm
screening methods for penicillin-susceptibility in S. aureus isolates. We also investigated the PCR (study 1All spa-types are shown as uniform size dots, regardless of how many isolates of each type that were identified

population structure of penicillin-susceptible S. aureus using protein A gene (spa) typing. gold standard)
62 902 0 100%
1Thenumbers are based on the assumption that the sorting of penicillin-resistant isolates using our screening method is correct.
2Thenumbers are based only on isolates screened as likely PcG-susceptible. Conclusions
Methods 3One isolate was false resistant.

All saved unique S. aureus isolated from blood cultures in southwestern Skåne county (population
approx. 500,000), Sweden in 2014 were thawed and subjected to susceptibility testing using E-tests
for benzylpenicillin (Biomerieux), disk diffusion with PcG (1U) and finally the chromogenic nitrocefin
test for betalactamase detection. All isolates that were determined as susceptible according to disk
diffusion and/or E-test and that were negative in the nitrocefin test were subjected to a PCR detecting
the S. aureus penicillinase (gold standard in this study) as well as to specific S. aureus protein A gene
(spa) sequencing and typing (3,4).
Flow chart of the screening process
All bacteremic S. Aureus isolates in 2014
Disk diffusion testing (PcG 1U)
E-test PcG
Chromogenic nitrocefin testing
The specificity of the different screening methods to identify true penicillin-susceptible S. aureus
•  More than 30% of bacteremic S.aureus isolates in our region were
varied. The sensitivity of each screening method is assumed to be quite good, and is not separately penicillin-susceptible, as confirmed by screening and PCR.
assessed. Using PCR as a reference a PcG (1U) zone of ≥26mm had the best specificity (99%) of the
tested methods (table above), as previously suggested (4). The specificity of the E-test based •  In order to optimize individual treatment, our data suggest that
screening was lower, while the specificity of the nitrocefin test was poor (83%). The zone distribution
for the disk diffusion method is shown in the figure below, and indicates that the ‘wild-type’ penicillin-susceptibility testing of S. aureus should be performed
subpopulation can be readily separated from other isolates using this screening method. more often in routine clinical microbiology in areas with low
prevalence of MRSA.
Screening zone distribution of S. aureus using PcG (1U) disk diffusion
•  The EUCAST standard PcG (1U) disk diffusion screening test had
45
40 an excellent, but not a perfect correlation with penicillinase-PCR.
35
•  Spa-typing of penicillin-susceptible S. aureus revealed that most
30
isolates were confined to a limited number of clonal clusters.
25
20

At least one of PcG MIC≤0.125 ug/mL or PcG
(1U) zone 26mm & negative nitrocefin test
Likely penicillin-susceptible isolates
Penicillinase PCR & spa-typing
Isolates with both PcG MIC>0.125 ug/mL and PcG
(1U) zone < 26mm & positive nitrocefin test
Penicillin-resistant isolates
No further testing
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