Daptomycin and vancomycin non-susceptible methicillin-resistant Staphylococcus aureus clonal lineages from bloodstream infection in a Brazilian teaching hospital

brazjinfectdis2019;23(2):139–142

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Brief

communication

Daptomycin

and

vancomycin

non-susceptible

methicillin-resistant

Staphylococcus

aureus

clonal

lineages

from

bloodstream

infection

in

a

Brazilian

teaching

hospital

Andreia

Paredes

Damasco

_,

_Thaina

_Miranda

_da

_Costa

_,

Priscylla

Guimarães

Migueres

Morgado

_,

_Lorrayne

_Cardoso

_Guimarães

_,

Fernanda

Sampaio

Cavalcante

_,

_Simone

_Aranha

_Nouér

_,

Kátia

Regina

Netto

dos

Santos

a_{UniversidadeFederaldoRiodeJaneiro,InstitutodeMicrobiologiaPaulodeGóes,DepartamentodeMicrobiologiaMédica,RiodeJaneiro,}

RJ,Brazil

b_{UniversidadeFederaldoRiodeJaneiro,CampusMacaé,Macaé,RJ,Brazil}

c_{UniversidadeFederaldoRiodeJaneiro,FaculdadedeMedicina,HospitalUniversitárioClementinoFragaFilho,RiodeJaneiro,RJ,Brazil}

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Articlehistory:

Received19December2018 Accepted28March2019 Availableonline24April2019

Keywords: Bloodstreaminfection S.aureus Vancomycin Daptomycin

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Introduction:Thisstudy aimed tocharacterize Staphylococcus aureus isolatesfrom blood-streaminfectionsinpatientsattendingateachinghospital,between2011and2015. Methods:The minimum inhibitory concentration for daptomycin, linezolid, oxacillin, teicoplanin, vancomycin, and trimethoprim/sulfamethoxazole was accessed by broth microdilution.SCCmectypeandclonalprofileweredeterminedbymoleculartests. Van-comycinheteroresistancewasevaluatedusingscreeningtestsandbypopulationanalysis profile/areaunderthecurve.

Results:Among200S.aureusisolates,55(27.5%)wereMRSA,carryingSCCmecII(45.5%)orIV (54.5%).ThemostfrequentMRSAlineageswereUSA100(ST5-II)(45.5%)andUSA800(ST5-IV) (30.9%).Sixisolateswereconfirmedasvancomycinheteroresistant,showingareaunderthe curveratio1.1,1.2or1.3(fourUSA100,oneUSA800andoneUSA1100isolates).

Conclusions: Daptomycinandvancomycinnon-susceptibleMRSAclonallineageswerefound inbloodstreaminfectionsoverfiveyears,highlightingtheimportanceofcontinuous surveil-lanceofmultiresistantbacteriainhospitals.

©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

∗ _{Correspondingauthor.}

E-mailaddress:[email protected](K.R.Santos).

1 _{Theseauthorscontributedequallytothiswork.}

https://doi.org/10.1016/j.bjid.2019.03.003

1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Staphylococcusaureusbloodstreaminfection(BSI)isoneof the most important causes of morbidity and mortality in hospitals, and its treatment hasbecome morechallenging overtheyears.1 _{Vancomycinisthemainchoicefortreating}

methicillin-resistant S. aureus(MRSA) BSI. Due to constant changeofepidemicclones,showingdifferentpatternsof resis-tance in the hospital settings, old antimicrobials, such as trimethoprim/sulfamethoxazole(TMP/STX)maybean alter-nativeinthetreatmentofinvasiveinfections.1 _Daptomycin

hasbeenefficaciousinthetreatmentofBSIandendocarditis byS.aureus.2_{However,thereislackofdataregardingratesof}

resistancetothisantimicrobialinS.aureusisolatesfromBSI inBrazil.

In Brazil and in other developing countries, data about antimicrobialresistanceratesandgenotypiccharacteristicsof S.aureusisolatesfromBSIarestillscarceandperformedwith veryfewisolates.3_{Inapreviousstudy,weanalyzedclinicaland}

microbiologicalcharacteristicsofS.aureusfrombloodstream infections(BSI)inaBrazilianteachinghospital,between2011 and 2013, focusing on their susceptibility to vancomycin.4

Here,wecontinued analyzingS.aureusisolatesfromBSIin thesamehospitalinordertoprovidemoreconclusivedata aboutantimicrobialresistanceprofilesandclonallineagesto helptheinfectioncontrolandpreventionteamcopewiththis typeofstaphylococcalinfection.

This study was performed at the University Hospital “ClementinoFragaFilho”(HUCFF),a490-beduniversity teach-inghospitallocatedinRiodeJaneiro,Brazil.Inthelastyearsat HUCFF,S.aureushasbeenresponsibleforabout15%ofBSI.The studywasapprovedbyHumanResearchEthicsCommitteeof theHUCFF(No.40652714.0.0000.5257)andevaluated consecu-tiveBSIS.aureusisolatesfromadults,betweenFebruary2011 andDecember2015.OnlythefirstisolateofaBSIepisodewas analyzed.ClinicaldatafrompatientswithhVISABSIwere col-lectedinaconfidentialmanner,ensuringtheprivacyofthe subjectsinvolved.

Previous bacterial identification was carried out by the automatedVITEK2® system(BioMerieux,Durham,USA)and confirmedusingclassicaltests.5_{Susceptibilitytomethicillin}

was determined by disk diffusion test.6 _{MICs were}

deter-minedbybrothmicrodilution(BMD)fordaptomycin,linezolid, oxacillin, teicoplanin, vancomycin, and TMP/STX (Sigma-AldrichChemicalCompany,StLouis,USA).6 _ThemecAgene

detection andSCCmectyping wereperformedaspreviously described.7_{Pulsed-fieldgelelectrophoresis(PFGE)}8_and

mul-tilocus sequence typing (MLST) were performed for MRSA isolates.9

MRSA isolates with vancomycin MIC=2mg/L were screened for hVISA, using BHI agar with 4mg/L of van-comycin and 16g/L of pancreatic digest of casein (Merck, Darmstadt, Germany) (BHI4ca),10 _{and Etest}® _(bioMerieux)

macromethod. S.aureusATCC29213 andMu3(hVISA) were usedascontrolstrains.MRSAisolatesdisplayingatleastone positive screeningtest result were subjected topopulation analysis profile/area under the curve (PAP-AUC).11 Isolates wereidentifiedashVISAiftheAUCratiowas≥0.9and≤1.3.

Two-tailed Fisher’s exact test was used to calculate p-values.Ap-value≤0.05wasconsideredstatistically signifi-cant.

Atotalof200S.aureusisolateswereincludedinthestudy. Nine individuals had two distinct episodes of BSI (n=191 patients). Fifty-five (27.5%) isolates were MRSA, being 25 (45.5%)SCCmec IIand30 (54.5%)SCCmecIV. TheMIC50 and

resistance or non-susceptibility rates to the antimicrobials areshowninTable1.SixisolateswereVISA(4MRSAand2 MSSA). Forty-seven(23.5%)isolateswere non-susceptibleto daptomycin(MIC>1mg/L),being20MRSAand27MSSA.MRSA isolateshadhigherratesofvancomycinresistanceand dapto-mycinnon-susceptibilitythenMSSAisolates(p=0.02and0.04, respectively)(datanotshown).

Atotalof36(18%)S.aureusisolatesshowedvancomycin MIC=2mg/L,19(53%)MRSA,whichwerethentestedfor van-comycinheteroresistancebyscreeningtests.Thirteenisolates werepositiveforthesetestsandsixofthemwereconfirmed ashVISA,showinganAUCratio1.1,1.2or1.3.

TheMRSAlineagesfoundwereUSA100(ST5-II)(45.5%), fol-lowedbyUSA800(ST5-IV)(30.9%),USA1100(ST30-IV)(18.2%), USA400 (ST1-IV)(5.4%) (Fig. 1). The Brazilianclone (ST239-III) was not found. The most prevalent lineage USA100 tended topresent multidrugresistance,withhighMIC val-ues for oxacillin, vancomycin, and daptomycin. Notably, mostofthedaptomycinnon-susceptibleMRSAisolates(65%) belongedtothislineage.Moreover,threeVISAisolateswere USA100.

Bloodstream infections caused byMRSA wasassociated with highermortalityrates than those causedbysensitive

Table1–MIC50andpercentualofantimicrobialresistanceamong200Staphylococcusaureusisolatesfrombloodstream

infectionforfiveyears(2011–2015)inateachinghospitalinRiodeJaneiroaccordingclonallineages.

S.aureusClonality/ST(n) Oxacillin Vancomycin Daptomycin Teicoplanin TMP/STX Linezolid MIC50 n(%)R MIC50 n(%)R MIC50 n(%)R MIC50 n(%)R MIC50 R(%) MIC50 n(%)R

MSSA(145) 0.5 0(0) 1 2(1.4) 1 27(18.6) 0.25 0(0) ≤0.125/2.3 0(0) 2 0(0) MRSA(55) 64 55(100) 1 4(7.3) 1 20(36.4) 0.5 0(0) ≤0.125/2.3 0(0) 2 0(0) USA100/ST5(25) 256 25(100) 2 3(12) 1 11(44.0) 0.5 0(0) ≤0.125/2.3 0(0) 1 0(0) USA800/ST5(17) 16 17(100) 1 1(5.9) 1 4(23.5) 0.5 0(0) ≤0.125/2.3 0(0) 2 0(0) USA1100/ST30(10) 4 10(100) 1 0(0) 1 2(20.0) ≤0.125 0(0) ≤0.125/2.3 0(0) 2 0(0) USA400/ST1(3) 16 3(100) 2 0(0) 1 1(33.3) 0.5 0(0) ≤0.125/2.3 0(0) 1 0(0)

ST,sequencetype; TMP/STX,trimethoprim/sulfamethoxazole;MIC,minimuminhibitoryconcentration;R,resistance;MSSA, methicillin-sensitiveS.aureus;MRSA,methicillin-resistantS.aureus.Resistancebreakpoints6_{–oxacillin:≥4␮g/mL,vancomycin:≥4␮g/mL,daptomycin:}

brazj infect dis.2019;23(2):139–142

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Fig.1–Generalcharacteristicsof55methicillin-resistantStaphylococcusaureusfrombloodstreaminfection,between2011 and2015.

MIC,MinimalInhibitoryConcentrationinmg/L;Oxa,oxacillin;Van,vancomycin;Dap,daptomycin;SCCmec,staphylococcal cassettechromosomemec;*hVISAisolates.

isolates.1 _{In this scenario, surveillance of antimicrobials}

resistance playsa major role by providing importantdata forempirical treatmentdecision. As data on antimicrobial susceptibility inBrazil isscarce, especially fordaptomycin

andTMP/STX,thepresentstudyhighlightedanunexpected high vancomycin anddaptomycin MICs withlowTMP/TSX MICsamongS.aureusisolatesfromBSIinaBrazilianhospital overfiveyears.

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Daptomycinhasbeen frequentlyusedinpersistent bac-teremiaincaseswithMICvaluesforvancomycin>1mg/L.12

However,inourstudyasubstantialnumberofisolateswere non-susceptibletodaptomycin.Interestingly,mostofthe dap-tomycinnon-susceptibleMRSAisolateswereassociatedwith the USA100 (ST5-II), the same lineage that presented six vancomycin non-susceptibleisolates (3hVISAand 3VISA). Althoughthereisno daptomycinresistancesurveillancein Brazil,whichmakescomparisonwithourresultsimpossible, ahigh non-susceptibility, asthe onefound inthe hospital ofstudy,maynotrepresentmostoftheBrazilianhospitals. Itshouldbenotedthatdaptomycinnon-susceptibleisolates belongingtotheUSA100lineagehavealreadybeenreported inBrazil.3_{Inaddition,therewasanassociationbetweenthe}

MRSAphenotypeand resistancetovancomycin and dapto-mycin(p≤0.05).Thisresultisofconcernoncedaptomycinis animportantalternativeforthetreatmentofBSIbyMRSA, VISAorhVISA,phenotypesthatwereallfoundinthepresent study.

In this study, we found 10 USA1100 (ST30-IV) isolates recoveredfromBSIinfections.Schuencketal.13_hadalready

described USA1100 causing invasive infections in patients hospitalizedatthesamehospital.Notably,thislineageis com-monlyobservedinindividualsatthecommunity. Thus,we hypothesized that isolates of USA1100 lineage were intro-duced to the hospital analyzed through the admission of colonized patients, as we recentlyevidenced in this same hospital.14

Chamonandcolleagues,15_{inastudyconductedatthesame}

hospital, found that USA400 (ST1-IV) and USA800 (ST5-IV) werethemostcommonlineagesbetween2008and2009,also showingthepresenceofoneUSA100(ST5-II)isolateamong BSIMRSAisolates.Therefore,therehasbeenachangeinthe epidemiologyofBSIinourhospital,highlightingclonal pro-filesthatwereinfrequentinthepast.Althoughthepresent studyinvolvesonlyoneBrazilianhospital,theresultsreflect thedeclineintheprevalenceoftheBEClineageandits replace-ment by other international clones, leading to significant differencesinantimicrobialsusceptibilitypatterns.

Inthisstudy,non-susceptibilityphenotypestodaptomycin andvancomycinwereobservedamongS.aureusisolatesfrom BSIoverfiveyearsataBrazilianteachinghospital.Considering thechangeintheepidemiologyofS.aureusinfectionsinrecent yearsinBrazil,theseresultsseemtoberelatedwithMRSA clonallineagesdisseminationinthisinstitution,reinforcing thatsurveillanceandspreadcontrolofmultiresistant bacte-riashouldbecontinuouslymonitoredinhealthinstitutions worldwide.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

ThisstudywassupportedbyBraziliangrantsfromFundac¸ão CarlosChagasFilhodeAmparoàPesquisadoEstadodoRiode Janeiro(FAPERJ),ConselhoNacionaldeDesenvolvimento Cien-tíficoeTecnológico(CNPq),Coordenac¸ãodeAperfeic¸oamento dePessoaldeNívelSuperior–Brasil(CAPES)–FinanceCode 001.

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1.CoreyGR.Staphylococcusaureusbloodstreaminfections: definitionsandtreatment.ClinInfectDis.2009;48:S254–9. 2.TaraiB,DasP,KumarD.Recurrentchallengesforclinicians:

emergencyofmethicilin-resistantStaphylococcusaureus,

vancomycin-resistance,andcurrenttreatmentoptions.JLab Physicians.2013;5:71–8.

3.OkadoJB,Avaca-CruscaJS,OliveiraAL,DabulANG,daCunha CamargoILB.Daptomycinandvancomycinheteroresistance revealedamongCC5-SCCmecIIMRSAcloneandinvitro evaluationoftreatmentalternatives.JGlobAntimicrob Resist.2018,http://dx.doi.org/10.1016/j.jgar.2018.05.001. pii:S2213-7165(18)30085-7.

4.DaCostaTM,MorgadoPG,CavalcanteFS,DamascoAP,Nouér SA,DosSantosKRN.Clinicalandmicrobiological

characteristicsofheteroresistantand

vancomycin-intermediatedStaphylococcusaureusfrom bloodstreaminfectionsinaBrazilianteachinghospital.PLOS ONE.2016;11:e0160506.

5.BannermanTL,PeacockSJ.Staphylococcus,Micrococcus,and othercatalase-positivecocci.In:MurrayPR,BaronEJ, JorgensenJH,LandryMJ,PfallerMA,editors.Manualofclinical microbiology.Washington:ASMPress;2007.p.390–410. 6.CLSI–ClinicalandLaboratoryStandardsInstitute.

Performancestandardsforantimicrobialsusceptibility testing:twentythirdinformationalsupplementM100-S25. Wayne,PA,USA:CLSI;2016.

7.Milheiric¸oC,OliveiraDC,deLencastreH.Updatetothe multiplexPCRstrategyforassignmentformecelementin

Staphylococcusaureus.AntimicrobAgentsChemother. 2007;51:3374–7.

8.VivoniAM,SantosKR,De-OliveiraMP,etal.Mupirocinfor controllingmethicillin-resistantStaphylococcusaureus:lessons fromadecadeofuseatauniversityhospital.InfectControl HospEpidemiol.2005;26:662–7.

9.EnrightMC,DayNP,DaviesCE,PeacockSJ,SprattBG. Multilocussequencetypingforcharacterizationof methicillin-resistantandmethicilin-susceptibleclonesof

Staphylococcusaureus.JClinMicrobiol.2000;38: 1008–15.

10.SatolaSW,FarleyMM,AndersonKF,PatelJB.Comparisonof detectionmethodsforheteroresistant

vancomycin-intermediateStaphylococcusaureus,withthe populationanalysisprofilemethodasthereferencemethod.J ClinMicrobiol.2011;49:177–83.

11.SatolaSW,CaliendoAM,FarleyMM,PatelJB,BurdEM.Lackof heteroresistanceamongStaphylococcusaureusisolateswith vancomycinof2microgramspermilliliterbyautomated testing.JClinMicrobiol.2009;47:2680–1.

12.HumphriesRM,PollettS,SakoulasJ.Acurrentperspectiveon daptomycinfortheclinicalmicrobiologist.ClinMicrobiolRev. 2013;26:759–80.

13.SchuenckRP,NouérSA,WinterCdeO,etal.Polyclonal presenceofnon-multiresistantmethicillinresistant

StaphylococcusaureusisolatescarryingSCCmecIVinhealth care-associatedinfectionsinahospitalinRiodeJaneiro, Brazil.DiagnMicrobiolInfectDis.2009;64:434–41.

14.CavalcanteS,PinheiroMV,FerreiraDC,etal.Characteristics ofmethicillin-resistantStaphylococcusaureusinpatientson admissiontoateachinghospitalinRiodeJaneiro,Brazil.AmJ InfectControl.2017;45:1190–3.

15.ChamonRC,RibeiroSS,daCostaTM,NouérAS,dosSantos KRN.CompletesubstitutionoftheBrazilianendemiccloneby othermethicillin-resistantStaphylococcusaureuslineagesin twopublichospitalsinRiodeJaneiro,Brazil.BrazJInfectDis. 2017;21:185–9.