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      Clonal expansion of community-associated meticillin-resistant Staphylococcus aureus (MRSA) in people who inject drugs (PWID): prevalence, risk factors and molecular epidemiology, Bristol, United Kingdom, 2012 to 2017

      1 , 2 , 3 , 4 , 5 , 1 , 6 , 1 , 6 , 4 , 2 , 7 , 8 , 9 , 5 , 9 , 5 , 5 , 10 , 3 , 2 , 12 , 6 , 11 , 12 , 1 , 12
      European Centre for Disease Prevention and Control (ECDC)
      Meticillin-Resistant Staphylococcus aureus, Staphylococcal epidemiology, Staphylococcal Infections/transmission, MRSA, Sepsis, Injecting drug use, Intravenous, Substance Abuse, Intravenous: complications, Substance Abuse, Intravenous: microbiology, Drug users, Substance-Related Disorders/complications, Substance-Related Disorders/microbiology, Sequence Analysis, DNA, Whole-genome sequencing, United Kingdom, Community acquired infections, Community acquired infections epidemiology, Community acquired infections microbiology

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          Background: In 2015, Bristol (South West England) experienced a large increase in cases of meticillin-resistant Staphylococcus aureus (MRSA) infection in people who inject drugs (PWID).

          Aim: We aimed to characterise and estimate the prevalence of MRSA colonisation among PWID in Bristol and test evidence of a clonal outbreak.

          Methods: PWID recruited through an unlinked-anonymous community survey during 2016 completed behavioural questionnaires and were screened for MRSA. Univariable logistic regression examined associations with MRSA colonisation. Whole-genome sequencing used lineage-matched MRSA isolates, comparing PWID (screening and retrospective bacteraemia samples from 2012-2017) with non-PWID (Bristol screening) in Bristol and national reference laboratory database samples.

          Results: The MRSA colonisation prevalence was 8.7% (13/149) and was associated with frequently injecting in public places (odds ratio (OR): 5.5; 95% confidence interval (CI):1.34–22.70), recent healthcare contact (OR: 4.3; 95% CI: 1.34–13.80) and injecting in groups of three or more (OR: 15.8; 95% CI: 2.51–99.28). People reporting any one of: injecting in public places, injection site skin and soft tissue infection or hospital contact accounted for 12/13 MRSA positive cases (sensitivity 92.3%; specificity 51.5%). Phylogenetic analysis identified a dominant clade associated with infection and colonisation among PWID in Bristol belonging to ST5-SCCmecIVg.

          Conclusions: MRSA colonisation in Bristol PWID is substantially elevated compared with general population estimates and there is evidence of clonal expansion, community-based transmission and increased infection risk related to the colonising strain. Targeted interventions, including community screening and suppression therapy, education and basic infection control are needed to reduce MRSA infections in PWID.

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          Staphylococcus aureus CC398: Host Adaptation and Emergence of Methicillin Resistance in Livestock

          Introduction Methicillin-resistant Staphylococcus aureus (MRSA) has been described in animals since 1972 (1), but a new lineage, clonal complex 398 (CC398), has emerged among livestock and begun colonizing and infecting humans. Human MRSA infections have been categorized into three groups based on their putative sources: health care-associated MRSA, community-associated MRSA, and health care-associated MRSA with community onset. A fourth category has recently been added to describe human MRSA cases associated with exposure to livestock (livestock-associated MRSA [LA-MRSA]). Human colonization with LA-MRSA multilocus sequence type 398 (ST398) was first recognized among swine farmers in France and The Netherlands in the early 2000s (2, 3). Since those early reports, ST398 and closely related STs within CC398 have been reported in diverse livestock hosts in many countries around the world (4–8). Human cases of MRSA CC398 have also been increasing rapidly and now account for up to 25% of the total MRSA cases in some parts of The Netherlands (9). Given its rapid emergence and trajectory of increasing importance in humans, the evolutionary history of MRSA CC398 has relevance for the epidemiology of MRSA and global health. Methicillin-susceptible S. aureus (MSSA) CC398 is prevalent among pigs in Europe (10), but the evolution and global dispersal of this group have yet to be clarified. A microarray-based study revealed that the core genomes of 6 CC398 isolates were distinct from those of more than 2,000 S. aureus isolates from humans (11), and it has been generally presumed that pigs or other animals are the natural hosts of CC398. Attempts to better characterize the evolution and epidemiology of CC398 have been hampered by the limited resolution of conventional S. aureus typing methods, including multilocus sequence typing (MLST) and spa sequence typing. While MLST defines CC398 and is useful for placing CC398 in the context of other S. aureus clonal complexes, it is of no use for characterizing variation within the group. spa typing has revealed geographic clustering among CC398 isolates in Europe (12, 13); however, the limited number of common spa types among CC398 isolates and the potential for homoplasy in the spa gene data restrict its phylogenetic utility (14). Whole-genome sequencing provides a superior genetic fingerprint, which can be used for source tracking and evolutionary studies. Thus far, whole-genome sequencing has been used to study the hospital transmission and spatiotemporal spread of ST239 (15). In this study, we applied whole-genome sequence typing (WGST) to a diverse collection of 89 CC398 isolates to study the origins and evolution of S. aureus CC398. RESULTS We sequenced the genomes of 88 S. aureus CC398 isolates (see Data set S1 in the supplemental material). Among the isolates, we sequenced an average of 2,651,848 bases (standard deviation [SD] = 80,311) at ≥10× coverage. Genomes were sequenced at an average depth of 104.36× (SD = 35.7, using the 2,872,582-base SO385 chromosome as a reference). Rooting the CC398 tree using ST36 as the outgroup revealed that a cluster of four isolates, characterized by the t899 spa type, was the first lineage to diverge from the other CC398 isolates (see Fig. S1 in the supplemental material). Much of the similarity between the t899 cluster and the ST36 isolate was mapped to the same ~123,000-bp region surrounding the spa gene. However, this region was incongruent with the phylogenetic signal generated by the rest of the chromosome in the t899 isolates. Comparative genomic analysis with other STs suggested that this region was acquired horizontally from an ST9 donor (see Fig. S2 in the supplemental material). When single nucleotide polymorphisms (SNPs) from this region were excluded from the phylogenetic analysis, the t899 lineage clustered with a more derived clade of European isolates and a clade of human-associated MSSA isolates from France, French Guiana, and the United States was identified as the first divergent CC398 lineage (see Fig. S3 in the supplemental material). This lineage was used to root the final CC398 WGST tree (Fig. 1). With the ST36 genome removed and excluding the SNPs from the 123,000-bp putative horizontally transferred region, we identified 4,238 SNPs, including 1,102 parsimony-informative SNPs with a consistency index (CI) of 0.9591. Among the SNPs, 3,552 were from coding regions (1,071 synonymous and 2,481 nonsynonymous). FIG 1 Maximum-parsimony tree of the 89 CC398 isolates (including ST398SO385) based on 4,238 total SNPs, including 1,102 parsimony-informative SNPs with a CI of 0.9591. Clades and groups of importance are labeled in a hierarchical fashion to facilitate description in the text. The tree was rooted with clade I based on an iterative selection process that identified this group as the most ancestral (see Materials and Methods). COO, country of origin; AT, Austria; BE, Belgium; CA, Canada; CH, Switzerland; CN, China; DE, Germany; DK, Denmark; ES, Spain; FI, Finland; FR, France; GF, French Guiana; HU, Hungary; IT, Italy; NL, The Netherlands; PE, Peru; PL, Poland; PT, Portugal; SI, Slovenia; US, United States; P, pig; H, human; R, horse; T, turkey; B, bovine; MET, methicillin susceptibility; R, resistant; S, susceptible. The phylogenetic tree presented in Fig. 1 is a highly accurate depiction of the evolutionary relationships among the 89 CC398 strains included in this study (including the reference). The lack of homoplasy among informative SNPs (CI = 0.9591) obviated the need for additional measures of robustness such as bootstrapping (16). The most ancestral lineage (clade I) was composed entirely of MSSA strains from humans in North America, South America, and Europe. In addition, with the exception of one isolate (P23-14_SD4.1), the strains that accounted for the most ancestral lineages within clade II (II group of interest [II-GOI]) were human-associated S. aureus from China (including two MRSA strains isolated from Danish adoptees from China). All but one of the livestock-associated strains belonged to clade IIa, which was derived from the human-associated lineages. Clade IIa was composed of several lineages whose evolutionary relationships could not be determined due to poor hierarchical resolution. The lack of resolution was likely due to a rapid radiation following introduction into livestock, as homoplasy was exceedingly rare among the parsimony-informative SNPs. The isolates within clades IIa1 and IIa2 consisted almost entirely of European isolates, while the 10 remaining lineages consisted almost entirely of North American isolates. The IIa1i lineage was dominated by Danish isolates, one-third of which were MSSA, while the IIa1ii lineage consisted largely of MRSA isolates from several European countries, except Denmark. Interestingly, 6 of the 10 smaller lineages included MSSA strains isolated from turkey meat from the United States (IIa-GOI). In this report, we use the term “human associated” for isolates belonging to clade I and clade II-GOI (n = 19) and use the term “livestock associated” for isolates belonging to subclade IIa (n = 70). Fifteen different spa types were identified among the 89 CC398 isolates, including t011, t034, t108, t567, t571, t899, t1250, t1451, t1793, t2876, t3085, t3625, t5462, t5463, and t5719 (Fig. 1). The two most common spa types, t011 and t034, represented 67% of the isolates. While some spa types were more common within individual clusters (e.g., t571 was disproportionately common among human-associated isolates), spa types were inconsistent with the overall CC398 phylogeny (Fig. 1). Sixty-one percent (30/49) of the CC398 MRSA isolates harbored staphylococcal cassette chromosome mec element (SCCmec) subtype Vc (5C2&5) containing the cadmium-zinc resistance gene czrC. All of the SCCmec Vc (5C2&5) cassettes were present in LA-MRSA strains. Of note, the czrC gene was also found in two livestock-associated MSSA isolates. The remaining LA-MRSA isolates carried SCCmec (sub)types IVa (2B), IVa (2B&5), IVc (2B), Vb (5C2&5), V*, and V**; a novel VII-like SCCmec cassette; and a nontypeable (NT) SCCmec cassette. The mecA gene was detected in only two human-associated isolates; in both cases, the mecA gene was coded within SCCmec subtype Vb (5C2&5). The type V* and V** SCCmec cassettes contained structurally different J1 regions that did not match the J1 regions associated with subtypes a to c. The type VII-like SCCmec cassette contained ccr type 5 (ccrC) and a class C1-like mec gene complex element previously identified in SCCmec type X (7C1-like) (17). Accordingly, this novel SCCmec type was referred to as VII-like (5C1-like) to distinguish it from archetypal SCCmec type VII (5C1). The NT cassette contained a class C1-like mec gene complex without any previously described ccr gene complex. The tetracycline resistance gene tet(M) was present in 99% (69/70) of the livestock-associated isolates but absent from the human-associated isolates (Fig. 1; see Data set S1 in the supplemental material). The prophage integrase gene Sa3int was detected in 29 CC398 isolates. Phylogenetic analysis of the Sa3int sequences showed that they belong to three separate clusters; one clade was typical of φSa3 prophages, one was typical of φAvβ prophages, and the third was suggestive of a novel φSa3 integrase variant (see Fig. S4 in the supplemental material). φSa3 prophages in association with one or more human innate immunomodulatory genes were detected in 95% (18/19) of the human-associated S. aureus isolates (Fig. 1; see Data set 1 in the supplemental material). All 18 positive isolates were from human samples, whereas the single isolate lacking φSa3 prophages originated from a pig farm. All 10 isolates belonging to clade I carried chp and scn (type C φSa3 prophages), whereas 6 of 8 isolates belonging to clade II-GOI carried sak, chp, and scn (type B φSa3 prophages) and 2 isolates carried scn only (an IEC type not previously described). In comparison, only 1 of 70 isolates belonging to clade II harbored a φSa3 prophage in association with sak, chp, and scn (type B). Interestingly, 10 livestock-associated isolates belonging to IIa-GOI were largely from turkey meat samples and carried a φAvβ prophage along with the associated genes SAAV_2008 and SAAV_2009 but lacked human innate immunomodulatory genes carried by φSa3 prophages. Sa2int and the lukF-lukS genes carried by φSa2 prophages were present in 6 of 19 human-associated isolates. Conversely, all livestock-associated S. aureus isolates lacked the lukF-lukS genes. DISCUSSION Since its discovery, MRSA CC398 has been perceived as a livestock-associated pathogen; however, the WGST-based phylogeny presented here strongly suggests that the CC398 lineage originated in humans as MSSA and then spread to livestock, where it subsequently acquired the SCCmec cassette and methicillin resistance. The isolates that formed the most basal clades (I and II-GOI) on the WGST-based phylogenetic trees were almost all human-associated MSSA strains, suggesting that these isolates were the most ancestral of those tested in this study (Fig. 1). Likewise, the clade structure observed in the livestock-dominated IIa clade supports a rapid radiation as CC398 moved from humans to animals (see Fig. S5 in the supplemental material). Thus, livestock-associated CC398 infections in humans may be seen as a reintroduction to the original host. Epidemiological data suggest that livestock-associated CC398 strains have lower transfer rates, and may be less virulent, in humans than other well-known STs (18). In this study, we showed that the lukF-lukS genes encoding Panton-Valentine leukocidin (PVL) were present in only 6 of the 89 genomes, all of which were human associated (see Data set S1 in the supplemental material). Strikingly, we found that all of the human-associated MSSA strains from clade I and clade II-GOI carried φSa3 in association with human innate immunomodulatory genes, whereas φSa3 was identified in only one livestock-associated isolate (see Fig. S6 in the supplemental material). Instead, a φAvβ prophage and the associated genes SAAV_2008 and SAAV_2009 were identified among a group of mainly turkey meat isolates in the livestock-associated clade IIa-GOI. It therefore appears that φSa3 was lost prior to (or early in) the formation of clade II, while φAvβ was introduced into avian MSSA CC398 isolates thereafter (Fig. 1). The human innate immunomodulatory genes carried by φSa3 prophages play crucial roles in human niche adaptation (19, 20), whereas the φAvβ-carried SAAV_2008 and SAAV_2009 genes (encoding a putative ornithine cyclodeaminase and a putative membrane protease of the CAAX family, respectively) belong to the avian-niche-specific accessory gene pool for broiler chicken-associated S. aureus ST5 (21). The loss of human-niche-specific genes in livestock-associated isolates, including those from turkeys, may be a result of adaptation to nonhuman hosts. A similar natural history has been reconstructed for broiler chicken-associated S. aureus ST5, which appears to have been introduced from humans into the chicken-breeding system, transmitted vertically, and disseminated worldwide (21). The ST5 jump from humans to chickens also appears to have been followed by the acquisition of avian-niche-specific genes (including the SAAV_2008 and SAAV_2009 genes carried by φAvβ prophages) and partial loss of human-niche-specific genes (including human innate immunomodulatory genes carried by φSa3 prophages) (21). The data presented here strongly suggest that CC398 acquired resistance to methicillin and tetracycline after the introduction to livestock from humans (see Fig. S7a and b in the supplemental material). The tetracycline resistance gene tet(M) was nearly universal among livestock-associated CC398 MRSA and MSSA isolates and completely missing from human-associated strains. Consequently, tetracycline use in food animal production is likely to select for livestock-associated S. aureus CC398 without differentially selecting for MRSA strains. MRSA can be selected for by a number of broad-spectrum cephalosporins that are used in food animal production in the United States and Europe. Likewise, zinc and other metals are frequently used in animal feed formulations and may coselect for MRSA CC398 strains that carry the czrC zinc resistance gene, as suggested previously (22). This hypothesis is supported by our findings that the vast majority of LA-MRSA strains carry SCCmec type Vc (5C2&5), which contains the czrC gene. This study demonstrates the potential power of WGST for epidemiological investigations. For example, two of the Danish MRSA isolates came from infants adopted from China. Both isolates were spa type t034, which is consistent with the majority of Danish CC398 isolates from pigs and humans; however, WGST showed that the isolates shared a recent common ancestor with a French isolate and that this clade was derived from other clades within II-GOI that were strictly Chinese in origin (Fig. 1, II-GOI). Although the French isolate obscures these results, they are most consistent with a Chinese rather than Danish origin of the isolates. WGST revealed thousands of SNPs among the 89 CC398 strains. These mutations may provide robust phylogenetic signals for future epidemiological and epizootological investigations involving CC398 strains. spa typing is routinely used for S. aureus epidemiology; however, in this study, homoplasy within the spa gene led to inconsistencies between the WGST CC398 phylogeny and spa types. Some spa types, such as t571 and t034, were observed in distant clades of the highly accurate WGST phylogenetic tree (Fig. 1). The t899 isolates exemplified the limitations of any single-locus typing method, as the spa gene was part of a ~123,000-bp region of DNA acquired from a distantly related S. aureus clone. A similar observation was made previously with S. aureus ST239, which originated as a hybrid between ST8-like and ST30-like chromosomes (23). Here, reliance on spa typing would have incorrectly placed these isolates outside of CC398. Interestingly, the large horizontally acquired region observed among the t899 CC398 strains also carries the SCCmec cassette, thus possibly presenting an alternative mechanism for SCCmec dissemination among S. aureus strains. In this study, we provide strong evidence that CC398 originated in humans as MSSA and then spread to livestock, where it acquired resistance to methicillin and tetracycline. Genomic analyses presented here, in conjunction with previous epidemiological data, suggest that the jump from humans to animals was followed by a decreased capacity for human colonization, transmission, and virulence, yet livestock-associated CC398 has been linked to an increase in MRSA infections in northern Europe. Further research is required to characterize the full scope of the genetic changes associated with the shift from humans to livestock. Likewise, additional research and surveillance are required to predict the public health impact of MRSA CC398 in the future. MATERIALS AND METHODS Bacterial isolates. This study included MRSA (n = 48) and MSSA (n = 40) CC398 isolates from 19 countries on four continents with strains from humans (n = 25) and livestock (n = 63, including strains from live animals, meat samples, and environmental contamination) (see Data set S1 in the supplemental material). A previously sequenced ST398 strain, SO385, from The Netherlands was used as the reference and included in all analyses (24). MLST. MLST was performed as described previously (http://saureus.mlst.net/misc/info.asp) (25). STs were assigned through the MLST database (http://www.mlst.net). The eBURST algorithm v3 was used to assign individual STs to specific CCs (http://eburst.mlst.net). spa typing. Amplification of the spa repeat region was performed using primers spa 1113f (5′ AAAGACGATCCTTCGGTGAGC 3′) and spa 1514r (5′ CAGCAGTAGTGCCGTTTGCTT 3′) and the conditions described previously (http://www.SeqNet.org). The spa types were determined based on the sequencing results using the spa plug-in included in the BioNumerics v4.6 software (Applied Math, Sint-Martens-Latem, Belgium). Genome sequencing. DNA samples were prepared for multiplexed, paired-end sequencing on an Illumina Genome Analyzer IIx (Illumina, Inc., San Diego, CA). For each isolate, 1 to 5 µg DNA in 200 µl was sheared in a 96-well plate with the SonicMAN (part no. SCM1000-3; Matrical BioScience, Spokane, WA) to a size range of 200 to 1,000 bp, with the majority of material at ca. 600 bp, using the following parameters: prechill, 0°C for 75 s; cycles, 20; sonication, 10 s; power, 100%; lid chill, 0°C for 75 s; plate chill, 0°C for 10 s; postchill, 0°C for 75 s. The sheared DNA was purified using the QIAquick PCR Purification kit (catalog no. 28106; Qiagen, Valencia, CA). The enzymatic processing (end repair, phosphorylation, A tailing, and adaptor ligation) of the DNA followed the guidelines described in the Illumina protocol (Preparing Samples for Multiplexed Paired-End Sequencing, catalog no. PE-930-1002, part no.1005361). The enzymes for processing were obtained from New England Biolabs (catalog no. E6000L; New England BioLabs, Ipswich, MA), and the oligonucleotides and adaptors were obtained from Illumina (catalog no. PE-400-1001). After ligation of the adaptors, the DNA was run on a 2% agarose gel for 2 h, after which a gel slice containing 500- to 600-bp fragments of each DNA sample was isolated and purified using the QIAquick Gel Extraction kit (catalog no. 28706; Qiagen, Valencia, CA). Individual libraries were quantified by quantitative PCR on an ABI 7900HT (part no. 4329001; Life Technologies Corporation, Carlsbad, CA) in triplicate at two concentrations, 1:1,000 and 1:2,000, using the Kapa Library Quantification kit (part no. KK4832 or KK4835; Kapa Biosystems, Woburn, MA). Based on the individual library concentrations, equimolar pools of no more than 12 indexed S. aureus libraries were prepared at a concentration of at least 1 nM using 10 mM Tris-HCl (pH 8.0)-0.05% Tween 20 as the diluent. To ensure accurate loading onto the flow cell, the same quantification method was used to quantify the final pools. The pooled paired-end libraries were sequenced on an Illumina Genome Analyzer IIx to a read length of at least 76 bp. Identification of SNPs. Illumina WGS data sets were aligned against the chromosome of the published ST398 reference genome (strain SO385; GenBank accession no. AM990992) (24) using the short-read alignment component of the Burrows-Wheeler Aligner. Each alignment was analyzed for SNPs using SolSNP (http://sourceforge.net/projects/solsnp/). In order to avoid false calls due to sequencing errors, SNP loci were excluded if they did not meet a minimum coverage of 10× and if the variant was present in less than 90% of the base calls for that position. SNP calls were combined for all of the sequenced genomes such that for the locus to be included in the final SNP matrix, it had to be present in all of the genomes. SNPs falling in the duplicated regions on the reference genome were discarded. Phylogenetic analysis. Phylogenetic trees were generated using the maximum-parsimony method in PAUP v4.0b10. For maximum-parsimony bootstrapping analysis, the analysis was constrained to build a maximum of 1,000 trees (100 replicates, 10 trees each). The root of the tree was determined through an iterative process as follows. A distance matrix and phylogenetic tree was generated comparing the chromosomes of ST398 (GenBank accession no. AM990992), ST36 (GenBank accession no. BX571856), ST8 (GenBank accession no. CP000255), ST1 (GenBank accession no. BA000033), and ST5 (GenBank accession no. BA000018). Through this process, ST36 was determined to be the most closely related non-CC398 STs. ST36 was used as an outgroup to root the CC398 WGST tree and identify the most ancient CC398 bifurcation point. CC398 descendants nearest to this bifurcation point were used to root subsequent trees. SCCmec typing. The presence of mecA and SCCmec types and subtypes was assessed in all 89 S. aureus CC398 isolates. The structural features unique to each of the type 1 to 5 ccr gene complexes; class A, B, and C2 mec gene complexes; and four J1 subtypes (a to d) of type IV SCCmec were determined by a PCR-based multiplex assay described by Kondo et al. (26). Structural features unique to the class C1 and C1-like mec gene complexes (17, 27) and the three subtypes of type V SCCmec (17) were determined by aligning the Illumina WGS data sets against reference sequences using CLC Genomics Workbench v4.7.2 (CLC bio, Aarhus, Denmark). The following reference sequences were used: mec class C1 (GenBank accession no. AB373032); mec class C1-like (GenBank accession no. AB505630); and SCCmec subtypes Va (5C2) (GenBank accession no. AB121219), Vb (5C2&5) (GenBank accession no. AB462393), and Vc (5C2&5) (GenBank accession no. AB505629). SCCmec nomenclature was applied as proposed by the International Working Group on the Classification of Staphylococcal Cassette Chromosome Elements (28). For brevity, the type is indicated by roman numerals and the subtype is identified by a lowercase latin letter. The combination of ccr and mec gene complexes is indicated by an arabic number and a latin letter, respectively, in parentheses. When a composite of two SCC elements carrying distinct ccr gene complexes is identified, this is indicated by an ampersand and an arabic numeral designating the ccr type. Detection of genes associated with antimicrobial resistance and host adaptation. All 89 genomes were analyzed for the presence of the tetracycline resistance gene tet(M), the cadmium-zinc resistance gene czrC, the φSa3 and φSa2 prophages (identified by Sa3int and Sa2int integrase genes), five genes carried by φSa3 prophages (sea, sep, sak, chp, and scn), two putative avian-niche-specific genes carried by φAvβ (a φSa3-like prophage) (SAAV_2008 and SAAV_2009), and two PVL genes carried by φSa2 prophages (lukF-PV and lukS-PV). Local BLASTN searches were performed on de novo contigs assembled from the Illumina WGS data sets, as well as a reference assembly, using CLC Genomics Workbench v4.7.2. The presence or absence of genes was determined using thresholds of 90% nucleotide identity, 90% coverage of the query sequence length, and a sequence depth of >10×. The query sequences used were tet(M) and czrC (GenBank accession no. AM990992); Sa3int, sea, sak, chp, and scn (GenBank accession no. NC_009641); sep (GenBank accession no. BA000018); SAAV_2008 and SAAV_2009 (GenBank accession no. CP001781); and Sa2int, lukF-PV, and lukS-PV (GenBank accession no. AB006796). All de novo contigs with BLASTN matches to Sa3int were selected, and the Sa3int genes were retrieved for phylogenetic reconstruction using Sa3int (GenBank accession no. NC_009641) and Avβint (GenBank accession no. CP001781) as reference sequences. Gene sequences were aligned using ClustalW v 2.0 (29), and the trees were generated using the maximum-parsimony method in PAUP v4.0b10. The φSa3 prophages received letter designations to reflect unique combinations of the five prophage-carried genes that modulate human innate immune responses (sea, sep, sak, chp, and scn) as described elsewhere (30). SUPPLEMENTAL MATERIAL Data set S1 Isolates included in this study. Download Data set S1, XLSX file, 0.1 MB. Data set S1, XLSX file, 0.1 MB Figure S1 Maximum-parsimony tree based on 27,475 SNPs from 89 isolates (including ST398SO385) rooted with an ST36 isolate (USA200-MRSA252) as the outgroup. The CI for the parsimony-informative SNPs was 0.8969. The t899 group (12152-5, UB08116, 30116, and 44523-1) was identified as the most ancestral and is highlighted in gray. Download Figure S1, PDF file, 0.3 MB. Figure S1, PDF file, 0.3 MB Figure S2 Graphic representation of the region flanking the spa gene of S. aureus ST398 strain SO385 (t011; MRSA), ST398 strain 12152-5 (t899; MRSA), and ST9 strain 2007-70-94-4 (t1334; MSSA). Light gray indicates areas with high homology to ST398 sequences, and dark gray indicates areas with high homology to ST9. The location of the spa gene is indicated in black. Approximate insertion nucleotides are reported based on the SO385 reference genome. Download Figure S2, PDF file, 0.7 MB. Figure S2, PDF file, 0.7 MB Figure S3 Maximum-parsimony tree based on 26,324 SNPS from 89 isolates (including ST398SO385) rooted with ST36 (USA200-MRSA252) as the outgroup. The SNPs from the horizontally transferred region surrounding the spa gene were excluded (region in reference ST398SO385, 12252 to 135180). The CI for the parsimony-informative SNPs was 0.9089. The most ancestral isolates within the CC398 lineage are highlighted in gray. Download Figure S3, PDF file, 0.3 MB. Figure S3, PDF file, 0.3 MB Figure S4 Phage tree. Shown is a maximum-parsimony tree of the Sa3int genes from 30 ST398 isolates, Sa3int (GenBank accession no. NC_009641), and Avβint (GenBank accession no. CP001781). Download Figure S4, PDF file, 0.7 MB. Figure S4, PDF file, 0.7 MB Figure S5 Cladograms colored to show host species. Download Figure S5, PDF file, 0.2 MB. Figure S5, PDF file, 0.2 MB Figure S6 Cladogram colored to show φSa3-positive isolates. Download Figure S6, PDF file, 0.2 MB. Figure S6, PDF file, 0.2 MB Figure S7a Cladogram colored to show SCCmec types. Download Figure S7a, PDF file, 0.2 MB. Figure S7a, PDF file, 0.2 MB Figure S7b Cladogram colored to show tet(M)-positive isolates. Download Figure S7b, PDF file, 0.2 MB. Figure S7b, PDF file, 0.2 MB
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            Statistics review 13: Receiver operating characteristic curves

            This review introduces some commonly used methods for assessing the performance of a diagnostic test. The sensitivity, specificity and likelihood ratio of a test are discussed. The uses of the receiver operating characteristic curve and the area under the curve are explained.
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              Decolonization in Prevention of Health Care-Associated Infections.

              Colonization with health care-associated pathogens such as Staphylococcus aureus, enterococci, Gram-negative organisms, and Clostridium difficile is associated with increased risk of infection. Decolonization is an evidence-based intervention that can be used to prevent health care-associated infections (HAIs). This review evaluates agents used for nasal topical decolonization, topical (e.g., skin) decolonization, oral decolonization, and selective digestive or oropharyngeal decontamination. Although the majority of studies performed to date have focused on S. aureus decolonization, there is increasing interest in how to apply decolonization strategies to reduce infections due to Gram-negative organisms, especially those that are multidrug resistant. Nasal topical decolonization agents reviewed include mupirocin, bacitracin, retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, photodynamic therapy, omiganan pentahydrochloride, and lysostaphin. Mupirocin is still the gold standard agent for S. aureus nasal decolonization, but there is concern about mupirocin resistance, and alternative agents are needed. Of the other nasal decolonization agents, large clinical trials are still needed to evaluate the effectiveness of retapamulin, povidone-iodine, alcohol-based nasal antiseptic, tea tree oil, omiganan pentahydrochloride, and lysostaphin. Given inferior outcomes and increased risk of allergic dermatitis, the use of bacitracin-containing compounds cannot be recommended as a decolonization strategy. Topical decolonization agents reviewed included chlorhexidine gluconate (CHG), hexachlorophane, povidone-iodine, triclosan, and sodium hypochlorite. Of these, CHG is the skin decolonization agent that has the strongest evidence base, and sodium hypochlorite can also be recommended. CHG is associated with prevention of infections due to Gram-positive and Gram-negative organisms as well as Candida. Conversely, triclosan use is discouraged, and topical decolonization with hexachlorophane and povidone-iodine cannot be recommended at this time. There is also evidence to support use of selective digestive decontamination and selective oropharyngeal decontamination, but additional studies are needed to assess resistance to these agents, especially selection for resistance among Gram-negative organisms. The strongest evidence for decolonization is for use among surgical patients as a strategy to prevent surgical site infections.

                Author and article information

                Euro Surveill
                Euro Surveill
                European Centre for Disease Prevention and Control (ECDC)
                28 March 2019
                : 24
                : 13
                [1 ]Field Epidemiology Service, Public Health England, Bristol, United Kingdom
                [2 ]Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
                [3 ]Public health laboratory Bristol, Public Health England, Bristol, United Kingdom
                [4 ]Bristol Drugs Project, Bristol, United Kingdom
                [5 ]Blood Borne Virus Section, HIV & STI Department, National Infection Service, Public Health England, London, United Kingdom
                [6 ]NIHR Health Protection Research Unit in Evaluation of Interventions at University of Bristol, Bristol, United Kingdom
                [7 ]Infectious Diseases Research Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
                [8 ]King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
                [9 ]University of West England, Bristol, United Kingdom
                [10 ]Public Health Institute, Liverpool John Moores University, Liverpool, United Kingdom
                [11 ]School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
                [12 ]Authors contributed equally to the work and share last authorship
                Author notes

                Correspondence: Simon Packer ( simon.packer@ 123456phe.gov.uk )

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                This article is copyright of the authors or their affiliated institutions, 2019.

                This is an open-access article distributed under the terms of the Creative Commons Attribution (CC BY 4.0) Licence. You may share and adapt the material, but must give appropriate credit to the source, provide a link to the licence, and indicate if changes were made.

                Custom metadata

                meticillin-resistant staphylococcus aureus,staphylococcal epidemiology,staphylococcal infections/transmission,mrsa,sepsis,injecting drug use,intravenous,substance abuse,intravenous: complications,intravenous: microbiology,drug users,substance-related disorders/complications,substance-related disorders/microbiology,sequence analysis, dna,whole-genome sequencing,united kingdom,community acquired infections,community acquired infections epidemiology,community acquired infections microbiology


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