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      MRSA Clonal Complex 22 Strains Harboring Toxic Shock Syndrome Toxin (TSST-1) Are Endemic in the Primary Hospital in Gaza, Palestine

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          Abstract

          Background

          Methicillin-resistant Staphylococcus aureus (MRSA) is an important pathogen in both community and healthcare-related settings worldwide. Current knowledge regarding the epidemiology of S. aureus and MRSA in Gaza is based on a single community-based carriage study. Here we describe a cross-sectional analysis of 215 clinical isolates collected from Al-Shifa Hospital in Gaza during 2008 and 2012.

          Methods

          All isolates were characterized by spa typing, SCC mec typing, and detection of genes encoding Panton-Valentine leukocidin (PVL) and toxic shock syndrome toxin (TSST-1). Representative genotypes were also subjected to multilocus sequence typing (MLST). Antibiotic susceptibility testing was performed using VITEK2 and MicroScan.

          Results

          MRSA represented 56.3% of all S. aureus strains, and increased in frequency from 2008 (54.8%) to 2012 (58.4%). Aside from beta-lactams, resistance was observed to tetracycline, erythromycin, clindamycin, gentamicin, and fluoroquinolones. Molecular typing identified 35 spa types representing 17 MLST clonal complexes (CC), with spa 998 (Ridom t223, CC22) and spa 70 (Ridom t044, CC80) being the most prevalent. SCC mec types I, III, IV, V and VI were identified among MRSA isolates, while type II was not detected. PVL genes ( lukF/S-PV) were detected in 40.0% of all isolates, while the TSST-1 gene ( tst) was detected in 27.4% of all isolates, with surprisingly high frequency within CC22 (70.4%). Both PVL and TSST-1 genes were found in several isolates from 2012.

          Conclusions

          Molecular typing of clinical isolates from Gaza hospitals revealed unusually high prevalence of TSST-1 genes among CC22 MRSA, which is noteworthy given a recent community study describing widespread carriage of a CC22 MRSA clone known as the ‘Gaza strain’. While the latter did not address TSST-1, tst-positive spa 998 (Ridom t223) has been detected in several neighboring countries, and described as endemic in an Italian NICU, suggesting international spread of a ‘Middle Eastern variant’ of pandemic CC22 strain EMRSA-15.

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          Most cited references50

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          eBURST: inferring patterns of evolutionary descent among clusters of related bacterial genotypes from multilocus sequence typing data.

          The introduction of multilocus sequence typing (MLST) for the precise characterization of isolates of bacterial pathogens has had a marked impact on both routine epidemiological surveillance and microbial population biology. In both fields, a key prerequisite for exploiting this resource is the ability to discern the relatedness and patterns of evolutionary descent among isolates with similar genotypes. Traditional clustering techniques, such as dendrograms, provide a very poor representation of recent evolutionary events, as they attempt to reconstruct relationships in the absence of a realistic model of the way in which bacterial clones emerge and diversify to form clonal complexes. An increasingly popular approach, called BURST, has been used as an alternative, but present implementations are unable to cope with very large data sets and offer crude graphical outputs. Here we present a new implementation of this algorithm, eBURST, which divides an MLST data set of any size into groups of related isolates and clonal complexes, predicts the founding (ancestral) genotype of each clonal complex, and computes the bootstrap support for the assignment. The most parsimonious patterns of descent of all isolates in each clonal complex from the predicted founder(s) are then displayed. The advantages of eBURST for exploring patterns of evolutionary descent are demonstrated with a number of examples, including the simple Spain(23F)-1 clonal complex of Streptococcus pneumoniae, "population snapshots" of the entire S. pneumoniae and Staphylococcus aureus MLST databases, and the more complicated clonal complexes observed for Campylobacter jejuni and Neisseria meningitidis.
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            Community-associated meticillin-resistant Staphylococcus aureus.

            Meticillin-resistant Staphylococcus aureus (MRSA) is endemic in hospitals worldwide, and causes substantial morbidity and mortality. Health-care-associated MRSA infections arise in individuals with predisposing risk factors, such as surgery or presence of an indwelling medical device. By contrast, many community-associated MRSA (CA-MRSA) infections arise in otherwise healthy individuals who do not have such risk factors. Additionally, CA-MRSA infections are epidemic in some countries. These features suggest that CA-MRSA strains are more virulent and transmissible than are traditional hospital-associated MRSA strains. The restricted treatment options for CA-MRSA infections compound the effect of enhanced virulence and transmission. Although progress has been made towards understanding emergence of CA-MRSA, virulence, and treatment of infections, our knowledge remains incomplete. Here we review the most up-to-date knowledge and provide a perspective for the future prophylaxis or new treatments for CA-MRSA infections. Copyright 2010 Elsevier Ltd. All rights reserved.
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              Classification of staphylococcal cassette chromosome mec (SCCmec): guidelines for reporting novel SCCmec elements.

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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                17 March 2015
                2015
                : 10
                : 3
                : e0120008
                Affiliations
                [1 ]Department of Laboratory Medicine, Al Azhar University-Gaza, Gaza Strip, Palestine
                [2 ]Public Health Research Institute, Rutgers University, Newark, New Jersey, United States of America
                [3 ]The Central Laboratories, Ministry of Health, Gaza Strip, Palestine
                [4 ]Department of Pathology and Laboratory Medicine, North Shore-LIJ Health System, Lake Success, New York, United States of America
                [5 ]Hofstra North Shore-LIJ School of Medicine, Hempstead, New York, United States of America
                [6 ]Institute of Medical Microbiology, University Hospital of Brussels, Brussels, Belgium
                [7 ]Institute of Medical Microbiology, University Hospital of Muenster, Muenster, Germany
                Ross University School of Veterinary Medicine, SAINT KITTS AND NEVIS
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: NAL JRM LC DP KB BNK. Performed the experiments: NAL JRM LC NA FAE CCG. Analyzed the data: NAL JRM LC CCG DP. Contributed reagents/materials/analysis tools: NA FAE CCG DP KB BNK. Wrote the paper: NAL JRM KB BNK.

                Article
                PONE-D-14-44259
                10.1371/journal.pone.0120008
                4364023
                25781188
                a34a5071-53cb-4aab-b0aa-3eb69b412767

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication

                History
                : 1 October 2014
                : 19 January 2015
                Page count
                Figures: 2, Tables: 1, Pages: 17
                Funding
                The first author (NAL) received support for living expenses from several institutions, including the Fulbright Scholar Program (Department of State, Bureau of Educational and Cultural Affairs, United States), the German Academic Exchange Service (DAAD, Germany), and the Erasmus Mundus External Cooperation Window (EM ECW lot III, Belgium), for support of his work during his visits to the Public Health Research Institute, Rutgers University, United States; the University Hospital of Muenster, Germany; and the Free University of Brussels, Belgium, respectively. All funding was for personal living expenses only; the agencies listed did not play any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
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                Research Article
                Custom metadata
                All relevant data are within the paper and its Supporting Information files.

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