Molecular Characteristics of Methicillin-Resistant Staphylococci Clinical Isolates from a Tertiary Hospital in Northern Thailand
Methicillin-resistant staphylococci are now recognized as a major cause of infectious diseases, particularly in hospitals. Molecular epidemiology is important for prevention and control of infection, but little information is available regarding staphylococcal infections in Northern Thailand. In the present study, we examined antimicrobial susceptibility patterns, detection of antimicrobial resistance genes, and SCCmec types of methicillin-resistant S. aureus (MRSA) and methicillin-resistant coagulase-negative staphylococci (MR-CoNS) isolated from patients in a hospital in Northern Thailand. The species of MRSA and MR-CoNS were identified using combination methods, including PCR, MALDI-TOF-MS, and tuf gene sequencing. The susceptibility pattern of all isolates was determined by the disk diffusion method. Antimicrobial resistance genes, SCCmec types, and ST239 were characterized using single and multiplex PCR. ST239 was predominant in MRSA isolates (10/23). All MR-CoNS () were identified as S. haemolyticus (), S. epidermidis (), S. cohnii (), S. capitis (), and S. hominis (). More than 70% of MRSA and MR-CoNS were resistant to cefoxitin, penicillin, oxacillin, erythromycin, clindamycin, gentamicin, and ciprofloxacin. In MRSA isolates, the prevalence of ermA (78.3%) and ermB (73.9%) genes was high compared to that of the ermC gene (4.3%). In contrast, ermC (87.1%) and qacA/B genes (70.9%) were predominant in MR-CoNS isolates. SCCmec type III was the dominant type of MRSA (13/23), whereas SCCmec type II was more present in S. haemolyticus (10/18). Ten MRSA isolates with SCCmec type III were ST239, which is the common type of MRSA in Asia. This finding provides useful information for a preventive health strategy directed against methicillin-resistant staphylococcal infections.
Staphylococcus is recognized as an important cause of nosocomial infection. The most prominent pathogen of the genus is the coagulase-positive Staphylococcus aureus, which causes osteomyelitis, endocarditis, septic arthritis, pneumonia, and skin infections . However, coagulase-negative staphylococci (CoNS) such as S. epidermidis, S. haemolyticus, S. lugdunensis, S. cohnii, S. capitis, and S. hominis are also associated with various infections with possible fatal outcomes in newborns or immunocompromised patients . It is well established that staphylococcal infections in hospitals show an increasing prevalence of methicillin-resistant S. aureus (MRSA) and methicillin-resistant coagulase-negative staphylococci (MR-CoNS) isolates [3, 4]. Methicillin resistance in staphylococci results from the recombinase-mediated insertion of the staphylococcal chromosomal cassette mec (SCCmec), the mobile genetic element that carries mecA and various antibiotic resistance genes. The mecA gene encodes penicillin-binding protein PBP2a that has a low affinity for β-lactam antibiotics . To date, eleven SCCmec types (I–XI) have been identified. SCCmec types I, II, and III have been associated more frequently with hospital-acquired MRSA (HA-MRSA), while SCCmec types IV and V are the most dominant in MRSA infections acquired in the community (CA-MRSA) . Previous studies reported the prevalence rate of these major clones varies markedly in different geographic regions; the predominant HA-MRSA clone in Asian countries is MRSA-ST239-III . S. epidermidis has been found to harbor SCCmec types I, II, III, IV, and V. Likewise, SCCmec types II, III, and V have been discovered in S. haemolyticus . It is generally accepted that the tolerance of chlorhexidine in S. aureus is associated with the family of the qac (qacA/B) gene, which encodes proton-motive force-dependent export pumps . Recently, a study suggested that qacA/B carriage might contribute to an increasing global dominance of CC22 and ST239 clones . Erythromycin resistance in staphylococci is predominantly caused by erythromycin resistance RNA methylase, whose action also affects resistance to other macrolides, lincosamides, and streptogramin B (MLSB). This resistance is mediated by the erm-type genes, caused almost exclusively by ermA or ermC . Little information is available on the molecular epidemiology of MRSA and MR-CoNS in Northern Thailand. This study was designed to characterize the antimicrobial resistance genes and SCCmec types of MRSA and MR-CoNS isolated from a hospital in Chiangrai Province located in Northern Thailand. These data will provide insights into the epidemiology of the MRSA and MR-CoNS in this region.
2. Materials and Methods
2.1. Bacterial Isolates
A total of 54 clinical isolates of staphylococci were collected from November 2015 to October 2016 from patients who were admitted to Chiangrai Prachanukroh Hospital, Chiangrai. The hospital is a (756-bed) teaching hospital that handles ∼3,500 admissions per day, located in the north of Thailand. The isolates were collected from blood (39 isolates, 72.2%), pus (10 isolates, 18.5%), sputum (4 isolates, 7.4%), and other body fluids (1 isolate, 1.9%).
The bacteria were initially identified by colony morphology, mannitol fermentation, Gram characteristics, catalase test, coagulase test, and DNase activity. The phenotypic methicillin resistance was assessed using the cefoxitin disk diffusion method in accordance with the Clinical and Laboratory Standard Institute guidelines (CLSI M100-S24) at our clinical laboratory, which has been accredited by the College of American Pathologists . S. aureus NCTC10442, S. aureus JCSC10442, and S. aureus WIS were used as reference strains for SCCmec typing. S. aureus COL was used as a positive control for mecA gene detection.
2.2. Species Identification of Methicillin-Resistant Staphylococci
All isolates were confirmed as staphylococci by a PCR method based on the 16S rRNA gene . The mecA gene was detected in all isolates to confirm the methicillin resistance . MRSA was identified using PCR for detecting the nuc gene as previously described by Sasaki et al. . The species level of MR-CoNS was identified by MALDI-TOF-MS  and tuf gene sequencing .
The direct colony of MALDI-TOF-MS analysis was analyzed as previously described . The score identification criteria were used as follows: a score of 2.000 to 3.000 indicated species-level identification, a score of 1.700 to 1.999 indicated genus-level identification, and a score <1.700 indicated an unreliable identification .
2.3. Determination of Antibiotic Susceptibility
The antibiotic susceptibility patterns of bacteria to penicillin (P; 10 units), clindamycin (DA; 2 µg), chloramphenicol (C; 30 µg), gentamicin (CN; 10 µg), erythromycin (E; 15 µg), cefoxitin (FOX; 30 µg), sulfamethoxazole/trimethoprim (SXT; 1.25/23.75 µg), vancomycin (VA; 30 µg), rifampicin (RD; 5 µg), linezolid (LZD; 30 µg), mupirocin (MUP; 5 µg), ciprofloxacin (CIP; 5 µg), fusidic acid (FD; 10 µg), and novobiocin (NV; 5 µg) (Oxoid) were determined according to the antibiotic disk diffusion method (CLSI, 2014).
2.4. Determination of SCCmec Types
Multiplex PCR was carried out as described by Zhang et al. . Amplification was performed in a total volume of 25 µl containing 3 µl of 10x buffer with 15 mM of Mg2+, 2.5 µl of 2.5 mM dNTP, 0.2 µl of 5 U Taq polymerase, various concentrations of each primer, and 3 µl of the DNA template. The condition for thermal cycler was set as follows: denaturation at 94°C for 4 min followed by 30 cycles at 94°C for 20 sec, 55°C for 30 sec, and 72°C for 30 min and a final extension at 72°C for 5 min. All PCR products were visualized using gel electrophoresis with 1% agarose gel stained with ethidium bromide.
2.5. ST239 Identification
The ST239 was determined by the PCR method using two oligonucleotide primer sets as previously described by Feil et al. . Amplification reaction was performed with the following condition: 1 cycle of predenaturation at 95°C for 15 min followed by 30 cycles at 95°C for 30 sec, 55°C for 30 sec, and 72°C for 30 sec and a final extension at 72°C for 7 min.
2.6. Detection of Antibiotic and Disinfectant Resistance Genes
The other antibiotic and disinfectant resistance genes including the ermA, ermB, ermC, and qacA/B genes (disinfectant) were detected by PCR as previously described [21–23]. The primer sets are shown in Supplementary Material 1. All PCR products were visualized using gel electrophoresis with 1% agarose gel stained with ethidium bromide. The absence of bias was ensured by the sequencing of each gene in the representative isolates.
3.1. Species Distribution of Staphylococci
The species of all isolates were identified by combined methods, including biochemical tests, PCR, MALDI-TOF-MS, and DNA sequencing. All 23 MRSA isolates were confirmed by detection of the nuc gene, and all species of MR-CoNS isolates were confirmed by tuf gene sequencing. The species distribution of MR-CoNS is given in Figure 1. The species included methicillin-resistant S. haemolyticus (), methicillin-resistant S. epidermidis (), methicillin-resistant S. cohnii (), methicillin-resistant S. capitis (), and methicillin-resistant S. hominis ().
3.2. Antimicrobial Susceptibility Testing
All methicillin-resistant staphylococci were tested for their susceptibility against 15 commonly used antibiotics (Figure 2). All MRSA isolates were sensitive to linezolid, fusidic acid, novobiocin, and vancomycin. Prevalence of resistance among the isolates was as follows: cefoxitin (100%), penicillin (100%), oxacillin (95.7%), erythromycin (86.9%), clindamycin (86.9%), gentamicin (72.1%), ciprofloxacin (72.1%), sulfamethoxazole/trimethoprim (56.5%), mupirocin (13.1%), rifampicin (8.6%), and chloramphenicol (4.3%). Likewise, none of the MR-CoNS isolates were resistant to linezolid and vancomycin. However, prevalence of resistance among the isolates was as follows: oxacillin (100%), cefoxitin (100%), penicillin (100%), gentamicin (87.1%), erythromycin (86.9%), ciprofloxacin (77.4%), clindamycin (64.5%), sulfamethoxazole/trimethoprim (70.9%), mupirocin (41.9%), rifampicin (29.0%), fusidic acid (16.1%), chloramphenicol (9.7%), and novobiocin (6.5%).
3.3. Distribution of SCCmec Types and ST239 Type Detection
All 54 staphylococci were mecA-positive isolates. SCCmec types of all isolates were assigned by multiplex PCR according to the procedures and primer sets listed. As shown in Table 1, all MRSA isolates could be classified into six types of SCCmec elements: types I (), II (), III (), IVa (), IVb (), and V (). The distribution of SCCmec types in all MR-CoNS used in this study was ranked as types I (), II (), III (), IVa (), IVc (), and V (). SCCmec type II was the predominant clone (55.6%) in S. haemolyticus. The distribution of SCCmec types in each species is given in Table 1. Interestingly, using the multiplex PCR method, we could detect ST239 in 10 isolates of MRSA, and all of them were of SCCmec type III.
3.4. Disinfectant and Antibiotic Resistance Genes
Among the 54 methicillin-resistant staphylococci isolates as shown in Table 1, 28 isolates (51.9%) harbored qacA/B. These included 6 isolates (26.1%) of S. aureus, 13 isolates (72.2%) of S. haemolyticus, 3 isolates (100%) of S. cohnii, 5 isolates (83.3%) of S. capitis, and 1 isolate (100%) of S. hominis. The erythromycin resistance genes (ermA, ermB, and ermC) were also detected in MRSA and MR-CoNS. The prevalence of ermA, ermB, and ermC genes found in MRSA was 78.3% (18/23), 73.9% (17/23), and 4.3% (1/23), respectively, whereas 12.9% (4/31), 12.9% (4/31), and 87.1% (27/31) of ermA, ermB, and ermC, respectively, were present in MR-CoNS. The most prevalent ermC gene was detected in MR-CoNS, including 88.9% in S. haemolyticus, 100% in S. cohnii, 100% in S. capitis, and 100% in S. hominis. The ermA and ermB genes were found in S. epidermidis and S. capitis (Table 1).
Methicillin-resistant staphylococci have dispersed worldwide and continue to be among the most common hospital pathogens. The prevalence and characterization of MRSA and MR-CoNS in hospitals have been reported from different parts of the world [24, 25]. However, the increase of antibiotic resistance in nosocomial isolates of MRSA and MR-CoNS aggravates this problem and poses a great challenge for the management of hospital-acquired infections. In the present study, we found that the 54 staphylococcal isolates belonged to 6 different species. The species distribution identification by MALDI-TOF-MS was consistent with the species identified by tuf gene sequencing, with the exception of one isolate (SP33) (Figure 1). Using MALDI-TOF-MS, this isolate was identified as S. epidermidis, but tuf gene sequencing identified it as S. haemolyticus. We assumed that the species assigned by tuf gene sequencing was more accurate because the score of MALDI-TOF-MS was only at the level of genus identification. Moreover, MALDI-TOF-MS could not identify 3 isolates of MR-CoNS. These 3 isolates were identified as S. cohnii by tuf gene sequencing. This result was consistent with a previous study reporting that MALDI-TOF-MS could not identify S. cohnii to the species level . Additionally, a phylogenetic tree based on tuf gene sequencing was compared with the MALDI-TOF dendrogram for all 31 isolates of MR-CoNS (Figure 1). Interestingly, if the disagreement for one isolate (SP 33) was not considered, the structure of each species was broadly in alignment. Only S. hominis was located in different structures of both phylogenetic trees. To the best of our knowledge, this is the first comparison between phylogenetic tree based on tuf gene sequencing and MALDI-TOF dendrogram of MR-CoNS.
We found that MRSA and MR-CoNS isolates were resistant to multiple antibacterial agents (Figure 2). Among MR staphylococci isolates, 82.6% were resistant to 7–10 antibiotics (96.8% of MR-CoNS and 60.9% of MRSA). This result is similar to the findings in China and France with a high rate of antibiotic resistance within MRSA clinical isolates [27, 28]. In this study, all MRSA and MR-CoNS isolates were sensitive to vancomycin and linezolid. Thus, these drugs remain suitable options for the treatment of serious infections caused by MRSA and MR-CoNS.
The mecA gene, encoding a PBP variant which confers resistance to methicillin, was detected in 100% of staphylococci isolated in this study. mecA is carried by the mobile genetic element SCCmec. The distribution of different SCCmec types in methicillin-resistant staphylococci varied depending on the host species, bacterial clones, and possibly geographical locations . SCCmec typing has become essential for the epidemiological characterization of MRSA and MR-CoNS clones. In this study, 54 methicillin-resistant staphylococci were investigated for their SCCmec types; SCCmec type III was found to be predominant, with a proportion of 56.5% (13/23) of MRSA isolates. Our results are in agreement with Chongtrakool et al., who reported SCCmec type III as the predominant type in many Asian countries such as Saudi Arabia, India, Sri Lanka, Singapore, Indonesia, Thailand, Vietnam, Philippines, and China, whereas SCCmec type I of MRSA isolates which shows high prevalence in Iran (56.9%) was found to be only 26.1% in our study [29, 30].
We found that ST239 was detected in 43.5% (10/23) MRSA isolates, and all positive clones carried SCCmec type III (ST239-SCCmec III). Previous studies have demonstrated that ST239-SCCmec III is the endemic HA-MRSA in many Asian countries, although a recent study showed that this clone is being steadily displaced by emerging CA-MRSA clones . ST239-SCCmec III was also reported to be the dominant clone among MRSA clinical isolates in Singapore during 2006–2010. Similarly, because of its high prevalence (77.1%), ST239-SCCmec II was accounted for as the most dominant nosocomial MRSA clone in 18 hospitals in China . It has been reported that ST239-SCCmec III was detected in at least 90% of HA-MRSA isolates in Sappasithiprasong Hospital, Northeast Thailand . These dominant types were resistant to many antibiotics such as erythromycin, gentamicin, sulfamethoxazole/trimethoprim, and ciprofloxacin (Table 1). Similar to the finding of Shahsavan et al., 82% of clinical MRSA isolates in Iran were characterized as ST239, and all these strains were resistant to ciprofloxacin, erythromycin, gentamicin, sulfamethoxazole/trimethoprim, and tetracycline .
SCCmec types have been characterized in 31 MR-CoNS isolates, as shown in Table 1, and SCCmec type II was the dominant type of S. haemolyticus (62.5%). The results of this study are similar to those of Pinheiro et al., who demonstrated the association between SCCmec type II and S. haemolyticus isolated from blood cultures . In contrast, Ruppe et al. demonstrated that SCCmec type V is preferentially associated with S. haemolyticus strains isolated from disparate geographical areas such as Cambodia, Algeria, Mali, and Moldova . The occurrence of different SCCmec types in many countries might reflect the genetic background of S. haemolyticus strains, connected with geographical locations. SCCmec type III was distributed in various MRSA clones and MR-CoNS species, conforming to our results that found the distribution of SCCmec type III in various species such as S. cohnii, S. capitis, and S. hominis. Significantly, SCCmec type IV was associated with methicillin-resistant S. epidermidis (MRSE). This supported the finding of Wisplinghoff et al. that SCCmec type IV is distributed in many MRSE strains .
High prevalence of ermA (78.3%) and ermB (73.9%) genes was found in MRSA isolates, compared to the ermC (4.3%). The results of this study are similar to those of Lim et al. and Akpaka et al., which documented the high carriage of ermA and a lower prevalence of ermC in S. aureus isolates in Malaysian patients and Trinidad and Tobago patients, respectively [36, 37]. On the contrary, high prevalence of ermC (87.1%) was found in MR-CoNS isolates compared to the ermA (12.9%) and the ermB (12.9%) genes. Likewise, Bouchami et al. reported that the prevalence of ermC, ermA, and ermB of MR-CoNS isolated from bacteremic patients in oncohematology was 25.9%, 7.4%, and 7.4%, respectively .
We found that 26.1% of MRSA isolates carried the qacA/B gene. Its prevalence in the present study is higher than that in a previous report by Lu et al., who found 25 (7.8%) of the 321 MRSA isolates harboring qacA/B . On the contrary, 70.9% of all MR-CoNS isolates in the present study carried the qacA/B gene. This prevalence was higher than the rate of the qacA/B gene carried by CoNS isolated from surgical sites (37.9%) , nurses (56.7%), and the general population in Hong Kong (13.5%) . The increased proportion of the qacA/B gene in MR-CoNS indicates that hospital-acquired infections could exert selective pressure for carriage of these strains.
In summary, most of the MRSA isolates in the present study were typed as ST239-SCCmec type III, while different MR-CoNS species carry various SCCmec types. This finding provides useful information for a preventive health strategy to combat methicillin-resistant staphylococcal infections.
The data used to support the findings of this study are included within the article.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
We would like to thank microbiology staff from Chiangrai Prachanukroh Hospital for specimen collection. We also acknowledge Dr. Keiichi Hiramatsu and Dr. Teruyo Ito for providing SCCmec-type strains. We thank Prof. Dr. Gavin Reynolds for editing the manuscript. This work was supported by a grant from the National Research Council of Thailand (R2560B064) to SS.
Supplementary Material 1: list of primers used in this study. (Supplementary Materials)
S. Y. Tong, J. S. Davis, E. Eichenberger, T. L. Holland, and V. G. Fowler Jr., “Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management,” Clinical Microbiology Reviews, vol. 28, no. 3, pp. 603–661, 2015.View at: Publisher Site | Google Scholar
C. von Eiff, G. Peters, and C. Heilmann, “Pathogenesis of infections due to coagulase-negative staphylococci,” Lancet Infectious Diseases, vol. 2, no. 11, pp. 677–685, 2002.View at: Publisher Site | Google Scholar
A. Japoni-Nejad, M. Rezazadeh, H. Kazemian et al., “Molecular characterization of the first community-acquired methicillin-resistant Staphylococcus aureus strains from Central Iran,” International Journal of Infectious Diseases, vol. 17, no. 11, pp. e949–e954, 2013.View at: Publisher Site | Google Scholar
R. Seng, T. Kitti, R. Thummeepak et al., “Biofilm formation of methicillin-resistant coagulase negative staphylococci (MR-CoNS) isolated from community and hospital environments,” PLoS One, vol. 12, no. 8, Article ID e0184172, 2017.View at: Publisher Site | Google Scholar
P. Tulinski, A. C. Fluit, J. A. Wagenaar et al., “Methicillin-resistant coagulase-negative staphylococci on pig farms as a reservoir of heterogeneous staphylococcal cassette chromosome mec elements,” Applied and Environmental Microbiology, vol. 78, no. 2, pp. 299–304, 2012.View at: Publisher Site | Google Scholar
E. Ghaznavi-Rad, M. Nor Shamsudin, Z. Sekawi, A. van Belkum, and V. A. Neela, “A simplified multiplex PCR assay for fast and easy discrimination of globally distributed staphylococcal cassette chromosome mec types in methicillin resistant Staphylococcus aureus,” Journal of Medical Microbiology, vol. 59, no. 10, pp. 1135–1139, 2010.View at: Publisher Site | Google Scholar
M. Xiao, H. Wang, Y. Zhao et al., “National surveillance of methicillin-resistant Staphylococcus aureus in China highlights a still-evolving epidemiology with 15 novel emerging multilocus sequence types,” Journal of Clinical Microbiology, vol. 51, no. 11, pp. 3638–3644, 2013.View at: Publisher Site | Google Scholar
Z. Zong, C. Peng, and X. Lü, “Diversity of SCCmec elements in methicillin-resistant coagulase-negative staphylococci clinical isolates,” PLoS One, vol. 6, no. 5, Article ID e20191, 2011.View at: Publisher Site | Google Scholar
S. Mayer, M. Boos, A. Beyer, A. C. Fluit, and F. J. Schmitz, “Distribution of the antiseptic resistance genes qacA, qacB and qacC in 497 methicillin-resistant and susceptible European isolates of Staphylococcus aureus,” Journal of Infection and Chemotherapy, vol. 47, no. 6, pp. 896–907, 2001.View at: Publisher Site | Google Scholar
J. A. Otter, A. Patel, P. R. Cliff et al., “Selection for qacA carriage in CC22, but not CC30, methicillin-resistant Staphylococcus aureus bloodstream infection isolates during a successful institutional infection control programme,” Journal of Antimicrobial Chemotherapy, vol. 68, no. 5, pp. 992–999, 2013.View at: Publisher Site | Google Scholar
A. C. Fluit, M. R. Visser, and F. J. Schmitz, “Molecular detection of antimicrobial resistance,” Clinical Microbiology Reviews, vol. 14, no. 4, pp. 836–871, 2001.View at: Publisher Site | Google Scholar
Clinical Laboratory Standards Institute, “Performance standards for antimicrobial susceptibility testing,” in Proceedings of Twenty-Fourth Informational Supplement: M100-S24, Wayne, PA, USA, January 2014.View at: Google Scholar
P. Kohner, J. Uhl, C. Kolbert, D. Persing, and F. R. Cockerill, “Comparison of susceptibility testing methods with mecA gene analysis for determining oxacillin (methicillin) resistance in clinical isolates of Staphylococcus aureus and coagulase-negative Staphylococcus spp.,” Journal of Clinical Microbiology, vol. 37, no. 9, pp. 2952–2961, 1999.View at: Google Scholar
C. Ryffel, W. Tesch, I. Birch-Machin et al., “Sequence comparison of mecA genes isolated from methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis,” Gene., vol. 94, no. 1, pp. 137-138, 1990.View at: Google Scholar
T. Sasaki, S. Tsubakishita, Y. Tanaka et al., “Multiplex-PCR method for species identification of coagulase-positive staphylococci,” Journal of Clinical Microbiology, vol. 48, no. 3, pp. 765–769, 2010.View at: Publisher Site | Google Scholar
A. Bizzini and G. Greub, “Matrix assisted laser desorption ionization time of flight mass spectrometry, a revolution in clinical microbial identification,” Clinical Microbiology and Infection, vol. 16, no. 11, pp. 1614–1619, 2010.View at: Publisher Site | Google Scholar
A. J. Loonen, A. R. Jansz, J. N. Bergland et al., “Comparative study using phenotypic, genotypic, and proteomics methods for identification of coagulase-negative staphylococci,” Journal of Clinical Microbiology, vol. 50, no. 4, pp. 1437–1439, 2012.View at: Publisher Site | Google Scholar
V. Suttisunhakul, A. Pumpuang, P. Ekchariyawat et al., “Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry for the identification of Burkholderia pseudomallei from Asia and Australia and differentiation between Burkholderia species,” PLoS One, vol. 12, no. 4, e0175294 pages, 2017.View at: Publisher Site | Google Scholar
K. Zhang, J. A. McClure, S. Elsayed, T. Louie, and J. M. Conly, “Novel multiplex PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus,” Journal of Clinical Microbiology, vol. 43, no. 10, pp. 5026–5033, 2005.View at: Publisher Site | Google Scholar
E. J. Feil, E. K. Nickerson, N. Chantratita et al., “Rapid detection of the pandemic methicillin-resistant Staphylococcus aureus clone ST 239, a dominant strain in Asian hospitals,” Journal of Clinical Microbiology, vol. 48, no. 4, pp. 1520–1522, 2008.View at: Publisher Site | Google Scholar
N. Ardic, M. Ozyurt, B. Sareyyupoglu, and T. Haznedaroglu, “Investigation of erythromycin and tetracycline resistance genes in methicillin-resistant staphylococci,” International Journal of Antimicrobial Agents, vol. 26, no. 3, pp. 213–218, 2005.View at: Publisher Site | Google Scholar
J. H. Youn, Y. H. Park, B. Hang’ombe, and C. Sugimoto, “Prevalence and characterization of Staphylococcus aureus and Staphylococcus pseudintermedius isolated from companion animals and environment in the veterinary teaching hospital in Zambia, Africa,” Comparative Immunology, Microbiology and Infectious Diseases, vol. 37, no. 2, pp. 123–130, 2014.View at: Publisher Site | Google Scholar
M. Zhang, M. M. O’Donoghue, T. Ito, K. Hiramatsu, and M. V. Boost, “Prevalence of antiseptic-resistance genes in Staphylococcus aureus and coagulase-negative staphylococci colonizing nurses and the general population in Hong Kong,” Journal of Hospital Infection, vol. 78, no. 2, pp. 113–117, 2011.View at: Publisher Site | Google Scholar
C. J. Chen and Y. C. Huang, “New epidemiology of staphylococcus aureus infection in Asia,” Clinical Microbiology and Infection, vol. 20, no. 7, pp. 605–623, 2014.View at: Publisher Site | Google Scholar
K. Becker, C. Heilmann, and G. Peters, “Coagulase-negative staphylococci,” Clinical Microbiology Reviews, vol. 27, no. 4, pp. 870–926, 2014.View at: Publisher Site | Google Scholar
T. F. Lee, H. Lee, C. M. Chen et al., ““Comparison of the accuracy of matrix-assisted laser desorption ionization–time of flight mass spectrometry with that of other commercial identification systems for identifying Staphylococcus saprophyticus in urine,” Journal of Clinical Microbiology, vol. 51, no. 5, pp. 1563–1566, 2013.View at: Publisher Site | Google Scholar
H. Kong, F. Yu, W. Zhang, X. Li, and H. Wang, “Molecular epidemiology and antibiotic resistance profiles of methicillin-resistant Staphylococcus aureus strains in a tertiary hospital in China,” Frontiers in Microbiology, vol. 8, p. 838, 2017.View at: Publisher Site | Google Scholar
F. Barbier, E. Ruppé, D. Hernandez et al., “Methicillin-resistant coagulase-negative staphylococci in the community: high homology of SCCmec IVa between Staphylococcus epidermidis and major clones of methicillin-resistant Staphylococcus aureus,” Journal of Infectious Diseases, vol. 202, no. 2, pp. 270–281, 2010.View at: Publisher Site | Google Scholar
P. Chongtrakool, T. Ito, X. X. Ma et al., “Staphylococcal cassette chromosome mec (SCCmec) typing of methicillin-resistant Staphylococcus aureus strains isolated in 11 Asian countries: a proposal for a new nomenclature for SCCmec elements,” Antimicrobial Agents and Chemotherapy, vol. 50, no. 3, pp. 1001–1012, 2006.View at: Publisher Site | Google Scholar
M. Moghadami, A. Japoni, A. Karimi, and M. Mardani, “Comparison of community and healthcare-associated MRSA in Iran,” Iranian Journal of Clinical Infectious Diseases, vol. 5, no. 4, pp. 206–212, 2010.View at: Google Scholar
Y. Liu, H. Wang, N. Du et al., “Molecular evidence for spread of two major methicillin-resistant Staphylococcus aureus clones with a unique geographic distribution in Chinese hospitals,” Antimicrobial Agents and Chemotherapy, vol. 53, no. 2, pp. 512–518, 2009.View at: Publisher Site | Google Scholar
S. Shahsavan, L. Jabalameli, P. Maleknejad et al., “Molecular analysis and antimicrobial susceptibility of methicillin resistant Staphylococcus aureus in one of the hospitals of Tehran university of medical sciences: high prevalence of sequence type 239 (ST239) clone,” Acta Microbiologica et Immunologica Hungarica, vol. 58, no. 1, pp. 31–39, 2011.View at: Publisher Site | Google Scholar
L. Pinheiro, C. I. Brito, V. C. Pereira et al., “Susceptibility profile of Staphylococcus epidermidis and Staphylococcus haemolyticus isolated from blood cultures to vancomycin and novel antimicrobial drugs over a period of 12 years,” Microbial Drug Resistance, vol. 22, no. 4, pp. 283–293, 2016.View at: Publisher Site | Google Scholar
E. Ruppe, F. Barbier, Y. Mesli et al., “Diversity of staphylococcal cassette chromosome mec structures in methicillin-resistant Staphylococcus epidermidis and Staphylococcus haemolyticus strains among outpatients from four countries,” Antimicrobial Agents and Chemotherapy, vol. 53, no. 2, pp. 442–449, 2009.View at: Publisher Site | Google Scholar
H. Wisplinghoff, A. E. Rosato, M. C. Enright, M. Noto, W. Craig, and G. L. Archer, “Related clones containing SCCmec type IV predominate among clinically significant Staphylococcus epidermidis isolates,” Antimicrobial Agents and Chemotherapy, vol. 47, no. 11, pp. 3574–3579, 2003.View at: Publisher Site | Google Scholar
K. Lim, Y. Hanifah, M. Yusof, and K. Thong, “ermA, ermC, tetM and tetK are essential for erythromycin and tetracycline resistance among methicillin-resistant Staphylococcus aureus strains isolated from a tertiary hospital in Malaysia,” Indian Journal of Medical Microbiology, vol. 30, no. 2, pp. 203–207, 2012.View at: Publisher Site | Google Scholar
P. E. Akpaka, R. Roberts, and S. Monecke, “Molecular characterization of antimicrobial resistance genes against Staphylococcus aureus isolates from Trinidad and Tobago,” Journal of Infection and Public Health, vol. 10, no. 3, pp. 316–323, 2017.View at: Publisher Site | Google Scholar
O. Bouchami, W. Achour, M. A. Mekni, J. Rolo, and A. Ben Hassen, “Antibiotic resistance and molecular characterization of clinical isolates of methicillin-resistant coagulase-negative staphylococci isolated from bacteremic patients in oncohematology,” Folia Microbiologica (Praha), vol. 56, no. 2, pp. 122–130, 2011.View at: Publisher Site | Google Scholar
Z. Lu, Y. Chen, W. Chen et al., “Characteristics of qacA/B-positive Staphylococcus aureus isolated from patients and a hospital environment in China,” Journal of Antimicrobial Chemotherapy, vol. 70, no. 3, pp. 653–657, 2015.View at: Publisher Site | Google Scholar
M. Temiz, N. Duran, G. G. Duran, N. Eryılmaz, and K. Jenedi, “Relationship between the resistance genes to quaternary ammonium compounds and antibiotic resistance in staphylococci isolated from surgical site infections,” Medical Science Monitor, vol. 20, pp. 544–550, 2014.View at: Publisher Site | Google Scholar