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Eurosurveillance Monthly Release 2005: Volume 10/ Issue 5

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Eurosurveillance, Volume 10, Issue 5, 01 May 2005

Surveillance report

Community acquired MRSA infections in a paediatric population in Greece

Citation style for this article: Vourli S, Perimeni D, Makri A, Polemis M, Voyiatzi A, Vatopoulos A. Community acquired MRSA infections in a paediatric population in Greece. Euro Surveill. 2005;10(5):pii=537. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=537

S Vourli¹, D Perimeni¹ , A Makri ², M Polemis¹, A Voyiatzi², A Vatopoulos¹
1. Department of Microbiology, National School of Public Health, Athens, Greece
2. Department of Microbiology, Penteli Children’s Hospital, Penteli Athens, Greece

We investigated the characteristics of 20 community acquired MRSA strains isolated in a paediatric hospital in Athens. Eighteen of these, all isolated from skin and soft tissue infections, carried the Panton-Valentine leukocidin (PVL) determinants, were found resistant to fusidic acid, tetracycline and kanamycin, and displayed a PFGE pattern identical to that of the well-described ST80 CA-MRSA clone circulating in various European countries.

Introduction
Community acquired (CA) methicillin resistant Staphylococcus aureus (MRSA) infections caused by hypervirulent strains producing the Panton Valentine Leukocidin (PVL) are an emerging public health issue worldwide [1]. Outbreaks of CA-MRSA infections have recently been described in Australia, Europe and the United States [1-6], mainly in otherwise/ healthy schoolchildren and young adults. Molecular studies have suggested that these infections are the result of the spread of a limited number of PVL-producing MRSA clones that are genetically distinct from nosocomial strains [1,2,6]. PVL producing MRSA strains are associated with severe deep skin infections and necrotising pneumonia and usually show an unusual antibiotic susceptibility profile, being resistant only to kanamycin, fusidic acid and occasionally tetracycline.
In this study we report the emergence of PVL positive CA-MRSA infections in a paediatric population in Greece.

Materials and Methods
All S. aureus strains isolated from community acquired skin and soft tissue infections in Penteli Children’s Hospital, a paediatric hospital in the north of Athens with a catchment population of one million inhabitants, from June to November 2004 were retrospectively analysed.
It should be noted that it is the hospital’s policy to systematically culture specimens from all skin and soft tissue infections.
Antibiotic susceptibility profiles were determined by the standard disk diffusion method, according to the instructions of the National Committee of Clinical Laboratory Standards [7]. Detection of the mecA gene and the lukF-PV and lukS-PV genes was performed by polymerase chain reaction (PCR) as previously described [8]. SmaI digests of chromosomal DNA were objected to pulsed-field electrophoresis (PFGE), as described previously [9].

Results and Discussion
During the study period a total of 129 patients were presented in the outpatient department of the hospital suffering from skin and soft tissue infections, and S. aureus was isolated from 99 of them. On sensitivity testing, 22 of them (22.2 %) were found to be MRSA, an alarmingly high rate that must be further confirmed by carefully designed prospective studies. MRSA accounted for 47% of all CA S. aureus infections in a recent study from Taiwan, [10].
Eighteen MRSA strains recovered from 18 patients were available for further study. Seven were recovered from abscesses, seven from cases of cellulitis, three from boils, and one from a wound infection. Two more MRSA strains isolated from outpatients during the same time period, from pus and from synovial fluid, were also included in the analysis.
The genes lukF-PV and lukS-PV were detected in all 18 skin and soft tissue isolates but not in the two isolates from pus and synovial fluid. All PVL-positive strains were resistant to fusidic acid, kanamycin and tetracycline, but sensitive to gentamicin, erythromycin and ciprofloxacin. PFGE analysis revealed high similarity among all PVL+ strains grouping them into one type (type C) divided into three subtypes (C1 displayed by 12 isolates, C2, by 4 and C3 by 2 isolates, respectively). The two PVL - strains showed different PFGE patterns (Pattern A and B respectively, data not shown).
Interestingly, Pattern C was found similar to the PFGE pattern of the well-described MLST80 strain that seems to be spreading through Europe [FIGURE] [5,11]. Moreover, PFGE pattern C is similar to the PFGE pattern of the PVL+ clone C, established and causing hospital acquired MRSA infections in one hospital in Patras, a city in southwest Greece [12]. Although Greece has one of the highest rates of MRSA infections in Europe [13], this PFGE type is not among the types circulating in the Greek hospitals [12], indicating that community acquired MRSA infections are possibly not the result of the spread of hospital MRSA strains in the community.

In that respect, and similarly to other areas in the world, PVL producing CA MRSA seems to be a new emerging infection in Greece.

Acknowledgement
Strain CA-MRSA 3925/02 (ST80) is a generous gift from Professor W Witte.
This work was supported by the Hellenic Centre for Infectious Disease Control (KEEL, Ministry of Health).

References

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