Research Open Access
Like 0



Antimicrobial resistance to mupirocin and fusidic acid, which are used for treatment of skin infections caused by is of concern.


To investigate resistance to fusidic acid and mupirocin in meticillin-susceptible (MSSA) from community-acquired skin and soft tissue infections (SSTIs) in Belgium.


We collected 2013–2023 data on fusidic acid and mupirocin resistance in SSTI-associated MSSA from two large Belgian laboratories. Resistant MSSA isolates sent to the Belgian Reference Centre were -typed and analysed for the presence of the and virulence genes and the resistance gene. In addition, we whole genome sequenced MSSA isolates collected between October 2021 and September 2023.


Mupirocin resistance increased between 2013 and 2023 from 0.5-1.5% to 1.7-5.6%. Between 2018 and 2023, 91.4% (64/70) of mupirocin-resistant isolates were co-resistant to fusidic acid. By September 2023, between 8.9% (15/168) and 10.1% (11/109) of children isolates from the two laboratories were co-resistant. Of the 33 sequenced isolates, 29 were sequence type 121, clonal and more distantly related to the European epidemic fusidic acid-resistant impetigo clone (EEFIC) observed in Belgium in 2020. These isolates carried the and genes conferring resistance to mupirocin and fusidic acid, respectively, and the and virulence genes.


We highlight the spread of a mupirocin-resistant EEFIC in children, with a seasonal trend for the third quarter of the year. This is of concern because this variant is resistant to the two main topical antibiotics used to treat impetigo in Belgium.


Article metrics loading...

Loading full text...

Full text loading...



  1. O’Neill AJ, Larsen AR, Skov R, Henriksen AS, Chopra I. Characterization of the epidemic European fusidic acid-resistant impetigo clone of Staphylococcus aureus. J Clin Microbiol. 2007;45(5):1505-10.  https://doi.org/10.1128/JCM.01984-06  PMID: 17344365 
  2. Rørtveit S, Skutlaberg DH, Langeland N, Rortveit G. The decline of the impetigo epidemic caused by the epidemic European fusidic acid-resistant impetigo clone: an 11.5-year population-based incidence study from a community in Western Norway. Scand J Infect Dis. 2014;46(12):832-7.  https://doi.org/10.3109/00365548.2014.947317  PMID: 25229166 
  3. Dalager-Pedersen M, Søgaard M, Schønheyder HC. Staphylococcus aureus skin and soft tissue infections in primary healthcare in Denmark: a 12-year population-based study. Eur J Clin Microbiol Infect Dis. 2011;30(8):951-6.  https://doi.org/10.1007/s10096-011-1179-0  PMID: 21279531 
  4. Deplano A, Hallin M, Bustos Sierra N, Michel C, Prevost B, Martiny D, et al. Persistence of the Staphylococcus aureus epidemic European fusidic acid-resistant impetigo clone (EEFIC) in Belgium. J Antimicrob Chemother. 2023;78(8):2061-5.  https://doi.org/10.1093/jac/dkad204  PMID: 37358399 
  5. Belgian Antibiotic Policy Coordination Commission (BAPCOC). Guide belge de traitement anti-infectieux en pratique ambulatoire/Belgische gids voor anti-infectieuze behandeling in de ambulante praktijk. [Belgian guide for treatment of infections in outpatient practice]. Brussels: BAPCOC; Nov 2022. French/Dutch. Available from: https://organesdeconcertation.sante.belgique.be/fr/documents/guide-belge-de-traitement-anti-infectieux-en-pratique-ambulatoire-2022
  6. Nederlands Huisartsen Genootschap (NHG). Bacteriële huidinfecties (M68). [Bacterial skin infections]. Utrecht: NHG; May 2019. Dutch. Available from: https://richtlijnen.nhg.org/files/pdf/61_Bacteri%C3%ABle%20huidinfecties_mei-2019.pdf
  7. Doudoulakakis A, Spiliopoulou I, Spyridis N, Giormezis N, Kopsidas J, Militsopoulou M, et al. Emergence of a Staphylococcus aureus clone resistant to mupirocin and fusidic acid carrying exotoxin genes and causing mainly skin infections. J Clin Microbiol. 2017;55(8):2529-37.  https://doi.org/10.1128/JCM.00406-17  PMID: 28592549 
  8. Haute autorité de santé (HAS). Prise en charge des infections cutanées bactériennes courantes. [Management of common bacterial skin infections]. Saint-Denis: HAS; Feb 2019. French. Available from: https://www.has-sante.fr/upload/docs/application/pdf/2019-04/prise_en_charge_des_infections_cutanees_bacteriennes_courantes_recommandations.pdf
  9. The European Committee on Antimicrobial Susceptibility Testing (EUCAST). Breakpoint tables for interpretation of MICs and zone diameters. Version 11.0, Jan 2023. Available from: https://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Disk_test_documents/2023_manuals/Manual_v_11.0_EUCAST_Disk_Test_2023.pdf
  10. Loffeld A, Davies P, Lewis A, Moss C. Seasonal occurrence of impetigo: a retrospective 8-year review (1996-2003). Clin Exp Dermatol. 2005;30(5):512-4.  https://doi.org/10.1111/j.1365-2230.2005.01847.x  PMID: 16045681 
  11. Ramsey MA, Bradley SF, Kauffman CA, Morton TM. Identification of chromosomal location of mupA gene, encoding low-level mupirocin resistance in staphylococcal isolates. Antimicrob Agents Chemother. 1996;40(12):2820-3.  https://doi.org/10.1128/AAC.40.12.2820  PMID: 9124848 
  12. Jarraud S, Mougel C, Thioulouse J, Lina G, Meugnier H, Forey F, et al. Relationships between Staphylococcus aureus genetic background, virulence factors, agr groups (alleles), and human disease. Infect Immun. 2002;70(2):631-41.  https://doi.org/10.1128/IAI.70.2.631-641.2002  PMID: 11796592 
  13. Hallin M, Deplano A, Denis O, De Mendonça R, De Ryck R, Struelens MJ. Validation of pulsed-field gel electrophoresis and spa typing for long-term, nationwide epidemiological surveillance studies of Staphylococcus aureus infections. J Clin Microbiol. 2007;45(1):127-33.  https://doi.org/10.1128/JCM.01866-06  PMID: 17093021 
  14. Bankevich A, Nurk S, Antipov D, Gurevich AA, Dvorkin M, Kulikov AS, et al. SPAdes: a new genome assembly algorithm and its applications to single-cell sequencing. J Comput Biol. 2012;19(5):455-77.  https://doi.org/10.1089/cmb.2012.0021  PMID: 22506599 
  15. Zhou W, Jin Y, Teng G, Chen W, Chen Y, Luo Q, et al. Comparative analysis of genomic characteristics, virulence and fitness of community-associated Staphylococcus aureus ST121 clone causing fatal diseases in China and other CA-MRSA clones. Virulence. 2023;14(1):2242547.  https://doi.org/10.1080/21505594.2023.2242547  PMID: 37534993 
  16. Kurt K, Rasigade JP, Laurent F, Goering RV, Žemličková H, Machova I, et al. Subpopulations of Staphylococcus aureus clonal complex 121 are associated with distinct clinical entities. PLoS One. 2013;8(3):e58155.  https://doi.org/10.1371/journal.pone.0058155  PMID: 23505464 
  17. Lamand V, Dauwalder O, Tristan A, Casalegno JS, Meugnier H, Bes M, et al. Epidemiological data of staphylococcal scalded skin syndrome in France from 1997 to 2007 and microbiological characteristics of Staphylococcus aureus associated strains. Clin Microbiol Infect. 2012;18(12):E514-21.  https://doi.org/10.1111/1469-0691.12053  PMID: 23078129 
  18. Koning S, van der Sande R, Verhagen AP, van Suijlekom-Smit LW, Morris AD, Butler CC, et al. Interventions for impetigo. Cochrane Database Syst Rev. 2012;1(1):CD003261. PMID: 22258953 
  19. George A, Rubin G. A systematic review and meta-analysis of treatments for impetigo. Br J Gen Pract. 2003;53(491):480-7. PMID: 12939895 
  20. Yang LPH, Keam SJ. Retapamulin: a review of its use in the management of impetigo and other uncomplicated superficial skin infections. Drugs. 2008;68(6):855-73.  https://doi.org/10.2165/00003495-200868060-00008  PMID: 18416589 
  21. Rosen T, Albareda N, Rosenberg N, Alonso FG, Roth S, Zsolt I, et al. Efficacy and safety of ozenoxacin cream for treatment of adult and pediatric patients with impetigo: a randomized clinical trial. JAMA Dermatol. 2018;154(7):806-13.  https://doi.org/10.1001/jamadermatol.2018.1103  PMID: 29898217 
  22. European Medicines Agency (EMA). Medicines. Amsterdam: EMA. [Accessed: 21 Feb 2024]. Available from: https://www.ema.europa.eu/en/medicines
  23. National Institute for Health and Care Excellence (NICE). Impetigo: antimicrobial prescribing. London: NICE; 26 Feb 2020. Available from: https://www.nice.org.uk/guidance/ng153
  24. Van den Wijngaert S, Bossuyt N, Ferns B, Busson L, Serrano G, Wautier M, et al. Bigger and Better? Representativeness of the influenza A surveillance using one consolidated clinical microbiology laboratory data set as compared to the Belgian Sentinel Network of Laboratories. Front Public Health. 2019;7:150.  https://doi.org/10.3389/fpubh.2019.00150  PMID: 31275914 
  25. Gorges H, Hall L, Heal C. Feasibility study for a randomised controlled trial for the topical treatment of impetigo in Australian general practice. Trop Med Infect Dis. 2021;6(4):197.  https://doi.org/10.3390/tropicalmed6040197  PMID: 34842831 

Data & Media loading...

Supplementary data

Submit comment
Comment moderation successfully completed
This is a required field
Please enter a valid email address
Approval was a Success
Invalid data
An Error Occurred
Approval was partially successful, following selected items could not be processed due to error