First case of infection with vancomycin-resistant Staphylococcus aureus in Europe
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Correspondence www.thelancet.com Vol 382 July 20, 2013 205 meticillin-resistant VRSA strain was isolated from pus of the toe amputation wound. The minimum inhibitory concentrations for vancomycin and teicoplanin were >256 μg/mL and 24 μg/mL, respectively. Vitek 2 and MicroScan systems both detected VRSA. MALDI-TOF analyses confirmed the identification of S aureus. Vancomycin- resistant Enterococcus faecalis (VRE) and P aeruginosa were also isolated from the same wound. The strain was sequence type ST105, SCCmec type II, and harboured the mecA and vanA genes, the latter was also identified in the VRE. The genetic background of the strain is similar to that of VRSA isolated in the USA. 2 However, we have not identified an epidemiological link with the USA of the patient or health-care providers, and the concomitant isolation of VRE suggests a possible source for the vanA gene, 3 supporting an independent acquisition of the vancomycin- resistance determinant. The VRSA was resistant to erythromycin, clindamycin, gentamicin, and ciprofloxacin, and susceptible to co-trimoxazole, tetracycline, tygecycline, linezolid, daptomycin, quinupristin/dalfopristin, fusidic acid, cloramphenicol, rifampicin, and mupirocin. Precautions were reinforced. The patient is clinically well, and is being treated with daptomycin, rifampicin, and amikacin, and aggressive wound care. An epidemiological investigation is ongoing, but so far transmission of VRSA from this patient to contacts at home, other patients or health-care workers from the dialysis unit was not detected. The identification of VRSA is particularly worrying since Portugal is a country with one of the highest prevalences of MRSA and VRE in Europe. 4 In all cases of VRSA detected so far there was no spread of the strain. However, the potential sustained use of vancomycin, and the circulation of strains capable of receiving elements carrying vancomycin-resistance de- First case of infection with vancomycin- resistant Staphylococcus aureus in Europe Although vancomycin is often prescribed for the treatment of meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant S aureus (VRSA) infections remain rare, with only few cases confirmed worldwide—mostly in the USA. 1 Here, we report the isolation and preliminary characterisation of the first VRSA strain in Europe isolated from a patient in Portugal. A 74-year-old woman with diabetes mellitus, chronic renal failure requiring haemodialysis, and peripheral vascular disease conditioning critical limb ischaemia underwent endovascular revascularisation and amputation of two gangrenous toes. Previous cultures of the wound amputation site revealed Pseudomonas aeruginosa and vancomycin-susceptible MRSA, for which she was treated with vancomycin and amikacin. In May, 2013, a Published Online June 21, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61219-2 Health professionals in Syria The US Centers for Disease Control and Prevention, UNICEF, and WHO, with support from the Office of Foreign Disaster Control, trained 50 staff from Syrian and Jordanian ministries of health and other organisations working in and around Syria in May, 2013, in Jordan. A third of Syria’s 21 million people are now displaced Published Online July 1, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)61507-X not have a research centre on health technologies for neglected or any other diseases, we should not conclude that it has no commitment to global health. UAEM can focus on a single component of global health but this should be made clear when reported. All authors are employees of Boston University— evaluated by the survey. The views expressed are those of the authors and do not necessarily represent the views of Boston University. *Veronika J Wirtz, Taryn Vian, Warren A Kaplan, Jonathan L Simon [email protected] Center for Global Health and Development, Boston University, Boston, MA 02118, USA 1 The Lancet. Measuring universities’ commitments to global health. Lancet 2013; 381: 1248. 2 University Global Health Impact Report Card. http://globalhealthgrades.org/ (accessed July 1, 2013). 3 Koplan JP, Bond TC, Merson MH, et al. Towards a common definition of global health. Lancet 2009; 373: 1993–95. terminants 5 raise the possibility of further selection of VRSA. To prevent the emergence and dissemination of these strains, adherence to infection control recommendations, antibiotic stewardship, and surveillance are essential. JM-C has received research grants and honoraria for serving on the speakers bureaus of Pfizer, Novartis and Gilead. MR has received honoraria for serving on speakers bureau of Pfizer. The other authors declare that they have no conflicts of interest. *José Melo-Cristino, Cristina Resina, Viviana Manuel, Luís Lito, Mário Ramirez [email protected] Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisbon, Portugal (JM-C, MR); Centro Hospitalar Lisboa Norte, Lisbon, Portugal (JM-C, CR, VM, LL) 1 Saravolatz LD, Pawlak J, Johnson LB. In vitro susceptibilities and molecular analysis of vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus isolates. Clin Infect Dis 2012; 55: 582–86. 2 Kos VN, Desjardins CA, Griggs A, et al. Comparative genomics of vancomycin- resistant Staphylococcus aureus strains and their positions within the clade most commonly associated with methicillin- resistant S. aureus hospital-acquired infection in the United States. MBio 2012; 3: e00112-12. 3 Zhu W, Clark N, Patel JB. pSK41-like plasmid is necessary for Inc18-like vanA plasmid transfer from Enterococcus faecalis to Staphylococcus aureus in vitro. Antimicrob Agents Chemother 2013; 57: 212–19. 4 European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2011. http://ecdc.europa.eu/en/ publications/Publications/Forms/ECDC_ DispForm.aspx?ID=998 (accessed May 21, 2013). 5 Espadinha D, Faria NA, Miragaia M, Lito LM, Melo-Cristino J, de Lencastre H. Extensive dissemination of methicillin-resistant Staphylococcus aureus (MRSA) between the hospital and the community in a country with a high prevalence of nosocomial MRSA. PLoS ONE 2013; 8: e59960. Science Faction/Science Faction/Corbis
Transcript of First case of infection with vancomycin-resistant Staphylococcus aureus in Europe
Correspondence
www.thelancet.com Vol 382 July 20, 2013 205
meticillin-resistant VRSA strain was isolated from pus of the toe amputation wound. The minimum inhibitory concentrations for vancomycin and teicoplanin were >256 μg/mL and 24 μg/mL, respectively. Vitek 2 and MicroScan systems both detected VRSA. MALDI-TOF analyses confirmed the identifi cation of S aureus. Vancomycin-resistant Enterococcus faecalis (VRE) and P aeruginosa were also isolated from the same wound.
The strain was sequence type ST105, SCCmec type II, and harboured the mecA and vanA genes, the latter was also identifi ed in the VRE. The genetic background of the strain is similar to that of VRSA isolated in the USA.2 However, we have not identified an epidemiological link with the USA of the patient or health-care providers, and the concomitant isolation of VRE suggests a possible source for the vanA gene,3 supporting an independent acquisition of the vancomycin-resistance determinant. The VRSA was resistant to erythromycin, clindamycin, gentamicin, and ciprofloxacin, and susceptible to co-trimoxazole, tetracycline, tygecycline, linezolid, daptomycin, quinupristin/dalfopristin, fusidic acid, cloramphenicol, rifampicin, and mupirocin.
Precautions were reinforced. The patient is clinically well, and is being treated with daptomycin, rifampicin, and amikacin, and aggressive wound care. An epidemiological investigation is ongoing, but so far transmission of VRSA from this patient to contacts at home, other patients or health-care workers from the dialysis unit was not detected.
The identification of VRSA is particularly worrying since Portugal is a country with one of the highest prevalences of MRSA and VRE in Europe.4
In all cases of VRSA detected so far there was no spread of the strain. However, the potential sustained use of vancomycin, and the circulation of strains capable of receiving elements carrying vancomycin-resistance de-
First case of infection with vancomycin-resistant Staphylococcus aureus in EuropeAlthough vancomycin is often prescribed for the treatment of meticillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant S aureus (VRSA) infections remain rare, with only few cases confirmed worldwide—mostly in the USA.1 Here, we report the isolation and preliminary characterisation of the fi rst VRSA strain in Europe isolated from a patient in Portugal.
A 74-year-old woman with diabetes mellitus, chronic renal failure requiring haemodialysis, and peripheral vascular disease conditioning critical limb ischaemia underwent endovascular revascularisation and amputation of two gangrenous toes. Previous cultures of the wound amputation site revealed Pseudomonas aeruginosa and vancomycin-susceptible MRSA, for which she was treated with vancomycin and amikacin. In May, 2013, a
Published OnlineJune 21, 2013http://dx.doi.org/10.1016/S0140-6736(13)61219-2
Health professionals in SyriaThe US Centers for Disease Control and Prevention, UNICEF, and WHO, with support from the Office of Foreign Disaster Control, trained 50 staff from Syrian and Jordanian ministries of health and other organisations working in and around Syria in May, 2013, in Jordan. A third of Syria’s 21 million people are now displaced
Published OnlineJuly 1, 2013http://dx.doi.org/10.1016/S0140-6736(13)61507-X
not have a research centre on health technologies for neglected or any other diseases, we should not conclude that it has no commitment to global health.
UAEM can focus on a single component of global health but this should be made clear when reported. All authors are employees of Boston University—evaluated by the survey. The views expressed are those of the authors and do not necessarily represent the views of Boston University.
*Veronika J Wirtz, Taryn Vian, Warren A Kaplan, Jonathan L [email protected]
Center for Global Health and Development, Boston University, Boston, MA 02118, USA
1 The Lancet. Measuring universities’ commitments to global health. Lancet 2013; 381: 1248.
2 University Global Health Impact Report Card. http://globalhealthgrades.org/ (accessed July 1, 2013).
3 Koplan JP, Bond TC, Merson MH, et al. Towards a common defi nition of global health. Lancet 2009; 373: 1993–95.
ter minants5 raise the possibility of further selection of VRSA. To prevent the emergence and dissemination of these strains, adherence to infection control recommendations, antibiotic stewardship, and surveillance are essential.JM-C has received research grants and honoraria for serving on the speakers bureaus of Pfi zer, Novartis and Gilead. MR has received honoraria for serving on speakers bureau of Pfi zer. The other authors declare that they have no confl icts of interest.
*José Melo-Cristino, Cristina Resina, Viviana Manuel, Luís Lito, Mário [email protected]
Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, 1649-028 Lisbon, Portugal (JM-C, MR); Centro Hospitalar Lisboa Norte, Lisbon, Portugal (JM-C, CR, VM, LL)
1 Saravolatz LD, Pawlak J, Johnson LB. In vitro susceptibilities and molecular analysis of vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus isolates. Clin Infect Dis 2012; 55: 582–86.
2 Kos VN, Desjardins CA, Griggs A, et al. Comparative genomics of vancomycin-resistant Staphylococcus aureus strains and their positions within the clade most commonly associated with methicillin-resistant S. aureus hospital-acquired infection in the United States. MBio 2012; 3: e00112-12.
3 Zhu W, Clark N, Patel JB. pSK41-like plasmid is necessary for Inc18-like vanA plasmid transfer from Enterococcus faecalis to Staphylococcus aureus in vitro. Antimicrob Agents Chemother 2013; 57: 212–19.
4 European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2011. http://ecdc.europa.eu/en/publications/Publications/Forms/ECDC_DispForm.aspx?ID=998 (accessed May 21, 2013).
5 Espadinha D, Faria NA, Miragaia M, Lito LM, Melo-Cristino J, de Lencastre H. Extensive dissemination of methicillin-resistant Staphylococcus aureus (MRSA) between the hospital and the community in a country with a high prevalence of nosocomial MRSA. PLoS ONE 2013; 8: e59960.
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