#Etiology, characteristics, and #outcomes of community-onset #necrotizing #fasciitis in #Korea: A multicenter study (PLoS One, abstract)

[Source: PLoS One, full page: (LINK). Abstract, edited.]


Etiology, characteristics, and outcomes of community-onset necrotizing fasciitis in Korea: A multicenter study

Tark Kim, Seong Yeon Park, Yee Gyung Kwak, Jiwon Jung, Min-Chul Kim, Seong-Ho Choi, Shi Nae Yu, Hyo-Lim Hong, Yong Kyun Kim, Se Yoon Park, Eun Hee Song, Ki-Ho Park, Oh Hyun Cho, Sang-Ho Choi , the Korean SSTI Study Group

Published: June 20, 2019 / DOI: https://doi.org/10.1371/journal.pone.0218668




Necrotizing fasciitis (NF) is a serious skin and soft tissue infection causing high mortality. Investigating region specific epidemiologic factors associated with NF is important for establishing appropriate treatment strategies. This multicenter study was done to provide an update of the microbial etiology, clinical characteristics, and outcomes of NF in Korea.

Materials and methods

A retrospective cohort of adult patients with NF was established using patient data from 13 general hospitals between January 2012 and December 2015 in Korea. We evaluated microbial etiology and clinical characteristics to identify risk factors associated with in-hospital mortality; analyses were performed using binary logistic regression models.


A total of 161 patients with NF were included. The most common underlying disease was diabetes mellitus (66 cases, 41.0%). A total of 148 organisms were isolated from 119 (73.9%) patients. Enteric Gram-negative organisms (36 patients) were the most common pathogen, followed by Staphylococcus aureus (30 patients) and streptococci (28 patients). Methicillin-resistant Staphylococcus aureus (MRSA) was identified in 6.2% (10/161) of patients. Of 37 enteric Gram-negative isolates tested, 26 (70.3%) isolates were susceptible to ceftriaxone. The in-hospital mortality rate was 22.4%. Intensive care unit admission, septic shock, and Gram-negative organism infections were significantly associated with in-hospital mortality, and surgery was not a favorable prognostic factor.


As initial empirical antibiotics, glycopeptides against MRSA and broad-spectrum antibiotics against third-generation cephalosporin-resistant organisms should be considered for patients with community-onset NF in Korea.


Citation: Kim T, Park SY, Kwak YG, Jung J, Kim M-C, Choi S-H, et al. (2019) Etiology, characteristics, and outcomes of community-onset necrotizing fasciitis in Korea: A multicenter study. PLoS ONE 14(6): e0218668. https://doi.org/10.1371/journal.pone.0218668

Editor: Marc O. Siegel, George Washington University, UNITED STATES

Received: December 30, 2018; Accepted: June 6, 2019; Published: June 20, 2019

Copyright: © 2019 Kim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: TK received the Soonchunhyang University Research Fund. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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

Keywords: Necrotizing fasciitis; Staphylococcus aureus; Antibiotics; MRSA; S. Korea.



Sequential #evolution of #virulence and #resistance during clonal spread of community-acquired #MRSA (Proc Natl Acad Sci USA, abstract)

[Source: Proceedings of the National Academy of Sciences of the United States of America, full page: (LINK). Abstract, edited.]

Sequential evolution of virulence and resistance during clonal spread of community-acquired methicillin-resistant Staphylococcus aureus

Richard Copin, William E. Sause, Yi Fulmer, Divya Balasubramanian, Sophie Dyzenhaus, Jamil M. Ahmed, Krishan Kumar, John Lees, Anna Stachel, Jason C. Fisher, Karl Drlica, Michael Phillips, Jeffrey N. Weiser, Paul J. Planet, Anne-Catrin Uhlemann, Deena R. Altman, Robert Sebra, Harm van Bakel, Jennifer Lighter, Victor J. Torres, and Bo Shopsin

PNAS published ahead of print January 11, 2019 / DOI: https://doi.org/10.1073/pnas.1814265116

Edited by Emil C. Gotschlich, The Rockefeller University, New York, NY, and approved December 6, 2018 (received for review August 17, 2018)



Epidemics of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) are of growing medical concern. To understand the emergence of virulence and antimicrobial resistance, both of which promote CA-MRSA spread, we examined an on-going disease cluster within an enclosed community by analyzing the genome sequences of CA-MRSA clones characterized by high prevalence and a profound persistence. Metabolic adaptation and a phage primed the clone for success, and then a fully optimized variant was created by selection of plasmid-mediated biocide resistance. The data provide mechanistic insight and indicate that high-risk populations are incubators for evolution of consequential phenotypes. Immediate interruption of this evolutionary pattern is essential for forestalling dissemination of resistance from high-risk communities to hospitals and the general population.



The past two decades have witnessed an alarming expansion of staphylococcal disease caused by community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). The factors underlying the epidemic expansion of CA-MRSA lineages such as USA300, the predominant CA-MRSA clone in the United States, are largely unknown. Previously described virulence and antimicrobial resistance genes that promote the dissemination of CA-MRSA are carried by mobile genetic elements, including phages and plasmids. Here, we used high-resolution genomics and experimental infections to characterize the evolution of a USA300 variant plaguing a patient population at increased risk of infection to understand the mechanisms underlying the emergence of genetic elements that facilitate clonal spread of the pathogen. Genetic analyses provided conclusive evidence that fitness (manifest as emergence of a dominant clone) changed coincidently with the stepwise emergence of (i) a unique prophage and mutation of the regulator of the pyrimidine nucleotide biosynthetic operon that promoted abscess formation and colonization, respectively, thereby priming the clone for success; and (ii) a unique plasmid that conferred resistance to two topical microbiocides, mupirocin and chlorhexidine, frequently used for decolonization and infection prevention. The resistance plasmid evolved through successive incorporation of DNA elements from non-S. aureus spp. into an indigenous cryptic plasmid, suggesting a mechanism for interspecies genetic exchange that promotes antimicrobial resistance. Collectively, the data suggest that clonal spread in a vulnerable population resulted from extensive clinical intervention and intense selection pressure toward a pathogen lifestyle that involved the evolution of consequential mutations and mobile genetic elements.

MRSA – evolution – antimicrobial resistance – virulence



1 R.C. and W.E.S. contributed equally to this work.

2 To whom correspondence may be addressed. Email: Bo.Shopsin@nyumc.org, Victor.Torres@nyumc.org, or Jennifer.Lighter@nyumc.org.

Author contributions: R.C., W.E.S., J. Lighter, V.J.T., and B.S. designed research; R.C., W.E.S., Y.F., D.B., S.D., J.M.A., K.K., A.S., J.C.F., M.P., and D.R.A. performed research; R.C., J. Lees, P.J.P., A.-C.U., R.S., and H.v.B. contributed new reagents/analytic tools; R.C., W.E.S., D.B., and S.D. analyzed data; and R.C., W.E.S., K.D., J.N.W., V.J.T., and B.S. wrote the paper.

The authors declare no conflict of interest.

This article is a PNAS Direct Submission.

Data deposition: All genomic data reported in this paper have been deposited in the National Center for Biotechnology Information BioProject database (accession no. PRJNA497094).

This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10.1073/pnas.1814265116/-/DCSupplemental.

Published under the PNAS license.

Keywords: Antibiotics; Drugs Resistance; Mupirocin; Chlorhexidine; MRSA; CA-MRSA; Staphylococcus aureus.


#Origin, #evolution, and #global #transmission of community-acquired #Staphylococcus aureus ST8 (Proc Natl Acad Sci USA, abstract)

[Source: Proceedings of the National Academy of Sciences of the United States of America, full page: (LINK). Abstract, edited.]

Origin, evolution, and global transmission of community-acquired Staphylococcus aureus ST8

Lena Strauß a, Marc Stegger b,c, Patrick Eberechi Akpaka d, Abraham Alabi e,f, Sebastien Breurec g,h, Geoffrey Coombs i,j, Beverly Egyir k, Anders Rhod Larsen b, Frederic Laurent l, Stefan Monecke m,n, Georg Peters o, Robert Skov b,p, Birgit Strommenger q, François Vandenesch l, Frieder Schaumburg o, and Alexander Mellmann a,1

Author Affiliations: a Institute of Hygiene, University Hospital Münster, DE 48149 Münster, Germany; b Department of Bacteria, Parasites, and Fungi, Statens Serum Institut, DK 2300 Copenhagen, Denmark; c Pathogen Genomics Division, Translational Genomics Research Institute, Flagstaff, AZ 86005; d Department of Paraclinical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago; e Department of Microbiology, Centre de Recherches Médicales de Lambaréné, GA 242 Lambaréné, Gabon; f Institute of Tropical Medicine, German Center for Infection Research, Eberhard Karls University, DE 72076 Tübingen, Germany; g Faculty of Medicine, University Hospital of Pointe-à-Pitre, University of the French West Indies, 97110 Pointe-à-Pitre, Guadeloupe, France; h Unité Environnement et Santé, Institut Pasteur de Guadeloupe, 97110 Pointe-à-Pitre, Guadeloupe, France; i School of Veterinary and Laboratory Sciences, Murdoch University, Western Australia, Australia, 6150; j PathWest Laboratory Medicine WA, Fiona Stanley Hospital, Western Australia, Australia 6150; k Department of Bacteriology, Noguchi Memorial Institute for Medical Research, LG581 Accra, Ghana; l National Reference Center for Staphylococci, Hospices Civils de Lyon, University of Lyon, FR 69002 Lyon, France; m Institute for Medical Microbiology and Hygiene, Technical University of Dresden, DE 01307 Dresden, Germany; n Alere Technologies, DE 07749 Jena, Germany; o Institute of Medical Microbiology, University Hospital Münster, DE 48149 Münster, Germany; p Clinical Microbiology, Medizinisches Versorgungszentrum SYNLAB Leverkusen GmbH, DE 51375 Leverkusen, Germany; q National Reference Centre for Staphylococci and Enterococci, Wernigerode Branch, Robert-Koch-Institut, DE 38855 Wernigerode, Germany

Edited by Richard P. Novick, New York University School of Medicine, New York, NY, and approved October 18, 2017 (received for review February 13, 2017)



USA300 is a hypervirulent, community-acquired, multidrug-resistant Staphylococcus aureus clone that started to spread in the United States around 17 years ago. Many studies detected it also in South America, Europe, and the Asia-Pacific region. In this study, we show that USA300 is also circulating in sub-Saharan Africa. Locating the temporal and spatial origin of clonal lineages is important with respect to epidemiology and molecular evolution of pathogens. We show that USA300 evolved from a less virulent and less resistant ancestor circulating in Central Europe around 160 years ago. Constant surveillance of pathogen transmission routes is vital to prevent and control potential outbreaks. Whole genome sequencing proved to be a useful tool for epidemiological surveillance.



USA300 is a pandemic clonal lineage of hypervirulent, community-acquired, methicillin-resistant Staphylococcus aureus (CA-MRSA) with specific molecular characteristics. Despite its high clinical relevance, the evolutionary origin of USA300 remained unclear. We used comparative genomics of 224 temporal and spatial diverse S. aureus isolates of multilocus sequence type (ST) 8 to reconstruct the molecular evolution and global dissemination of ST8, including USA300. Analyses of core SNP diversity and accessory genome variations showed that the ancestor of all ST8 S. aureus most likely emerged in Central Europe in the mid-19th century. From here, ST8 was exported to North America in the early 20th century and progressively acquired the USA300 characteristics Panton–Valentine leukocidin (PVL), SCCmec IVa, the arginine catabolic mobile element (ACME), and a specific mutation in capsular polysaccharide gene cap5E. Although the PVL-encoding phage ϕSa2USA was introduced into the ST8 background only once, various SCCmec types were introduced to ST8 at different times and places. Starting from North America, USA300 spread globally, including Africa. African USA300 isolates have aberrant spa-types (t112, t121) and form a monophyletic group within the clade of North American USA300. Large parts of ST8 methicillin-susceptible S. aureus (MSSA) isolated in Africa represent a symplesiomorphic group of ST8 (i.e., a group representing the characteristics of the ancestor), which are rarely found in other world regions. Isolates previously discussed as USA300 ancestors, including USA500 and a “historic” CA-MRSA from Western Australia, were shown to be only distantly related to recent USA300 clones.

USA300 – molecular evolution – CA-MRSA – comparative genomics – Africa



1 To whom correspondence should be addressed. Email: mellmann@uni-Muenster.de.

Author contributions: L.S., M.S., G.P., R.S., F.S., and A.M. designed research; L.S., M.S., P.E.A., A.A., S.B., G.C., B.E., A.R.L., F.L., S.M., B.S., F.V., F.S., and A.M. performed research; L.S., M.S., and A.M. analyzed data; and L.S., M.S., and A.M. wrote the paper.

The authors declare no conflict of interest.

This article is a PNAS Direct Submission.

Data deposition: The data reported in this paper have been deposited in the European Nucleotide Archive (accession no. PRJEB14816).

This article contains supporting information online at http://www.pnas.org/lookup/suppl/doi:10.1073/pnas.1702472114/-/DCSupplemental.

Copyright © 2017 the Author(s). Published by PNAS.

This open access article is distributed under Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND).

Keywords: Antibiotics; Drugs Resistance; MRSA; CA-MRSA; Staphylococcus Aureus.


#MRSA #infections among #patients in the #emergency #department: a European multicentre study (J Antimicrob Chemother., abstract)

[Source: Journal of Antimicrobial Chemotherapy, full page: (LINK). Abstract, edited.]

MRSA infections among patients in the emergency department: a European multicentre study

C. Bouchiat1,*, S. Curtis2, I. Spiliopoulou3, M. Bes1, C. Cocuzza4, I. Codita5, C. Dupieux1, N. Giormezis3, A. Kearns2, F. Laurent1, S. Molinos6,7, R. Musumeci4, C. Prat6,7, M. Saadatian-Elahi8, E. Tacconelli9, A. Tristan1, B. Schulte10 and F. Vandenesch1 on behalf of the ESCMID Study Group on Staphylococci and Staphylococcal Infections (ESGS)

Author Affiliations: 1National Reference Center for Staphylococci, 59 Bd Louis Pinel, 69677 Bron cedex, Lyon, France; 2Staphylococcus Reference Service, Public Health England, 61 Colindale Avenue London NW9 5EQ, UK; 3National Reference Laboratory for Staphylococci, University of Patras, University Campus, Rion 26504, Patras, Greece; 4Laboratory of Clinical Microbiology and Virology, University of Milano-Bicocca, Via Cadore 48, Monza, Italy; 5Cantacuzino National Institute of Research, Splaiul Independentei 103, RO-050096 Bucharest, Romania; 6Servei de Microbiologia Hospital Universitari Germans Trias i Pujol, Badalona, Spain; 7CIBER Enfermedades Respiratorias. Carretera del Canyet s/n. 08916 Badalona, Spain; 8Epidemiology unit, Hospices Civils de Lyon, Place d’Arsonval, 69008 Lyon, France; 9Division of Infectious Diseases, Department of Internal Medicine 1, University Hospital Tuebingen, Geissweg 3, 72076 Tuebingen, Germany; 10Institut für Mikrobiologie und Infektionsmedizin, University Hospital Tuebingen, Auf der Morgenstelle 28, 72076 Tuebingen, Germany

*Corresponding author. CNR des Staphylocoques—Centre de Biologie Est, 59 Boulevard Louis Pinel, 69677 Bron cedex, France. Tel: +33-4-27-85-52-57; Fax: +33-4-72-35-73-35; E-mail: coralie.bouchiat@chu-lyon.fr

Received July 26, 2016. Revision requested August 26, 2016. Revision received September 9, 2016. Accepted September 13, 2016.




MRSA is a therapeutic concern worldwide, and a major agent of community-acquired skin and soft tissue infections (CA-SSTIs). While the US epidemiology of MRSA in CA-SSTIs is well described and reports the high prevalence of the USA300 clone, data on the European situation are lacking.


To determine the prevalence and clonal characteristics of MRSA in CA-SSTIs in seven European emergency departments.

Patients and methods

From April to June 2015, patients presenting to the tertiary hospital emergency department with a Staphylococcus aureus CA-SSTI were prospectively enrolled. S. aureus isolates were characterized by antimicrobial susceptibility testing, detection of Panton–Valentine leucocidin encoding genes and spa-typing, MLST and/or DNA microarray.


Two-hundred and five cases of S. aureus-associated CA-SSTIs were included, comprising folliculitis, furuncles, abscesses, paronychia, impetigo, carbuncles and cellulitis. Of the 205 cases, we report an MRSA prevalence rate of 15.1%, with a north (0%) to south (29%) increasing gradient. Fifty-one isolates were Panton–Valentine leucocidin-positive (24.9%), whether MSSA or MRSA, with a heterogeneous distribution between countries. Clonal distribution of MSSA and MRSA showed high diversity, with no predominant circulating clone and no archetypical USA300 CA-MRSA clone.


This original prospective multicentre study highlights stark differences in European MRSA epidemiology compared with the USA, and that the USA300 CA-MRSA clone is not predominant among community-infected patients in Europe.

© The Author 2016. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com

Keywords: Staphylococcus Aureus; MRSA; Antibiotics; Drugs Resistance; European Region.


#Comparison of #Outcomes among Adult #Patients with #Nosocomial #Bacteremia Caused by Methicillin-Susceptible and Methicillin-Resistant #Staphylococcus aureus: A Retrospective Cohort Study (Plos One, abstract)

[Source: PLoS One, full page: (LINK). Abstract, edited.]

Open Access / Peer-reviewed / Research Article

Comparison of Outcomes among Adult Patients with Nosocomial Bacteremia Caused by Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus: A Retrospective Cohort Study [      ]

Jann-Tay Wang,  Le-Yin Hsu,  Tsai-Ling Lauderdale,  Wen-Chien Fan,  Fu-Der Wang

Published: December 21, 2015 / DOI: 10.1371/journal.pone.0144710



Several studies have shown that patients with bacteremia caused by methicillin-resistant Staphylococcus aureus (MRSA) have worse outcomes than those with bacteremia caused by methicillin-susceptible S. aureus (MSSA). However, only a limited number of studies have stratified the MRSA isolates into healthcare-associated (HA-) and community-associated (CA-) MRSA strains in such a comparison. This three-year retrospective cohort study, enrolling adult patients with nosocomial S. aureus bacteremia (SAB), was designed to investigate whether CA-MRSA and/or HA-MRSA strains were associated with different outcomes in comparison to MSSA in such a setting. The drug susceptibilities and staphylococcal cassette chromosome mec (SCCmec) types were determined for all of the causative isolates available. The MRSA bacteremia was further categorized into those caused by CA-MRSA strains (CA-MRSA-S bacteremia) when the causative isolates carried the type IV or V SCCmec element, those caused by HA-MRSA strains (HA-MRSA-S bacteremia) when the isolates carried the type I, II, or III SCCmec element, or unclassified MRSA bacteremia when the isolates were not available. The relevant demographic, clinical, and laboratory data were collected by reviewing the patients’ charts. The primary outcome was all-cause in-hospital mortality. A total of 353 patients were studied. The overall in-hospital mortality rate was 32.6%, with 23.3% in MSSA, 30.5% in CA-MRSA-S, 47.5% in HA-MRSA-S, and 35.3% in unclassified MRSA bacteremia, respectively. The multivariate analysis showed that HA-MRSA-S, but not CA-MRSA-S, bacteremia was associated with a significantly worse outcome compared with MSSA. The other risk factors independently associated with all-cause in-hospital mortality included the Charlson co-morbidity index, septic shock, thrombocytopenia, and persistent bacteremia. Resistance to linezolid and daptomycin was found among the MRSA isolates. The present study showed that bacteremia caused by HA-MRSA-S, but not CA-MRSA-S, was an independent risk factor for all-cause in-hospital mortality in patients with nosocomial SAB. Continuous monitoring regarding the susceptibilities of MRSA to linezolid and daptomycin is necessary.


Citation: Wang J-T, Hsu L-Y, Lauderdale T-L, Fan W-C, Wang F-D (2015) Comparison of Outcomes among Adult Patients with Nosocomial Bacteremia Caused by Methicillin-Susceptible and Methicillin-Resistant Staphylococcus aureus: A Retrospective Cohort Study. PLoS ONE 10(12): e0144710. doi:10.1371/journal.pone.0144710

Editor: Karsten Becker, University Hospital Münster, GERMANY

Received: August 24, 2015; Accepted: November 23, 2015; Published: December 21, 2015

Copyright: © 2015 Wang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: An anonymized dataset and the details of the computer code for statistical analyses are available from the corresponding author at fdwang@vghtpe.gov.tw.

Funding: This study was granted by Ministry of Science and Technology, Taiwan (NSC 101-2314-B-002-087-MY3). The sponsor has no role in study design, data collection, data interpretation, and preparation of the manuscript.

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

Keywords: Research; Abstracts; Antibiotics; Drugs Resistance; Staphylococcus Aureus; MRSA; CA-MRSA; HA-MRSA.