Resistance to methicillin and other antibiotics in isolates of Staphylococcus aureus from blood and cerebrospinal fluid, England and Wales, 1989–95

doi:10.1016/S0140-6736(97)12148-1

The Lancet

Volume 350, Issue 9074, 2 August 1997, Pages 323-325

https://doi.org/10.1016/S0140-6736(97)12148-1 Get rights and content

Summary

Background

Methicillin-resistant Staphylococcus aureus (MRSA) strains are colonising hospital patients in most areas of England and Wales, UK. The extent to which they cause invasive infection can be gauged from their presence in isolates from blood or cerebrospinal fluid.

Method

About 200 clinical laboratories reported the results of susceptibility testing of between 4501 and 6370 isolates of S aureus from blood or cerebrospinal fluid in each of the years 1989–95. We assessed the rate of resistance to methicillin and other antibiotics for each of these years.

Findings

Resistance to methicillin was stable at about 1·5% of isolates during 1989–91, but increased thereafter to 13·2% in 1995 (p<0·001). At the same time there was a significant increase in the percentage of isolates resistant to erythromycin, clindamycin, ciprofloxacin, gentamicin, trimethoprim, and rifampicin (p<0·001 for each)–resistance characteristics often seen in MRSA. Resistance to benzylpenicillin increased slightly but significantly (p<0·001); resistance to fusidic acid was stable (p>0·05); resistance to tetracycline decreased significantly (p<0·001).

Interpretation

Among cases of S aureus bacteraemia, the proportion due to MRSA has increased significantly. Bacteraemia due to MRSA has a poor prognosis, especially if not treated with suitable antibiotics. Therefore, these findings are important, especially for management of patients and the development of antibiotic policies.

Introduction

During the past few years in most developed countries there has been an increase in colonisation and infection of hospital patients by strains of Staphylococcus aureus resistant to methicillin and other antibiotics.1, 2 In England and Wales, UK, this increase has been reflected in the numbers of isolates referred to the Laboratory of Hospital Infection of the Central Public Health Laboratory, for bacteriophage typing.³ Opinions differ about the threat to health posed by methicillin-resistant S aureus (MRSA).1, 4, 5 Colonisation has commonly been found to exceed infection,⁶ and the incidence of documented bacteraemia in England and Wales has been low. However, bacteraemia caused by MRSA has a poor prognosis, especially if effective antibiotic treatment, generally with vancomycin, is not given.⁷ Since 1992, we have detected an increase in resistance to methicillin among S aureus strains causing bacteraemia in England and Wales.

Section snippets

Methods

Clinical laboratories in England and Wales are encouraged to report all clinically relevant isolations of S aureus from blood or cerebrospinal fluid, to the Public Health Laboratory Service Communicable Disease Surveillance Centre. Results are provided on a standard form, which includes relevant details of patients and clinical details.

Since 1989, the form has included a list of 30 antibiotics and laboratories have been asked to report the results of susceptibility testing as sensitive,

Results

During the period covered by this survey the National External Quality Assessment Scheme issued cultures of S aureus strains on several occasions. The median results for the percentage of laboratories obtaining the correct results were ⩾98·4% (JJS Snell, National External Quality Assessment Scheme, Public Health Laboratory Service, London, personal communication). The high median values indicate a good level of proficiency at detecting antibiotic resistance.

The number of reports of S aureus

Discussion

Surveillance, based on reports of routine diagnostic testing, has the advantage that data on many isolates can be collected, which allows investigation of significant trends in resistance. Our results show that, since 1992, the proportion of MRSA among cases of bacteraemia due to S aureus has increased substantially. The testing of S aureus isolates for susceptibility to methicillin seems to be almost universal in clinical microbiology laboratories, and we believe, therefore, that the increase

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Multi-resistant Staphylococcus aureus: a suitable case for inactivity?
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Hong Kong strains of methicillin-resistant and methicillin-sensitive Staphylococcus aureus have similar virulence
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In many parts of the world, MRSA are responsible for a high proportion of S. aureus infections in patients in contact with healthcare. Molecular studies have shown this is due to one or more MRSA clones that have become endemic in each hospital or healthcare facility, resulting in hospital- or healthcare-associated MRSA (HA-MRSA). The infection rate and clones responsible for HA-MRSA can vary substantially in different geographical locations. Molecular methods have allowed clones to be categorized, as well as the opportunity to track the evolution and spread of clones in healthcare settings and around the world. The genomes of HA-MRSA isolates belonging to the same clonal group can show dramatic variability particularly in the carriage of mobile genetic elements (MGEs) encoding virulence and resistance genes. HA-MRSA are potentially resistant to all classes of antibiotics, although individual isolates that are fully drug resistant are not reported. The incidence of fluoroquinolone resistance in HA-MRSA is remarkably high, suggesting use of this class of antibiotics as well as the β-lactams contributes to the selection and success of HA-MRSA clones in the hospital setting.
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Resistance trends have changed greatly over the 14 years (1997–2011) whilst I was Director of the UK Antibiotic Resistance Monitoring and Reference Laboratory (ARMRL). Meticillin-resistant Staphylococcus aureus (MRSA) first rose, then fell with improved infection control, although with the decline of one major clone beginning before these improvements. Resistant pneumococci too have declined following conjugate vaccine deployment. If the situation against Gram-positive pathogens has improved, that against Gram-negatives has worsened, with the spread of (i) quinolone- and cephalosporin-resistant Enterobacteriaceae, (ii) Acinetobacter with OXA carbapenemases, (iii) Enterobacteriaceae with biochemically diverse carbapenemases and (iv) gonococci resistant to fluoroquinolones and, latterly, cefixime. Laboratory, clinical and commercial aspects have also changed. Susceptibility testing is more standardised, with pharmacodynamic breakpoints. Treatments regimens are more driven by guidelines. The industry has fewer big profitable companies and more small companies without sales income. There is good and bad here. The quality of routine susceptibility testing has improved, but its speed has not. Pharmacodynamics adds science, but over-optimism has led to poor dose selection in several trials. Guidelines discourage poor therapy but concentrate selection onto a diminishing range of antibiotics, threatening their utility. Small companies are more nimble, but less resilient. Last, more than anything, the world has changed, with the rise of India and China, which account for 33% of the world's population and increasingly provide sophisticated health care, but also have huge resistance problems. These shifts present huge challenges for the future of chemotherapy and for the edifice of modern medicine that depends upon it.

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The Lancet

Summary

Background

Method

Findings

Interpretation

Introduction

Section snippets

Methods

Results

Discussion

References (11)

Methicillin-resistant Staphylococcus aureus: implications for the 1990s and effective control measures

Am J Med

Multi-resistant Staphylococcus aureus: a suitable case for inactivity?

J Hosp Infect

New threats to the control of methicillin-resistant Staphylococcus aureus

J Hosp Infect

Surveillance of methicillin-resistant Staphylococcus aureus in England and Wales 1986–1990;

J Hosp Infect

Hong Kong strains of methicillin-resistant and methicillin-sensitive Staphylococcus aureus have similar virulence

J Hosp Infect

Cited by (147)

Novel Compounds Based on Chalcone- and Pyrazoline-DIM Hybrids as Inhibitors of Staphylococcus aureus, Synthesis, DFT Studies, Biological Evaluation and Docking Studies

The extreme drug resistance (XDR) Staphylococcus aureus strains among patients: A retrospective study

Antimicrobial Resistance in Mycobacterium tuberculosis: The Odd One Out

Inducible clindamycin resistance among staphylococcus aureus isolates in a tertiary care hospital of Assam

Hospital-associated MRSA and antibiotic resistance-What have we learned from genomics?

Fourteen years in resistance

ArticlesResistance to methicillin and other antibiotics in isolates of Staphylococcus aureus from blood and cerebrospinal fluid, England and Wales, 1989–95

Summary

Background

Method

Findings

Interpretation

Introduction

Section snippets

Methods

Results

Discussion

Am J Med

J Hosp Infect

J Hosp Infect

J Hosp Infect

J Hosp Infect

Articles
Resistance to methicillin and other antibiotics in isolates of Staphylococcus aureus from blood and cerebrospinal fluid, England and Wales, 1989–95