Staphylococcus aureus colonization and infection occur more commonly among persons living or working in crowded conditions, but characterization of S. aureus colonization within medical communities in China is lacking. A total of 144 (15.4%, 144/935) S. aureus isolates, including 28 (3.0%, 28/935) MRSA isolates, were recovered from the nares of 935 healthy human volunteers residing on a Chinese medical college campus. All S. aureus isolates were susceptible to vancomycin, quinupristin/dalfopristin and linezolid but the majority were resistant to penicillin (96.5%), ampicillin/sulbactam (83.3%) and trimethoprim/sulfamethoxazole (93.1%). 82%, (23/28) of the MRSA isolates and 66% (77/116) of the MSSA isolates were resistant to multiple antibiotics, and 3 MRSA isolates were resistant to mupirocin—an agent commonly used for nasal decolonization. 16 different sequence types (STs), as well as SCCmec genes II, III, IVd, and V, were represented among MRSA isolates. We also identified, for the first time, two novel STs (ST1778 and ST1779) and 5 novel spa types for MRSA. MRSA isolates were distributed in different sporadic clones, and ST59-MRSA-VId- t437 was found within 3 MRSA isolates. Moreover, one isolate with multidrug resistance belonging to ST398-MRSA-V- t571 associated with animal infections was identified, and 3 isolates distributed in three different clones harbored PVL genes. Collectively, these data indicate a high prevalence of nasal MRSA carriage and molecular heterogeneity of S. aureus isolates among persons residing on a Chinese medical college campus. Identification of epidemic MRSA clones associated with community infection supports the need for more effective infection control measures to reduce nasal carriage and prevent dissemination of MRSA to hospitalized patients and health care workers in this community.
Citation: Du J, Chen C, Ding B, Tu J, Qin Z, Parsons C, et al. (2011) Molecular Characterization and Antimicrobial Susceptibility of Nasal Staphylococcus aureus Isolates from a Chinese Medical College Campus. PLoS ONE 6(11): e27328. doi:10.1371/journal.pone.0027328
Editor: Mark Alexander Webber, University of Birmingham, United Kingdom
Received: July 11, 2011; Accepted: October 13, 2011; Published: November 17, 2011
Copyright: © 2011 Du 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.
Funding: This study was supported by grants from Wenzhou Municipal Science and Technology Bureau, China (H2010064) and the 11th Five-Year Plan of the Ministry of Sciences and Technology (2010DFA32100, 2009ZX09303-005, 2008ZX10003-016). 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.
Staphylococcus aureus is one of the most prevalent and clinically significant pathogens worldwide, causing a variety of illnesses ranging from benign, superficial skin eruptions to life-threatening infections with bacteraemia, endocarditis, pneumonia and toxic shock syndrome . Since methicillin-resistant S. aureus (MRSA) was first identified in 1961, it has become the most common cause of nosocomial and community infections worldwide . The recent emergence of highly virulent community-associated MRSA (CA-MRSA) isolates which cause disease in individuals with no apparent risk factors for hospital acquisition of MRSA has raised widespread concern over how CA-MRSA is transmitted in the community setting , .
S. aureus is a member of commensal microflora and readily colonizes the anterior nares in humans. Many infections caused by S. aureus occur in persons with prior nasal carriage , and this carriage is an important risk factor for nosocomial S. aureus infection in patients undergoing surgery, hemodialysis, implantation of intravascular devices, and among HIV-infected patients . One study revealed that nasal carriage of S. aureus is an important source of S. aureus bacteremia , and eliminating nasal carriage of S. aureus may prevent systemic S. aureus infection . Determination of the prevalence of S. aureus nasal carriage, as well as antimicrobial resistance profiles and molecular typing for nasal S. aureus isolates, in healthy populations is beneficial for identifying risk factors associated with S. aureus infection , , . Molecular typing of S. aureus is also helpful for supporting infection control measures, investigating suspected outbreaks and preventing nosocomial transmission . Identification of (Panton-Valentine Leukocidin) PVL genes, pulsed-field gel electrophoresis (PFGE), staphylococcal cassette chromosome mec (SCCmec) typing, spa typing, and multilocus sequence typing (MLST) have been used to monitor the evolutionary process of pandemic clones . However, studies characterizing S. aureus isolates in China have largely focused on isolates recovered from clinical specimens in the context of clinical disease. One surveillance study performed in China showed that 63% of S. aureus isolates were MRSA, including 77% of nosocomial isolates and 43% of community isolates . In addition, two major epidemic MRSA clones, ST239-MRSA-SCCmec type III and ST5-MRSA-SCCmec type II, are distributed across China in unique geographic patterns . These data suggest that dissemination of virulent MRSA clones among healthy persons in China may contribute to the presence of clinically significant MRSA infections in some locations. To our knowledge, there are limited published studies characterizing MRSA isolates recovered from nares of healthy individuals in China who work and reside in the health care setting. Therefore, we sought to determine the prevalence, antimicrobial resistance profiles, and molecular characteristics of nasal S. aureus isolates from students on a large medical college campus in China.
Materials and Methods
Isolation and identification of nasal S. aureus isolates
935 volunteers from the campus of Wenzhou Medical College in Wenzhou, Southeast China without symptoms or signs of clinical illness were enrolled in the study over a one-month time period. The healthy volunteers included had not used antibiotics in past two months. Samples were collected from both anterior nares of volunteers by rotating a sterile polyester fiber-tipped swab moistened with sterile saline. Swabs were placed in 3 mL of Luria-Bertani broth and transported to the Department of Clinical Microbiology of the first Affiliated Hospital of Wenzhou Medical College. Gram-positive, catalase-positive, coagulase-positive isolates were confirmed as S. aureus using a Vitek-60 microbiology analyzer (bioMe'rieu, Marcy l'Etoile, France). The Ethics Committee of the first Affiliated Hospital of Wenzhou Medical College exempted this study from review because the present study focused on bacteria.
S. aureus susceptibility to penicillin (10 µg), ampicillin/sulbactam (20/10 µg), cefazolin (30 µg), vancomycin (30 µg), erythromycin (15 µg), clindamycin (2 µg), rifampicin (5 µg), linezolid (30 µg), mupirocin (5 µg), quinupristin/dalfopristin (15 µg), tetracycline (30 µg), trimethoprim/sulfamethoxazole (1.25/23.75 µg), gentamicin (10 µg), ciprofloxacin (5 µg), and levofloxacin (5 µg) were determined using the disk diffusion method in accordance with standards recommended by the Clinical and Laboratory Standards Institute (CLSI) . All disks were obtained from Oxoid Ltd., and S. aureus ATCC 25923 was used as a quality control strain. Susceptibility of S. aureus to mupirocin was also determined using disk diffusion, with a zone diameter ≥14 mm using a 5-µg disc indicating susceptibility as described previously . MICs of mupirocin for mupirocin-resistant isolates were further determined by the agar dilution method in accordance with the CLSI guidelines . mupA was detected among mupirocin-resistant isolates as described previously.
S. aureus isolates were cultured on blood agar overnight. Three to four bacterial colonies were suspended in 150 µL sterile distilled water with lysostaphin (1 mg/mL) (Sangon, China) and incubated at 37°C for 30 min. DNA was extracted using the Genomic DNA Extraction kit according to the manufacturer's instructions (Sangon, China). DNA was stored at −20°C and prepared for PCR amplification.
Detection of MRSA and PVL genes
A multiplex PCR protocol described previously was used for simultaneous amplification of mecA, 16S rRNA, and PVL genes . Isolates harboring mecA were confirmed as MRSA using MRSA N315 as a positive control strain.
SCCmec typing of MRSA isolates was performed using eight unique and specific pairs of primers for SCCmec types and subtypes I, II, III, IVa, IVb, IVc, IVd, and V as described previously . The MRSA isolates with unexpected fragments or lacking fragments by multiplex PCR were defined as non-typeable (NT). MRSA NCTC 10442 (SCCmecI), MRSA N315 (SCCmec II), MRSA 85/2082 (SCCmec III), MRSA JCSC 4744 (SCCmec IV) and MRSA WZ153 (SCCmec V) were used for positive controls.
The spa variable repeat region from each MRSA isolate was amplified by simplex PCR oligonucleotide primers as previously described , . Purified spa PCR products were sequenced, and spa types were assigned by using the spa database website (http://www.ridom.de/spaserver).
Multilocus sequence typing (MLST)
MLST of MRSA isolates was conducted through amplification of internal fragments of the seven housekeeping genes of S. aureus as described previously . Following purification and sequencing of these genes, allele quantification and sequence typing were assigned using a well-characterized online database (http://saureus.mlst.net/). The DNA sequences of novel STs were verified by Pro. Enright and deposited in MLST database.
A total of 144 S. aureus isolates were isolated from the nares of the 935 volunteers in the study. The nasal carriage rate of S. aureus was 15.4% (144/935). 19.4% (28/144) of S. aureus isolates were identified as MRSA. The prevalence of nasal MRSA carriage was 3.0% (28/935). The resistance profiles of MRSA, MSSA and S. aureus isolates to antimicrobials tested were listed in Table 1. All S. aureus isolates tested were susceptible to vancomycin, quinupristin/dalfopristin and linezolid. The majority of S. aureus isolates were resistant to penicillin (96.5%), ampicillin/sulbactam (83.3%) and trimethoprim/sulfamethoxazole (93.1%). Isolates displayed complete or intermediate levels of resistance to gentamicin (16.0% and 18.1%), tetracycline (28.5% and 16.7%), ciprofloxacin (23.6% and 22.2%), clindamycin (31.2% and 23.6%) and erythromycin (52.1% and 30.6%). The resistance rates of MRSA isolates to gentamicin, ciprofloxacin, levofloxacin, erythromycin and clindamycin were significantly higher than those among MSSA isolates (Table 1). However, the intermediate resistance rates of MSSA isolates to gentamicin, tetracycline, erythromycin, clindamycin and rifampicin were higher than for MRSA isolates (Table 1). 82.1% (23/28) of MRSA isolates and 66.4% (77/116) of MSSA isolates were resistant to at least 3 different antimicrobials tested. Three MRSA isolates with no zone of inhibition to mupirocin (2.1%, 3/144) were resistant to mupirocin. The mupirocin MICs for the 3 MRSA isolates were >512 µg/mL determined by agar dilution method. The 3 MRSA isolates were positive for mupA detected by PCR.
MRSA isolates expressing SCCmec V (15 isolates), SCCmec II (5 isolates), SCCmec III (4 isolates) and SCCmec IVd (3 isolates) were identified (Table 2). The remaining isolate was non-typeable by multiplex PCR. MLST revealed 16 different sequence types (STs) for 22 of the MRSA isolates, including ST6, ST15, ST25, ST59, ST88, ST188, ST338, ST438,ST398, ST943, ST946, ST1295, ST1556, ST1623, ST1778 and ST1779 were identified (Table 1). Since at least one of the 7 housekeeping genes for MLST typing could not be amplified among the remaining 6 MRSA isolates, STs for these isolates were not available. The STs most commonly identified were ST59 (4 isolates), ST25 (3 isolates), ST188 (2 isolates) and ST438 (2 isolates). Two novel STs recently deposited in the MLST database (http://saureus.mlst.net/), ST1778 and ST1779, were also identified.
19 MRSA isolates were assigned 12 previously characterized spa types, and 5 other isolates were assigned 5 novel spa types (Table 2). spa typing could not be assigned for the remaining 5 MRSA isolates. Furthermore, MRSA isolates were distributed among different sporadic clones. ST59-MRSA-VId-spa t437 was identified for 3 MRSA isolates. Three isolates, representing ST1556-MRSA-V- t437, ST25-MRSA-NT- t078 and ST338-MRSA-V- t163 clones, harbored PVL genes. One isolate exhibiting multidrug resistance was characterized as an ST398-MRSA-V-spa t571 clone. Three MRSA isolates typed as ST25 exhibited different spa types and SCCmec types and belonged to different clones. Although 2 ST188 MRSA isolates harbored SCCmec (V), these isolates exhibited two different spa types, t189 and t1751.
The prevalence of S. aureus nasal carriage among healthy adults ranges from approximately 20% to 30%, with higher prevalences in overcrowded populations , , , . In the United States, a national population-based survey conducted over a 3-year period revealed nasal S. aureus colonization for 32% of study participants . In contrast, a relatively low rate of nasal S. aureus carriage (6.3%) was found for children under the age of 5 in India . The prevalence of nasal colonization with S. aureus in our study was 15.4%, a prevalence similar to that observed (16%) for a suburban military camp cohort in Beijing, China . However, the prevalence of nasal MRSA carriage in our study (3.0%) was higher than prevalences previously reported for cohorts from developed countries, including the United States , , . Furthermore, no nasal MRSA colonization was found among Chinese healthy military volunteers in another study . In contrast, a relatively high prevalence of MRSA colonization was found (11.6%) for a cohort of healthy children aged ≤14 years in community settings in Taiwan over a 5-year period . These data indicate that MRSA colonization varies significantly, even within similar populations in developed countries. The isolation of nasal S. aureus with a single sample may result in underestimating the number of intermittent carriers. In order to improving the isolation of nasal S. aureus, multiple nasal swabs should be taken from both anterior nares of volunteers. Additional studies are needed to clarify relationships between MRSA colonization, age, general antibiotic use, and other variables within overcrowded populations at higher risk for MRSA infections.
Our study revealed that 93% of nasal S. aureus isolates were resistant to trimethoprim-sulfamethoxazole, with MSSA isolates exhibiting the highest rates of resistance. These data contradict several studies reporting low rates of resistance to trimethoprim-sulfamethoxazole for S. aureus isolates recovered from the nares –. For example, in one study of 371 nasal S. aureus isolates, only 7 (1.9%) were resistant to trimethoprim-sulfamethoxazole . Our data are not in agreement with another study reporting trimethoprim-sulfamethoxazole susceptibility rates of 78.6% and 95.3%, for MRSA and MSSA isolates, respectively, recovered from patients in 12 cities across China . Similar to other surveillance studies , , we found high rates of resistance for nasal S. aureus isolates to penicillin, ampicillin/sulbactam and erythromycin, and no discernable resistance of these isolates to vancomycin, quinupristin/dalfopristin or linezolid. Mupirocin is used commonly for treating MRSA skin and soft-tissue infections and eliminating nasal MRSA colonization among patients and medical staff. Our study indicated that 10.7% of nasal MRSA isolates were resistant to mupirocin, in agreement with mupirocin resistance rates observed for MRSA isolates recovered in the context of clinical infection in another study conducted in Wenzhou, China . Therefore, different decolonization strategies including mupirocin may prove more successful for reducing nasal MRSA carriage among members of the Chinese medical community, and possibly Chinese hospital-associated MRSA infections.
Understanding the molecular characteristics of MRSA isolates recovered from healthy individuals may facilitate a better understanding of mechanisms for geographic distribution of MRSA in certain populations, as well as the population-based risk for aggressive community-acquired MRSA infections. CA- MRSA isolates from different geographic areas have demonstrated significant genetic diversity . The vast majority of CA-MRSA isolates worldwide belong to 5 clones: pandemic clone USA300 (ST8), European clone (ST80), midwest clone (ST1), southwest pacific oceanic clone (ST30) and pacific clone (ST59) . Studies performed in Taiwan indicate that ST59 was the most common MLST type for MRSA isolates associated with community-acquired infections and nasal colonization, particularly pediatric infections , , , . The majority (90%) of MRSA isolates recovered from healthy individuals over a 5-year period in Taiwan were clustered into minor variants of two clonal types, ST59 and ST338 . However, the nasal MRSA isolates recovered in our study showed considerable heterogeneity, with ST59 and ST338 accounting for only 14.3% and 3.6% of STs, respectively. One recently published study found that among MRSA isolates associated with pediatric infections on the Chinese mainland, ST59-MRSA-SCCmecVI-t437 was the most common clone identified (59%), followed by ST1 (8%) and ST338 (8%) . ST59-MRSA-SCCmecVI-t437 and ST338-MRSA-SCCmecV-t163 clones were identified from healthy volunteers in our study, indicating that these two clones may contribute to community infection and dissemination among hospital employees. HA-MRSA infections are caused by a relatively small number of epidemic MRSA clones , and ST239-MRSA-SCCmec type III and ST5-MRSA-SCCmec type II are two major epidemic MRSA clones identified in China . Interestingly, these two clones were not isolated in our study. In previous studies published by our group , , ST88 was the most common clone identified among PVL-positive isolates. In the present study, ST88-MRSA-SCCmecV was identified for only one PVL-negative nasal MRSA isolate. Whether CA-MRSA clones identified within the nares of healthy individuals are responsible for clinical infections caused by CA-MRSA in China remains to be determined.
CA-MRSA pathogenesis has been linked to carriage of PVL encoding genes . Relatively high prevalences of PVL gene expression were also found among nasal S. aureus isolates in Chengdu, China (22%) , and Taiwan (19.1%) , . We noted a somewhat lower prevalence (11%) of PVL gene expression for nasal MRSA isolates in our study. Whether a higher prevalence of PVL expression for nasal S. aureus isolates portends a higher rate of clinical S. aureus infections, and more severe CA-MRSA infections, in Chinese populations remains to be determined. Epidemiologic studies tracking incident CA-MRSA infections in our institution, and determining whether infections caused by PVL-expressing CA-MRSA isolates arise in persons in contact with healthy volunteers in our study harboring these isolates, is ongoing.
ST398-MRSA is usually associated with animal infection, especially in pigs , and persons in close contact with animals are more likely to harbor ST398-MRSA isolates , , , . Recently published data suggest that human infections caused by MRSA-ST398 are increasing , , , . One nasal MRSA isolate belonging to ST398-MRSA-V-spa t571 was found in our study. It would be interesting to determine whether medical students performing cadaveric procedures using animals are more likely to harbor ST398-MRSA.
In conclusion, we found a relatively high prevalence of nasal MRSA carriage within healthy persons from a Chinese medical college campus. Among these nasal MRSA isolates, epidemic clones associated with community infection were found, supporting policies for reducing nasal carriage in order to prevent spread of MRSA to community members and hospitalized patients. Moreover, antibiotic resistance patterns for these isolates indicate that unique decolonization strategies may be needed.
We gratefully acknowledge the students from Wenzhou Medical College, Zhongyong Wang and Liqing Zhu, for participation in the collection of nasal specimens and Yuanyuan Lu for performing experiment. We are also grateful to T. Ito for the kind gift of MRSA NCTC 10442 (SCCmec I), MRSA N315 (SCCmec II), MRSA85/2082 (SCCmec III), and MRSA JCSC4744 (SCCmec IV).
Conceived and designed the experiments: FY QB LZ JP LW. Performed the experiments: JD CC QC YS JT BD. Analyzed the data: ZQ CP CS. Contributed reagents/materials/analysis tools: BD. Wrote the paper: FY. Revised the manuscript critically for important intellectual content: ZQ CP CS.
- 1. Lowy FD (1998) Staphylococcus aureus infections. N Engl J Med 339: 520–532.
- 2. Deresinski S (2005) Methicillin-resistant Staphylococcus aureus: an evolutionary, epidemiologic, and therapeutic odyssey. Clin Infect Dis 40: 562–573.
- 3. Taiwo SS (2009) Methicillin resistance in Staphylococcus aureus: a review of the molecular epidemiology, clinical significance and laboratory detection methods. West Afr J Med 28: 281–290.
- 4. Cohen PR (2007) Community-acquired methicillin-resistant Staphylococcus aureus skin infections: implications for patients and practitioners. Am J Clin Dermatol 8: 259–270.
- 5. Wertheim HF, Melles DC, Vos MC, van Leeuwen W, van Belkum A, et al. (2005) The role of nasal carriage in Staphylococcus aureus infections. Lancet Infect Dis 5: 751–762.
- 6. Kluytmans J, van Belkum A, Verbrugh H (1997) Nasal carriage of Staphylococcus aureus: epidemiology, underlying mechanisms, and associated risks. Clin Microbiol Rev 10: 505–520.
- 7. von Eiff C, Becker K, Machka K, Stammer H, Peters G (2001) Nasal carriage as a source of Staphylococcus aureus bacteremia. Study Group. N Engl J Med 344: 11–16.
- 8. Bischoff WE, Wallis ML, Tucker KB, Reboussin BA, Sherertz RJ (2004) Staphylococcus aureus nasal carriage in a student community: prevalence, clonal relationships, and risk factors. Infect Control Hosp Epidemiol 25: 485–491.
- 9. Lamaro-Cardoso J, de Lencastre H, Kipnis A, Pimenta FC, Oliveira LS, et al. (2009) Molecular epidemiology and risk factors for nasal carriage of staphylococcus aureus and methicillin-resistant S. aureus in infants attending day care centers in Brazil. J Clin Microbiol 47: 3991–3997.
- 10. Lowy FD, Aiello AE, Bhat M, Johnson-Lawrence VD, Lee MH, et al. (2007) Staphylococcus aureus colonization and infection in New York State prisons. J Infect Dis 196: 911–918.
- 11. Enright MC, Robinson DA, Randle G, Feil EJ, Grundmann H, et al. (2002) The evolutionary history of methicillin-resistant Staphylococcus aureus (MRSA). Proc Natl Acad Sci U S A 99: 7687–7692.
- 12. Diep BA, Otto M (2008) The role of virulence determinants in community-associated MRSA pathogenesis. Trends Microbiol 16: 361–369.
- 13. Xiao YH, Wang J, Li Y (2008) Bacterial resistance surveillance in China: a report from Mohnarin 2004–2005. Eur J Clin Microbiol Infect Dis 27: 697–708.
- 14. Liu Y, Wang H, Du N, Shen E, Chen H, et al. (2009) Molecular evidence for spread of two major methicillin-resistant Staphylococcus aureus clones with a unique geographic distribution in Chinese hospitals. Antimicrob Agents Chemother 53: 512–518.
- 15. Institute CaLS (2008) Performance standards for antimicrobial susceptibility testing, 18th informational supplement (M100-S18). Clinical and Laboratory Standards Institute, Wayne, PA,USA.
- 16. Fuchs PC, Jones RN, Barry AL (1990) Interpretive criteria for disk diffusion susceptibility testing of mupirocin, a topical antibiotic. J Clin Microbiol 28: 608–609.
- 17. Anthony RM, Connor AM, Power EG, French GL (1999) Use of the polymerase chain reaction for rapid detection of high-level mupirocin resistance in staphylococci. Eur J Clin Microbiol Infect Dis 18: 30–34.
- 18. McClure JA, Conly JM, Lau V, Elsayed S, Louie T, et al. (2006) Novel multiplex PCR assay for detection of the staphylococcal virulence marker Panton-Valentine leukocidin genes and simultaneous discrimination of methicillin-susceptible from -resistant staphylococci. J Clin Microbiol 44: 1141–1144.
- 19. Zhang K, McClure JA, Elsayed S, Louie T, Conly JM (2005) Novel multiplex PCR assay for characterization and concomitant subtyping of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus. J Clin Microbiol 43: 5026–5033.
- 20. Koreen L, Ramaswamy SV, Graviss EA, Naidich S, Musser JM, et al. (2004) spa typing method for discriminating among Staphylococcus aureus isolates: implications for use of a single marker to detect genetic micro- and macrovariation. J Clin Microbiol 42: 792–799.
- 21. Harmsen D, Claus H, Witte W, Rothganger J, Turnwald D, et al. (2003) Typing of methicillin-resistant Staphylococcus aureus in a university hospital setting by using novel software for spa repeat determination and database management. J Clin Microbiol 41: 5442–5448.
- 22. Enright MC, Day NP, Davies CE, Peacock SJ, Spratt BG (2000) Multilocus sequence typing for characterization of methicillin-resistant and methicillin-susceptible clones of Staphylococcus aureus. J Clin Microbiol 38: 1008–1015.
- 23. Choi CS, Yin CS, Bakar AA, Sakewi Z, Naing NN, et al. (2006) Nasal carriage of Staphylococcus aureus among healthy adults. J Microbiol Immunol Infect 39: 458–464.
- 24. Gorwitz RJ, Kruszon-Moran D, McAllister SK, McQuillan G, McDougal LK, et al. (2008) Changes in the prevalence of nasal colonization with Staphylococcus aureus in the United States, 2001–2004. J Infect Dis 197: 1226–1234.
- 25. Pathak A, Marothi Y, Iyer RV, Singh B, Sharma M, et al. (2010) Nasal carriage and antimicrobial susceptibility of Staphylococcus aureus in healthy preschool children in Ujjain, India. BMC Pediatr 10: 100.
- 26. Qu F, Cui E, Guo T, Li H, Chen S, et al. (2010) Nasal colonization of and clonal transmission of methicillin-susceptible Staphylococcus aureus among Chinese military volunteers. J Clin Microbiol 48: 64–69.
- 27. Sdougkos G, Chini V, Papanastasiou DA, Christodoulou G, Stamatakis E, et al. (2008) Community-associated Staphylococcus aureus infections and nasal carriage among children: molecular microbial data and clinical characteristics. Clin Microbiol Infect 14: 995–1001.
- 28. Graham PL 3rd, Lin SX, Larson EL (2006) A U.S. population-based survey of Staphylococcus aureus colonization. Ann Intern Med 144: 318–325.
- 29. Lo WT, Wang CC, Lin WJ, Wang SR, Teng CS, et al. (2010) Changes in the nasal colonization with methicillin-resistant Staphylococcus aureus in children: 2004–2009. PLoS One 5: e15791.
- 30. Wang H, Liu Y, Sun H, Xu Y, Xie X, et al. (2008) In vitro activity of ceftobiprole, linezolid, tigecycline, and 23 other antimicrobial agents against Staphylococcus aureus isolates in China. Diagn Microbiol Infect Dis 62: 226–229.
- 31. Liu QZ, Wu Q, Zhang YB, Liu MN, Hu FP, et al. (2010) Prevalence of clinical meticillin-resistant Staphylococcus aureus (MRSA) with high-level mupirocin resistance in Shanghai and Wenzhou, China. Int J Antimicrob Agents 35: 114–118.
- 32. Wang CC, Lo WT, Chu ML, Siu LK (2004) Epidemiological typing of community-acquired methicillin-resistant Staphylococcus aureus isolates from children in Taiwan. Clin Infect Dis 39: 481–487.
- 33. Boyle-Vavra S, Ereshefsky B, Wang CC, Daum RS (2005) Successful multiresistant community-associated methicillin-resistant Staphylococcus aureus lineage from Taipei, Taiwan, that carries either the novel Staphylococcal chromosome cassette mec (SCCmec) type VT or SCCmec type IV. J Clin Microbiol 43: 4719–4730.
- 34. Huang YC, Hwang KP, Chen PY, Chen CJ, Lin TY (2007) Prevalence of methicillin-resistant Staphylococcus aureus nasal colonization among Taiwanese children in 2005 and 2006. J Clin Microbiol 45: 3992–3995.
- 35. Geng W, Yang Y, Wu D, Huang G, Wang C, et al. (2010) Molecular characteristics of community-acquired, methicillin-resistant Staphylococcus aureus isolated from Chinese children. FEMS Immunol Med Microbiol 58: 356–362.
- 36. Gomes AR, Westh H, de Lencastre H (2006) Origins and evolution of methicillin-resistant Staphylococcus aureus clonal lineages. Antimicrob Agents Chemother 50: 3237–3244.
- 37. Yu F, Chen Z, Liu C, Zhang X, Lin X, et al. (2008) Prevalence of Staphylococcus aureus carrying Panton-Valentine leukocidin genes among isolates from hospitalised patients in China. Clin Microbiol Infect 14: 381–384.
- 38. Yao D, Yu FY, Qin ZQ, Chen C, He SS, et al. (2010) Molecular characterization of Staphylococcus aureus isolates causing skin and soft tissue infections (SSTIs). BMC Infect Dis 10: 133.
- 39. Boyle-Vavra S, Daum RS (2007) Community-acquired methicillin-resistant Staphylococcus aureus: the role of Panton-Valentine leukocidin. Lab Invest 87: 3–9.
- 40. Fan J, Shu M, Zhang G, Zhou W, Jiang Y, et al. (2009) Biogeography and virulence of Staphylococcus aureus. PLoS One 4: e6216.
- 41. Lo WT, Lin WJ, Tseng MH, Wang SR, Chu ML, et al. (2008) Risk factors and molecular analysis of panton-valentine leukocidin-positive methicillin-resistant Staphylococcus aureus colonization in healthy children. Pediatr Infect Dis J 27: 713–718.
- 42. van Duijkeren E, Ikawaty R, Broekhuizen-Stins MJ, Jansen MD, Spalburg EC, et al. (2008) Transmission of methicillin-resistant Staphylococcus aureus strains between different kinds of pig farms. Vet Microbiol 126: 383–389.
- 43. Krziwanek K, Metz-Gercek S, Mittermayer H (2009) Methicillin-Resistant Staphylococcus aureus ST398 from human patients, upper Austria. Emerg Infect Dis 15: 766–769.
- 44. van Belkum A, Melles DC, Peeters JK, van Leeuwen WB, van Duijkeren E, et al. (2008) Methicillin-resistant and -susceptible Staphylococcus aureus sequence type 398 in pigs and humans. Emerg Infect Dis 14: 479–483.
- 45. Hallin M, De Mendonca R, Denis O, Lefort A, El Garch F, et al. (2011) Diversity of accessory genome of human and livestock-associated ST398 methicillin resistant Staphylococcus aureus strains. Infect Genet Evol 11: 290–299.