Geoffrey Coombs 1, Graeme Nimmo 2, Julie Pearson 1, Samantha Cramer 1 and Keryn Christiansen 1

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1 Community Onset MRSA Infections in Australia: A Tale of Two Clones Geoffrey Coombs 1, Graeme Nimmo 2, Julie Pearson 1, Samantha Cramer 1 and Keryn Christiansen 1 Community Associated MRSA First isolated in the Kimberley region of WA (199) in the aboriginal population. ST-MRSA-IV (WA MRSA ) [PVL NEGATIVE] Udo EE et al (1993) J Hosp Infect 2, 97-1 Genetic analysis of community strains of methicillin-resistant Staphylococcus aureus in Western Australia 1 Department of Microbiology and Infectious Diseases PathWest Laboratory Medicine WA Royal Perth Hospital Division of Microbiology Pathology Queensland Central Laboratory Antimicrobial 21 Australian Society for Antimicrobials 2 th February 21 Auckland Region (via Western Samoa) (1992) ST3-MRSA-IV (WSPP) [PVL POSITIVE] World-wide dissemination of community MRSA Community Associated MRSA Papua New Guinea Asia Europe United Kingdom Ireland Canada United States of America Central America South America Community Associated MRSA Lack risk factors associated with healthcare-associated MRSA Skin and soft tissue infections in young people Laboratory Findings - Susceptible to most non-β-lactam antimicrobials - Very rapid growth times - Clone types different from healthcare-associated MRSA - SCCmec IV (V, VII, VIII) - Panton Valentine leukocidin (PVL) [lukf and luks genes] - Greater clonal diversity 1

2 Community Associated MRSA Western Australia Clonal Complex 1 Clonal Complex Clonal Complex 72 ST1-MRSA-IV (WA1) ST-MRSA-IV (WA) *ST72-MRSA-IV (WA) ST73-MRSA-V (WA1) *ST-MRSA-IV (USA3) *ST772-MRSA-V (WA6) ST-MRSA-IV (WA67) Clonal Complex 7 ST72-MRSA-IV (WA) ST-MRSA-IV (WA) ST7-MRSA-IV (WA) ST1-MRSA-IV (WA7) ST-MRSA-V (WA3) ST7-MRSA-IV (WA79) ST-MRSA-V (WA77) ST13-MRSA-IV (WA72) ST-MRSA-VIII (WA16) Clonal Complex ST76-MRSA-IV (WA31) Clonal Complex ST-MRSA-IV (WA3) ST69-MRSA-IV (WA19) *ST-MRSA-IV (Euro) ST-MRSA-IV (WA1) ST612-MRSA-IV (WA2) *ST3-MRSA-IV (WA17) ST-MRSA-IV (WA21) *ST923-MRSA-IV (WA62) ST72-MRSA-IV (WA3) *ST-MRSA-IV (WA6) ST1173-MRSA-IV (WA) ST-MRSA-IV (WA71) Clonal Complex ST-MRSA-IV (WA7) Clonal Complex 9 ST7-MRSA-IV (WA2) ST-MRSA-IV (WA2) ST3-MRSA-IV (WA13) ST2-MRSA-IV ST-MRSA-V (WA11) ST-MRSA-V (WA1) Clonal Complex 12 Clonal Complex 97 ST-MRSA-V (WA3) ST12-MRSA-IV (WA69) ST93-MRSA-IV (WA) ST-MRSA-V (WA3) ST12-MRSA-novel (WA9) ST117-MRSA-IV (WA63) ST-MRSA-V (WA1) ST-MRSA-V (WA) Clonal Complex 3 Clonal Complex 121 ST-MRSA-V (WA6) *ST3-MRSA-IV (WSPP) ST77-MRSA-V (WA22) ST-MRSA-V T (WA) ST39-MRSA-IV (WA6) ST6-MRSA-IV (WA1) Clonal Complex 1 ST6-MRSA-IV (WA66) Clonal Complex ST1-MRSA-IV (WA3) ST73-MRSA-IV (WA) ST-MRSA-IV (WA23) ST1-MRSA-IV (WA7) ST73-MRSA-IV (WA6) ST-MRSA-IV (WA7) ST26-MRSA-IV (WA39) ST-MRSA-V (WA) Clonal Comples 361 ST7-MRSA-IV (WA2) ST-MRSA-V (WA) ST361-MRSA-VIII (WA2) ST77-MRSA-V (WA22) ST61-MRSA-V (WA61) Clonal Complex 9 Clonal Complex 39 ST3-MRSA-IV (WA) ST9-MR SA-IV (WA-1) ST39-MRSA-V ST3-MRSA-V (WA6) *ST9-MRSA-IV (WA-) ST3-MRSA-novel (WA) *ST9-MRSA-IV (WA6) Clonal Complex 672 ST3-MRSA-V (WA7) ST9-MRSA-IV (WA73) ST672-MRSA-IV (WA29) *ST9-MRSA-V T (Taiwan) ST672-MRSA-V (WA7) Undefined Clonal Complex ST7-MRSA-IV (WA2) ST133-MRSA-IV (WA76) *ST92-MRSA-V (WA2) Singletons *ST93-MRSA-IV (Qld) ST3-MRSA-IV (WA7) Notifications /7/23 to 3/6/29 1 clones 19 clonal clusters 2 singletons Year SCCmec IV clones 23 SCCmec V clones 2 SCCmec VIII clones 2 novel SCCmec clones 13 *PVL positive clones Five major global community-associated MRSA clones ST-MRSA IV (European MRSA) ST9-MRSA-V T (Taiwan MRSA) ST-MRSA-IV (USA3) ST1-MRSA-IV (USA) ST3-MRSA-IV (Oceania MRSA) Panton-Valentine leucocidin (lukf/luksluks genes) POSITIVE () 2-2 () Percentage of Staphylococcus aureus Identified as MRSA 2 27 public teaching hospitals private laboratories % MRSA % 1.% 1.3% 16.% 1.% Each institution collected 1 consecutive clinically significant S aureus isolates from 1 different outpatients (exclude dialysis and day surgery patients) Year of Survey Significant increase from 2 to 2 (p <.1) 2

3 () Percentage of Staphylococcus aureus Identified as MRSA by Region 3 % of S aureus Qld NSW ACT Vic Tas SA WA NT Aust () and as a Percentage of S aureus % of S aureus All MRSA 2 Community S aureus Surveillance Programme 2 Community S aureus Surveillance Programme Box Plot of Age of Patients Infected with and and Acquisition by Decade of Life Mean: years Median: 3 years Mean: 69 years Median: 7 years 1% % 6% % 2% %

4 2 Community S aureus Surveillance Programme 2 Community S aureus Surveillance Programme Box Plot of Age of Patients Infected with PVL Positive and PVL Negative PVL Status by Decade of Life of Patients Infected with PVL Positive and PVL Negative 1% PVL NEG Mean: 3 years Median: 6 years PVL POS Mean: 33 years Median: 3 years % 6% % 2% % PVL NEG PVL POS 2 Community S aureus Surveillance Programme s [3 isolates consisting of 22 clones,62% of MRSA] s [27 isolates consisting of clones, 3% of MRSA] ST93-MRSA-IV (Qld MRSA) [1] ST22-MRSA-IV (EMRSA-1) [112] 2 Community S aureus Surveillance Programme Qld (ST93-MRSA MRSA-IV) 27.% of MRSA EMRSA-1 (ST22-MRSA-IV) 2.% of MRSA ST1-MRSA-IV (WA MRSA-1) [63] ST239-MRSA-II (Aus2 and Aus3 EMRSA) [93] ST1-MRSA-V [1] ST-MRSA-II (New York Japan MRSA or USA1 ) [1] ST-MRSA-IV (WA MRSA-3) [2] ST36-MRSA-II (EMRSA-16 or USA2) [1] ST73-MRSA-IV (WA MRSA-6) [] ST-MRSA-IV [1] ST-MRSA-V [2] ST-MRSA-IV (WA MRSA-) ST-MRSA-IV (USA3) [1] ST3-MRSA-IV (WA MRSA-13) [1] ST3-MRSA-IV (WSPP) 7] ST-MRSA-V (WA MRSA-) [2] ST-MRSA-V (WA MRSA-) [7] ST-MRSA-IV (WA MRSA-23) [2] ST9-MRSA-IV (WA MRSA-1) [2] ST9-MRSA-V (Taiwan ) [1] ST72-MRSA-IV (WA MRSA-) [2] ST13 MRSA-IV (WA MRSA-72) [1] ST7-MRSA.-V (WA MRSA-2) [1] ST-MRSA-IV (European ) [2] ST-MRSA-V [1] ST27-MRSA-V [1] First identified in Caucasian patients in Ipswich Queensland (Munckhof et al 23) - boils, bacteraemia, pneumonia Epidemic potential Substantial outbreaks (causing boils) in aboriginals living in rural NSW (Gosbell et al 2) Multiple reports of severe infections Including necrotising pneumonia (including fatal cases), deep abscesses, osteomyeltis, septic arthritis and bacteraemia First identified in the Midlands and South- East England in the early 199s Major clone in United Kingdom, Ireland, several European countries, New Zealand, Singapore and Australia First reported in Australia in 1997 (Pearman et al 199) In Western Australia frequently isolated from patients in long term care facilities and pre-employment screening of healthcare workers from Ireland and the United Kingdom

5 2 Community S aureus Surveillance Programme EMRSA-1 (ST22-MRSA-IV) 2.% of MRSA 2 Community S aureus Surveillance Programme EMRSA-1 (ST22-MRSA-IV) 2.% of MRSA Antibiogram: Ciprofloxacin R % Erythromycin R 9% Tetracycline R 1% Mupirocin R % Fusidic Acid R % Rifampicin R % Gentamicin R % Cotrimoxazole R 1% Clindamycin R 3% Antibiogram: Ciprofloxacin R 1% Erythromycin R 63% Tetracycline R 3% Mupirocin R <1% Fusidic Acid R <1% Rifampicin R % Gentamicin R % Cotrimoxazole R % Regional Distribution as a Percentage of MRSA <1% Australia: 27.% Australia: 2.% 1-% 6-1% 11-2% 33.3% 21-% % 1.7% >% 6.%.% 1.% 2.% 1.6% 32.% 32.9% Panton Valentine Leucocidin: Panton Valentine Leucocidin: ACT 7.1% 12.1% ACT 1.3% 19.2% Positive Negative %.% 2 Community S aureus Surveillance Programme Regional Distribution 2 2 7% EMRSA-1 (ST22-MRSA-IV) 2.% of MRSA 2 Community S aureus Surveillance Programme EMRSA-1 (ST22-MRSA-IV) 2.% of MRSA Percentage of Staphylococcus aureus 6% 2 2 % % 3% All MRSA All MRSA Qld NSW ACT Vic Tas SA 2% 1% WA NT Aust Qld NSW ACT Percentage of MRSA Vic Tas SA WA NT Aust Qld EMRSA (SAP22 data not available)

6 2 Community S aureus Surveillance Programme EMRSA-1 (ST22-MRSA-IV) 2.% of MRSA Summary Percentage of S aureus infections identified as MRSA increasing in the Australian community Number of Isolates per decade of life Decade of Life Decade of Life Although polyclonal this increase is primarily a tale of two clones 1% % 6% % 2% % Qld Clone (ST93-IV) UK EMRSA-1 (ST22-IV) WA 1 (ST1-IV) PVL Positive PVL Negative AUS 2 WSPP (ST3-IV) AUS 3 WA 3 (ST-IV) WA 2 (ST7-IV) USA3 (ST-IV) Acknowledgments Nadishani Liyanage Kathaluwa Department of Microbiology and Infectious Diseases Gram-positive Bacteria Typing and Research Unit PathWest Royal Perth Hospital Frances O Brien Molecular Genetics Research Unit, Curtin University of Technology Lottery West State Biomedical Facility: Genomics, Dept of Clinical Immunology and Immunogenetics, Royal Perth Hospital. PathWest Laboratory Medicine - WA Australian Group for Antimicrobial Resistance () Australian Government Department of Health and Ageing 6

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