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Livestock-associated meticillin-resistant Staphylococcus aureus (MRSA) among human MRSA isolates, European Union/European Economic Area countries, 2013 
Staphylococcus aureus colonises the anterior nares of nearly all domesticated animals and ca 30% of humans [1-5]. Livestock-associated meticillin-resistant S. aureus (LA-MRSA) poses a zoonotic risk, particularly for those working in close contact with livestock [6]. The highest livestock densities in European Union/European Economic Area (EU/EEA) countries in 2013 were in Benelux countries (Belgium, the Netherlands, and Luxembourg), Nordic countries (Denmark and Norway) and Mediterranean islands (Cyprus and Malta) [7]. Several lineages of LA-MRSA have been described [8-10]. The most widespread LA-MRSA lineage in Europe and North America is clonal complex (CC) 398 including multilocus sequence type (MLST) ST398, which is commonly associated with swine, but has also been identified in cattle and poultry [5,8,11]. Carriage of MRSA CC398 is common in individuals with frequent livestock contact, such as swine farmers and people living in areas with high livestock density [2,11]. The impact of this carriage on otherwise healthy persons appears to be low and LA-MRSA infections have a similar severity to that of other MRSA infections [2,11].
In 2014, the death of four individuals from LA-MRSA CC398 in Denmark led to considerable political and media attention in Nordic countries and the European Parliament regarding the potential burden of LA-MRSA in pigs and humans [12]. The risk management options for LA-MRSA include the identification of transmission chains to interrupt transmission. In addition, consistently wearing face masks when working in pig stables has been shown to lower MRSA carriage rates by 37% [13].
Within Decision 2012/506/EU on case definitions for reporting communicable diseases, reporting of MRSA in the EU/EEA is included under the ?special health issue? of ?Antimicrobial resistance? [14]. The European Centre for Disease Prevention and Control (ECDC) coordinates European surveillance of MRSA through the European Antimicrobial Resistance Surveillance Network (EARS-Net), which collects national clinical laboratory data on invasive MRSA isolates in EU/EEA countries. However, subtyping information that would allow for identification of LA-MRSA isolates is not collected as part of the routine antimicrobial resistance (AMR) surveillance at the European level [15].
A survey conducted in 2006 to 2007 of 357 hospital-serving laboratories in 26 European countries did not identify LA-MRSA among invasive MRSA isolates from humans [3]. In 2007, a survey acquired data on MRSA and LA-MRSA, including screening samples from 21 staphylococcal reference laboratories in 15 countries. Eight countries reported LA-MRSA isolates from humans, including clinical isolates; the proportion of MRSA that were LA-MRSA was above 2% in four countries and in one region in Germany [16].
In 2010, a survey of 29 European countries showed that 19 had a system for surveillance of MRSA, of which 10 had mandatory reporting of MRSA cases [17]. The most frequently used typing methods were DNA sequencing of the repeat region of the S. aureus protein A gene (spa-typing; n = 25), PFGE (n = 24), staphylococcal cassette chromosome mec (SCCmec) typing (n = 24), multilocus sequence typing (MLST; n = 20), toxin gene profiling (n = 17) and multiple-loci variable number tandem repeat analysis (MLVA; n = 6) [17,18]. A laboratory-based system ?Nordic MRSA? contains comprehensive spa, MLST and Pantone-Valentine leukocidin (PVL) data on isolates typed in Denmark, Finland, Iceland, Sweden and Norway from 2009 to 2014 and is updated regularly [19].
The inter-laboratory reproducibility of spa-typing in Europe has been long-established [1,4]. In 2010, 24 of 29 European staphylococcal reference laboratories had access to equipment for spa-typing [17]. MLST is currently considered one of the gold standards in molecular typing techniques to investigate the evolution of S. aureus [20,21]. Whole genome sequencing (WGS) is rapidly replacing MLST for more in-depth study of S. aureus, including its evolution [22,23].
In 2011, ECDC recruited 360 laboratories serving 450 hospitals in 26 European countries to assess the feasibility of linking clinical, epidemiological and spa-typing data from S. aureus blood stream infections during a six-month investigation period. The common view of the participating European staphylococcal reference laboratories was that acquisition of linked clinical, epidemiological and typing data was not feasible due to the differences in national sampling strategies, the paucity of information provided by clinicians on laboratory request forms and the absence of ?a systematic and consistent identification (through internationally agreed identifiers) of hospitals and diagnostic laboratories? [17,18]. Therefore, monitoring and assessing the public health threat posed by LA-MRSA in Europe relies on microbiological confirmations, rather than epidemiological case-based surveillance.
Given the sparse information available at the European level on the occurrence of LA-MRSA in humans, ECDC initiated this study to map the identification of LA-MRSA (i.e. CC398 and ?other? LA-MRSA) in EU/EEA countries and the MRSA subtyping capacity/availability in EU/EEA national/regional reference laboratories. The study also aimed to describe the detected LA-MRSA according to their site of isolation.
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- Pete Kinross1, Andreas Petersen2,6, Robert Skov2, Evelyn Van Hauwermeiren1, Annalisa Pantosti7, Fr?d?ric Laurent3, Andreas Voss4, Jan Kluytmans5, Marc J Struelens1, Ole Heuer1, Dominique L Monnet1, the European human LA-MRSA study group8
Staphylococcus aureus colonises the anterior nares of nearly all domesticated animals and ca 30% of humans [1-5]. Livestock-associated meticillin-resistant S. aureus (LA-MRSA) poses a zoonotic risk, particularly for those working in close contact with livestock [6]. The highest livestock densities in European Union/European Economic Area (EU/EEA) countries in 2013 were in Benelux countries (Belgium, the Netherlands, and Luxembourg), Nordic countries (Denmark and Norway) and Mediterranean islands (Cyprus and Malta) [7]. Several lineages of LA-MRSA have been described [8-10]. The most widespread LA-MRSA lineage in Europe and North America is clonal complex (CC) 398 including multilocus sequence type (MLST) ST398, which is commonly associated with swine, but has also been identified in cattle and poultry [5,8,11]. Carriage of MRSA CC398 is common in individuals with frequent livestock contact, such as swine farmers and people living in areas with high livestock density [2,11]. The impact of this carriage on otherwise healthy persons appears to be low and LA-MRSA infections have a similar severity to that of other MRSA infections [2,11].
In 2014, the death of four individuals from LA-MRSA CC398 in Denmark led to considerable political and media attention in Nordic countries and the European Parliament regarding the potential burden of LA-MRSA in pigs and humans [12]. The risk management options for LA-MRSA include the identification of transmission chains to interrupt transmission. In addition, consistently wearing face masks when working in pig stables has been shown to lower MRSA carriage rates by 37% [13].
Within Decision 2012/506/EU on case definitions for reporting communicable diseases, reporting of MRSA in the EU/EEA is included under the ?special health issue? of ?Antimicrobial resistance? [14]. The European Centre for Disease Prevention and Control (ECDC) coordinates European surveillance of MRSA through the European Antimicrobial Resistance Surveillance Network (EARS-Net), which collects national clinical laboratory data on invasive MRSA isolates in EU/EEA countries. However, subtyping information that would allow for identification of LA-MRSA isolates is not collected as part of the routine antimicrobial resistance (AMR) surveillance at the European level [15].
A survey conducted in 2006 to 2007 of 357 hospital-serving laboratories in 26 European countries did not identify LA-MRSA among invasive MRSA isolates from humans [3]. In 2007, a survey acquired data on MRSA and LA-MRSA, including screening samples from 21 staphylococcal reference laboratories in 15 countries. Eight countries reported LA-MRSA isolates from humans, including clinical isolates; the proportion of MRSA that were LA-MRSA was above 2% in four countries and in one region in Germany [16].
In 2010, a survey of 29 European countries showed that 19 had a system for surveillance of MRSA, of which 10 had mandatory reporting of MRSA cases [17]. The most frequently used typing methods were DNA sequencing of the repeat region of the S. aureus protein A gene (spa-typing; n = 25), PFGE (n = 24), staphylococcal cassette chromosome mec (SCCmec) typing (n = 24), multilocus sequence typing (MLST; n = 20), toxin gene profiling (n = 17) and multiple-loci variable number tandem repeat analysis (MLVA; n = 6) [17,18]. A laboratory-based system ?Nordic MRSA? contains comprehensive spa, MLST and Pantone-Valentine leukocidin (PVL) data on isolates typed in Denmark, Finland, Iceland, Sweden and Norway from 2009 to 2014 and is updated regularly [19].
The inter-laboratory reproducibility of spa-typing in Europe has been long-established [1,4]. In 2010, 24 of 29 European staphylococcal reference laboratories had access to equipment for spa-typing [17]. MLST is currently considered one of the gold standards in molecular typing techniques to investigate the evolution of S. aureus [20,21]. Whole genome sequencing (WGS) is rapidly replacing MLST for more in-depth study of S. aureus, including its evolution [22,23].
In 2011, ECDC recruited 360 laboratories serving 450 hospitals in 26 European countries to assess the feasibility of linking clinical, epidemiological and spa-typing data from S. aureus blood stream infections during a six-month investigation period. The common view of the participating European staphylococcal reference laboratories was that acquisition of linked clinical, epidemiological and typing data was not feasible due to the differences in national sampling strategies, the paucity of information provided by clinicians on laboratory request forms and the absence of ?a systematic and consistent identification (through internationally agreed identifiers) of hospitals and diagnostic laboratories? [17,18]. Therefore, monitoring and assessing the public health threat posed by LA-MRSA in Europe relies on microbiological confirmations, rather than epidemiological case-based surveillance.
Given the sparse information available at the European level on the occurrence of LA-MRSA in humans, ECDC initiated this study to map the identification of LA-MRSA (i.e. CC398 and ?other? LA-MRSA) in EU/EEA countries and the MRSA subtyping capacity/availability in EU/EEA national/regional reference laboratories. The study also aimed to describe the detected LA-MRSA according to their site of isolation.
full article