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PubMed1985

Distribution of plasmid-borne resistance to nucleic acid binding compounds in methicillin-resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) which are epidemic in Australian hospitals have been found to be genetically different from strains previously isolated in Australia and in Europe. A characteristic feature of the recent Australian isolates is a plasmid which encodes resistance to nucleic acid binding compounds (NAB) such as propamidine isethionate. Of 753 MRSA strains isolated from around the world in 1980-1983, c. 60% were NAB resistant. The determinant for this resistance could be transferred from 90% of strains to a recipient strain in mixed culture. A plasmid analysis revealed that, in general, the largest plasmid of MRSA isolates coded for NAB resistance and may carry other determinants for penicillinase production and resistance to gentamicin, trimethoprim, neomycin, tetracycline, cadmium and mercury. Some plasmids exhibited unusual behaviour with the appearance of deletion mutants after transfer and, in one case, a high-frequency alteration in the expression of gentamicin resistance from high-level to low-level resistance, correlated to a deletion of c. 0.5 megadalton of plasmid DNA. These results demonstrate that these NAB-resistance plasmids are not unique to Australian MRSA strains but are widely distributed throughout the world.

Benzamidines↗

PubMed1980

Evidence for two mechanisms of plasmid transfer in mixed cultures of Staphylococcus aureus.

Non-lysogenic Staphylococcus aureus strain 1030 was lysogenized with 12 different bacteriophages. Lysogeny was associated with acquisition of phase inducibility to mitomycin C treatment or ultraviolet irradiation, with the presence of plaque-forming phage in culture supernatants and with considerable narrowing in susceptibility to the typing bacteriophages and also with increased sensitivity to trimethoprim and sulphadiazine. The presence of prophages in the donor and/or the recipient could either promote or inhibit transfer of plasmids between mixed cultured. Transfer frequencies in mixed culture after 18 h incubation could be as high as 7 . 0 x 10(-1) resistant recipients/final donor, and evidence was adduced for a mechanism distinct from transfer by spontaneous transduction. It is suggested that this method of gene transfer be described as 'phage-mediated conjugation'. Chromosomal genes were not transferred by this method. Two similar plasmids cp-2 and cp-3 were able to promote their own transfer through clones of 1030; plasmids coding for resistance to either neomycin or tetracycline could be transferred to a recipient by the presence of cp-2 or cp-3 simultaneously in the donor. The presence of plasmids in 1030 was associated with a small increase in sensitivity to trimethoprim or sulphadiazine.

Drug Resistance, Microbial↗

PubMed1995

Geographic spread of epidemic multiresistant Staphylococcus aureus clone in Brazil.

Staphylococcus aureus isolates from five large teaching hospitals and one medium-size community hospital located in geographically distant parts of Brazil, in the south and southeast (Rio de Janeiro, Niteroi, Sao Paulo, Porto Alegre) and in the north (Manaus), were tested for their antibiotic resistance patterns and genetic backgrounds. Eighty-five of the 152 isolates were identified as methicillin-resistant S. aureus (MRSA) by using a combination of an agar dilution screen and a mecA gene-specific DNA probe. All MRSA isolates were resistant to penicillin, erythromycin, gentamicin, oxacillin, and cephalothin, and the majority of isolates (74%) were also resistant to chloramphenicol, sulfamethoxazole-trimethoprim, ciprofloxacin, and clindamycin as well and were susceptible only to vancomycin. Isolates obtained from hospitals in Sao Paulo, Rio de Janeiro, Niteroi, and Porto Alegre (1,600 km from one another) and Manaus (3,700 km from Rio de Janeiro) were examined by a variety of molecular fingerprinting techniques: the nature of the mecA polymorph and Tn554 attachment sites and restriction fragment length polymorphism of genomic DNAs after SmaI restriction and separation of the digested DNA by pulsed-field gel electrophoresis. The overwhelming majority of the isolates shared a common pulsed-field gel electrophoresis pattern and carried mecA polymorph III in combination with Tn554 pattern B, indicating the presence of a single, epidemic MRSA clone spread over large geographic distances of Brazil.

Brazil↗

PubMed1997

Structural characterization of an abnormally cross-linked muropeptide dimer that is accumulated in the peptidoglycan of methicillin- and cefotaxime-resistant mutants of Staphylococcus aureus.

Laboratory mutants of Staphylococcus aureus strain ATCC 8325 (27S) selected for increased minimal inhibitory concentration (MIC) values to methicillin and cefotaxime showed increased rates of cell wall turnover and detergent-induced autolysis in virtual parallel with the increasing MIC for the antibiotic. Also in parallel with the increasing MICs for the particular antibiotic used in the selection was the gradual accumulation of an unusual muropeptide in the peptidoglycan of the mutants, muropeptide 12, which is a minor component of the cell wall of the parental strain. Analysis of muropeptide 12, its peptide derivative, and its lysostaphin degradation products by high pressure liquid chromatography, Edman degradation, and mass spectrometry suggests that muropeptide 12 is a dimer in which the two monomeric components are interlinked by two pentaglycyl cross-bridges, thus generating a 14-member macrocyclic ring structure. This unusual cross-linked structure may be the product of the abnormal activity of penicillin-binding protein 2 which has grossly reduced antibiotic binding capacity in the mutant staphylococci.

Amino Acid Sequence↗

PubMed2005

[Hospital-acquired pneumonia caused by methicillin-resistant Staphylococcus aureus].

Methicillin-resistant Staphylococcus aureus (MRSA) is an increasingly common cause of hospital acquired pneumonia (HAP) and the second most frequently isolated pathogen from patients who die from HAP. High-risk units for MRSA colonization such as intensive care (ICU's) are the most affected. Multiple risk factors for transmission of MRSA have been identified, including colonization pressure and severity of illness at ICU admission. On the other hand, the most important predisposing factor for MRSA infection is prolonged mechanical ventilation and/or previous antibiotic therapy. Controlling the spread of MRSA remains a major challenge for hospitals. Screening programs, together with contact precautions for cases with MRSA and judicious antimicrobial use are major factors for a successful control. Early appropriate initial therapy is of crucial importance and improves outcome. The standard therapy has been glycopeptides but, in spite of its in vitro activity, mortality in critically ill patients treated with glycopeptides has consistently been reported high, mainly due to their poor lung penetration. Linezolid shows better clinical cure and survival rates, but further studies are needed. As the treatment options for MRSA pneumonia are limited and inadequate, development of more effective drugs is mandatory.

Anti-Bacterial Agents↗

PubMed1977

Mercury and organomercurial resistances determined by plasmids in Staphylococcus aureus.

Penicillinase plasmids of Staphylococcus aureus often contain genes conferring resistance to inorganic mercury (Hg(2+)) and the organomercurial phenylmercury acetate. The mechanism of resistance was found to be the enzymatic hydrolysis of the organomercurial phenylmercury to benzene plus inorganic ionic mercury, which was then enzymatically reduced to metallic mercury (Hg(0)). The Hg(0) was rapidly volatilized from the medium into the atmosphere. After the mercurial was degraded and the mercury was volatilized, the resistant cells were able to grow. These plasmids also conferred the ability to volatilize mercury from thimerosal, although the plasmid-bearing strains were equally as thimerosal sensitive as the S. aureus without plasmids. None of the plasmids conferred the ability to volatilize mercury from several other organomercurials, however: methylmercury, ethylmercury, p-hydroxymercuribenzoate, merbromin, and fluorescein mercuric acetate. (Organomercurial resistance-conferring plasmids of Escherichia coli and Pseudomonas aeruginosa that we have been studying confer the ability to degrade two or three of these organomercurials.) Although mercury was not volatilized from p-hydroxymercuribenzoate or fluorescein mercuric acetate, the plasmid-bearing strains were resistant to these organomercurials. The ability to volatilize mercury from Hg(2+) and phenylmercury was inducible. The range of inducers included Hg(2+), phenylmercury, and several organomercurials that were not substrates for the degradation system. Mercury-sensitive mutants have been isolated from the parental plasmids pI258 and pII147. Thirty-one such mercury-sensitive strains fall into three classes: (i) mercury-sensitive strains totally devoid of the phenylmercury hydrolase and Hg(2+) reductase activities; (ii) mutants with normal hydrolase levels and no detectable reductase; and (iii) mutants with essentially normal hydrolase levels and low and variable (5 to 25%) levels of reductase activities. The mercury-sensitive strains were also sensitive to phenylmercury, including those with the potential for hydrolase activity.

Drug Resistance, Microbial↗

PubMed2005

Frequency and possible infection control implications of gastrointestinal colonization with methicillin-resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) is a major cause of health care-associated infections. Multiple factors, including transmission from unrecognized reservoirs of MRSA, are responsible for failure to control the spread of MRSA. We conducted prospective surveillance to determine the frequency of gastrointestinal colonization with MRSA among patients and its possible impact on nosocomial transmission of MRSA. Stool specimens submitted for Clostridium difficile toxin A/B assays were routinely inoculated on colistin-naladixic acid agar plates, and S. aureus was identified by using standard methods. Methicillin resistance was confirmed by growth on oxacillin-salt screening agar. For patients whose stool yielded MRSA, information regarding any previous cultures positive for MRSA or other organisms that would require contact precautions was obtained from the laboratory's computer system. During a 1-year period, 151 (9.8%) of 1,543 patients who had one or more stool specimens screened had MRSA in their stool. Ninety-three (62%) of the 151 patients had no previous history of MRSA colonization or infection. Of these 93, 75 were inpatients. Sixty (80%) of the 75 inpatients with no previous history of MRSA were not under "contact precautions." The 60 patients would have spent an estimated total of 267 days without being placed under contact precautions if their positive stool cultures had not resulted in their being isolated. Placing patients under contact precautions based on their positive stool cultures prevented an estimated 35 episodes of MRSA transmission. We conclude that gastrointestinal colonization with MRSA may serve as an unrecognized reservoir from which transmission of MRSA may occur in health care facilities.

Adult↗

PubMed2004

Prevalence of genes encoding for members of the staphylococcal leukotoxin family among clinical isolates of Staphylococcus aureus.

Well-characterized Staphylococcus aureus nasal and blood isolates (N = 429) were tested by polymerase chain reaction for the prevalence of genes that encode leukocidal toxins. The leukotoxin genes lukE+lukD were found at high prevalence, significantly more so in blood (82%) than in nasal isolates (60.5%). Although almost all isolates were positive for the gamma-hemolysin gene, none was positive for lukM. Genes encoding Panton-Valentine leukocidin (PVL) components were very rare in either nasal or blood isolates. The lukE+lukD-negative isolates were significantly more likely to be positive for the staphylococcal enterotoxin gene combination seg/sei (89.5%) and the toxic shock syndrome toxin-1 gene (39.3%) than lukE+lukD-positive isolates (41.7% and 12.7%, respectively). The lukE+lukD-negative isolates were also more likely to show positivity for the accessory gene regulatory locus agr III, but less likely to be positive for the agr II locus. The co-possession of different virulence factors and their probable synergy should receive more attention in order to better understand their role in pathogenicity.

Bacterial Proteins↗

PubMed1992

Stimulation of PAF-synthesis in pulmonary artery endothelial cells by Staphylococcus aureus alpha-toxin.

Staphylococcus aureus alpha-toxin is a pore-forming exotoxin that probably represents a significant virulence factor in staphylococcal infections. Previous studies demonstrated that this agent stimulated arachidonate metabolism with subsequent formation of prostacyclin in endothelial cells and leukotriene B4 in granulocytes. We now examined the effect of alpha-toxin on the synthesis of platelet-activating factor (PAF) in cultured porcine pulmonary artery endothelial cells. PAF was labeled by bioincorporation of tritiated acetate and separated/quantitated using thin-layer chromatography, straight-phase-HPLC, or post-HPLC-bioassay. Alpha-toxin induced synthesis of small amounts of PAF in a time- and dose-dependent manner. The maximal amount of PAF elicited by alpha-toxin was approximately 7% of that observed after application of the ionophore A23187. Staphylococcal alpha-toxin but not the ionophore induced a rapid fall in cellular ATP-content. On kinetic grounds, the decrease in ATP-levels did not explain the differences in stimulated PAF-synthesis. Low amounts of PAF induced by the action of alpha-toxin on endothelial cells may contribute to the development of inflammatory lesions in infectious disease.

Adenosine Triphosphate↗

PubMed2005

Functional interrelationships between cell membrane and cell wall in antimicrobial peptide-mediated killing of Staphylococcus aureus.

Perturbation of the Staphylococcus aureus cytoplasmic membrane (CM) is felt to play a key role in the microbicidal mechanism of many antimicrobial peptides (APs). However, it is not established whether membrane permeabilization (MP) alone is sufficient to kill susceptible staphylococci or if the cell wall (CW) and/or intracellular targets contribute to AP-induced lethality. We hypothesized that the relationships between MP and killing may differ for distinct APs. In this study, we investigated the association between AP-induced MP and lethality in S. aureus whole cells versus CW-free protoplasts, and in comparison to the MP of liposomes modeled after whole CMs in terms of phospholipid composition, fluidity and charge. Four APs with different structure-activity relationships were examined: thrombin-induced platelet microbicidal protein 1 (tPMP-1), human neutrophil protein 1 (hNP-1), gramicidin D, and polymyxin B. MP was quantified fluorometrically by calcein release. All APs tested, except polymyxin B, caused concentration-dependent MP and killing of whole cells, but not of protoplasts. The reduced AP susceptibility of protoplasts was associated with increased cardiolipin and lysyl-phosphatidylglycerol content and reduced fluidity of their CMs. However, liposomal MP induced by tPMP-1, hNP-1, and gramicidin D paralleled that of whole cells. Collectively, these results indicate that (i) structurally distinct APs likely exert their staphylocidal effects by differing mechanisms, (ii) MP is not the sole event leading to AP-induced staphylocidal activity, (iii) a complex interrelationship exists between the CM and CW in AP-induced killing, and (iv) liposomes modeled upon whole cell or protoplast CMs can recapitulate the respective susceptibilities to killing by distinct APs.

Anti-Bacterial Agents↗

PubMed2001

Impact of transcription factors AP-1 and NF-kappaB on the outcome of experimental Staphylococcus aureus arthritis and sepsis.

Staphylococcus aureus infection is, despite adequate antibiotic treatment, a disease characterized by high mortality. The bacterium triggers an exaggerated immune response in the host, which on the one hand acts as an efficient defense, but on the other hand gives rise to tissue damage. In this study we have modulated the hosts response to S. aureus by inhibition of nuclear factor kappaB (NF-kappaB) and activator protein-1 (AP-1)-triggered release of pro-inflammatory cytokines and tissue-destructive proteins, respectively. Mice were administered with antisense oligonucleotides (ODN) to the p65 subunit of NF-kappaB and/or a double-stranded oligonucleotide (mCoAP-1) with homology to the murine AP-1 binding site of collagenase IV gene (metalloproteinase-9; MMP-9), solely or in combination with antibiotics. In mice systemically treated with antisense ODN to NF-kappaB p65 alone, the bacterial burden in the kidneys was significantly increased (P = 0.04) The same tendency was seen when mCoAP-1 was administered either alone or in combination with antibiotics. We also found significantly (P = 0.04) elevated levels of IL-6 in p65 antisense treated mice. Surprisingly, this p65 antisense therapy approach, which has turned out to be highly efficient in amelioration of aseptic arthritis and colitis, failed to change the clinical course of either septic arthritis or sepsis. We suggest that interaction with transcription factors leads to increased bacterial burden in vivo, abrogating the potential benefits of the anti-inflammatory properties exerted by these compounds.

Animals↗

PubMed2005

Antibacterial activity of Curcuma longa L. against methicillin-resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) has been emerging worldwide as one of the most important hospital and community pathogens. Therefore, new agents are needed to treat MRSA associated infections. The present study investigated the antimicrobial activity of ethyl acetate, methanol and water extracts of Curcuma longa L. (C. longa) against MRSA. The ethyl acetate extract of C. longa demonstrated a higher antibacterial activity than the methanol extract or water extract. Since the ethyl acetate extract was more active than the other extracts, the study examined whether the ethyl acetate extract could restore the antibacterial activity of beta-lactams and alter the MRSA invasion of human mucosal fibroblasts (HMFs). In the checkerboard test, the ethyl acetate extract of C. longa markedly lowered the MICs of ampicillin and oxacillin against MRSA. In the bacterial invasion assay, MRSA intracellular invasion was significantly decreased in the presence of 0.125-2 mg/mL of C. longa extract compared with the control group. These results suggest that the ethyl acetate extract of C. longa may have antibacterial activity and the potential to restore the effectiveness of beta-lactams against MRSA, and inhibit the MRSA invasion of HMFs.

Anti-Bacterial Agents↗

PubMed1981

Hydrophobic interaction chromatography of Staphylococcus aureus delta-toxin.

Staphylococcus aureus delta-toxin bound avidly to agarose gels containing phenyl, octyl, or decyl ligands, but less so to agarose with hexyl groups. Agarose with ethyl or butyl moieties did not bind any more toxin than did agarose without attached ligands. About 10% of the applied toxin preparation did not bind to gels and eluted with the starting buffer. The nonadsorbed material was not hemolytic, did not react with anti-delta-toxin immunoglobulin G, and did not appear to be a peptide. Toxin bound to phenyl-Sepharose was not eluted with water, solutions containing chaotropic ions or ethylene glycol, or by increasing the pH, but was eluted with 50% ethanol. The ethanol-eluted delta-toxin (EEDT) was soluble in water, ethanol, 10% sucrose, or 6 M urea, but was poorly soluble in aqueous salt solutions at neutral pH. Regardless of whether the soluble or insoluble form of delta-toxin was applied to the gel, the resultant EEDT fraction was water soluble. The hemolytic activity of EEDT was markedly reduced when assayed in saline, but was the same as that of the original toxin preparation when assayed in isotonic sucrose. A significant portion of EEDT, when rechromatographed on phenyl-Sepharose, did not bind to the gel. This unbound fraction may represent toxin aggregates in which the hydrophobic regions of the toxin monomers are interiorized within the aggregates.

Bacterial Toxins↗

PubMed1978

Pulmonary infection of mice with Staphylococcus aureus.

The survival of Staphylococcus aureus in the lungs of mice was studied under various conditions. Doses of 10(7) to 10(9) washed staphylococci were quantitatively introduced into the lungs after intratracheal inoculation in mice under either ether or sodium pentobarbital anesthesia. Mice were sacrificed at intervals, the lungs were excised and homogenized, and the cocci were enumerated by plate count. The 50% lethal dose was 6 x 10(8) cocci per mouse, and mice died within 24 h but without proliferation of the inoculum. Mice given 10(8) cocci intratracheally under pentobarbital anesthesia regularly survived and eliminated the organisms over a 48-h period. The use of ether anesthesia resulted in persistence of the inoculum for up to 48 h, but the organisms were then eliminated. Inability to proliferate did not appear to result from a lack of iron because pretreatment of the mice with ferric ammonium citrate or Imferon did not alter inoculum survival. Staphylococci inoculated intratracheally in mice infected with influenza virus 3 to 21 days previously showed no enhanced persistence or multiplication. Cocci preclumped with fibrinogen, inocula mixed with 10 times the number of Formalin-killed staphylococci, or inocula of the encapsulated Smith strain did not survive any better than conventional inocula, suggesting that phagocytosis might not be the sole mechanism for elimination. However, a sedimentable fraction from normal or infected lung homogenates proved either inhibitory or cidal for staphylococci in vitro.

Animals↗

PubMed2005

Antimicrobial activity of berberine alone and in combination with ampicillin or oxacillin against methicillin-resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) bacteria have been responsible for substantial morbidity and mortality in hospitals because they usually have multidrug resistance. Some natural products are candidates as new antibiotic substances. In the present study, we investigated the antimicrobial activity of berberine, the main antibacterial substance of Coptidis rhizoma (Coptis chinensis Franch) and Phellodendri cortex (Phellodendron amurense Ruprecht), against clinical isolates of MRSA, and the effects of berberine on the adhesion to MRSA and intracellular invasion into human gingival fibroblasts (HGFs). Berberine showed antimicrobial activity against all tested strains of MRSA. Minimum inhibition concentrations (MICs) of berberine against MRSA ranged from 32 to 128 microg/mL. Ninety percent inhibition of MRSA was obtained with 64 microg/mL or less of berberine. In the checkerboard dilution test, berberine markedly lowered the MICs of ampicillin and oxacillin against MRSA. An additive effect was found between berberine and ampicillin, and a synergistic effect was found between berberine and oxacillin against MRSA. In the presence of 1-50 microg/mL berberine, MRSA adhesion and intracellular invasion were notably decreased compared with the vehicle-treated control group. These results suggest that berberine may have antimicrobial activity and the potential to restore the effectiveness of beta-lactam antibiotics against MRSA, and inhibit the MRSA adhesion and intracellular invasion in HGFs.

Ampicillin↗

PubMed2006

Evaluation of the humoral immune response in BALB/c mice immunized with a naked DNA vaccine anti-methicillin-resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) is the major pathogen involved in nosocomial infections, leading to high rates of morbidity and mortality in hospitals worldwide. The methicillin resistance occurs due to the presence of an additional penicillin-binding protein, PBP2a, which has low affinity for beta-lactam antibiotics. In the past few years, vancomycin has been the only antibiotic option for treatment of infections caused by multiresistant MRSA; however, reports of vancomycin-resistant strains have generated great concerns regarding the treatment to overcome these infections. In the present study, we report preliminary results regarding the humoral immune response generated in BALB/c mice by two different doses of naked DNA vaccine containing an internal region, comprising the serine-protease domain, of the PBP2a of MRSA. The immunization procedure consisted of four immunizations given intramuscularly within 15-day intervals. Blood was collect weekly and anti-PBP2a-specific antibodies were screened by ELISA. BALB/c mice immunized with DNA vaccine anti-PBP2a have shown higher antibody titers mainly after the fourth immunization, and intriguingly, no correlation between the humoral immune response and DNA dose was observed. Our results suggest that the DNA vaccine anti-PBP2a induced an immune response by production of specific antibodies anti-MRSA in a non-dose-dependent manner, and it could represent a new and valuable approach to produce specific antibodies for passive immunization to overcome MRSA infections.

Animals↗

PubMed2003

sarU, a sarA homolog, is repressed by SarT and regulates virulence genes in Staphylococcus aureus.

In searching the Staphylococcus aureus genome, we previously identified sarT, a homolog of sarA, which encodes a repressor for alpha-hemolysin synthesis. Adjacent but transcribed divergently to sarT is sarU, which encodes a 247-residue polypeptide, almost twice the length of SarA. Sequence alignment disclosed that SarU, like SarS, which is another SarA homolog, could be envisioned as a molecule with two halves, with each half being homologous to SarA. SarU, as a member of the SarA family proteins, disclosed conservation of basic residues within the helix-turn-helix motif and within the beta hairpin loop, two putative DNA binding domains within this protein family. The transcription of sarU is increased in a sarT mutant. Gel shift and transcriptional fusion studies revealed that SarT can bind to the sarU promoter region, probably acting as a repressor for sarU transcription. The expression of RNAII and RNAIII of agr is decreased in a sarU mutant. As RNAIII expression is up-regulated in a sarT mutant, we hypothesize that sarT may down regulate agr RNAIII expression by repressing sarU, a positive activator of agr expression. We propose that, in addition to the quorum sensing effect of the autoinducing peptide of agr, the sarT-sarU pathway may represent a secondary amplification loop whereby the expression of agr (e.g., those found in vivo) might repress sarT, leading to increased expression of sarU. Elevated sarU expression would result in additional amplification of the original agr signal.

Amino Acid Sequence↗

PubMed2006

The emergence of vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus.

Methicillin-resistant Staphylococcus aureus (MRSA) is well-recognised as a major cause of infection in the health care setting but, even more worryingly, is now emerging in the community. The glycopeptides-notably vancomycin-have traditionally been the mainstay of treatment of MRSA but overuse has led to the emergence of vancomycin-intermediate and vancomycin-resistant MRSA (VISA and VRSA, respectively). Although the mechanisms underlying vancomycin resistance are not yet fully understood, changes to the bacterial cell wall-the site of action of the glycopeptides-are believed to be key. Recent evidence also supports the transfer of genetic material among bacteria as contributing to the development of VRSA. Based on the cases identified to date, risk factors for the development of VRSA may include older age, compromised blood flow to the lower limbs, and the presence of chronic ulcers. The true extent of the problem, however, remains to be determined-it is likely that many cases of VISA and VRSA infection go undetected because of suboptimal screening programmes and possible limitations of automated and non-automated detection methods. Effective screening directed at those patients considered to be most at risk should therefore be a priority. Not surprisingly, the spread of MRSA from the hospital to the community setting, coupled with the emergence of VISA and VRSA, has become a major cause of concern among clinicians and microbiologists. The treatment options available for these infections are now severely compromised and thus new classes of antimicrobial agents effective against MRSA, VISA and VRSA are urgently required.

Anti-Bacterial Agents↗