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Characterization of transposon mutants of biofilm-producing Staphylococcus epidermidis impaired in the accumulative phase of biofilm production: genetic identification of a hexosamine-containing polysaccharide intercellular adhesin.

The primary attachment to polymer surfaces followed by accumulation in multilayered cell clusters leads to production of Staphylococcus epidermidis biofilms, which are thought to contribute to virulence in biomaterial-related infections. We isolated Tn917 transposon mutants of biofilm-producing S. epidermidis 13-1, which were completely biofilm negative. In pulsed-field gel electrophoresis no obvious deletions of the mutants were noted. The Tn917 insertions of mutants M10 and M11 were located on different EcoRI fragments but on identical 60-kb SmaI and 17-kb BamHI chromosomal fragments. Linkage of transposon insertions of mutants M10 and M11 with the altered phenotype was demonstrated by phage transduction, whereas the several other mutants apparently represented spontaneous variants. In a primary attachment assay with polystyrene spheres, no significant difference between any of the mutants and the wild type could be detected. Cell clustering as an indication of intercellular adhesion, which is a prerequisite for accumulation in multilayered cell clusters, was not detected with any mutant. These results demonstrate that the mutants were impaired in the accumulative phase of biofilm production. Mutants M10 and M11 did not produce detectable amounts of a specific polysaccharide antigen (D. Mack, N. Siemssen, and R. Laufs, Infect. Immun. 60:2048-2057, 1992), whereas substantially reduced amounts of antigen were produced by the spontaneous variants. Hexosamine was determined as the major specific component of the antigen enriched by gel filtration of biofilm-producing S. epidermidis 1457 because almost no hexosamine was detected in material prepared from the isogenic biofilm-negative transductant 1457-M11, which differentiates the antigen from other S. epidermidis polysaccharide components. Our results provide direct genetic evidence for a function of the antigen in the accumulative phase of biofilm production by S. epidermidis by mediating intercellular adhesion.

Antigens, Bacterial↗

Impact of the accessory gene regulatory system (Agr) on extracellular proteins, codY expression and amino acid metabolism in Staphylococcus epidermidis.

The quorum-sensing system Agr is part of a complex regulatory network of gene expression in staphylococci. This study presents the effect of an agr mutation on a biofilm-forming Staphylococcus epidermidis isolate by employing proteome and transcriptome analysis. The agr mutant exhibited a significantly lowered amount of extracellular proteins: amongst others SspA, AtlE, GehD and the phenol soluble modulins PSM1/2. Cytoplasmic proteome analysis and expression profiling indicated that the agr inactivation led to a strongly altered regulation of metabolism and virulence. Most strikingly, expression of CodY, a global regulator of virulence and stationary phase gene expression, was decreased in the agr mutant. In this respect, homologous genes known to be controlled by CodY in Bacillus subtilis and Lactococcus lactis were found to be up-regulated in the S. epidermidis agr mutant. The combined data show that wild-type and agr mutant differ with respect to amino acid biosynthesis and oligopeptide transport, carbohydrate utilization, as well as GMP and IMP interconversion. Due to the varying physiological properties S. epidermidis agr mutants, which often occur spontaneously, might be capable of colonizing alternative ecological niches in the human host and could, therefore, have an advantage in adapting to changing environmental conditions.

Amino Acids↗

Adherent microorganisms on lumenal surfaces of long-term intravenous catheters. Importance of Staphylococcus epidermidis in patients with cancer.

Using electron microscopy, we prospectively evaluated how frequently adherent microorganisms colonized silicone rubber intravenous (Hickman) catheters removed from patients with cancer. Thirteen (87%) of 15 catheters had gram-positive cocci in glycocalyx adherent to the surface of the catheter lumen. Fungal elements or gram-negative bacilli were mixed with the gram-positive cocci in the glycocalyx on the lumens of three catheters. A consistent morphologic form was adherent to, and the same species was recovered from, the corresponding catheter for six of 27 organisms causing septicemia during catheterization: four of five Staphylococcus epidermidis bacteremias and the only Staphylococcus aureus bacteremia, and one of five candidemias. Three of these six septicemias were successfully treated without removal of the catheter. Although adherent organisms, particularly S epidermidis, were likely to be present on the surface of the lumen of long-term, indwelling, silicone intravenous catheters, septicemias potentially related to these organisms occurred infrequently (fewer than two per 1000 days of catheter use), and the suspect septicemias could sometimes be treated without removal of the catheter.

Adult↗

Relation of human serum antibody against Staphylococcus epidermidis cell surface polysaccharide detected by enzyme-linked immunosorbent assay to passive protection in the mouse.

A specific and rapid enzyme-linked immunosorbent assay (ELISA) has been applied for the detection of immunoglobulins to Staphylococcus epidermidis cell surface polysaccharides in human serum. Positive IgG, IgM and IgA titres of more than 1: 6400, 1: 1600 and 1: 400 were observed with this assay against passive protective human serum. However, IgG, IgM and IgA titres of less than 1: 400, 1: 100 and 1: 50 were shown in non-protective serum. When the cross-reactivity of passive protective human serum to homologous and heterologous cell surface polysaccharides was examined by inhibition test with ELISA, remarkable inhibition was shown with homologous cell surface polysaccharide, whereas no inhibition was observed with heterologous substances. According to these results, the quantitation of human serum antibody by the ELISA method against Staph. epidermidis cell surface polysaccharide was found to be significant for the demonstration of passive protective activities against Staph. epidermidis.

Animals↗

Characterization of the importance of polysaccharide intercellular adhesin/hemagglutinin of Staphylococcus epidermidis in the pathogenesis of biomaterial-based infection in a mouse foreign body infection model.

The production of biofilm is thought to be crucial in the pathogenesis of prosthetic-device infections caused by Staphylococcus epidermidis. An experimental animal model was used to assess the importance of biofilm production, which is mediated by polysaccharide intercellular adhesin/hemagglutinin (PIA/HA), in the pathogenesis of a biomaterial-based infection. Mice were inoculated along the length of a subcutaneously implanted intravenous catheter with either wild-type S. epidermidis 1457 or its isogenic PIA/HA-negative mutant. The wild-type strain was significantly more likely to cause a subcutaneous abscess than the mutant strain (P < 0.01) and was significantly less likely to be eradicated from the inoculation site by host defense (P < 0.05). In addition, the wild-type strain was found to adhere to the implanted catheters more abundantly than the PIA/HA-negative mutant (P < 0.05). The reliability of the adherence assay was assessed by scanning electron microscopy. To exclude contamination or spontaneous infection, bacterial strains recovered from the experimental animals were compared to inoculation strains by analysis of restriction fragment length polymorphism patterns by pulsed-field gel electrophoresis. In vitro binding of the wild-type strain and its isogenic mutant to a fibronectin-coated surface was similar. These results confirm the importance of biofilm production, mediated by PIA/HA, in the pathogenesis of S. epidermidis experimental foreign body infection.

Abscess↗

Ommaya-catheter-related Staphylococcus epidermidis cerebritis and recurrent bacteremia documented by molecular typing.

A 26-year-old woman receiving intrathecal chemotherapy for acute leukemia developed Ommaya-catheter-associated cerebritis and bacteremia caused by two clones of Staphylococcus epidermidis. Genomic fingerprinting of 19 staphylococcal isolates from the cerebrospinal fluid, blood, catheter and skull biopsy was necessary to establish the etiologic diagnosis and to guide medical and surgical therapy.

Adult↗

Posterior lens capsule abscess due to Propionibacterium acnes and Staphylococcus epidermidis following extracapsular cataract extraction.

A case of posterior lens capsular abscess occurring many months after an extracapsular cataract extraction is presented. This was caused by a mixed infection involving Propionibacterium acnes and Staphylococcus epidermidis. The significance of Staph epidermidis after such a long postoperative period is uncertain, but the case shows features typical of secondary endophthalmitis due to P acnes, including a long delay in onset and a grumbling course not brought under control by medical treatment. It supports the theory that the nidus of infection is localised in the posterior lens capsule by showing development of a visible capsular abscess with associated vitreous involvement. The subsequent removal of the capsule and vitreous, despite leaving the intraocular lens in place, led to complete resolution of the inflammation. Both organisms have previously been found to be sequestered in the posterior lens capsule by histological and microbiological examination of excised capsular specimens. It is important to consider them as possible causative agents in the formation of a postoperative capsular abscess.

Abscess↗

An outbreak of Staphylococcus epidermidis septicemia.

During 45 wk from August 1980 to June 1981, the catheter sepsis rate increased from a prior 2 to 34% (23 of 68 patients on intravenous hyperalimentation). The causative organism was Staphylococcus epidermidis, grown on blood cultures in 21 of the 23 patients and on the catheter-tips of all 23. Routine cultures of the catheter-tips of the 45 patients who received intravenous hyperalimentation during this period with no evidence of catheter sepsis grew S. epidermidis on three catheter-tips (6.7%), possibly contamination during catheter removal. Sepsis resolved within 24 hr after catheter removal, with no antibiotics given for the sepsis. The organism had identical antibiograms on the blood and catheter-tip cultures in each patient, but antibiograms varied between patients. In these complex patients undergoing multiple medical events, the intravenous hyperalimentation nurse recorded that iv tubing in septic patients had leaked solution at the attachment to the catheter hub, and a review of nursing notes on charts of patients who had been on intravenous hyperalimentation revealed that a leak had been noted in the patients who subsequently had catheter sepsis. The leak was due to a manufacturing defect resulting in a decrease in diameter of the plastic connection of the iv tubing, which produced a loose attachment to the hub. The problem was remedied by switching to a Luer-lok attachment. However, in July 1982, two patients had separation of the Luer due to a manufacturing defect in the threads, followed by a catheter sepsis. Sepsis from the local contamination was not manifest until 5.4 +/- 2.7 days later. Quality control by manufacturers is emphasized.

Catheters, Indwelling↗

Teichoic acid enhances adhesion of Staphylococcus epidermidis to immobilized fibronectin.

Adhesion is a prerequisite for coagulase-negative staphylococci to cause invasive disease and may be mediated by adhesive host molecules adsorbed on implanted polymers. In this study, we can confirm previous observations demonstrating binding of Staphylococcus epidermidis to fibronectin (FN) adsorbed polymer surfaces. So far, the nature of FN-recognizing adhesin(s) in S. epidermidis remains elusive. Since teichoic acids (TA) have been shown to exert binding functions for extracellular matrix molecules in several Gram-positive species, we have purified wall TA of S. epidermidis laboratory strains KH11 and RP62A, as well as clinical isolate AB9. Using a polymethylmethacrylate (PMMA) coverslip adhesion assay, a microtitre plate assay and a particle agglutination assay, we found that purified TA significantly enhanced adhesion of S. epidermidis KH11 and RP62A to FN coated surfaces. Enhanced adhesion was dose-dependent and saturable. Preincubation, either of microorganisms or of FN coated surfaces, with TA promoted adhesion, while adhesion to TA-adsorbed PMMA was comparably low. This observation may suggest a potential role of cell wall carbohydrates as bridging molecules between microorganisms and immobilized FN in early steps of S. epidermidis pathogenesis.

Bacterial Adhesion↗

Role of an energy-dependent efflux pump in plasmid pNE24-mediated resistance to 14- and 15-membered macrolides in Staphylococcus epidermidis.

We have elucidated a new mechanism for bacterial resistance to the 14-membered macrolides oleandomycin and erythromycin and the 15-membered macrolide azithromycin. Plasmid pNE24, previously isolated from a clinical specimen of Staphylococcus epidermidis, was characterized as causing resistance to 14-membered but not 16-membered macrolides by a mechanism suggested to involve reduced antibiotic permeation of bacterial cells (B. C. Lampson, W. von David, and J. T. Parisi, Antimicrob. Agents Chemother. 30:653-658, 1986). Our recent investigations have demonstrated that S. epidermidis 958-2 containing plasmid pNE24 also contains an energy-dependent macrolide efflux pump which maintains intracellular antibiotic concentrations below those required for binding to ribosomes. Thus, when strain 958-2 was pretreated with the inhibitor carbonyl cyanide m-chlorophenylhydrazone (CCCP), macrolide accumulated at the same rate and to the same extent as in CCCP-treated or untreated control cells lacking plasmid pNE24 (strain 958-1). In contrast, macrolide did not accumulate in energy-competent strain 958-2 but did accumulate to levels equal to those of ribosomes immediately following CCCP addition. Furthermore, intracellular macrolide was excreted and bacteria resumed growth when CCCP but not macrolide was removed from the growth medium. As expected, the 16-membered macrolide niddamycin accumulated to the same level in energy-competent strains 958-1 and 958-2 at the same rapid rate. Macrolide incubated with lysates prepared from both strains or recovered from cells of strain 958-2 was unmodified and bound to ribosomes from strains 958-1 and 958-2 with identical affinities and kinetics, thus precluding a role for ribosome or drug alteration in the resistance mechanism. We conclude that the presence of plasmid pNE24 results in specific energy-dependent efflux of 14- and 15-membered macrolides.

Aminoglycosides↗

[In vitro activity of fusidic acid in combination with various antibiotics against Staphylococcus epidermidis].

In vitro antibacterial activity of fusidic acid (FUC) in combination with cefotaxime (CTX), imipenem (IMP), gentamicin (GEN), amikacin (AKN), rifampin (RIF), fosfomycin (FOS), vancomycin, pefloxacin (PEF) was studied against 19 presumably pathogen meti-R Staphylococcus epidermidis strains. The study was carried out by means of a microtiter checkerboard method (FICs index, 19 strains) and killing-curves (3 strains). FUC x GEN, FUC x AKN and FUC x IMP combinations were found synergistic with achievable therapeutic concentrations for IMP (MIC in the combination less than 1 microgram/ml) but with higher concentrations for AKN and GEN (greater than or equal to 8 micrograms/ml). FUC x PEF combinations were regularly antagonistic. FUC x RIF, and FUC x FOS combinations showed a modal FIC greater than or equal to 4 but were found respectively additive and synergistic with killing-curve method. Remaining FUC combinations results were variable. FUC resistant mutant frequency, studied for 3 S. epidermidis strains, was similar as S. aureus one's (0.5.10(-7) a 2.5.10(-8)).

Drug Resistance, Microbial↗

Hospital dispersion of Staphylococcus epidermidis isolates resistant to a fluoroquinolone, pefloxacin.

Since 1985, nosocomial infections have been frequently treated with a new fluoroquinolone, pefloxacin, at the Cardiological and Neurological Hospital in Lyon. From 1986 to 1988, the incidence of resistance of clinical Staphylococcus epidermidis strains to pefloxacin increased from 31 to 57%. Dispersion of these resistant strains in the hospital environment was recognized when they were detected on 22% of staff members' fingers (139 samples were investigated) and in 28% of the environmental samples (180 were investigated). There was an association between carriage rate and work place. Most of the pefloxacin-resistant S. epidermidis were resistant to oxacillin, gentamicin, erythromycin, cotrimoxazole and fosfomycin. Intensive use of pefloxacin selected multiresistant S. epidermidis which became ubiquitous in the hospital environment.

Carrier State↗

A porcine model of Staphylococcus epidermidis catheter-associated infection.

The suitability of using catheterized, partially nephrectomized (uremic) pigs to study catheter-associated infection in peritoneal dialysis was investigated. In some pigs, an inoculum of 10(9) cfu of Staphylococcus epidermidis ATCC 35984 was deposited around the catheter exit site and the organism was allowed to colonize over 21 days. The strain was recoverable from tissues and catheter samples at various locations along the catheter tract from inoculated pigs at postmortem examination. Uninoculated control catheters were colonized to a significantly lesser degree and by various other staphylococcal species. Immune response by inoculated pigs toward catheter-associated bacteria was indicated by a significant increase in serum antistaphylococcal IgG concentration and an increased percentage of peripheral polymorphonuclear leukocytes. Uremia had no significant effect on serologic response. Immunoblotting against S. epidermidis lysostaphin-extracted proteins showed that although incubation with inoculated group antisera produced more intense banding and reacted to a wider range of protein than did antisera from uninoculated controls, common antigenic proteins among the groups were found.

Animals↗

Significance of Staphylococcus epidermidis in the clinical laboratory.

Susceptibility to 11 antibiotics was determined for 63 cultures of Staphylococcus aureus and 63 cultures of Staphylococcus epidermidis obtained at random from the clinical laboratory. The incidence of resistance to nine of these antibiotics was greater for S. epidermidis than for S. aureus. Studies of the minimal inhibitory concentration of these cultures to clindamycin showed that 61 cultures of S. aureus were susceptible whereas only 46 cultures of S. epidermidis were susceptible to this antibiotic. Although cultures of S. aureus were more active in the production of seven virulence factors, some cultures of S. epidermidis produced virulence factors. By successive cultivation in increasing concentrations of clindamycin, resistant variants were obtained for 10 cultures of S. aureus and 3 cultures of S. epidermidis. The presence of subinhibitory concentrations of clindamycin inhibited the production of some virulence factors by the resistant variants. In view of the greater resistance of S. epidermidis to antibiotics and its ability to produce virulence factors, its isolation in the clinical laboratory should not be regarded lightly.

Anti-Bacterial Agents↗

The interaction of cationic liposomes with the skin-associated bacterium Staphylococcus epidermidis: effects of ionic strength and temperature.

Cationic liposomes have been prepared from dipalmitoylphosphatidylcholine (DPPC), cholesterol (Chol) and stearylamine (SA). These phospholipid vesicles were exposed to adsorbed biofilms of the skin-associated bacteria Staphylococcus epidermidis, to which they showed a strong affinity. The interaction (as assessed by the apparent monolayer coverage of the biofilms by liposomes) was described in terms of a Langmuir adsorption isotherm which enabled determination of the maximum theoretical coverage of the bacterial surface and association/dissociation constants. The interaction was shown to be dependent on the ionic strength of the surrounding medium; on increasing the ionic strength the biofilm-vesicle dissociation constant decreased. This suggested that the adsorption was mediated by electrostatic effects. The adsorption of the vesicles was examined at various temperatures, enabling determination of thermodynamic parameters for the interaction. The adsorbed state of the liposomes was energetically favoured and the interaction was enthalpy driven. The Gibbs energies of adsorption were in a range from -15 to -19 kJ mol-1 and the enthalpies of adsorption from -26 to -22 kJ mol-1. Studies using cell populations of different hydrophobicity showed that the hydrophobic character of the bacterial cells also had an effect on the adsorption of the vesicles to the biofilm.

Adsorption↗

Characterization of thirteen Staphylococcus epidermidis and S. saprophyticus bacteriophages.

Thirteen bacteriophages of coagulase-negative staphylococci belonging to the Siphoviridae family (morphotype B1) were compared by seroneutralization kinetics, protein profiles, G + C content, DNA size and DNA/DNA hybridization. A previous classification into three morphological groups was confirmed. The Staphylococcus epidermidis phage group, although morphologically homogeneous, was heterogeneous by DNA/DNA hybridization (27 to 100% homology) and seroneutralization kinetics. Two new phage "species", STA1139 (STA for Staphylococcus) and STA1154A, corresponding to two morphological types of S. saprophyticus phages, were identified. Species STA1154A was particularly interesting because the size of its capsid, only 46 nm in diameter, and of its DNA, evaluated as 13 kbp, were smaller than those of other staphylococcal phages.

Base Composition↗

Competition between Neisseria gonorrhoeae and Staphylococcus epidermidis during iron-limited or replete continuous culture.

Neisseria gonorrhoeae strain P9-2 was grown in iron-limited or replete continuous culture at a dilution rate of 0.05 h-1, in the presence and absence of Staphylococcus epidermidis. Gonococci maintained expression of pili (P+) and the transparent colony phenotype in pure culture during transitions of iron- and cystine-limited growth. They competed well with staphylococci during iron-limited co-culture and comprised greater than 95% of the population. Transition to cystine-limited growth allowed the staphylococcus to predominate but the gonococcus did not wash out. Furthermore, the gonococcal opaque colony phenotype (O+), indicating synthesis of outer membrane proteins II, was now expressed. Restoration of iron limitation returned the co-culture to its original composition but with P+O+ gonococci dominating. These results suggest that environments might exist in Man where gonococci can compete successfully with normal indigenous bacteria during infection.

Iron↗

A natural history study of experimental Staphylococcus epidermidis endophthalmitis.

The purpose of this study was to find a "threshold" quantity of organisms (i.e. inoculum) to produce clinical endophthalmitis and determine the natural course of intravitreal bacterial counts following inoculation in a rabbit model of Staphylococcus epidermidis endophthalmitis. S. epidermidis endophthalmitis was induced experimentally in 18 New Zealand white rabbits. Eyes were injected with 2.0 x 10(3) (Group I: n = 3), 2.0 x 10(4) (Group II: n = 3), 3.0 x 10(5) (Group III: n = 3), 3.0 x 10(6) (Group IV: n = 3), 3.0 x 10(7) (Group V: n = 3), or 3.0 x 10(8) (Group VI: n = 3) organisms. Serial quantitative bacterial cultures (colony counts) were performed on the vitreous every eight hours for 9 days. All eyes in Groups I and II became culture negative by 24-64 hours post-inoculation (PI). All eyes in Groups III-VI remained culture positive [approximately 600-4000 colony forming units (CFU) per cm3] at 48 to 72 hours PI and were stable for the remainder of the nine day study period. Previous work suggests that the host's inflammatory response is more important than had been recognized. Previous rabbit models of infectious endophthalmitis are known to become culture negative ("autosterilized") despite continued intraocular inflammation. This rabbit model demonstrates a "threshold" of infection where the host's immune response is overwhelmed and "autosterilization" does not occur. When inoculated with 3.0 x 10(5) or greater S. epidermidis organisms of this strain, continued active bacterial replication can now be studied in the rabbit.

Animals↗