**14. Conclusion**

The presence of resistant strains in the community, especially *S. aureus*, poses a risk to public health since the treatment may fail, delaying the elimination of pathogens involved in these infections. This delay can result in serious complications leading to early death of the patient. New treatment alternatives and the rediscovery of antimicrobials that are no longer being used provide to the medical community a new opportunity for successful treatment.

In addition to antimicrobial resistance, community strains have become more virulent, which provides another challenge to the attending physician to choose the best treatment strategy possible. Attention should also be directed to CoNS strains resistant to methicillin, which can serve as reservoirs of resistance genes *S. aureus* that are more virulent. The detections of virulence factors and antimicrobial additional resistance can be truly challenging and lead to treatment failure if it is not detected quickly. Fortunately there are new approaches that are becoming affordable to microbiology laboratories that can detect as far as the patient is attended. But to reach the 100% of the treatment success it will need more than top notch technologies.

### **15. References**

70 Epidemiology Insights

*vanA, vanB* and *vanC*. The samples relating to employees of the hospital were also resistant

MRSCoN may be involved in severe infections and present different resistances, as well as virulence factors able to offer health risks of individuals with impaired immune systems or in development as in the case of neonates. Despite its great importance in critically ill patients, its presence in healthy individuals deserves special attention mainly because they

The emergence of *S. aureus* resistant to methicillin in the community as the main agent of serious infections of skin and soft tissue is disturbing since oxacillin would be the drug of choice to treat infections caused by strains resistant to other antibiotics. Several techniques can be used to detect resistance to oxacillin, but PCR is the safest and most effective. In addition to PCR, other techniques allow genetic characterization of CA-MRSA detailing an arsenal of toxins and differentiation of clones involved in outbreaks. These techniques help epidemiologist determine correct measures in controlling the spread of this pathogen.

Studies in Epidemiology associated with molecular studies represent good tools for understand the distribution and inform treatment success. The detection of antimicrobial resistance in strains from patients living in the community reveals that the alternatives available to the medical community for successful treatment are decreasing gradually, thus, presenting an opportunity to research new drugs, and antimicrobial agents considered older and well established such as trimethoprim/sulfamethoxazole, which is re-emerging as an

The presence of CA-MRSA strains involved in nosocomial infection implies the need for greater control of its spread among hospitalized patients, since the reports of strains of community origin suggest they are also more virulent compared to strains of nosocomial origin, and may lead to serious complications of rapid evolution. Treatment strategies that may delay or prevent the expression of these factors will need to be established, as well as

The presence of resistant strains in the community, especially *S. aureus*, poses a risk to public health since the treatment may fail, delaying the elimination of pathogens involved in these infections. This delay can result in serious complications leading to early death of the patient. New treatment alternatives and the rediscovery of antimicrobials that are no longer being used provide to the medical community a new opportunity for successful treatment. In addition to antimicrobial resistance, community strains have become more virulent, which provides another challenge to the attending physician to choose the best treatment strategy possible. Attention should also be directed to CoNS strains resistant to methicillin, which can serve as reservoirs of resistance genes *S. aureus* that are more virulent. The detections of virulence factors and antimicrobial additional resistance can be truly challenging and lead to treatment failure if it is not detected quickly. Fortunately there are new approaches that are becoming affordable to microbiology laboratories that can detect as

to other classes of antimicrobials (Palazzo et al., 2005).

are both sources of genes for virulence and resistance.

option for treating infections caused by CA-MRSA.

administering the correct treatment quickly and effectively.

**13. Future prospects** 

**14. Conclusion** 


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**5** 

*Brazil* 

**MRSA Epidemiology in Animals** 

Maria de Lourdes Ribeiro de Souza da Cunha

*UNESP- Univ. Estadual Paulista, Biosciences Institute, Botucatu, SP* 

Until the 1990s, methicillin-resistant *Staphylococcus aureus* (MRSA) was traditionally considered a pathogen causing nosocomial infections, being the so-called HA-MRSA (healthcare-associated methicillin-resistant *Staphylococcus aureus*). However, over time, cases of MRSA-positive individuals were observed who never had contact with hospital services, and strains from these individuals were identified and named CA-MRSA (communityassociated methicillin-resistant *Staphylococcus aureus*). In 2003 in the Netherlands, a new MRSA strain arose in patients that could not be typed through PFGE (pulsed field gel electrophoresis) with *Sma*I, with resistance to digestion by this enzyme (Bens et al., 2006), being called since then NT-MRSA (non typeable methicillin-resistant *Staphylococcus aureus*). Investigations of this NT-MRSA intensified, and it was observed that these patients carrying this strain had previous contact with pigs and the geographic distribution of cases showed clusters near pig farms (van Loo et al., 2007). With more advanced studies, it was possible to determine strains strictly related to animals, such as those found in pigs, which were named LA-MRSA (livestock-associated methicillin-resistant *Staphylococcus aureus*) in 2010

The resistance to methicillin in staphylococci is mediated by the *mecA* gene that encodes a modified penicillin-binding protein (PBP), the PBP2a or 2', which shows reduced affinity to the resistant penicillins to penicillinase, such as methicillin and oxacillin and for all other beta-lactam antibiotics (van Duijkeren et al., 2004). Due to the need for better characterizing these isolates, they have been classified in a more detailed manner, beginning with the SCC*mec* types and patterns identified by PFGE, and are currently based on sequence type and *spa* typing. With the use of techniques such as MLST (multi locus sequence typing) and *spa* typing, characteristic clones from animals have been observed, and it is suspected that some have tropism by determined host species. An example of this is ST398, which in addition to being strictly linked to pigs, has carried novel types of SCC*mec*. Li et al. (2011) analyzed the *SCCmec* element structure carried by 31 CC398 MRSA strains isolated from participants of a conference. The strains were classified into novel types, IX and X, type V (5C2&5) subtype c and type IVa, all carriers of genes conferring resistance to metals. The SCC*mec* structures from CC398 strains were distinct from those usually found in humans, complementing evidence that humans are not the original host for CC398. With the absence of a complete evaluation of risk factors

**1. Introduction** 

(Vanderhaeghen et al., 2010).

Patrícia Yoshida Faccioli-Martins and

