Epidemiology of methicillin-resistant staphylococci in Europe

Methicillin-resistant staphylococci are mostly resistant not only to all beta-lactams but also to a wide range of other antibiotics, and have emerged as major nosocomial pathogens during the past two decades. Considerable variations in the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) exist between institutions and between geographic areas. In Europe, in general, a north-south gradient is observed, MRSA strains being rare in Scandinavian hospitals (<2%) and far more prevalent in Mediterranean hospitals (>40%). Whether low or high, the rates of MRSA prevalence in European countries have remained approximately the same during the last decade. Recent findings suggest that MRSA might also be emerging as a community-acquired pathogen. The first stage in the emergence of MRSA is its acquisition by methicillin-susceptible S. aureus, and the integration into its chromosome, of the mecA gene, which, together with the other mec genes, is carried on a mobile genetic element, the staphylococcal chromosomal cassette mec (SCCmec). The origin of SCCmec elements as well as the mechanisms of their acquisition remain unknown. Molecular epidemiology studies using different techniques clearly indicate that the massive geographic spread of MRSA results from the dissemination of relatively few highly epidemic clones. Five major lineages (the so-called Iberian, Brazilian, Hungarian, New York/Japan and pediatric pandemic MRSA clones) have been defined. In Europe, the Iberian clone has been reported in several countries; the Brazilian, pediatric and Hungarian clones have also been detected, but less frequently. A unique Italian clone is predominant in Italy. As with S. aureus, coagulase-negative staphylococci (CNS) represent a serious concern in hospital-acquired infections. Despite marked geographic variations, in some areas of Europe high proportions (60-70%) of CNS are methicillin resistant. The formation of biofilm is a key virulence factor of S. epidermidis, the prominent CNS pathogen, which is the most common cause of bacteremia in device-related infections. Another emerging nosocomial pathogen, S. hemolyticus, is characterized by a tendency to develop multiple antibiotic resistances, with a unique predisposition to glycopeptide resistance.