Journal of Laboratory Physicians
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ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 4  |  Page : 314-316  

High prevalence of clindamycin resistance in Staphylococcus aureus blood culture isolates in São Paulo, Brazil


Department of Pathology, Division of Microbiology, School of Medicine, Santa Casa de São Paulo, São Paulo, Brazil

Date of Submission29-Nov-2016
Date of Acceptance21-Mar-2017
Date of Web Publication11-Sep-2017

Correspondence Address:
Marcelo J Mimica
Departamento de Ciências Patológicas, Faculdade de Ciências Médicas da Santa Casa de São Paulo, Disciplina de Microbiologia, Rua Cesário Motta Júnior, 112, São Paulo
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JLP.JLP_161_16

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   Abstract 

Background: Clindamycin has become an important antimicrobial option for the treatment of Staphylococcus aureus. However, little is known about the current patterns of clindamycin-susceptibility in S. aureus invasive isolates, both in our country and in other developing countries in the world.
Aims: The aim of this study was to determine the prevalence of constitutive and inducible clindamycin resistance in methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA) blood culture isolates in São Paulo, Brazil.
Materials and Methods: From July 2011 to June 2012, all S. aureus isolates from blood cultures collected at our hospital were included in the study. Antimicrobial susceptibility testing was performed according to recommendations of the Clinical and Laboratory Standards Institute.
Results: Total prevalence of clindamycin resistance was 68%, including 7.2% with inducible resistance. In MRSA resistance rate was 90.8% whereas in MSSA the rate was 32.7%.
Conclusions: Our high prevalence of clindamycin resistance highlights the importance of performing D-test in a routine base, as well of maintaining continued surveillance for the prevalence of clindamycin resistance.

Keywords: Clindamycin, methicillin resistant Staphylococcus aureus, Staphylococcus aureus


How to cite this article:
Lupinacci FS, Bussius D, Acquesta F, Fam G, Rossi R, Navarini A, Mimica MJ. High prevalence of clindamycin resistance in Staphylococcus aureus blood culture isolates in São Paulo, Brazil. J Lab Physicians 2017;9:314-6

How to cite this URL:
Lupinacci FS, Bussius D, Acquesta F, Fam G, Rossi R, Navarini A, Mimica MJ. High prevalence of clindamycin resistance in Staphylococcus aureus blood culture isolates in São Paulo, Brazil. J Lab Physicians [serial online] 2017 [cited 2019 May 20];9:314-6. Available from: http://www.jlponline.org/text.asp?2017/9/4/314/214260


   Introduction Top


Staphylococcus aureus is a major cause of community- and health-care associated infections worldwide. In the last decades, treatment of such infections has been complicated by escalating antimicrobial resistance. Penicillin- and methicillin-resistant strains have disseminated globally and more recently, community-associated methicillin- resistant S. aureus (CA-MRSA) as well vancomycin-intermediate, and vancomycin-resistant S. aureus isolates have been described and are also disseminating.[1],[2],[3]

Clindamycin has become an important antimicrobial option for the treatment of both methicillin-susceptible S. aureus (MSSA) and MRSA, mainly CA S. aureus infections.[3],[4] However, little is known about the current patterns of clindamycin-susceptibility in S. aureus invasive isolates, both in our country and in other developing countries in the world.

Resistance to clindamycin in S. aureus derives from target site modification, mediated by erm genes, which lead to ribosomal methylation. Resistance may occur either in an inducible or constitutive form.[4]

The aim of this study was to determine the prevalence of constitutive and inducible clindamycin resistance in MSSA, and MRSA blood culture isolates in São Paulo, Brazil.


   Materials and Methods Top


From July 2011 to June 2012, all S. aureus isolates from blood cultures collected at our hospital were included in the study. Our hospital is a quaternary care general hospital in São Paulo, Brazil. Isolates were identified using traditional microbiology methods, including Gram stain, catalase, coagulase, and DNAse.

Antimicrobial susceptibility testing was performed according to recommendations of the Clinical and Laboratory Standards Institute (CLSI).[5] D-test was performed to detect inducible clindamycin resistance, also following recommendations issued by the CLSI.[5]

S. aureus isolates from blood cultures of patients that already had an isolate included in the study were excluded. Thus, only one (the first) isolate per patient was included in the study.


   Results Top


During the study, we included 125 isolates. Seventy-six (60.8%) were MRSA and 49 (39.2%) were MSSA. Total prevalence of clindamycin resistance was 68% (85/125), including 76 (60.8%) with constitutive resistance and 9 (7.2%) with inducible resistance. Regarding the MRSA, one of the 76 isolates had inducible clindamycin resistance, and 68 had constitutive resistance. Only 7 (9.2%) MRSA were clindamycin susceptible. Of the 49 MSSA, 16 were resistant to clindamycin, including eight with inducible resistance and eight with constitutive resistance. Thirty-three (67.3%) were clindamycin susceptible.


   Discussion Top


Although inducible clindamycin resistance was present in only nine isolates, this finding highlights the paramount importance of the routine use by D-test by clinical microbiology laboratories, since the resistance in these isolates would not be detected without this specific method. D-test is recommended routinely both by the CLSI and by the European Committee on Antimicrobial Susceptibility Testing.[5],[6] However, even in developing countries, only a fraction of clinical laboratories follow such recommendations.[7]

The high prevalence of clindamycin resistance may impact empirical therapy in the era of dissemination of CA-MRSA since clindamycin is now used globally as empirical treatment for possible S. aureus infections where CA-MRSA is common.[4],[7] Others have also reported elevated rates of clindamycin resistance in S. aureus.[8],[9],[10] Glycopeptides, trimethoprim-sulfamethoxazole and a number of new antimicrobial agents are being used in such cases, but their use is sometimes problematic, due to resistance or limited scientific evidence supporting it.[3] In addition, clindamycin is an important part of antimicrobial therapy for cases of toxic shock syndrome. Linezolid has recently also been showed to reduce toxic shock syndrome toxin-1 production and could be an option in these cases. However, its costs and availability are still a concern.[11]

Continued surveillance for the presence of clindamycin resistance is paramount to ensure adequate empirical antimicrobial therapy. Appropriate in vitro antimicrobial susceptibility tests, including D-test, are important not only as part of surveillance efforts but also to guarantee correct specific treatment for individual patients with staphylococcal infections.


   Conclusions Top


Our high prevalence of clindamycin resistance highlights the importance of performing D-test in a routine base, as well of maintaining continued surveillance for the prevalence of clindamycin resistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Mimica MJ, Berezin EN, Carvalho RB. Healthcare associated PVL negative methicillin-resistant Staphylococcus aureus with SCCmec type IV. Pediatr Infect Dis J 2009;28:934.  Back to cited text no. 1
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2.
Mimica MJ, Berezin EN, Damaceno N, Carvalho RB. SCCmec type IV, PVL-negative, methicillin-resistant Staphylococcus aureus in cystic fibrosis patients from Brazil. Curr Microbiol 2011;62:388-90.  Back to cited text no. 2
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3.
Tarai B, Das P, Kumar D. Recurrent challenges for clinicians: Emergence of methicillin-resistant Staphylococcus aureus, vancomycin resistance, and current treatment options. J Lab Physicians 2013;5:71-8.  Back to cited text no. 3
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4.
Cadena J, Sreeramoju P, Nair S, Henao-Martinez A, Jorgensen J, Patterson JE. Clindamycin-resistant methicillin-resistant Staphylococcus aureus: Epidemiologic and molecular characteristics and associated clinical factors. Diagn Microbiol Infect Dis 2012;74:16-21.  Back to cited text no. 4
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5.
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing: Twenty-Third Informational Supplement, M100-S23. Wayne, PA: EUA, Clinical and Laboratory Standards Institute; 2013.  Back to cited text no. 5
    
6.
The European Committee on Antimicrobial Susceptibility Testing. Available from: http://www.eucast.org/clinical_breakpoints/. [Last accessed on 2016 Nov 28].  Back to cited text no. 6
    
7.
Patra KP, Vanchiere JA, Bocchini JA Jr. Adherence to CLSI recommendations for testing of Staphylococcus aureus isolates in Louisiana hospitals: Report of a clinical failure and results of a questionnaire study. J Clin Microbiol 2011;49:3019-20.  Back to cited text no. 7
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8.
Changchien CH, Chen SW, Chen YY, Chu C. Antibiotic susceptibility and genomic variations in Staphylococcus aureus associated with Skin and Soft Tissue Infection (SSTI) disease groups. BMC Infect Dis 2016;16:276.  Back to cited text no. 8
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9.
Ghaznavi-Rad E, Neela V, Nor Shamsudin M, Ghasemzadeh Moghaddam H, Tavakol M, van Belkum A, et al. Diversity in the antimicrobial susceptibility patterns of methicillin-resistant Staphylococcus aureus clones. Eur J Clin Microbiol Infect Dis 2012;31:3317-21.  Back to cited text no. 9
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10.
McDougal LK, Fosheim GE, Nicholson A, Bulens SN, Limbago BM, Shearer JE, et al. Emergence of resistance among USA300 methicillin-resistant Staphylococcus aureus isolates causing invasive disease in the United States. Antimicrob Agents Chemother 2010;54:3804-11.  Back to cited text no. 10
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11.
Stevens DL, Ma Y, Salmi DB, McIndoo E, Wallace RJ, Bryant AE. Impact of antibiotics on expression of virulence-associated exotoxin genes in methicillin-sensitive and methicillin-resistant Staphylococcus aureus. J Infect Dis 2007;195:202-11.  Back to cited text no. 11
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