Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health care-associated infections. Additionally, over the decades, the spread of community-associated (CA-MRSA) clones has become a serious problem. The aim of this study was to gain data on the current epidemiology of MRSA in Slovakia. Between January 2020 and March 2020, single-patient MRSA isolates (invasive and/or colonizing) were collected in Slovakia from hospitalized inpatients (16 hospitals) or outpatients (77 cities). Isolates were characterized via antimicrobial susceptibility testing, spa typing, SCCmec typing, the detection of mecA/mecC, genes coding for Panton-Valentine leukocidin (PVL), and the arcA gene (part of the arginine catabolic mobile element [ACME]). Out of 412 isolates, 167 and 245 originated from hospitalized patients and outpatients, respectively. Inpatients were most likely older (P < 0.001) and carried a strain exhibiting multiple resistance (P = 0.015). Isolates were frequently resistant to erythromycin (n = 320), clindamycin (n = 268), and ciprofloxacin/norfloxacin (n = 261). 55 isolates were resistant to oxacillin/cefoxitin only. By clonal structure, CC5-MRSA-II (n = 106; spa types t003, t014), CC22-MRSA-IV (n = 75; t032), and CC8-MRSA-IV (n = 65; t008) were the most frequent. We identified PVL in 72 isolates (17.48%; 17/412), with the majority belonging to CC8-MRSA-IV (n = 55; arcA+; t008, t622; the USA300 CA-MRSA clone) and CC5-MRSA-IV (n = 13; t311, t323). To the best of our knowledge, this is the first study on the epidemiology of MRSA in Slovakia. The presence of the epidemic HA-MRSA clones CC5-MRSA-II and CC22-MRSA-IV was found, as was, importantly, the emergence of the global epidemic USA300 CA-MRSA clone. The extensive spread of USA300 among inpatients and outpatients across the Slovakian regions warrants further investigation. IMPORTANCE The epidemiology of MRSA is characterized by the rise and fall of epidemic clones. Understanding the spread, as well as the evolution of successful MRSA clones, depends on the knowledge of global MRSA epidemiology. However, basic knowledge about MRSA epidemiology is still fragmented or completely missing in some parts of the world. This is the first study of MRSA epidemiology in Slovakia to identify the presence of the epidemic HA-MRSA clones CC5-MRSA-II and CC22-MRSA-IV and, importantly and unexpectedly, the emergence of the global epidemic USA300 CA-MRSA clone in the Slovakian community and hospitals. So far, USA300 has failed to spread in Europe, and this study documents an extensive spread of this epidemic clone in a European country for the first time.

Department of Clinical Biochemistry Haematology and Microbiology Unilabs Slovensko s r o Roznava Slovakia

Department of Clinical Microbiology Unilabs Slovensko s r o Stropkov Slovakia

Department of Computer Science Czech Technical University Faculty of Electrical Engineering Prague Czech Republic

Department of Medical Microbiology Charles University 2nd Faculty of Medicine and Motol University Hospital Prague Czech Republic

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Suetens C, Latour K, Karki T, Ricchizzi E, Kinross P, Moro ML, Jans B, Hopkins S, Hansen S, Lyytikainen O, Reilly J, Deptula A, Zingg W, Plachouras D, Monnet DL, The Healthcare-Associated Infections Prevalence Study G . 2018. Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017. Euro Surveill 23. doi:10.2807/1560-7917.ES.2018.23.46.1800516. PubMed DOI PMC

Kock R, Becker K, Cookson B, van Gemert-Pijnen JE, Harbarth S, Kluytmans J, Mielke M, Peters G, Skov RL, Struelens MJ, Tacconelli E, Navarro Torne A, Witte W, Friedrich AW. 2010. Methicillin-resistant Staphylococcus aureus (MRSA): burden of disease and control challenges in Europe. Euro Surveill 15:19688. doi:10.2807/ese.15.41.19688-en. PubMed DOI

Chambers HF, Deleo FR. 2009. Waves of resistance: Staphylococcus aureus in the antibiotic era. Nat Rev Microbiol 7:629–641. doi:10.1038/nrmicro2200. PubMed DOI PMC

David MZ, Daum RS. 2010. Community-associated methicillin-resistant Staphylococcus aureus: epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev 23:616–687. doi:10.1128/CMR.00081-09. PubMed DOI PMC

Challagundla L, Reyes J, Rafiqullah I, Sordelli DO, Echaniz-Aviles G, Velazquez-Meza ME, Castillo-Ramirez S, Fittipaldi N, Feldgarden M, Chapman SB, Calderwood MS, Carvajal LP, Rincon S, Hanson B, Planet PJ, Arias CA, Diaz L, Robinson DA. 2018. Phylogenomic classification and the evolution of clonal complex 5 methicillin-resistant Staphylococcus aureus in the western hemisphere. Front Microbiol 9:1901. doi:10.3389/fmicb.2018.01901. PubMed DOI PMC

Glaser P, Martins-Simoes P, Villain A, Barbier M, Tristan A, Bouchier C, Ma L, Bes M, Laurent F, Guillemot D, Wirth T, Vandenesch F. 2016. Demography and intercontinental spread of the USA300 community-acquired methicillin-resistant Staphylococcus aureus lineage. mBio 7:e02183-15–e02115. doi:10.1128/mBio.02183-15. PubMed DOI PMC

EARS-Net. 2022. European Centre for Disease Prevention and Control. Antimicrobial resistance in EU/EEA (EARS-Net) - Annual Epidemiological Report 2020.

Rolo J, Miragaia M, Turlej-Rogacka A, Empel J, Bouchami O, Faria NA, Tavares A, Hryniewicz W, Fluit AC, de Lencastre H, Group CW, CONCORD Working Group . 2012. High genetic diversity among community-associated Staphylococcus aureus in Europe: results from a multicenter study. PLoS One 7:e34768. doi:10.1371/journal.pone.0034768. PubMed DOI PMC

Tkadlec J, Capek V, Brajerova M, Smelikova E, Melter O, Bergerova T, Polivkova S, Balejova M, Hanslianova M, Fackova D, Neradova K, Tejkalova R, Vagnerova I, Bartonikova N, Chmelarova E, Drevinek P, Krutova M. 2021. The molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) in the Czech Republic. J Antimicrob Chemother 76:55–64. doi:10.1093/jac/dkaa404. PubMed DOI

Grundmann H, Aanensen DM, van den Wijngaard CC, Spratt BG, Harmsen D, Friedrich AW, European Staphylococcal Reference Laboratory Working G . 2010. Geographic distribution of Staphylococcus aureus causing invasive infections in Europe: a molecular-epidemiological analysis. PLoS Med 7:e1000215. doi:10.1371/journal.pmed.1000215. PubMed DOI PMC

Zarfel G, Luxner J, Folli B, Leitner E, Feierl G, Kittinger C, Grisold A. 2016. Increase of genetic diversity and clonal replacement of epidemic methicillin-resistant Staphylococcus aureus strains in South-East Austria. FEMS Microbiol Lett 363. doi:10.1093/femsle/fnw137. PubMed DOI PMC

Horvath A, Dobay O, Sahin-Toth J, Juhasz E, Pongracz J, Ivan M, Fazakas E, Kristof K. 2020. Characterisation of antibiotic resistance, virulence, clonality and mortality in MRSA and MSSA bloodstream infections at a tertiary-level hospital in Hungary: a 6-year retrospective study. Ann Clin Microbiol Antimicrob 19:17. doi:10.1186/s12941-020-00357-z. PubMed DOI PMC

Chmielarczyk A, Pomorska-Wesołowska M, Szczypta A, Romaniszyn D, Pobiega M, Wójkowska-Mach J. 2017. Molecular analysis of meticillin-resistant Staphylococcus aureus strains isolated from different types of infections from patients hospitalized in 12 regional, non-teaching hospitals in southern Poland. J Hosp Infect 95:259–267. doi:10.1016/j.jhin.2016.10.024. PubMed DOI

Kot B, Piechota M, Jakubczak A, Gryzińska M, Witeska M, Grużewska A, Baran K, Denkiewicz P. 2022. The prevalence of virulence determinants in methicillin-resistant Staphylococcus aureus isolated from different infections in hospitalized patients in Poland. Sci Rep 12:5477. doi:10.1038/s41598-022-09517-x. PubMed DOI PMC

Diep BA, Gill SR, Chang RF, Phan TH, Chen JH, Davidson MG, Lin F, Lin J, Carleton HA, Mongodin EF, Sensabaugh GF, Perdreau-Remington F. 2006. Complete genome sequence of USA300, an epidemic clone of community-acquired meticillin-resistant Staphylococcus aureus. Lancet 367:731–739. doi:10.1016/S0140-6736(06)68231-7. PubMed DOI

Moran GJ, Krishnadasan A, Gorwitz RJ, Fosheim GE, McDougal LK, Carey RB, Talan DA, Group EMINS . 2006. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med 355:666–674. doi:10.1056/NEJMoa055356. PubMed DOI

Nurjadi D, Fleck R, Lindner A, Schafer J, Gertler M, Mueller A, Lagler H, Van Genderen PJJ, Caumes E, Boutin S, Kuenzli E, Gascon J, Kantele A, Grobusch MP, Heeg K, Zanger P, StaphTrav N . 2019. Import of community-associated, methicillin-resistant Staphylococcus aureus to Europe through skin and soft-tissue infection in intercontinental travellers, 2011–2016. Clin Microbiol Infect 25:739–746. doi:10.1016/j.cmi.2018.09.023. PubMed DOI

Hetem DJ, Derde LPG, Empel J, Mroczkowska A, Orczykowska-Kotyna M, Kozińska A, Hryniewicz W, Goossens H, Bonten MJM, Group MWS . 2016. Molecular epidemiology of MRSA in 13 ICUs from eight European countries. J Antimicrob Chemother 71:45–52. doi:10.1093/jac/dkv298. PubMed DOI

Argudin MA, Deplano A, Nonhoff C, Yin N, Michel C, Martiny D, De Keersmaecker SCJ, Hallin M. 2021. Epidemiology of the Staphylococcus aureus CA-MRSA USA300 in Belgium. Eur J Clin Microbiol Infect Dis 40:2335–2347. doi:10.1007/s10096-021-04286-3. PubMed DOI

Shore AC, Tecklenborg SC, Brennan GI, Ehricht R, Monecke S, Coleman DC. 2014. Panton-Valentine leukocidin-positive Staphylococcus aureus in Ireland from 2002 to 2011: 21 clones, frequent importation of clones, temporal shifts of predominant methicillin-resistant S. aureus clones, and increasing multiresistance. J Clin Microbiol 52:859–870. doi:10.1128/JCM.02799-13. PubMed DOI PMC

Klein S, Boutin S, Heeg K, Zanger P, Nurjadi D. 2021. Genomic structure of ST8-t008 USA300 and USA300-LV MRSA in the Rhine-Neckar Region, Germany, 2012–2018. Int J Antimicrob Agents 57:106312. doi:10.1016/j.ijantimicag.2021.106312. PubMed DOI

Tattevin P, Diep BA, Jula M, Perdreau-Remington F. 2009. Methicillin-resistant Staphylococcus aureus USA300 clone in long-term care facility. Emerg Infect Dis 15:953–955. doi:10.3201/eid1506.080195. PubMed DOI PMC

Pallin DJ, Egan DJ, Pelletier AJ, Espinola JA, Hooper DC, Camargo CA, Jr, 2008. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med 51:291–298. doi:10.1016/j.annemergmed.2007.12.004. PubMed DOI

Miller LG, Perdreau-Remington F, Rieg G, Mehdi S, Perlroth J, Bayer AS, Tang AW, Phung TO, Spellberg B. 2005. Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles. N Engl J Med 352:1445–1453. doi:10.1056/NEJMoa042683. PubMed DOI

Dufkova K, Bezdicek M, Cuprova K, Pantuckova D, Nykrynova M, Brhelova E, Kocmanova I, Hodova S, Hanslianova M, Juren T, Lipovy B, Mayer J, Lengerova M. 2022. Sequencing independent molecular typing of Staphylococcus aureus isolates: approach for infection control and clonal characterization. Microbiol Spectr 10:e0181721. doi:10.1128/spectrum.01817-21. PubMed DOI PMC

Ilczyszyn WM, Sabat AJ, Akkerboom V, Szkarlat A, Klepacka J, Sowa-Sierant I, Wasik B, Kosecka-Strojek M, Buda A, Miedzobrodzki J, Friedrich AW. 2016. Clonal structure and characterization of Staphylococcus aureus strains from invasive infections in paediatric patients from south Poland: association between age, spa types, clonal complexes, and genetic markers. PLoS One 11:e0151937. doi:10.1371/journal.pone.0151937. PubMed DOI PMC

Pomorska K, Jakubu V, Malisova L, Fridrichova M, Musilek M, Zemlickova H. 2021. Antibiotic resistance, spa typing and clonal analysis of methicillin-resistant Staphylococcus aureus (MRSA) isolates from blood of patients hospitalized in the Czech Republic. Antibiotics (Basel) 10. doi:10.3390/antibiotics10040395. PubMed DOI PMC

EUCAST. 2022. European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Version 12.0, 2022.

Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, Harbarth S, Hindler JF, Kahlmeter G, Olsson-Liljequist B, Paterson DL, Rice LB, Stelling J, Struelens MJ, Vatopoulos A, Weber JT, Monnet DL. 2012. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 18:268–281. doi:10.1111/j.1469-0691.2011.03570.x. PubMed DOI

Okolie CE, Wooldridge KG, Turner DP, Cockayne A, James R. 2015. Development of a new pentaplex real-time PCR assay for the identification of poly-microbial specimens containing Staphylococcus aureus and other staphylococci, with simultaneous detection of staphylococcal virulence and methicillin resistance markers. Mol Cell Probes 29:144–150. doi:10.1016/j.mcp.2015.03.002. PubMed DOI

Stegger M, Andersen PS, Kearns A, Pichon B, Holmes MA, Edwards G, Laurent F, Teale C, Skov R, Larsen AR. 2012. Rapid detection, differentiation and typing of methicillin-resistant Staphylococcus aureus harbouring either mecA or the new mecA homologue mecA(LGA251). Clin Microbiol Infect 18:395–400. doi:10.1111/j.1469-0691.2011.03715.x. PubMed DOI

Harmsen D, Claus H, Witte W, Rothganger J, Claus H, Turnwald D, Vogel U. 2003. Typing of methicillin-resistant Staphylococcus aureus in a university hospital setting by using novel software for spa repeat determination and database management. J Clin Microbiol 41:5442–5448. doi:10.1128/JCM.41.12.5442-5448.2003. PubMed DOI PMC

Kondo Y, Ito T, Ma XX, Watanabe S, Kreiswirth BN, Etienne J, Hiramatsu K. 2007. Combination of multiplex PCRs for staphylococcal cassette chromosome mec type assignment: rapid identification system for mec, ccr, and major differences in junkyard regions. Antimicrob Agents Chemother 51:264–274. doi:10.1128/AAC.00165-06. PubMed DOI PMC

Zhang K, McClure JA, Conly JM. 2012. Enhanced multiplex PCR assay for typing of staphylococcal cassette chromosome mec types I to V in methicillin-resistant Staphylococcus aureus. Mol Cell Probes 26:218–221. doi:10.1016/j.mcp.2012.04.002. PubMed DOI

Milheirico C, Oliveira DC, de Lencastre H. 2007. Update to the multiplex PCR strategy for assignment of mec element types in Staphylococcus aureus. Antimicrob Agents Chemother 51:3374–3377. doi:10.1128/AAC.00275-07. PubMed DOI PMC