Adebayo SHITTU Department of Microbiology Faculty of Science Obafemi Awolowo University

1. The study of antibiotic resistance and epidemiology of MRSA in Africa: patterns, problems and prospects Adebayo SHITTU Department of Microbiology Faculty of Science Obafemi Awolowo University Ile-Ife, NIGERIA ISSSI, 2012; Lyon, France, 28 August, 2012.

2. Introduction • Methicillin-resistant Staphylococcus aureus (MRSA) continues to be a major challenge to human health (hospital and community infections). • It has been established as a pathogen for a wide variety of domestic animals and linked with livestock associated infections. • The mecA gene (carried by the staphylococcal chromosome cassette – SCC element) - encodes an altered penicillin-binding protein (PBP) 2a • MRSA: multi-resistance to antibiotics, spread of epidemic clones • Multicentre matched outcome study of 659 surgical patients (Duke Infection Control Hospital Network – DICON). Skin and soft tissue infections (SSIs) due to MRSA led to -7-fold increased risk of death, - 35-fold increased risk of hospital readmission, - more than 3 weeks of additional hospitalization, and - more than $60,000 of additional charges. compared with uninfected controls(Anderson et al., 2009; PloS One:e8305).

3. Introduction • 31 countries that participated in the European Antimicrobial Resistance Surveillance System (EARSS) in 2007. - blood stream infections (BSIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) and third-generation cephalosporin- resistant Escherichia coli - 27,711 episodes of MRSA bloodstream infections (BSIs) were associated with - 5,503 excess deaths; - 255,683 excess hospital days in the participating EU countries; - Total costs attributed to excess hospital stays for MRSA was 44 million Euros. (de Kraker et al., 2011; PloS One:e1001104). • Worldwide MRSA clones CC5: ST5 SCCmec type II (New York/Japan); ST5-IV (paediatric); ST228-I (southern German) CC8: ST250-I (Archaic clone); ST8-IV (EMRSA -2,-6); ST8-II (Irish-1); ST239-III (Brazilian/Portuguese); ST247-I (Iberian) CC22: ST22-IV (EMRSA-15) CC30: ST36-II (EMRSA-16) CC45: ST45-IV (Berlin) (Enright et al., 2002; Proc Natl Acad Sci USA; 99:7687–7692; Deurenberg & Stobberingh, 2008;Infect Genet Evol 2008; 8:747–763). • MRSA host species adaptation: ST398

4. Introduction Facts on Africa: World’s second largest continent and second most populous after Asia Account for one seventh of the world’s population Made up of 57 countries Over 1,000 languages Malaria is Africa's leading cause of under-five mortality Diarrheal diseases remain the biggest cause of sickness-linked death Map of Africa http://www.vbmap.org/africa-maps-4/map-africa-3/

5. Introduction • HIV, tuberculosis, malaria and various enteric and pneumococcal infections – considered more important cause of morbidity and mortality than infections due to S. aureus/MRSAin “resource-rich but mismanaged” countries in Africa. • A number of reports on the ‘three waves on the epidemiology of MRSA’ have been described extensively in developed countries but the disease burden is not well understood and appreciated in Africa. • Data on antibiotic resistance, distribution of MRSA clones in Africa - Reduce ineffective antibiotic prescribing, poor clinical outcome; assist and guide therapy. - Provide insights to mechanism of dissemination; guide infection control measures. • One of the earliest reports of MRSA in Africa was in a Durban hospital in South Africa (Scragg et al., 1978, Trans R Soc Trop Med Hyg, 72:325-328). • This was followed by studies in Nigeria (Rotimi et al., 1987, Cent Afr J Med, 32: 155-158), South Africa (Peddie et al., 1988, S Afr Med J, 74:223-224) and Ethiopia (Geyid and Lemeneh, 1991, Ethiop Med J: 29:149-161).

6. Global Prevalence and Epidemiology of MRSA Africa? Stefani et al., (2012): IJAA; 39:273– 282. De Lencastre and Tomasz A (2011): IJMM; 301:623-629. ? ? Otto M (2012): Cell Microbiol pages n/a-n/a, DOI: 10.1111/j.1462-5822.2012.01832.x Otter JA, French GL (2010): Lancet Infect Dis; 10:227-239.

7. Prevalence, antibiotic resistance and epidemiology of MRSA in Africa Methicillin resistance detected by oxacillin (E-test)

8. Prevalence of MRSA in Africa: Nigeria (West Africa), South Africa (South Africa) and East Africa (Eritrea) Prevalence of MRSA (Nigeria): 12.5-16.2% Prevalence of MRSA (South Africa): 27% Six tertiary institutions in North-East Nigeria; (January-December, 2007) 12/96 14 health care institutions in KwaZulu-Natal – South Africa: March 2001-August 2003) 61/227 Four health care institutions in South-West Nigeria; (January-April 2009) 11/68 278 S. aureus isolates (National Reference Laboratory, Eritrea) 26/278 Prevalence of MRSA (Eritrea): 9.4%

9. Prevalence of MRSA in North Africa Borg et al., (2007) JAC, 60:1310-1315.

10. Antibiotic resistance and epidemiology of MRSA in South Africa Pulsotype F: resistant to ciprofloxacin, susceptible to rifampicin (t037-ST239-III – Brazilian/Hungarian clone) South Africa Pulsotype A: resistant to rifampicin; ( t064-ST1173-IV; t064-ST1338-IV; PVL-negative; DLV and SLV of ST612 respectively). Pulsotype G: susceptible to tetracycline and minocycline; (t045-ST5-III – similar to New York/Japan clone) 61 MRSA isolates – 14 health care institutions in KZN – South Africa (227 consecutive non-duplicate S. aureus isolates: March 2001-August 2003) Shittu et al., 2009; JMM: 58:1219-1226.

11. MRSA-ST612-IV: resistant to rifampicin, gentamicin and cotrimoxazole MRSA-ST239-III: susceptible to rifampicin 100MRSA: 10CAMRSA + 90HAMRSA; Five hospitals in Cape Town; January 2007 to December, 2008

12. 61 MRSA isolates – 14 health care institutions in KZN – South Africa (227 consecutive non-duplicate S. aureus isolates: March 2001-August 2003) Seven Pulsotypes: Pulsotype A: Predominant in KZN hospitals ( t064-ST1173-IV; t064-ST1338-IV; PVL-negative; DLV and SLV of ST612 respectively). Pulsotype F: Predominant in hospitals in Durban (t037-ST239-SCCmec III – Brazilian/Hungarian clone) Pulsotype G: Observed in Durban, Pietermaritzburg (t045-ST5-SCCmec III – similar to New York/Japan clone) Predominant clones in South Africa: MRSA-ST612-IV and ST239-III MRSA-ST239-III and ST612-IV: Multiresistance; Resistance to gentamicin and cotrimoxazole: a common feature Resistance to mupirocin (MRSA-ST239-III): emerging trend in South Africa 320 MRSA isolates: August 2005-November 2006; nine provinces of South Africa Type D-spaCC12-ST239-III: identified in all the provinces with the exception of the Eastern and Western Cape. Type K-spaCC64-SCCmecIV-ST612: most widespread clone; not detected in Limpopo, Gauteng, and North West Provinces. Moodley A et al. J. Clin. Microbiol. 2010;48:4608-4611 Moodley et al., JCM; 2010, 48:4608-4611

13. Antibiotic resistance and epidemiology of MRSA in Nigeria West Africa ST8: South-West Nigeria ST241: single locus variant of ST239 – Maiduguri: North-East Nigeria

14. 86 MRSA isolates from seven major tertiary health care centres in Cameroon, Madagascar, Morocco, Niger and Senegal Central Africa: ST88, ST5 Predominant clones in West Africa: multiresistant MRSA-ST239/241-III – Niger and Northern Nigeria PVL-positive MRSA-ST5-IV/V – Senegal Resistance to tetracycline and cotrimoxazole: common feature to ST239/241, ST5 and ST88

15. Fluoroquinolone-resistant PVL-positive multi-resistant MRSA in the hospital setting Tunisia; PVL+ve ST80-IV Morocco ST239/241 Algeria PVL +ve; ST80-IV Epidemiology of MRSA in North Africa

16. Predominant MRSA clones in Africa PVL+ve-ST80-IV ST239/241-III PVL +ve ST5-IV/V ? ST88-IV ? ST88-IV/V ? ST612-IV, ST239-III http://www.enchantedlearning.com/geography/africa/outlinemap/map.GIF

17. Problems associated with basic research on MRSA in Africa • Lack of funding; preference for ‘priority’ diseases: malaria, HIV/AIDS, tuberculosis. • Laboratory Service - Lack of basic infrastructure especially at the level of Primary Health Care. - Inability to incorporate antibiotic susceptibility testing as an integral part of laboratory practice at the level of Primary Health Care. - Lack of knowledge and expertise on molecular tools in understanding the evolution of infectious diseases/brain drain. - Lack of cooperation, support and network between countries on a regional and continental level.

18. Research on MRSA in Africa: Prospects for the Future • http://www.african-german-staph.net/ - funded by the DFG (Germany) • Three African locations: • Albert Schweitzer Hospital Lambarene Gabon • Ifakara Health Research and Development Center, Bagamoyo, Tanzania • Center for Investigations on Health, Manhica, Mozambique • Three German locations • University of Münster (Institute of Medical Microbiology, Institute of Hygiene) • University of Freiburg (Division of Infectious Diseases) • University of Saarland (Institute of Medical Microbiology and Hygiene, Center of Bioinformatics, and Institute of Biomedical Engineering) • Collection of 100 clinical and 100 commensal S. aureus isolates/location (altogether 1200 isolates). • spa typing: The technique for this analysis has been distributed to all participating labs (African and German). • Microarray Analysis

19. http://www.admerproject.org/ Antibiotic Drug Use, Monitoring and Evaluation of Resistance Collaboration between Denmark and Ghana Emergence of a critical mass of medical personnel/scientists in a number of African countries. Resistance to trimethoprim/sulphamethoxazole (cotrimoxazole) is a common feature in the following MRSA clones in Africa; ST8-IV/V, ST239-III, ST88-IV, ST612-IV and the Egyptian ST80-IV - available over-the-counter (OTC) in many African countries; self medication - Price of cotrimoxazole: Nigeria: $2 (20 tablets) Liberia: $1.20 (20 tablets) Tanzania: $2 (20 tablets) - Prophylaxis or treatment of Pnemocystis infections in HIV-positive patients - need to understand the mechanism for resistance Need for various initiatives - Improve laboratory service in the surveillance of antimicrobial resistance (S. aureus/MRSA) at the national, regional and continental level in Africa. - Develop strategies (e.g. early detection of PVL +ve S. aureus/MRSA) which impact on quality of patient care. - Encourage cheap and effective infection control strategies based on hand hygiene. - Surveillance of imported S. aureus/MRSA in Africa. - Cooperation, support and network between countries on a regional and continental level.

20. ACKNOWLEDGEMENTS • Professor D.O. Kolawole – Kwara State University, Nigeria • Dr Edet Udo – University of Kuwait, Kuwait City • Professor Johnson Lin – University of KwaZulu-Natal, South Africa • Dr Donald Morrison – Scottish MRSA Reference Centre, Glasgow • Dr Ulrich Nübel – Robert Koch Institute, Wernigerode, Germany • Dr Birgit Strommenger – Robert Koch Institute, Wernigerode, Germany • Dr Franziska Layer – Robert Koch Institute, Wernigerode, Germany • Dr Srdjan Stepanovic – deceased • Professor Iruka Okeke – Haverford College, USA • Members of the German-African Network on the Staphylococci