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/lp/springer-journals/systematic-review-and-meta-analysis-of-the-epidemiology-of-vancomycin-LQqohJO7Cf
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- Springer Journals
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- Copyright © The Author(s) 2021
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- 2047-2994
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- 10.1186/s13756-021-00967-y
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Abstract
Background: Vancomycin‑resistant Staphylococcus aureus ( VRSA) is a serious public health challenging concern worldwide. Objectives: Therefore, the objective of present study of 62 published studies was to evaluate the prevalence of VRSA based on different years, areas, isolate source, antimicrobial susceptibility testing, and the genetic determinants. Methods: We searched the relevant articles that focused on the prevalence rates of VRSA in PubMed, Scopus, Embase, and Web of Science from 2000 to 2019. Statistical analyses were conducted using STATA software (version 14.0). Results: The prevalence of VRSA was 2% before 2006, 5% in 2006–2014, and 7% in 2015–2020 that showed a 3.5‑fold increase in the frequency of VRSA between before 2006 and 2020 years. The prevalence of VRSA was 5% in Asia, 1% in Europe, 4% in America, 3% in South America, and 16% in Africa. The frequencies of VRSA isolated from clinical, non‑ clinical, and mixed samples were 6%, 7%, and 14%, respectively. The prevalence of VRSA was 12% using disk diffusion agar method, 7% using MIC‑base methods, and 4% using mixed‑methods. The prevalence of vanA, vanB, and vanC1 positive were 71%, 26%, and 4% among VRSA strains. The most prevalent genotype was staphylococcal cassette chro‑ mosomemec (SCCmec) II, which accounted for 57% of VRSA. The most prevalent staphylococcal protein A (spa) types were t002, t030, and t037. Conclusion: The prevalence of VRSA has been increasing in recent years particularly in Africa/Asia than Europe/ America. The most prevalent of genetic determinants associated with VRSA were vanA and SCCmec II. This study clari‑ fies that the rigorous monitoring of definite antibiotic policy, regular surveillance/control of nosocomial‑associated infections and intensive surveillance of vancomycin‑resistance are required for preventing emergence and further spreading of VRSA. Keywords: Antimicrobial resistance, Vancomycin‑resistant Staphylococcus aureus, Systematic review and meta‑ analysis Introduction Staphylococcus aureus is a major human nosocomial and *Correspondence: 18351803031@163.com; dr.kouhsari@goums.ac.ir community-acquired pathogen that causes infections of School of International Pharmaceutical Business, China Pharmaceutical the skin and soft tissues, and life-threatening systemic University, Jiangsu Province, Nanjing 211198, People’s Republic of China Laboratory Sciences Research Center, Golestan University of Medical diseases and is associated with the high rate of morbidity Sciences, Gorgan, Iran and mortality worldwide [1–3]. It remains a challenging, Full list of author information is available at the end of the article © The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 2 of 13 global public health crisis due to the emergence and Keywords fields. No limitations were used while search - spread of methicillin-resistant S. aureus (MRSA) and ing the databases. But inclusion in the study for full vancomycin-resistant S. aureus (VRSA) [1, 4]. Currently, analysis required at least the abstract to be available in MRSA and VRSA are categorized as agents of high sig- English. The search strategy was designed and conducted nificance with potential to cause considerably devastating by study investigators (E.K, S.K and M.SH). The detailed worldwide mortality in the absence of effective contain - search strategy and complete list of studies included in ment and treatment options [1, 5, 6]. In addition, VRSA the study are shown in Additional file 1: Table. References tends to be multi-drug resistant (MDR) against a diver- lists of all related studies were also reviewed for any other sity of currently available antimicrobial agents. related publication. The records found through database The glycopeptide vancomycin has been regarded as searching were merged and the duplicates were removed the last therapeutic agent for the treatment of infections using EndNote X7 (Thomson Reuters, New York, NY, due to severe MRSA and other resistant Gram-positive USA). One of the team researchers randomly evaluated strains [7]. In 2002, the first case of VRSA was recovered the search results and confirmed that no relevant study in a 40-year-old Michigan woman with diabetes [8]. Hith- had been ignored. All these steps were done by the three erto, the previous in vitro literature proposed two mech- authors (M.SH) and any disagreements about article anism underlying vancomycin resistance of VRSA: (1) selection were resolved through discussion, and a fourth Decreased permeability and thickened and poorly cross- author (E.K) acted as arbiter. linked cell wall, whereby many vancomycin molecules are trapped within the cell wall [1, 9], (2) Another type Inclusion and exclusion criteria of vancomycin resistance in bacteria is mediated by sev- Three reviewers (YW, E.K, and QW) screened all titles eral van gene clusters (plasmid-mediated) that are found and abstracts independently and excluded irrelevant in some Gram-positive pathogens specially, enterococ- or duplicate articles first. Three reviewers then inde - cal species [1]. A recent published systematic review and pendently assessed the remaining articles for inclusion. meta-analysis, by Shariati et al. [10], analyzed the preva- Discrepancies were resolved by discussion. Identified lence VRSA, vancomycin intermediate S. aureus (VISA) studies, met the criteria of being original articles pub- and heterogeneous VISA (hVISA) variability depending lished in English, and concerning the prevalence of VRSA on different years and locations. based on different years, areas, isolate source, antimicro - In current comprehensive systematic review and bial susceptibility testing, and the genetic determinants. meta-analysis, we pooled the published studies that have The exclusion criteria were as follows: (1) studies that reported the prevalence of VRSA, and made sub-group contained duplicate data or were overlapping articles; variability of the prevalence of VRSA in different years, (2) reviews, meta-analysis and/or systematic review, and areas, isolate source, and antimicrobial susceptibility test- conference abstracts or article without full text; and (3) ing. We also analyzed the genetic backgrounds of VRSA VRSA rate was not presented or clearly reported; (4) arti- strains. The results of present study will help to more cles that included fewer than 10 S. aureus isolates. completely elucidate the current epidemiology of VRSA and will promote the more proper antimicrobial steward- Data extraction ship programs to combat, control, management and limit The following items were extracted from each included the development of these drug-resistant organisms. study: the last name of the first author, year of study, year published, continent, country, number of tested S. Methods aureus, sample source, isolates number of VRSA, phe- Guidelines notypic and genotypic methods used, and the genetic This review is reported accordant with the Preferred determinants associated with VRSA isolates. Data were Reporting Items for Systematic Reviews and Meta Analy- collected by two independent examiners and verified by ses guidelines (PRISMA) [11]. another researcher (Additional file 1: Table). Search strategy Assessment of study quality Four bibliographic databases, including international The quality of the included studies was assessed by 2 databases (MEDLINE [PubMed], Scopus, Embase, and reviewers (N.S and M.H) independently using an adapted Web of Science) for relevant articles were searched version of the tool proposed by the Newcastle–Ottawa (Until January 8, 2020) by using the following keywords: assessment scale adapted for cross-sectional studies [12]. (“Staphylococcus aureus” OR “S. aureus” OR “Vancomy- A score ranging from 0 to 7 points was attributed to each cin Resistant Staphylococcus aureus” OR “Vancomycin study (≥ 6 points: high quality, ≤ 5 points: low quality). Resistant S. aureus” OR “VRSA”) in the Title/Abstract/ A higher score indicated a higher study quality. A third Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 3 of 13 reviewer (E.K) adjudicated in any cases where there was Risk of bias within studies disagreement. Publication bias was assessed for 62 studies (Additional file 2: Figure S1). The analysis displayed visual asymmetry of the funnel plot and a significant Egger’s test (P < 0.05). Study outcomes The main outcome of interest was the weighted pooled Characteristics of included studies resistance rate (WPR) of strains resistant to vancomy- The 62 studies included [14–75] in the analysis investi - cin. A subgroup analysis was performed; (1) subgroup gated 807 VRSA isolates from 12,816 S. aureus isolates. analyses were then employed by publication date (< 2006, Among the 62 studies included, 25 cross-sectional stud- 2006–2014, and 2015–2020), (2) geographic areas (con- ies also investigated 367 VRSA isolates from 3925 MRSA tinent/countries), (3) antimicrobial susceptibility test- isolates (Table 1). All 62 studies had a cross-sectional ing, (4) quality of studies, (5) isolate source, and (6) the design. The quality of data was high in 43 (69.3%) stud - genetic determinants associated with VRSA. ies and low in 19 (30.7%) studies. The forest plots that show the analyses for overall VRSA and subgroups are Risk of bias within studies displayed in the Additional file 3: Figure S2. In addition, Publication bias was analysed using Egger’s linear regres- twenty-one case-reports [76–96] included in qualitative sion test. synthesis (which were not taken into account during the meta-analysis) that reported 29 VRSA isolates between Statistical analysis 1999 to 2019 among different continents (Additional Cross-sectional studies presenting raw data on VRSA file 1: Table). However, most case reports have been from were included in the meta-analysis that was performed America (n = 14 isolates) and Asia (n = 11 isolates) con- by computing the pooled using a random- effects model tinents. There has been no report of VRSA isolates in with Stata/SE software, v.14.1 (StataCorp, College Sta- Oceania. tion, TX). The inconsistency across studies was exam - ined by the forest plot as well as the I statistic. Values of The prevalence of VRSA in three study periods I (25%, 50% and 75%) were interpreted as the presence To analyze the trends for changes in the prevalence of of low, medium, or high heterogeneity, respectively. So, VRSA in more recent years, we performed a subgroup the DerSimonian and Laird random effects models were analysis for three periods (< 2006, 2006–2014, and 2015– used [13]. Subgroup analyses were then employed by 2020) (Table 2, Fig. 2). As shown in the Table 2, the preva- publication year, geographic areas (continent/countries), lence of VRSA gradually increased from 2% (95% CI 0–4) antimicrobial susceptibility testing, quality of studies, of 466 strains before 2006 to 6% (95% CI 3–9) of 6692 isolate source and the genetic determinants associated strains in 2006–2014, reaching 7% (95% CI 4–11) of 5798 with VRSA. Publication bias was assessed using Egger’s strains in 2015–2020. Thus, the frequency of VRSA dur - test. All statistical interpretations were reported on a 95% ing the years 2006–2014 represents a threefold increase confidence interval (CI) basis. over the years before 2006. Additionally, the frequency of VRSA during the years 2015–2020 represents a ~ 1.2- Results fold increase over the years before 2015. The changes in Study selection VRSA and VRSA from MRSA prevalence between peri- A total of 2750 records were identified in the initial ods are showed in Fig. 2. The prevalence of VRSA from search. From these, 2565 articles were excluded after an MRSA gradually increased from 1% (95% CI 0–5) before initial screening of the title and abstract due to their irrel- 2006 to 5% (95% CI 0–14) in 2006–2014, reaching 6% evance and duplication. The full texts of the remaining (95% CI 0–10) in 2015–2020. 185 articles were reviewed (Fig. 1). Prevalence of VRSA at different locations Study characteristics The prevalence of VRSA differed among geographic From the 185 articles, 102 were excluded for the follow- regions in the subgroup analysis, as shown in Table 1 ing reasons: meta-analysis, review, conference abstract and Figs. 3, 4, 5. The prevalence of VRSA was 5% (95% CI and article without full text (n = 66), and non-relevant 3–8) among 11,074 S. aureus isolates in Asia, 1% (95% CI data or no data for VRSA (n = 36). Eighty-three studies 0–5) among 456 S. aureus isolates in Europe, 4% (95% CI included in qualitative synthesis (62 cross-sectional stud- 2–7) among 395 isolates in America, 3% (95% CI 0–17) ies and 21 case reports) (Additional file 1: Table; Addi- among 171 isolates in South America and 16 (95% CI tional file 2: Figure S1). Finally, 62 cross-sectional studies 3–35) among 720 isolates in Africa. There has been no [14–75] were included in this meta-analysis. Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 4 of 13 Fig. 1 Flow diagram showing the study selection process report of VRSA from Oceania. The most frequent VRSA rate for VRSA was 7% (95% CI 1–15) in 424 non-clinical prevalence was 29% (95% CI 24–35) in Nigeria, followed S. aureus strains in six studies. by 18% (95% CI 12–26) in Saudi Arabia (Table 1 and Figs. 4, 5). Prevalence of VRSA based on AST methods Disk diffusion agar and Mixed-methods were the most Prevalence of VRSA based on different clinical samples frequent antimicrobial susceptibility testing method In this subgroup analysis, we divided the VRSA strains (n = 33), followed by MIC-base methods (n = 25). The into three groups (clinical, non-clinical, and both of prevalence of VRSA was 12% (95% CI 2–27) among them). In total, the frequency of VRSA was 14% (95% CI 6736 S. aureus isolates using disk diffusion agar method, 0–44) in 501 S. aureus strains isolated from mixed (clini- 7% (95% CI 4–12) among 5671 isolates using MIC-base cal, non-clinical) samples in four studies, higher than methods, and 4 (95% CI 2–7) among 6596 isolates using in the clinical samples in (6% [95% CI 4–8] in 11,891 S. mixed-methods (Table 1). aureus strains in 53 studies) (Table 1). The prevalence Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 5 of 13 Table 1 Prevalence of VRSA in S. aureus and VRSA in MRSA based on quality, continent, countries, isolate source, and AST method Subject Sub group No. studies No. strains Proportion (95% CI) %Weight P I P sig Overall VRSA 62 12,816 0.06 (0.04, 0.09) 100 0 0.9574 0 VRSA from MRSA 25 3925 0.06 (0.03, 0.09) 100 0 0.9366 0 Quality High quality VRSA 43 10,990 0.05 (0.03, 0.07) 70.83 0 0.9599 0 VRSA from MRSA 19 3390 0.07 (0.03, 0.12) 68.85 0 0.9531 0 Low quality VRSA 19 1826 0.1 (0.04, 0.17) 28.68 0 0.9460 0 VRSA from MRSA 9 675 0.02 (0.01, 0.05) 31.15 0.03 0.5328 0 Continent Asia VRSA 46 11,074 0.05 (0.03, 0.08) 75.03 0 0.9555 0 VRSA from MRSA 22 3416 0.06 (0.03, 0.11) 82.07 0 0.9443 0 South America VRSA 2 171 0.03 (0.00, 0.17) 1.39 0.16 VRSA from MRSA – Africa VRSA 7 720 0.16 (0.03, 0.35) 11.20 0 0.9706 0 VRSA from MRSA 1 50 0.00 (0.00, 0.07) 3.06 0 America VRSA 3 395 0.04 (0.02, 0.07) 6.48 0.23 0.3054 0 VRSA from MRSA 2 272 5(0.03, 0.08) 8.08 1 Europe VRSA 4 456 0.01 (0, 0.05) 5.90 0.03 0.6616 0.14 VRSA from MRSA 2 187 0 (0, 0.02) 6.19 0.87 Countries Pakistan VRSA 5 934 0.1 (0.01, 0.24) 8.40 0 0.9693 0.01 VRSA from MRSA 3 301 0.07 (0, 0.25) 11.61 0.06 India VRSA 14 5647 0.07 (0.03, 0.13) 23.42 0 0.9778 0 VRSA from MRSA 6 3529 0.06 (0, 0.18) 23.50 0.01 0.98 0.03 Brazil VRSA 3 203 0.03 (0.01, 0.07) 4.48 0.00 0 0 VRSA from MRSA 1 140 0.04 (0.01, 0.08) 4.08 0 Nigeria VRSA 2 273 0.29 (0.24, 0.35) 3.30 0 VRSA from MRSA – Iran VRSA 16 3464 0.02 (0.01, 0.04) 26.28 0 0.7848 0 VRSA from MRSA 6 875 0.04(0.01, 0.08) 23.20 0.01 67.03 Algeria VRSA 3 583 0.01 (0, 0.04) 1.72 0.01 VRSA from MRSA 1 220 0.02 (0, 0.05) 4.08 0.01 USA VRSA 2 363 0.04 (0.02, 0.07) 3.39 0 VRSA from MRSA 1 132 0.08 (0.04, 0.13) 3.66 0 Italy VRSA 3 448 0.02 (0, 0.05) 5.03 0.02 VRSA from MRSA 1 179 0.01 (0, 0.04) 4.10 0.03 Saudi Arabia VRSA 2 128 0.18 (0.12, 0.26) 3.02 0 VRSA from MRSA 1 98 0.15 (0.09, 0.24) 3.95 0 Tanzania VRSA 1 53 0.11 (0.04, 0.23) 1.53 0 VRSA from MRSA – – . (.,.) Egypt VRSA 4 394 0.16 (0.01, 0.45) 6.36 0 0.9719 0.02 VRSA from MRSA 1 50 0 (0, 0.07) 3.66 1 Turkey VRSA 5 469 0.05 (0, 0.14) 7.65 0 0.8895 0.02 VRSA from MRSA 3 245 0.04 (0, 0.13) 9.56 0.1 Bangladesh VRSA 2 73 0.12 (0.05, 0.21) 2.86 0 VRSA from MRSA 2 73 0.27 (0.13, 0.43) 5.76 0 Germany VRSA 1 8 0.13 (0, 0.53) 0.87 0.15 VRSA from MRSA 1 8 0.13 (0, 0.53) 2.09 0.15 Jordan VRSA 1 139 0.04 (0.01, 0.08) 1.68 0 VRSA from MRSA – – . (.,.) Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 6 of 13 Table 1 (continued) Subject Sub group No. studies No. strains Proportion (95% CI) %Weight P I P sig Isolate source Clinical VRSA 53 11,891 0.06 (0.04, 0.08) 84.56 0 0.9582 0 VRSA from MRSA 23 5779 0.06 (0.03, 0.10) 85.92 0 0.9420 0 Clinical, non‑ clinic VRSA 4 501 0.14 (0.00, 0.44) 06.54 0 0.9815 0.04 VRSA from MRSA 1 179 0.01 (0.00, 0.04) 04.10 0.03 Non‑ clinical VRSA 6 424 0.07 (0.01, 0.15) 8.91 0 0.8615 0 VRSA from MRSA 3 245 0.04 (0.00, 0.13) 9.98 0.10 AST method(s) MIC‑base VRSA 25 5671 0.07 (0.04, 0.12) 39.87 0 0.9599 0 VRSA from MRSA 9 1223 0.09 (0.03, 0.17) 30.99 0 0.874 0 Mixed‑methods VRSA 32 6596 0.04 (0.02, 0.07) 51.95 0 0.9527 0 VRSA from MRSA 17 4995 0.04 (0.01, 0.09) 64.48 0 0.9538 0 Disk diffusion VRSA 33 6736 0.12 (0.02, 0.27) 8.18 0 0.9532 0 VRSA from MRSA 1 85 0.05 (0.01, 0.17) 3.52 0.03 I : the percentage of variance in a meta-analysis that shows study heterogeneity. VRSA: Vancomycin-resistant Staphylococcus aureus. MRSA: Methicillin-resistant Staphylococcus aureus. AST: Antimicrobial Susceptibility Testing. MIC: minimum inhibitory concentration Table 2 Prevalence of VRSA in S. aureus and VRSA in MRSA based on year published Subject Sub group No. studies No. strains Proportion (95% CI) %Weight P I P sig 2015–2020 VRSA 31 5798 0.07 (0.04, 0.11) 54.71 0 0.9579 0 VRSA from MRSA 16 1608 0.06 (0.03, 0.10) 61.54 0 0.8246 0 2006–2014 VRSA 28 6692 0.06 (0.03, 0.09) 39.35 0 0.9620 0 VRSA from MRSA 9 4408 0.05 (0.00, 0.14) 28.22 0 0.9771 0.01 < 2006 VRSA 4 466 0.02 (0, 0.04) 5.93 0.17 0.3949 0.01 VRSA from MRSA 3 327 0.01 (0, 0.05) 10.24 – – 0.15 I : the percentage of variance in a meta-analysis that shows study heterogeneity. VRSA Vancomycin-resistant Staphylococcus aureus, MRSA Methicillin-resistant Staphylococcus aureus Prevalence in Year group Prevalence in continent 0.16 0.08 0.07 0.07 0.06 0.06 0.06 0.05 0.04 0.06 0.05 0.05 0.05 0.03 0.04 0.04 0.02 0.03 0.02 0.01 0.00 0.00 0.01 0.01 0.00 Asia South AmericaAfricaAmerica Europe <20062006-2014 2015-2020 VRSA VRSA from MRSA VRSA VRSA from MRSA Fig. 3 Prevalence of VRSA in continent Fig. 2 The prevalence of VRSA in S. aureus and VRSA in MRSA based on published year CI 0–55) among 250, 75, and 9 of the S. aureus strains, Prevalence of genetic determinants associated with VRSA respectively (Table 3). The prevalence of SCCmec II, The prevalence of vanA, vanB, and vanC1 positive were SCCmec III, and SCCmec IV were 57% (95% CI 33–8), %71 (95% CI 48–89), 26% (95% CI 5–52), and 4% (95% 17% (95% CI 1–43), and 39% (95% CI 14–67) among the S. aureus strains, respectively (Table 3). Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 7 of 13 0.29 0.27 0.18 0.16 0.15 0.130.13 0.12 0.11 0.10 0.08 0.07 0.07 0.06 0.05 0.04 0.04 0.04 0.04 0.04 0.03 0.02 0.02 0.02 0.01 0.01 0.00 0.00 0.00 0.00 VRSA VRSA from MRSA Fig. 4 The prevalence of VRSA in S. aureus and VRSA in MRSA based on countries Fig. 5 Distribution of VRSA, among different countries based on meta‑analysis of published original articles Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 8 of 13 Table 3 Prevalence of genetic determinants associated with VRSA Subject Sub group No. studies No. strains Proportion (95% CI) %Weight P I P sig vanA VRSA 34 181 0.71 (0.48, 0.89) 100 0 0.8515 0 vanB VRSA 16 20 0.26 (0.05, 0.52) 100 0 0.6002 0 vanC1 VRSA 4 1 0.04 (0, 0.55) 100 0.21 0.3341 0.63 SCCmec II VRSA 4 13 0.57 (0.33, 0.8) 100 0.58 0 0 SCCmec III VRSA 2 3 0.17 (0.01, 0.43) 100 – – 0.02 SCCmec IV VRSA 6 14 0.39 (0.14, 0.67) 100 0.1 0.4635 0 I : the percentage of variance in a meta-analysis that shows study heterogeneity. VRSA: Vancomycin-resistant Staphylococcus aureus. MRSA: Methicillin-resistant Staphylococcus aureus Discussion Furthermore, 773 strains of VRSA were found in The MRSA infections are the major clinical, public health, Africa/Asia versus 34 VRSA in Europe/America. The and economic challenges and also because concerns proposition that VRSA is more prevalent in African/ associated to inadequate dosing, poor tissue penetration Asian countries than in Europe/America. There are of the drug and antimicrobial resistance is dramatically numerous reasons including; the high public hygiene associated with the limited number of antimicrobials that standards, careful consideration of current antimicrobial can be used for the treatment of MRSA infections since treatments and the more successful monitoring of noso- they remain a significant cause of mortality [97, 98]. The comial-associated infections in most of developed coun- vancomycin has been considered as the last resort for tries [108, 109] may account in the lower prevalence of the treatment of MRSA infections [7]. Increasingly, lit- VRSA in developed, in comparison to developing coun- erature have reported the vancomycin treatment failure tries. However, the lack of testing in many situations in [99–101]. Our meta-analysis reports the prevalence of developing countries due to limited resources, may lead VRSA worldwide. In 62 studies (including 12,816 strains) to the false impression of higher VRSA prevalence as the chosen for our analysis, the global prevalence of VRSA total number tested is not the true number of S. aureus was only 6%. Thus, we think that the incidence of VRSA infections. was underestimated, probably because of the resistance The most reports (46 reports) of VRSA were from mechanisms and biological features of VRSA strains. By Asia (particularly from Iran [16 reports] and India [14 the way, VRSA tends to be MDR against a diversity of reports]) was higher than on the other continents. On the currently available antibiotics including β-lactams, have other hand, it should be mentioned that 56.8% (459/807) been found from livestock farming that emphasizes the of VRSA strains were reported from Iran and India. Thus, over-use and misuse of antibiotics in animals [102–104]. our meta-analysis displays that the Asian data are biased To analyze the trends in the prevalence of VRSA in towards Iran and India. Current evidence of VRSA in more recent years, we allotted the study published into India and Iran supports rigorous monitoring of definite three periods: before 2006, 2006–2014, and 2015–2020. antibiotic policy, and active surveillance of nosocomial- Our study suggests that the prevalence of VRSA has associated infections. Furthermore, there is an alarm for been increasing in recent years. A threefold increase was the high prevalence of VRSA strains in Nigeria (29%) and found in the frequency of VRSA between before 2006 to Saudi Arabia (18%). 2006–2014 and ~ 1.2-fold increase between 2006–2014 The clinical laboratories have the important role in the diagnosis of VRSA cases to warrant rapid recognition, and 2015–2020. In recent years, the possible purposes for isolation, and monitoring by infection control person the emergence or detecting more VRSA strains include: - most frequent administration of vancomycin for treat- nel [110]. Several methods can be used to determine the ment of MRSA infections, improved diagnostics, inade- susceptibility of S. aureus isolates to vancomycin. The quate monitoring of definite antibiotic policy, insufficient vancomycin resistance rates differ significantly when surveillance for vancomycin-resistance and the change comparing the disk diffusion and MIC tests (threefold; in the vancomycin-resistance breakpoints since 2006 12%/4%). Disk diffusion is unreliable and does not dif - [105–107]. ferentiate between wild type isolates and those with non- The incidence rates of VRSA strains have diverse vanA-mediated glycopeptide resistance [111, 112]. The all over the world: the occurrence of VRSA was 16% in MIC tests method is considered the gold standard tech- Africa, 5% in Asia and 1% in Europe, 4% in North Amer- nique for determining the susceptibility of S. aureus iso- ica, and 3% in South America. lates to vancomycin [111, 112]. However, these tests are Wu et al. Antimicrob Resist Infect Control (2021) 10:101 Page 9 of 13 time-consuming, laborious, and inappropriate for clinical VRSA were vanA and SCCmec II. We found that VRSA is laboratories specially in developing countries, so it may not considered only to classic hospital clones of S. aureus. be some number of VRSA strains may have been missed. Carful antimicrobial treatments by healthcare providers, Up to now, the genetic backgrounds associated with adherence to recommended infection control recommen- VRSA is clear, and also a molecular biological method to dations, and, finally, the control of both MRSA and VRE detect VRSA strains is available. In cross-sectional stud- are needed for preventing further emergence and dissemi- ies indicated in Table 3, the occurrence of mobile vanco- nation of VRSA strains. mycin-resistance genes; vanA and vanB in VRSA strains by PCR showed that 71% and 26% of the VRSA strains Supplementary Information were vanA and vanB positive. This relative high rate of The online version contains supplementary material available at https:// doi. org/ 10. 1186/ s13756‑ 021‑ 00967‑y. vanA and vanB in VRSA strains suggests the high poten- tial of horizontal gene transfer of resistance determinants Additional file 1: Table. Characteristics of the eligible cross‑sectional associated with VRSA from a vancomycin-resistant Ente- studies. rococcus species or from one of the other vanA positive Additional file 2: Fig. S1. Funnel plot of the meta‑analysis on overall bacteria [113, 114]. In the other VRSA isolates did not vancomycin‑resistant S. aureus in 62 studies included. detect vanA and vanB suggests that possibly decreased Additional file 3: Fig. S2. Detailed forrest plots of the meta‑analysis. permeability, thickened and poorly cross-linked cell wall may be responsible for the increase of vancomycin resist- Acknowledgements ance in VRSA isolates. Additionally, numerous studies None. did not detect vanC1 gene. It has been demonstrated Authors’ contributions that SCCmec IV and V are prevalent in community-asso- NS, MH, SK, MSH, QW contributed to the conception, design, drafting of the ciated MRSA strains while SCCmec I, II, and III are the work. EK, YW, QW contributed in revising and final approval of the version to most common in hospital-acquired MRSA strains[115, be published. All authors read and approved the final manuscript. 116]. The results of our analysis display that SCCmec II Funding and V were the most frequent molecular types associated None. with VRSA strains. It has been showed a partial vanco- Availability of data and materials mycin resistance potential in SCCmec IV MRSA clones All the data in this review are included in the manuscript. [117, 118]. However, we found that the high prevalence of SCCmec IV in VRSA strains suggesting that VRSA Declarations is not considered to classic hospital clones of S. aureus. Han et al. [119] displayed that the reduced vancomycin Ethical approval Not applicable in this section. susceptibility was lower in SCCmec IV MRSA than SCC- mec II MRSA isolates, in concordance with our meta- Informed consent analysis. The Centers for Disease Control and Prevention Not applicable in this section. (CDC) [110] has issued the risk factors that may involve Competing interests to VRSA emergence including: prior MRSA and entero- The authors declare that they have no competing interests. coccal infections or colonization, underlying conditions Author details (such as chronic skin ulcers and diabetes), and previous The Medical Lab of Hainan Cancer Hospital, Hainan Province, Haikou 570312, treatment with vancomycin. Infection control precau- People’s Republic of China. Department of Microbiology, School of Medicine, tions should remain in place until a defined endpoint Shahid Sadoughi University of Medical Sciences, Yazd, Iran. School of Inter‑ national Pharmaceutical Business, China Pharmaceutical University, Jiangsu has been determined in consultation with public health Province, Nanjing 211198, People’s Republic of China. Clinical M icrobiology authorities. The current study had some limitations were Research Center, Ilam University of Medical Sciences, Ilam, Iran. 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Munckhof WJ, Kleinschmidt SL, Turnidge JD. Resistance development in community‑acquired strains of methicillin‑resistant Staphylococcus Publisher’s Note aureus: an in vitro study. Int J Antimicrob Agents. 2004;24(6):605–8. Springer Nature remains neutral with regard to jurisdictional claims in pub‑ 119. Han JH, Edelstein PH, Lautenbach E. Reduced vancomycin susceptibil‑ lished maps and institutional affiliations. ity and staphylococcal cassette chromosome mec (SCC mec) type Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? Choose BMC and benefit from om: : fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. 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Journal
Antimicrobial Resistance & Infection Control – Springer Journals
Published: Jun 30, 2021
Keywords: Antimicrobial resistance; Vancomycin‑resistant Staphylococcus aureus; Systematic review and meta-analysis