Running Head: Evolution of Methicillin-Resistant Staphylococcus aureus 1

Staphylococcus epidermis in the Evolution of Methicillin-Resistant Staphylococcus aureus

Michelle S. Lai
The Pennsylvania State University


Evolution of Methicillin-Resistant Staphylococcus aureus 2

Staphylococcus epidermis in the Evolution of Methicillin-Resistant Staphylococcus aureus

MRSA, or Methicillin-resistant Staphylococcus aureus, is part of one of the largest rising
threats to individual and public health antibiotic resistance. Driven by selection through too
strong or improper utilization of antibiotic medications, the bacteria has evolved mechanisms to
evade death upon exposure to a multitude of the currently available drugs for treatment. In the
meantime, most of the other organisms of its species have been killed, leaving the ecological
niche free of competition. Because of this, the remaining strong, resistant microbe grows
unchecked and usurps the host body, often leading to death and spread to other humans. In fact,
each year twenty-three thousand people die from antibiotic resistant bacteria in the United States
alone.
7

The most dangerous aspect of this resistance is that as a result of high selecting forces in
hospitals, that is where the newly dominant strains emerge the most rapidly and abundantly, and
upon entry to a new host, it becomes a nosocomial infection. Therefore, even though a patient
may have entered the hospital for a completely different health problem, he could die from this
highly virulent disease, and any chance of recovery is completely out of his control. In addition
to the hospital strains, there are strains brought back to the regular population that spread through
surface and direct contact. Clearly, the exponential increase in such infections over the last few
decades calls for massive scientific research efforts in attempt to outsmart these microbes.
Because MRSA is one of the most lethal and prominent of this type of disease, exploration of it
is critical.

Evolution of Methicillin-Resistant Staphylococcus aureus 3

Description and Mechanisms
S. aureus is a Gram positive bacteria that in a group setting takes the form of grape-like
clusters, and the disease that it causes is denominated a staph infection. Although more than
twenty species of Staphylococcus exist, as far as the interaction with humans, only S. aureus and
S. epidermidis carry significance, and S. aureus is the most pathogenic of the genus.
14
The two
differ mainly in the chemicals they produce S. aureus excretes coagulase, toxins, and
hemolysins, which contribute to its high infectivity. Microorganisms in the staphylococcus have
the metabolism of facultative anaerobes, which means that they perform aerobic respiration in
the presence of oxygen, but in its absence are capable of using energy through fermentation or
anaerobic respiration.
In normal conditions, S.aureus can be found on the human skin as harmless contributors
to the existing microflora, but it mainly thrives in the nasal passages.
9
To invade the host, the
microorganism adheres to the epithelial cells with MSCRAMM, a class of molecules on the
surface of microbes that recognize adhesive matrixes, a type of glycoprotein. This is a product of
the S. aureus cell that aids in its resistance to antibiotics. Also aiding in colonizing the nasal
passages in humans are the clumping factor B, which is another surface protein that binds to
cytokeratin 10, a protein which cells in the nose express. Wall-associated teichoic acid, a
polysaccharide of glycerol phosphate, is also a method that S. aureus utilizes to attach to
epithelial cells. All of these three have been targeted or inhibited using drugs in attempts to rid
disease.
15

Evolution of Methicillin-Resistant Staphylococcus aureus 4

Both the resistant and nonresistant strains of S. aureus survive very well, not only inside
the host cells, but outside of the cells as well.
4
Specifically, the methicillin-resistant strain
evolves and transmits much more efficaciously in the hospital than in the community. For this
reason, in hospital settings, they often populate medical instruments as well as equipment
intended to stay in the body, such as catheters and pacemakers in the heart.
6
A common theory
existed that a human whose skin was already populated with the microbe would be more
susceptible to an infection, but in one study, a protective effect was demonstrated in the fact that
in the aftermath of a hospital acquired infection, these individuals actually have a less serious
disease due to the prior exposure.
Once S. aureus has entered the human body, factors in the nonspecific immune system
that attempt to prevent infections include lysozyme, Immunoglobulin A (IgA), and lactoferrin, a
globular glycoprotein found in mucoses.

Among its many clever techniques for evading the
immune system, S. aureus hides inside the epithelial cells as well as inside macrophages and
endothelial cells.
4
In the case that these methods do not work, the host falls ill to face horrid
symptoms including boils, pyogenic pockets rising from hair follicles, and cellulitis, a condition
that results in oozing and swelling. Further, the microbe can cause toxic shock syndrome.

In
extreme cases, its effects even range to destruction of limbs (to the point that amputation is
required) and death.
6
One of the most significant genes involved in the control of virulence and colonization in
novel environments is the accessory gene regulator agr, which regulates on the global level in the
organism. Much like the flagella in chemotaxis, this special regulator operates in quorum
sensing, or response to the stimulus of cell density. When the S. aureus invades the host, agr is
Evolution of Methicillin-Resistant Staphylococcus aureus 5

down-regulated, or decreased, as a result. This has thought to be one of the most important
contributing factors during colonization of the host by giving the microbes the ability to bind
fibrinogen, a glycoprotein in plasma that leads to clotting and attachment to tissue, promoting its
continued survival.
4
In addition, another mechanism of resistance that S. aureus has adopted is the ability to
evade molecules called neutrophils. These are the type of white blood cells that are most
abundant in humans and participate largely in the innate portion of the immune system and
readily attack foreign cells. The method by which it avoids lysing by neutrophils is by secreting
certain toxins that then lyse the neutrophils themselves, using groups of peptides called phenol
soluble modulins (PSM).
11

Emergence of Resistance
The complex biochemistry by which resistant S. aureus operates begs the question of
how exactly its resistance phenotype evolved and how it functions compared to the normal
strain. In the 1880s, the first case of staph was recorded,
8
but not until 1960 was methicillin, a
type of penicillin, used as an effective treatment.
1
Since the first case of a strain resistant to this
drug was identified in Britain in 1961, the pathogen acquired some method of working around it
in merely the time span of one year, a terrifyingly quick progression. Geographical distance did
not stand in its way, as the first case in the United States was diagnosed seven years later in
1968.
What is even more alarming is that today only ten percent of all strains of S. aureus are
sensitive to this drug; in other words, only one out of ten people will survive an infection if only
Evolution of Methicillin-Resistant Staphylococcus aureus 6

methicillin is used for treatment.
7
To make matters worse, it resists not only methicillin, but
other beta-lactam drugs that are similar to penicillin, including the medications oxacillin and
amoxicillin. Therefore, although in the health perspective it is viewed as a horrible monster, in
the biological perspective, MRSA is actually a species to admire for its extraordinary
evolutionary success; or, perhaps, humans are incredibly effective at driving pathogens to
extreme measures.
Primarily, bacteria evolve extremely well due to their ability to reproduce at astonishing
rates, which are a result of living in large populations and the shortness of their generation
times.
2
MRSA has a generation time of twenty minutes, meaning that twenty minutes after the
creation of a bacteria, it has already replicated itself to create another one. Based on this, it only
takes around ten generations before the infected host cell has grown to over one million bacteria.
This explains how this disease spread so quickly from person to person and how it causes
symptoms so rapidly, since the incubation period is only a matter of days after initial infection in
the host.

Mainly, MRSA strains have been shown to resist methicillin through gene expression of a
slightly altered form of a binding protein called PBP2. In original strains of S. aureus, the
binding protein is PBP26, which binds to the penicillin-like drugs very well. The altered gene
allows the bacteria to avoid them because the protein has a lower affinity for them, and thus
larger amounts of release if bound in the first place. Another mechanism by which MRSA
obtains its ability to survive methicillin treatment is by expressing another binding protein called
PBP2a. If the genes for regulation mutate to increase PBP2a, it will increase its action of cross-
linking, or transpeptidation, of PBPs in the host.
13
Evolution of Methicillin-Resistant Staphylococcus aureus 7

At this point in time, because methicillin is almost completely ineffective and only drives
the evolution with continued use, the scientific community has developed a number of ways to
avoid it. The most common of the other types of medications is the use of vancomycin, an
antibiotic in the glycopeptide class that came into use about forty years ago.
7
However,
unsurprisingly, in 2002 the first case of resistance to this treatment emerged. Now, a growing
number of MRSA strains have in turn adapted to evade death from this drug in addition to death
from penicillin-like drugs.
8
Other methods to approaching the problem of resistance are preventative in nature,
targeting the virulence factors in the bacteria. The reason for this recent turn of focus is that
creating new medications or trying existing antibiotics created for other diseases leads to yet
another round of resistance, where more people are dying. This arm race of sorts against the
microorganisms appears to be a losing battle for the humans, so rather than spending all
resources and effort on developing new methods of treatment, many scientists are now searching
for other effective ways to rid of the bacteria, such as removing a nutrient that is completely
necessary for its survival.
16
An example is combination therapy, in which a whole set of drugs is
administered together so that any MRSA strains that survive are then eliminated by a different
medication.
3


The Role of Skin Bacteria Staphylococcus epidermis in MRSA Evolution
A discovery in December of 2013 revealed a new perspective on the method in which
MRSA acquired its ability to resist methicillin: the strain obtained its resistance-conferring genes
from its previously mentioned close relative Staphylococcus epidermidis, a harmless strain
normally found in great abundance on human skin that participates in symbiosis through
Evolution of Methicillin-Resistant Staphylococcus aureus 8

commensalism.
12
That is, the microbes utilize the products on the skin for their growth, but are
not detrimental or beneficial to the host. This is a great eye-opener to why the resistance has
evolved so quickly and intensely; after all, the microorganism that is speculated to have aided its
performance is found to sometimes compose over ninety percent of all of the flora that is present
on the skin.
2

The association with the harmless species on the skin draws into the discussion
community strains and transmission, in contrast to the ones that spread through hospitals as
aforementioned. Community strains of S. aureus have profound effects, although not as large as
nosocomial infections, on the human population. In the past few years, there have been
numerous numbers of outbreaks in professional football players and other athletes due to the
high skin-to-skin contact.
10
Although S. aureus and S. epidermidis have differences, mainly in toxicity, the two
species share one important factor: the ACME gene cluster. To be more specific, the strain of S.
aureus that is responsible for the majority of resistant infections currently, USA300, obtained it
from its relative microbial species. The ACME gene, or arginine catabolic mobile element, was
determined to exist in both species through phylogenetic analysis by Paul Planets research
laboratory at Columbia University. According to Planet, the exchange of genes occurred through
horizontal transfer, which means it was conferred from organism to organism rather than through
a mutation of an organisms own genes.
5
Even though ACME codes for many genes, two are especially critical in the methods of
resistance: opp-3, an ATP-binding cassette transporter, and arc, a deiminase system of arginine.
4

The opp-3 aids the bacteria in adhesion to eukaryotic cells, resisting peptides in antibiotics, and
Evolution of Methicillin-Resistant Staphylococcus aureus 9

working for increased intake of nutrient peptides. With this feature, MRSA can become a
permanent resident of the skin, increasing the probability that it can enter the body and cause
infection, spreading its strain. The other gene, arc, that controls the deiminase system breaks
down L-arginine, increasing the pH of human skin. Since the skin is already an acidic
environment for the microbes, this raising of pH gives them more selective advantage in that
they prefer acidic conditions. On top of this, the catabolism provides another ATP source for the
microorganisms survival and reproduction.
4

In Planets study of the ACME gene cluster, another gene was identified as crucial to
MRSAs ability to resist high levels of treatment. This gene, speG, is found normally in S.
epidermidis and allows the USA300 strain of S. aureus to survive through very high polyamine
concentrations, which is produced by the skin. Resulting from this is a tolerance to polyamines
that gives it the chance to thrive on the skin while other MRSA strains are killed. To take this
idea further, the strain is now able to produce a stronger biofilm on the cells and tissues of the
host similar to the way the opp-3 genes affect the microbes, and it adheres tightly, giving it
resistance to some types of antibiotics.
12


The Future of Methicillin-Resistant Staphylococcus aureus:
In order to most effectively control S. aureus outbreaks, a more effective vaccine needs to
be developed. Currently, there are vaccines, but they do not halt enough of the bacteria in their
tracks. In the history of other diseases, this was the ultimate step in elimination and eradication in
the case of small pox. The setback in this approach is that as a result of its complexity and
multiple virulence factors, S. aureus is difficult to stop when a vaccine targets just one or two of
Evolution of Methicillin-Resistant Staphylococcus aureus 10

these pathways. A solution to this involves targeting multiple virulence factors, such as the
ACME gene or PSM peptides in neutrophil lysing.
Although in Planets discovery there is no proven, direct evidence that the ACME gene
transfer has aided in the microbes colonization on the skin, because the conclusions drawn are
observational and theoretical, the new lead opens up doors for a whole new area of research in
attempts to disable their attachment to skin and kill them before they even enter the body to
cause infection. This goes along well with the general switch of focus to studying virulence
factors and developing drugs to target them.
Future direction to change treatment protocols, research focuses, and vaccine
composition are the first steps to eliminating this deadly disease. Because S. aureus has existed
for such a long time in human pathology history, it is well time that they should be understood to
great depth. The revelation that S. epidermidis may be the culprit for the gene transfer leading to
its cousins success brings into light the implications of their continuing interactions and possible
methods to intervene at this point of the virulence mechanism. The only way to save these
hundreds of thousands of lives lost each year to Methicillin-resistant S. aureus is to learn as
much as possible about the pathogen and continue pursuing development of better treatments and
preventions.


Evolution of Methicillin-Resistant Staphylococcus aureus 11

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