Evolution and global transmission of a multidrug-resistant, community-associated MRSA lineage from the Indian subcontinent
Authors: Steinig Eike J. , Duchene Sebastian , Robinson D. Ashley , Monecke Stefan , Yokoyama Maho , Laabei Maisem , Slickers Peter , Andersson Patiyan , Williamson Deborah , Kearns Angela , Goering Richard , Dickson Elizabeth , Ehricht Ralf , Ip Margaret , O’Sullivan Mathew V.N. , Coombs Geoffrey W. , Petersen Andreas , Brennan Grainne , Shore Anna C , Coleman David C. , Pantosti Annalisa , de Lencastre Herminia , Westh Henrik , Kobayashi Nobumichi , Heffernan Helen , Strommenger Birgit , Layer Franziska , Weber Stefan , Aamot Hege , Skakni Leila , Peacock Sharon J. , Sarovich Derek , Harris Simon , Parkhill Julian , Massey Ruth C. , Holden Mathew T.G. , Bentley Stephen D. , Tong Steven Y.C. 
Published: December 2017

The evolution and global transmission of antimicrobial resistance has been well documented in Gram-negative bacteria and healthcare-associated epidemic pathogens, often emerging from regions with heavy antimicrobial use. However, the degree to which similar processes occur with Gram-positive bacteria in the community setting is less well understood. Here, we trace the recent origins and global spread of a multidrug resistant, community-associatedStaphylococcus aureuslineage from the Indian subcontinent, the Bengal Bay clone (ST772). We generated whole genome sequence data of 340 isolates from 14 countries, including the first isolates from Bangladesh and India, to reconstruct the evolutionary history and genomic epidemiology of the lineage. Our data shows that the clone emerged on the Indian subcontinent in the early 1970s and disseminated rapidly in the 1990s. Short-term outbreaks in community and healthcare settings occurred following intercontinental transmission, typically associated with travel and family contacts on the subcontinent, but ongoing endemic transmission was uncommon. Acquisition of a multidrug resistance integrated plasmid was instrumental in the divergence of a single dominant and globally disseminated clade in the early 1990s. Phenotypic data on biofilm, growth and toxicity point to antimicrobial resistance as the driving force in the evolution of ST772. The Bengal Bay clone therefore combines the multidrug resistance of traditional healthcare-associated clones with the epidemiological transmission of community-associated MRSA. Our study demonstrates the importance of whole genome sequencing for tracking the evolution of emerging and resistant pathogens. It provides a critical framework for ongoing surveillance of the clone on the Indian subcontinent and elsewhere.

Importance

The Bengal Bay clone (ST772) is a community-acquired and multidrug-resistantStaphylococcus aureuslineage first isolated from Bangladesh and India in 2004. In this study, we show that the Bengal Bay clone emerged from a virulent progenitor circulating on the Indian subcontinent. Its subsequent global transmission was associated with travel or family contact in the region. ST772 progressively acquired specific resistance elements at limited cost to its fitness and continues to be exported globally resulting in small-scale community and healthcare outbreaks. The Bengal Bay clone therefore combines the virulence potential and epidemiology of community-associated clones with the multidrug-resistance of healthcare-associatedS. aureuslineages. This study demonstrates the importance of whole genome sequencing for the surveillance of highly antibiotic resistant pathogens, which may emerge in the community setting of regions with poor antibiotic stewardship and rapidly spread into hospitals and communities across the world.