Journal Search Engine
Search Advanced Search Adode Reader(link)
Download PDF Export Citaion korean bibliography PMC previewer
ISSN : 1229-1153(Print)
ISSN : 2465-9223(Online)
Journal of Food Hygiene and Safety Vol.34 No.6 pp.576-582
DOI : https://doi.org/10.13103/JFHS.2019.34.6.576

Profiles of Enterotoxin Genes and Antimicrobial Resistance in Staphylococcus pseudintermedius Strains Isolated from Livestock and Companion Animals

Gi Yong Lee, Haeng Ho Lee, Hong Sik Um, Soo-Jin Yang*
Department of Animal Science and Technology, Chung-Ang University, Anseong, Korea
Correspondence to: Soo-Jin Yang, Department of Animal Science and Technology, Chung-Ang University, 4726 Seodong-daero, Daedeok-myeon, Anseong-si, Gyeonggi 17546, Korea Tel: +82-31-670-3256; Fax: +82-31-675-1381. E-mail: soojin@cau.ac.kr
October 21, 2019 November 4, 2019 November 6, 2019

Abstract


Staphylococcus pseudintermedius is an opportunistic pathogen in dogs and is recognized as a zoonotic pathogen causing public health concern. Although canine-associated S. pseudintermedius has mainly been recognized for its antimicrobial resistance and ability to cause skin infections in dogs, information on antimicrobial resistance profiles and enterotoxigenicity of S. pseudintermedius in livestock is very limited. In this study, we investigated the prevalence of 18 different staphylococcal enterotoxin (SE) genes and toxic shock syndrome toxin gene (tst-1) in S. pseudintermedius strains isolated from dogs, pigs, and beef cattle. Moreover, antimicrobial resistance profiles of the strains were determined along with the presence of mecA and SCCmec types. Except for one bovine isolate, all S. pseudintermedius isolates from dogs and pigs were resistant to multiple drugs (≥ 4 different drugs). Four out of six canine isolates were methicillin resistant and carried SCCmec type V. In addition, 11 different SE genes (seb, sec, see, seg, sei, sej, sel, seo, sep, seq, and seu) and tst-1 were identified in S. pseudintermedius isolates from dogs, pigs, and beef cattle. Most S. pseudintermedius isolates (83%) harbored multiple SE genes, and sel (42%) and sep (42%) were most frequently detected in the isolates. Our results suggested that S. pseudintermedius isolates from livestock and companion animals may serve as a reservoir for SE genes and antimicrobial resistance.



초록


    Rural Development Administration
    PJ012811

    Staphylococcus pseudintermedius is an opportunistic pathogen, causing pyoderma, atoptic dermatitis, otitis externa, skin and soft tissue infections in domestic animals1,2). Although S. pseudintermedius has most frequently been isolated from the nares, mouth, and skin regions of healthy dogs and cats as well as from dogs and cats with skin infections2-4), the carriage of S. pseudintermedius in other animals such as birds, horses, and goats has recently been reported1,5,6). Pilla et al. (2013) also reported the occurrence of S. pseudintermedius in bovine mastitis7). Since these animal-associated staphylococci can be transmitted by direct/indirect contacts with the animals or through consumption of foods of animal origin, S. pseudintermedius has raised food safety concerns over the past decades8). More recently, increased number of zoonotic infections has been reported in humans as antimicrobial resistance in S. pseudintermedius increases worldwide9-12). Methicillin-resistant S. pseudintermedius (MRSP) and multidrug-resistant (MDR) MRSP are of particular concern because β-lactam antibiotics are still the first choice of treatment for staphylococcal infections13-15).

    There are more than 20 different staphylococcal enterotoxins (SEs) that are functionally related and have similarities in sequences16,17). These SEs are known to be associated with food poisoning and toxic shock syndrome in humans16-18). Although the SEs have been identified in at least several species of staphylococci, S. aureus has most frequently been reported to be enterotoxigenic16-20). There are only few studies so far that described the presence of SE genes and toxic shock syndrome toxin gene (tst-1) in S. pseudintermedius, especially in antimicrobial resistant S. pseudintermedius strains from livestock and companion animals7-21-23). Thus, in this study, we determined and compared the occurrence of SE genes and tst-1 in S. pseudintermedius strains isolated from dogs, pigs, and beef cattle. In addition, antimicrobial resistance profiles in the S. pseudintermedius strains were examined. Furthermore, the presence of mecA and staphylococcal cassette chromosome mec (SCCmec) types of mecA-positive S. pseudintermedius strains were determined along with their antimicrobial resistance profiles.

    Materials and methods

    Bacterial isolation and identification

    The 12 S. pseudintermedius isolates used in this study are listed in Table 1. A total of 401 swab samples were collected from dogs (n = 42), pigs (n = 190), and beef cattle (n = 169) between 2017 and 2018. Six canine-associated S. pseudintermedius strains were isolated from ear canals of dogs attending three different tertiary veterinary hospitals in Seoul, Seongnam, and Yongin. Five swine-associated S. pseudintermedius strains and one bovine-associated S. pseudintermedius strain were isolated from nasal swab samples from finishing pigs and beef cattle, respectively.

    Each swab sample was inoculated onto Baired Parker Agar (BPA; Difco Laboratories) and incubated at 37oC for 24-48 h. All putative staphylococcal colonies were selected and subcultured on BPA for identification. All S. pseudintermedius strains were identified using the Vitek 2 system (bioMérieux, Marcy-l'Étoile, France) and 16S rRNA sequencing method as described previously24). In addition, the sequence of tuf gene was analyzed using a set of specific primers (Forward, 5’-GCCAGTTGAGGACGTATTCT-3’; Reverse, 5’-CCATTTCAGTACCTTCTGGTAA-3’) to confirm S. pseudintermedius isolates25).

    Antimicrobial susceptibility test

    Susceptibilities to antimicrobial agents were determined using the disk diffusion methods according to the 2019 Clinical and Laboratory Standards Institute (CLSI) guidelines26). The antimicrobial agents used were ampicillin (AMP, 10 μg), chloramphenicol (CHL, 30 μg), enrofloxacin (ENR, 5 μg), erythromycin (ERY, 15 μg), gentamicin (GEN, 30 μg), kanamycin (KAN, 30 μg), oxacillin (OXA, 1 μg), rifampin (RIF, 5 μg), sulfamethoxazole-trimethoprim (SXT, 23.73-1.25 μg) and tetracycline (30 μg) (BD Difco, Detroit, MI, USA). The minimum inhibitory concentrations (MICs) to oxacillin were determined by using micro-broth dilution method26).

    Detection of antimicrobial resistant genes

    Total genomic DNA samples were prepared from S. pseudintermedius as described previously27). The presence of mecA gene was screened in all S. pseudintermedius strains, and SCCmec types were determined on mecA-positive S. pseudintermedius strains using the multiplex PCR method as described before27).

    Detection of staphylococcal enterotoxin (SE) genes

    A total of 19 different SE genes were detected in the 12 S. pseudintermedius strains as previously described16,18). Briefly, the carriage of 5 classical SE genes (sea, seb, sec, sed, and see) and 13 newer SE genes (seg, seh, sei, sej, sek, sel, sem, sen, seo, sep, seq, ser, and seu) was examined by eight sets of multiplex PCR assays. Primers used for amplification of SE genes and their expected sizes are shown in Table 2. The multiplex PCR assays were carried out with eight different sets of mixtures using the following conditions: an initial denaturation at 95oC for 3 min; 30 cycles of denaturing at 95oC for 30s, annealing at 53oC for 45s, extension at 72oC for 40s; and a final enlongation at 72oC for 10 min. In addition, a singular PCR reaction for toxic shock syndrome toxin-1 (tst-1) gene was conducted as described before18). Mixture of genomic DNAs from reference S. aureus strains were used for positive controls for each PCR assay (COL: seb; FRI472: sed, seg, sej, sel, sem, sen, seo, ser, seu; FRI913: sea, sec, see, sek, selq, tst1; and MW2: seh; N135: sei, sep)18).

    Results and discussion

    Although coagulase-positive S. pseudintermedius has most frequently been isolated from both healthy dogs and dogs with skin infections2-4), the colonization of S. pseudintermedius has also been observed in the other small animals and farm animals1,5,6). As shown in Table 1, prevalence of S. pseudintermedius in different animal species varied from 0.6 to 14.3%. Six, five, and one S. pseudintermedius strains were isolated from dogs (14.3%), pigs (3%), and beef cattle (0.6%), respectively. To the best of our knowledge, this is the first study to report swineassociated S. pseudintermedius strains in Korea, particularly MDR S. pseudintermedius strains.

    As shown in Table 1, antimicrobial susceptibility assays revealed different antimicrobial resistance patterns among S. pseudintermedius isolates depending on origins of isolation. Interestingly, the six S. pseudintermedius isolates from dogs exhibited higher levels of MDR phenotype than other animal isolates. Of note, methicillin resistance was observed only in 4 canine-associated S. pseudintermedius isolates. These 4 MRSP isolates harbored SCCmec type V for methicillin resistance. The bovine isolate (SP-471) was susceptible to all the 11 antimicrobial agents tested, including OXA. In contrast to the SP-471, a previous study reported isolation of bovine-asssociated S. pseudintermedius from subclinical dairy cow mastitis with MDR phenotype, especially methicillin resistance7). Similar to the S. pseudintermedius isolates from dogs, five swine-associated S. pseudintermedius isolates exhibited MDR phenotype. Except for the single bovine isolate, all other S. pseudintermedius isolates from dogs and pigs displayed resistance to ENR, ERY, and SXT. These high levels of resistance to non-β-lactam antibiotic agents in S. pseudintermedius isolates from animals have also been described in previous studies1,2,28). In addition, in line with the previous studies, which reported >57% of CHL resistance14,28-30), 7 out of 12 S. pseudintermedius isolates (58.3%) were resistant to CHL. Although methicillin resistance and highest level of MDR phenotype was observed only in canine-associated S. pseudintermedius isolates, continued monitoring of antimicrobial resistance in S. pseudintermedius isolates are necessary in major companion animals and farm animals.

    Staphylococcal food poisoning cases acquired by eating enterotoxin-contaminated food are the one of the most commonly reported types of foodborne diseases worldwide17). The frequent incidence of food poisoning by staphylococci is in part due to the fact that staphylococci, such as S. aureus, can grow over a wide range of hosts and environments31). Although the majority of studies related to SEs have been associated with S. aureus, several groups have reported that S. pseudintermedius strains isolated from dogs produce SEs. Aside from dogs, very few information is available for S. pseudintermedius isolates from other animals, especially food-producing animals. As shown in Table 3, 11 different SE genes (seb, sec, see, seg, sei, sej, sel, seo, sep, seq, and seu) and tst-1 were identified in S. pseudintermedius strains isolated from dogs, pigs, and beef cattle. Except for one isolate (SP-281), all S. pseudintermedius isolates harbored at least one of the 19 SE genes. Although the bovine isolate (SP-471) were susceptible to all antimicrobial agents tested, SP-471 carried highest number of SE genes (9 SE genes) among the 12 S. pseudintermedius isolates. It has been reported that the most common SEs are SEA and SEB in staphylococci-related food poisoning16,17,19). Previous studies also reported that canine-associated S. pseudintermedius isolates most frequently carry sec21-23,32). However, none of the 12 S. pseudintermedius isolates carried sea and only 2/12 (16.7%) S. pseudintermedius isolates were positive for seb. In addition, only 2/6 canine-associated S. pseudintermedius isolates were positive for sec. Although these sec genes were not sequenced for further analysis, it has been reported that canine-associated S. pseudintermedius often produce SEC variant (SECcanine)33). In addition to the SECcanine, several antigenic variants of SEC (i.e. SECbovine, SECovine, SEC1-3) have also been reported21,32). Interestingly, see and seq genes were detected only in canine isolates, indicating that these genes might be host specific. Structure of SEE is similar to SEA and has been reported in some cases of food poisoning17,34). Tanabe et al. (2013) also reported presence of seq in S. pseudintermedius strains isolated from dogs23). Among the 12 SE genes detected, sel and sep were each identified in 5 S. pseudintermedius isolates, resulting in highest prevalence rate (41.7%) among the 19 different SE genes. Previously, SEL was detected in a pathogenicity island of bovine mastitis S. aureus (SaPIbov) isolate exhibiting a variety of biological activities including superantigenic, pyrogenic, and endotoxigenic activity in a rabbit model35). SEP was also characterized in a MRSA strain isolated from a human bacteremia case36). In addition to SEs, toxic shock syndrome toxin (TSST-1), encoded by tst-1, has been well studied as a non-specific T-cells activator and inducer of fatal toxic shock syndrome, although TSST-1 lacks emetic activity16,17,37). While all 6 S. pseudintermedius isolates from dogs were negative for tst- 1, four isolates from pigs and one isolate from beef cattle were found to be positive for tst-1 gene. In a previous study, Hu et al. (2008) showed that sec, seg, sei, sel, sem, seo, and tst-1 genes were frequently associated with SCCmec type I and type II38). As shown in Table 3, only the four MRSP isolates which carries SCCmec type V had see or seq genes. These results indicate that prevalence of SE genes and tst-1 among S. pseudintermedius isolates may be associated with host factors in different animals and environmental factors.

    In conclusion, our results indicate that S. pseudintermedius strains isolated from livestock and companion animals became resistant to multiple antimicrobial agents used to treat infections in humans. Although methicillin resistance was observed only in canine isolates, all the pig isolates were resistant to at least 4 different antimicrobial agents. In addition to antimicrobial resistance, most S. pseudintermedius isolates carried multiple SE genes and tst-1 that can cause foodproducing in humans. Our results also indicated that S. pseudintermedius isolates from livestock and companion animals may serve as a reservoir for staphylococcal enterotoxin genes.

    국문요약

    Staphylococcus pseudintermedius는 개에서 기회감염을 유 발하는 병원체이며, 공중보건학적으로도 주요한 인수공통 병원체이다. 개에서 분리된 S. pseudintermedius 균주들은 주로 항생제 내성 및 개에서 피부 감염을 유발하는 주요 원인균으로 연구되어 왔지만, 가축에서 분리된 S. pseudintermedius 균주들의 항생제 내성 및 장내 독소 생 성에 대한 정보는 매우 제한적이다. 본 연구에서는 개, 돼 지, 육우에서 분리된 S. pseudintermedius 균주들에서 18가 지의 장내 독소 (staphylococcal enterotoxin; SE) 유전자와 toxic shock syndrome toxin 유전자(tst-1)의 분포양상을 조사 하였다. 또한, S. pseudintermedius 균주들의 항생제 내성 양 상과 더불어 mecA 유전자 및 SCCmec type 또한 확인하였 다. 육우에서 분리한 하나의 균주를 제외한 모든 개와 돼지 분리주 들이 4개 이상의 항생제에 내성을 보였으며, 개에 서 분리된 6개의 균주 중 4개의 S. pseudintermedius 균주 들이 메티실린 내성과 더불어 SCCmec V를 가진 것으로 확인 되었다. 총 11개의 SE 유전자들 (seb, sec, see, seg, sei, sej, sel, seo, sep, seq, seu) 및 tst-1가 개, 돼지 및 육 우로부터 분리된 S. pseudintermedius 균주들에서 확인 되 었으며, 대부분의 분리주들 (83%)에서 2개 이상의 SE 유 전자들이 확인 되었고, 그 중 sel (42%) 및 sep (42%)가 가장 빈번하게 검출 되었다.

    본 연구를 통하여 반려견에서 뿐만 아니라 주요 가축 에서 존재하는 S. pseudintermedius 균주들에서 높은 항 생제 내성 양상을 확인 하였으며 , 항생제 내성과 더불어 여러 staphylococcal enterotoxin 및 tst-1유전자들을 전파 할 가능성을 확인 하였다 .

    Acknowledgement

    This work was supported by Cooperative Research Program for Agriculture Science & Technology Development (Grant No. PJ012811 to SJY) funded by Rural Development Administration, Republic of Korea.

    Figure

    Table

    The characteristics of S. pseudintermedius strains isolated from dogs, pigs and beef cattle

    Primer sequences used for SEs, tst-1, and mecA genes PCR amplification

    The prevalence of SEs and tst-1 genes from S. pseudintermedius

    Reference

    1. Ruscher, C., Lubke-Becker, A., Wleklinski, C.G., Soba, A., Wieler, L.H., Walther, B., Prevalence of methicillin-resistant Staphylococcus pseudintermedius isolated from clinical samples of companion animals and equidaes. Vet Microbiol. 136(1-2), 197-201 (2009).
    2. Weese, J.S., van Duijkeren, E., Methicillin-resistant Staphylococcus aureus and Staphylococcus pseudintermedius in veterinary medicine. Vet Microbiol. 140(3-4), 418-29 (2010).
    3. Penna, B., Mendes, W., Rabello, R., Lilenbaum, W., Carriage of methicillin susceptible and resistant Staphylococcus schleiferi among dog with or without topic infections. Vet Microbiol. 162(1), 298-9 (2013).
    4. Penna, B., Varges, R., Medeiros, L., Martins, G.M., Martins, R.R., Lilenbaum, W., Species distribution and antimicrobial susceptibility of staphylococci isolated from canine otitis externa. Vet Dermatol. 21(3), 292-6 (2010).
    5. Biberstein, E.L., Jang, S.S., Hirsh, D.C., Species distribution of coagulase-positive staphylococci in animals. J. Clin Microbiol. 19(5), 610-5 (1984).
    6. Futagawa-Saito, K., Suzuki, M., Ohsawa, M., Ohshima, S., Sakurai, N., Ba-Thein, W., Fukuyasu, T., Identification and prevalence of an enterotoxin-related gene, se-int, in Staphylococcus intermedius isolates from dogs and pigeons. J. Appl Microbiol. 96(6), 1361-6 (2004).
    7. Pilla, R., Bonura, C., Malvisi, M., Snel, G.G., Piccinini, R., Methicillin-resistant Staphylococcus pseudintermedius as causative agent of dairy cow mastitis. Vet Rec. 173(1), 19 (2013).
    8. Kadariya, J., Smith, T.C., Thapaliya, D., Staphylococcus aureus and staphylococcal food-borne disease: an ongoing challenge in public health. Biomed Res Int. 2014, 827965 (2014).
    9. van Duijkeren, E., Kamphuis, M., van der Mije, I.C., Laarhoven, L.M., Duim, B., Wagenaar, J.A., Houwers, D.J., Transmission of methicillin-resistant Staphylococcus pseudintermedius between infected dogs and cats and contact pets, humans and the environment in households and veterinary clinics. Vet Microbiol. 150(3-4), 338-43 (2011).
    10. Soedarmanto, I., Kanbar, T., Ulbegi-Mohyla, H., Hijazin, M., Alber, J., Lammler, C., Akineden, O., Weiss, R., Moritz, A., Zschock, M., Genetic relatedness of methicillin-resistant Staphylococcus pseudintermedius (MRSP) isolated from a dog and the dog owner. Res Vet Sci. 91(3), e25-7 (2011).
    11. Somayaji, R., Priyantha, M.A., Rubin, J.E., Church, D., Human infections due to Staphylococcus pseudintermedius, an emerging zoonosis of canine origin: report of 24 cases. Diagn Microbiol Infect Dis. 85(4), 471-6 (2016).
    12. Van Hoovels, L., Vankeerberghen, A., Boel, A., Van Vaerenbergh, K., De Beenhouwer, H., First case of Staphylococcus pseudintermedius infection in a human. J. Clin Microbiol. 44(12), 4609-12 (2006).
    13. Gronthal, T., Eklund, M., Thomson, K., Piiparinen, H., Sironen, T., Rantala, M., Antimicrobial resistance in Staphylococcus pseudintermedius and the molecular epidemiology of methicillin-resistant S. pseudintermedius in small animals in Finland. J. Antimicrob Chemother. 72(4), 1021-30 (2017).
    14. Bond, R., Loeffler, A., What’s happened to Staphylococcus intermedius? Taxonomic revision and emergence of multidrug resistance. J. Small Anim Pract. 53(3), 147-54 (2012).
    15. Thakuria, B., Lahon, K., The beta lactam antibiotics as an empirical therapy in a developing country: an update on their current status and recommendations to counter the resistance against them. J. Clin Diagn Res. 7(6), 1207-14 (2013).
    16. Fisher, E.L., Otto, M., Cheung, G.Y.C., Basis of virulence in enterotoxin-mediated staphylococcal food poisoning. Front Microbiol. 9, 436 (2018).
    17. Balaban, N., Rasooly, A., Staphylococcal enterotoxins. Int J Food Microbiol. 61(1), 1-10 (2000).
    18. Park, J.Y., Fox, L.K., Seo, K.S., McGuire, M.A., Park, Y.H., Rurangirwa, F.R., Sischo, W.M., Bohach, G.A., Detection of classical and newly described staphylococcal superantigen genes in coagulase-negative staphylococci isolated from bovine intramammary infections. Vet Microbiol. 147(1-2), 149-54 (2011).
    19. Podkowik, M., Park, J.Y., Seo, K.S., Bystron, J., Bania, J., Enterotoxigenic potential of coagulase-negative staphylococci. Int J Food Microbiol. 163(1), 34-40 (2013).
    20. Zhang, Y., Wang, Y., Cai, R., Shi, L., Li, C., Yan, H., Prevalence of enterotoxin genes in Staphylococcus aureus isolates from pork production. Foodborne Pathog Dis. 15(7), 437-43 (2018).
    21. Yoon, J.W., Lee, G.J., Lee, S.Y., Park, C., Yoo, J.H., Park, H.M., Prevalence of genes for enterotoxins, toxic shock syndrome toxin 1 and exfoliative toxin among clinical isolates of Staphylococcus pseudintermedius from canine origin. Vet Dermatol. 21(5), 484-9 (2010).
    22. Phumthanakorn, N., Fungwithaya, P., Chanchaithong, P., Prapasarakul, N., Enterotoxin gene profile of methicillinresistant Staphylococcus pseudintermedius isolates from dogs, humans and the environment. J. Med Microbiol. 67(6), 866-73 (2018).
    23. Tanabe, T., Toyoguchi, M., Hirano, F., Chiba, M., Onuma, K., Sato, H., Prevalence of staphylococcal enterotoxins in Staphylococcus pseudintermedius isolates from dogs with pyoderma and healthy dogs. Microbiol Immunol. 57(9), 651-4 (2013).
    24. Forsman, P., Tilsala-Timisjarvi, A., Alatossava, T., Identification of staphylococcal and streptococcal causes of bovine mastitis using 16S-23S rRNA spacer regions. Microbiology. 143(11), 3491-500 (1997).
    25. Khosravi, A.D., Roointan, M., Abbasi Montazeri, E., Aslani, S., Hashemzadeh, M., Taheri Soodejani, M., Application of tuf gene sequence analysis for the identification of species of coagulase-negative staphylococci in clinical samples and evaluation of their antimicrobial resistance pattern. Infect Drug Resist. 11, 1275-82 (2018).
    26. Clinical and Laboratory Standards Institute. 2019 Performance standards for antimicrobial disk and dilution susceptibility tests for bacteria isolated from animals, VET08, 38.
    27. Kondo, Y., Ito, T., Ma, X.X., Watanabe, S., Kreiswirth, B.N., Etienne, J., Hiramatsu, K., 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(1), 264-74 (2007).
    28. Cain, C.L., Antimicrobial resistance in staphylococci in small animals. Vet Clin North Am Small Anim Pract. 43(1), 19-40 (2013).
    29. Perreten, V., Kadlec, K., Schwarz, S., Gronlund Andersson, U., Finn, M., Greko, C., Moodley, A., Kania, S.A., Frank, L.A., Bemis, D.A., Franco, A., Iurescia, M., Battisti, A., Duim, B., Wagenaar, J.A., van Duijkeren, E., Weese, J.S., Fitzgerald, J.R., Rossano, A., Guardabassi, L., Clonal spread of methicillin-resistant Staphylococcus pseudintermedius in Europe and North America: an international multicentre study. J. Antimicrob Chemother. 65(6), 1145-54 (2010).
    30. Kadlec, K., Schwarz, S., Perreten, V., Andersson, U.G., Finn, M., Greko, C., Moodley, A., Kania, S.A., Frank, L.A., Bemis, D.A., Franco, A., Iurescia, M., Battisti, A., Duim, B., Wagenaar, J.A., van Duijkeren, E., Weese, J.S., Fitzgerald, J.R., Rossano, A., Guardabassi, L., Molecular analysis of methicillin-resistant Staphylococcus pseudintermedius of feline origin from different European countries and North America. J. Antimicrob Chemother. 65(8), 1826-8 (2010).
    31. Chon, J.W., Sung, K., Khan, S., 2017 Methicillin-resistant Staphylococcus aureus (MRSA) in food- producing and companion animals and food products. Chapter 3.
    32. Edwards, V.M., Deringer, J.R., Callantine, S.D., Deobald, C.F., Berger, P.H., Kapur, V., Stauffacher, C.V., Bohach, G.A., Characterization of the canine type C enterotoxin produced by Staphylococcus intermedius pyoderma isolates. Infect Immun. 65(6), 2346-52 (1997).
    33. Cardona, I.D., Cho, S.H., Leung, D.Y., Role of bacterial superantigens in atopic dermatitis : implications for future therapeutic strategies. Am J Clin Dermatol. 7(5), 273-9 (2006).
    34. Van den Bussche, R.A., Lyon, J.D., Bohach, G.A., Molecular evolution of the staphylococcal and streptococcal pyrogenic toxin gene family. Mol Phylogenet Evol. 2(4), 281-92 (1993).
    35. Orwin, P.M., Fitzgerald, J.R., Leung, D.Y., Gutierrez, J.A., Bohach, G.A., Schlievert, P.M., Characterization of Staphylococcus aureus enterotoxin L. Infect Immun. 71(5), 2916-9 (2003).
    36. Calderwood, M.S., Desjardins, C.A., Sakoulas, G., Nicol, R., Dubois, A., Delaney, M.L., Kleinman, K., Cosimi, L.A., Feldgarden, M., Onderdonk, A.B., Birren, B.W., Platt, R., Huang, S.S., Program CDCPE. Staphylococcal enterotoxin P predicts bacteremia in hospitalized patients colonized with methicillin-resistant Staphylococcus aureus. J. Infect Dis. 209(4), 571-7 (2014).
    37. Durand, G., Bes, M., Meugnier, H., Enright, M.C., Forey, F., Liassine, N., Wenger, A., Kikuchi, K., Lina, G., Vandenesch, F., Etienne, J., Detection of new methicillin-resistant Staphylococcus aureus clones containing the toxic shock syndrome toxin 1 gene responsible for hospital- and communityacquired infections in France. J. Clin Microbiol. 44(3), 847-53 (2006).
    38. Hu, D.L., Omoe, K., Inoue, F., Kasai, T., Yasujima, M., Shinagawa, K., Nakane, A., Comparative prevalence of superantigenic toxin genes in meticillin-resistant and meticillinsusceptible Staphylococcus aureus isolates. J. Med Microbiol. 57(9), 1106-12 (2008).
    39. Becker, K., Roth, R., Peters, G., Rapid and specific detection of toxigenic Staphylococcus aureus: use of two multiplex PCR enzyme immunoassays for amplification and hybridization of staphylococcal enterotoxin genes, exfoliative toxin genes, and toxic shock syndrome toxin 1 gene. J Clin Microbiol. 36(9), 2548-53 (1998).
    40. Omoe, K., Hu, D.L., Takahashi-Omoe, H., Nakane, A., Shinagawa, K., Comprehensive analysis of classical and newly described staphylococcal superantigenic toxin genes in Staphylococcus aureus isolates. FEMS Microbiol Lett. 246(2), 191-8 (2005).