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Background  Among all cases of nosocomial pneumonia,  Staphylococcus aureus  is the second most prevalent pathogen (17.8%). In Europe, 29.9% of the isolates are oxacillin-resistant .  The changing epidemiology of methicillin-resistant  Staphylococcus aureus  (MRSA) nosocomial infections and the decreasing susceptibility to first-line antibiotics leave clinicians with few therapeutic options. The objective of our study was to determine the antimicrobial susceptibility, the associated molecular mechanisms of resistance and the epidemiological relatedness of MRSA strains isolated from the endotracheal tubes (ETT) of intubated critically ill patients in the intensive care unit (ICU) with nosocomial pneumonia caused by  Staphylococcus aureus .    Methods  The antimicrobial susceptibility to vancomycin, linezolid, ciprofloxacin, clindamycin, erythromycin, chloramphenicol, fusidic acid, gentamicin, quinupristin-dalfopristin, rifampicin, sulfamethoxazole/trimethoprim, and tetracycline were measured. Resistance mechanisms were then analyzed by polymerase chain reaction and sequencing. Molecular epidemiology was carried out by multi-locus sequence typing.    Results   S. aureus  isolates were resistant to ciprofloxacin, erythromycin, gentamicin, tetracycline, clindamycin, and fusidic acid. The most frequent mutations in quinolone-resistant  S. aureus  strains were S84L in the  gyrA  gene, V511A in the  gyrB  gene, S144P in the  grlA  gene, and K401R/E in the  grlB  gene. Strains resistant to erythromycin carried the  ermC ,  ermA,  and  msrA  genes; the same  ermC  and  ermA  genes were detected in strains resistant to clindamycin. The  aac(6′)-aph(2″)  gene was related to gentamicin resistance, while resistance to tetracycline was related to  tetK  (efflux pump). The  fusB  gene was detected in the strain resistant to fusidic acid. The most frequent sequence types were ST22, ST8, and ST217, which were distributed in four clonal complexes (CC5, CC22, CC45, and CC59).    Conclusions  High levels of resistance to second-line antimicrobials threatens the treatment of nosocomial respiratory infections due to methicillin-resistant  S. aureus  with decreased susceptibility to linezolid and vancomycin. The wide genotypic diversity found reinforces the central role of ICU infection control in preventing nosocomial transmission.

antimicrobial resistance and infection control

Molecular characterization of methicillin-resistant Staphylococcus aureus clinical strains from the endotracheal tubes of patients with nosocomial pneumonia