OBJECTIVE—The purpose of this study was to assess the virulence potential of Staphylococcus aureus strains isolated from diabetic foot ulcers and to discriminate noninfected from infected ulcers.

RESEARCH DESIGN AND METHODS—Diabetic patients hospitalized in a diabetic foot department with a foot ulcer were prospectively enrolled if they had been free of antibiotic treatment over the previous 6 months. At admission, ulcers were classified as infected or noninfected on the basis of clinical examination, according to the International Working Group on the Diabetic Foot system. Only patients carrying S. aureus as the sole pathogen were included. In individuals with a grade 1 ulcer, a second bacterial specimen was obtained 1 month later. Using virulence genotyping markers, clonality tools, and an in vivo Caenorhabditis elegans model, we correlated the virulence of 132 S. aureus strains with grade, time of collection, and ulcer outcome.

RESULTS—Among virulence genes, the most relevant combination derived from the logistic regression was the association of cap8, sea, sei, lukE, and hlgv (area under the curve 0.958). These markers were useful to distinguish noninfected (grade 1) from infected (grades 2–4) ulcers and to predict wound status at the follow-up. With use of the nematode model, S. aureus strains isolated from grade 1 ulcers were found to be significantly less virulent than strains from ulcers at or above grade 2 (P < 0.001).

CONCLUSIONS—This study highlights the coexistence of two S. aureus populations on diabetic foot ulcers. A combination of five genes that may help distinguish colonized grade 1 from infected grade ≥2 wounds, predict ulcer outcome, and contribute to more appropriate use of antibiotics was discovered.

Foot ulcers are common in diabetic patients, with prevalence as high as 25% (1). These ulcers frequently become infected, and spread of infections to soft tissue and to bony structures is a major causal factor for lower-limb amputation (2). Early diagnosis and adequate treatment are essential. Because microorganisms are always present on skin wounds, diagnosis of infection must be based not on microbiological findings but on clinical criteria, as emphasized by the Infectious Diseases Society of America and the International Working Group on the Diabetic Foot (IWGDF) and more recently by the French Society for Infectious Pathology (35). However, because of the confounding impact of neuropathy and ischemia on local and systemic inflammatory response, diagnosing foot infection at an early stage in diabetic individuals may be difficult.

Recently, we demonstrated the value of using a miniaturized oligonucleotide array covering different genes of Staphylococcus aureus, by far the most common and virulent pathogen in diabetic foot infection (3), and we showed that the virulence gene profile of S. aureus enables us to distinguish grade 1 from grades 2–4 ulcers because the former generally displayed a very low level of virulence genes (6). One of the main limitations in that work was the limited panel of genes used. Here we analyzed the most prevalent virulence-associated genes and the in vivo virulence potential of the different S. aureus strains isolated from diabetic foot ulcers. The aim was to detect genetic markers to distinguish noninfected and infected ulcer and to predict outcome of grade 1 ulcers.

From 1 March 2004 through 31 July 2007, a prospective longitudinal study of patients with diabetic foot ulcers at Nîmes University Hospital was conducted as described previously (6). Seventy-four patients (63%), hospitalized before or during April 2006, were enrolled previously (6). This study was approved by the local ethics committee and performed in accordance with the Declaration of Helsinki as revised in 2000.

Bacterial isolation

After wound debridement, samples for bacterial culture were obtained by swabbing the wound base, needle aspiration, or tissue biopsies and were sent immediately to the bacteriology department. Only patients with monomicrobial cultures positive for S. aureus were included in the study. Patients with grade 1 ulcers were closely followed over a period of 6 months to confirm the wound status (infected/noninfected ulcer). If the wound healed, a microbiological specimen was obtained 1 month later. If the wound did not heal, antibiotic therapy was initiated and surgical debridement or minor amputation was performed according to the wound status; a sample for bacteriological culture was obtained before antibiotic treatment was begun and the ulcer grade was updated.

Microbiological study

Genus, species, and antibiotic susceptibilities were determined using the Vitek 2 card (bioMérieux, Marcy-l'Etoile, France) and interpreted according to the recommendations of the French Society for Microbiology (7). Susceptibility to methicillin was screened by agar diffusion using cefoxitin disks (Bio-Rad, Marnes-La-Coquette, France) (7).

Virulence profile of S. aureus strains

To assess the virulence potential of strains, the presence of 31 among the most prevalent virulence-associated genes was evaluated by PCR as described previously (8,9): staphylococcal enterotoxins A, B, C, D, E, G, H, I, J, K, and Q (se), toxic shock syndrome toxin 1 (tst), exfoliative toxins A and B (etA and etB), Panton Valentine leukocidin (PVL) (lukS-PV_lukF-PV), LukDE leukocidin (lukE), β- and two γ-hemolysins (hlb, hlg, and hlgv), epidermal cell differentiation inhibitor (edinC), nine microbial surface components recognizing adhesive matrix molecules (MSCRAMM) (bbp, cna, ebpS, clfA, clfB, fib, fnbA, fnbB, and eno), and capsular types 5 and 8 (cap5 and cap8). The accessory gene regulator (agr) allele group was determined by multiplex PCR (10).

Clonality of S. aureus strains

To eliminate a bias in the distribution of virulence genes due to the presence of clonal bacteria in each grade, we used different epidemiological methods. This analysis also allowed us to compare strains isolated at admission and during follow-up to determine whether they were identical.

Macrorestriction analysis of SmaI-digested chromosomal DNA was performed by pulsed field gel electrophoresis (PFGE) with the CHEF DRII system (Bio-Rad) (11). The PFGE patterns were analyzed by GelCompar software (Applied Math, Kortrijk, Belgium) and compared by the algorithmic clustering method known as the unweighted-pair group method using arithmetic averages with the Dice coefficient of similarity.

Staphylococcal chromosomal cassette (SCCmec) type was determined by PCR typing according to a simplified strategy of Kondo's typing system without determining the differences in the junkyard region (see supplemental glossary, available in an online appendix at http://dx.doi.org/10.2337/dc08-1010) (12). The spa sequence (see supplemental glossary) typing was performed according to the Ridom Staph Type standard protocol (http://www.ridom.com) and by using the Ridom SpaServer, which automatically analyzes spa repeats, assigns spa types, and clusters related spa types in a spa group (http://spa.ridom.de/index.shtml).

Caenorhabditis elegans in vivo model

C. elegans (see supplemental glossary) has been used to develop an easy model system of host-pathogen interactions to identify basic evolutionarily conserved pathways associated with microbial pathogenesis. This test is based on the capacity of pathogens ingested by C. elegans nematodes to infect and ultimately kill the worms (13). The survival of nematodes fed on different S. aureus strains is an indirect marker of their virulence potential. Fer-15 worms were infected as previously described (14). In brief, nematode growth medium plates were inoculated with 10 μl of an overnight culture of S. aureus strains and incubated at 37°C for 8 h. Between 25 and 30 C. elegans worms were transferred from a lawn of Escherichia coli OP50 to a lawn of the bacterium to be tested, incubated at 25°C, and examined at 24-h intervals with a stereomicroscope (Leica MS5) for viability. Nematodes were classified as dead if they failed to respond to touch. All experiments were conducted in triplicate and repeated at least five times for each selected strain. S. aureus virulence was assessed using the nematode survival curve and calculating the LT50 and LT100 (the times required to kill 50 and 100% of the worms, respectively).

Statistical analysis

For each qualitative variable (virulence genotyping), comparison between ulcer grades was assessed using Fisher's exact test. The ability to diagnose infection of a wound was expressed by sensitivity, specificity, and positive and negative predictive values; area under the receiver operating characteristic (AUCROC) curve was calculated by the nonparametric Hanley method. To assess the utility of combining several virulence markers, we used a logistic regression with a backward procedure to select the most relevant markers; only markers for which AUCROC was >0.80 were initially entered as explanatory variables in the regression analysis. An ROC curve was then generated for the combination derived from the regression model, and its area was compared with that of every single virulence marker by a nonparametric method adapted to paired data (15). To compare overall survival curves in the nematode killing assay, a Cox regression was used. Statistical analysis was performed using S-Plus 2000 software (Insightful, Seattle, WA), and results were considered significant for P < 0.05.

Clinical and bacteriological data

From 513 selected patients, 118 were included because they had been free of any antibiotic treatment for at least 6 months, and S. aureus was the single organism isolated from the bacterial culture of their wound (Fig. 1). In 69, the current wound was the first episode of ulceration, whereas in 49 it was a recurrence. The characteristics of the study population are shown in Fig. 1 and Table 1. Of the wounds, 24 (20%) were classified as grade 1 and were followed for 6 months. Of the 118 S. aureus strains, 48 (41%) were methicillin-resistant (MRSA). During the follow-up period, 9 grade 1 ulcers healed (38%), whereas 15 worsened. In two healing ulcers, samples remained positive for S. aureus compared with positive results for 12 of the 15 nonhealed ulcers. In total, 132 S. aureus strains were isolated (118 on the initial cultures and 14 during the follow-up period) (Fig. 1).

All recurrent ulcers were positive for MRSA, whereas methicillin-susceptible S. aureus (MSSA) was isolated in all but one of the ulcers appearing as the first episode. A higher prevalence of MRSA with increasing severity of infection was also noted, with a statically significant difference for grade 1 compared with grades 2–4 (P = 0.021).

Virulence profile

Virulence genotyping of the 132 strains evaluated by PCR is shown in Table 2. Individual gene analysis showed that the prevalence rates of 10 genes (sea, seb, sec, sei, sej, hlb, hlg, hlgv, cap5, and lukE) were significantly more often associated with strains isolated from grades 2–4 ulcers, whereas the cap8 gene was most frequently found in strains from grade 1 ulcers (P < 0.05). From the logistic model analysis, a five-gene combination of sea, sei, lukE, hlgv, and cap8 was the most predictive for differentiating grade 1 from grades 2–4 ulcers: mean ± SD AUCROC was 0.940 ± 0.028 (95% CI 0.885–0.995), which is significantly greater than that from combining all of the 30 virulence genes (0.810 ± 0.078) (P < 0.05); sensitivity was 0.977 ± 0.025, specificity was 0.871 ± 0.063, and positive and negative predictive values were 0.884 and 0.975, respectively. Using the logistic regression equation, three grade 1 ulcers were misclassified owing to absence of cap8 but presence of sea, sei, lukE, and hlgv genes; interestingly, these ulcers rapidly worsened. Conversely, 17 grades 2–4 ulcers were misclassified owing to absence of sea, sei, lukE, and hlgv genes.

Clonality study

By using PFGE, a wide genomic diversity was shown among the 132 S. aureus isolates (data not shown), allowing us to exclude a bias in the statistical analysis. PFGE also revealed the spread of three clonal MRSA groups (44 strains; 33% of the isolates). A major group, clustering 29 strains (66% of MRSA strains) matched the Lyon clone (agr allele 1, spa type t008, and SCCmec type IV). The first minor clone (eight strains, 16% of MRSA) was the “classic pediatric” clone (agr allele 2, spa type related to t311, and SCCmec type IV). The second minor clone (three strains, 6% of MRSA) was the “new pediatric” clone (agr2 allele, spa type t777, and SCCmec type VI).

Comparison between strains isolated from patients’ ulcers at admission and follow-up demonstrated that those isolated from healing and slowly worsening ulcers had no clonal link. On the other hand, the strains from the three rapidly worsening ulcers were similar in each ulcer (data not shown).

S. aureus–mediated killing of C. elegans

When feeding on E. coli OP50, C. elegans has a 2-week life span (LT100 of worms varying between 11 and 14 days and LT50 between 3 and 5 days). When feeding on a pathogen, worms die far more rapidly, with a life span between 3 and 7 days (LT50 between 1 and 2 days).

Three strains (two MSSA and one MRSA) chosen at random among those isolated at admission in each of the four ulcer grades were tested for their capacity to kill C. elegans. In addition, strains initially isolated from grade 1 ulcers were compared with those isolated at the follow-up: strains from three ulcers with different outcomes were chosen: one that healed, one that worsened rapidly, and one that degraded slowly (Fig. 2). According to their killing ability, two populations of bacteria can be observed: the first with LT50 <2 days, suggesting a high virulence potential, and the second with LT50 >3 days, suggesting lower virulence (P < 0.001). All of the strains with LT50 <2 days were isolated from ulcers grades 2–4 except for one (NSA22465); conversely, all of the strains but one with LT50 >3 days were isolated from grade 1 ulcers. Interestingly, no significant difference in the killing potentials of MRSA and MSSA was observed within ulcers of the same grade: both strains from grade 1 had a similarly long LT50 (3.5 ± 0.3 days), and MRSA and MSSA from ulcers grades 2–4 had a similarly short LT50 (1.7 ± 0.2 days). Finally, both at entry and at follow-up, the LT50 for strains isolated from healing ulcers was relatively long (3.7 vs. 3.6 days, NS), whereas it was short for the strains from rapidly worsening ulcers (1.67 vs. 1.71 days, NS). For the strain from a slowly worsening ulcer, the LT50 was significantly shorter at follow-up than at admission (1.8 vs. 3.3 days, P < 0.001).

This study demonstrated for the first time the existence of two populations of S. aureus strains in diabetic foot ulcers: strains isolated from noninfected ulcers with a low virulence potential (as shown by the in vivo nematode model results) as opposed to strains isolated from infected ulcers with a high virulence potential. Moreover, the presence or absence of five virulence genes separated the two populations and allowed us to distinguish noninfected from infected wounds.

The fact that determining five virulence genes may help to differentiate noninfected from infected wound is an attractive result. Among infection-associated genes, four corresponded to MRSA markers (sea, sei, lukE, and hlgv) and hlgv, sea, and lukE-lukD genes are shared in the Lyon clone. Moreover, hospital-acquired MRSA strains shared the enterotoxin gene cluster locus, notably sei (16). sea is the most studied and interesting gene; its product has a strong proinflammatory effect (17). In our study, this gene was not exclusively related to the virulence of MRSA infection, as it was also detected in MSSA strains. Recently, an innate immune evasion cluster located on β-hemolysin–converting bacteriophages and carrying sea was discovered. It is easily transferred among strains (18). This potential of transfer via bacteriophage could explain our results and, notably, the presence of the sea gene in MSSA strains. The higher prevalence of sea, sei, lukE, and hlgv genes among the strains isolated from grades 2–4 compared with grade 1 ulcers and the absence of differences in MRSA clones between grade 1 and grades 2–4 ulcers suggest that these markers are really interesting, as they actually could be virulence markers. Finally, a number of studies demonstrated that the noninfected ulcer marker, capsular polysaccharide T8 (Cap8) was strongly associated with MSSA strains, as suggested by our study (19). However, its role in virulence has not been clearly defined. Production of Cap8 appears to be regulated by various environmental cues, and its overproduction might be implicated in S. aureus virulence (20,21).

Another interesting point is the low level of clonal strains isolated in this study (33%). Among MRSA strains, results indicated that a major clone matching the Lyon clone (66%) was widely distributed. Our study is in accordance with a recent report showing that this clone is currently the most prevalent MRSA clone in France (16). Interestingly, although dissemination of PVL-producing clones has been extensively reported and discussed since the beginning of the new millennium, these strains were not detected in our study.

The use of the C. elegans model demonstrated that S. aureus virulence was not dependent on methicillin resistance as suggested previously (22,23). This result is interesting because nearly half of the S. aureus strains isolated were methicillin resistant. We can speculate that within the same bacterial species there are pathogens with different virulence potential against the host. These bacterial populations with variable virulence represent a new challenge in terms of pathogenicity, treatment, and prevention of transmission.

Our study suggests that testing for the presence of five genes may not only help clinicians to distinguish grade 1 from grades 2–4 ulcers but will also predict wound outcome. At follow-up, S. aureus was isolated from 13 grade 1 ulcers. cap8 was detected in S. aureus from the two healing ulcers, but the strains had pulsotypes and genotypes different from those of the baseline sample. Three of the 15 worsening ulcers (corresponding to the three false-positive results) rapidly degraded; both pulsotype and virulence profiles were found to be unchanged, suggesting that the isolates were the same and the wound was actually infected at baseline and not simply colonized. Finally, S. aureus from slowly worsening recalcitrant ulcers harbored virulence markers that were absent at baseline: pulsotypes and genotypes were different in every case, suggesting that new, more virulent S. aureus strains had colonized the ulcer (Fig. 1).

In summary, the increasing prevalence of resistant staphylococci and the small number of new antimicrobial drugs must stimulate the discovery of new solutions for diabetic foot infections in the near future. Testing for the presence of five genes will be a useful tool in management of diabetic foot ulcers. One-step multiplex PCR assays are relatively easy and rapid to perform (2 h after obtaining a specimen) at low cost (∼5 USD). This testing will allow early discrimination between noninfected grade 1 and infected grades 2–4 diabetic foot ulcers, such that antibiotic treatment is prescribed for those most likely to benefit.

This work was supported by the Coloplast Foundation, the French Speaking Association for Diabetes and Metabolic Diseases (ALFEDIAM-Aventis grant), the Foundation for Medical Research of Languedoc-Roussillon-Rouergue the Institut National de la Santé et de la Recherche Médicale, la Region Languedoc Roussillon, and the Montpellier 1 University. Fer-15 nematodes were provided by the Caenorhabditis Genetics Center, a foundation of the National Institutes of Health National Center for Research Resources.

We thank the team of the Department of Diabetology for help in recruiting patients.

Singh N, Armstrong DG, Lispky BA: Preventing foot ulcers in patients with diabetes.
Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA: Risk factors for foot infections in individuals with diabetes.
Diabetes Care
Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, Tan JS; Infectious Diseases Society of America: Diagnosis and treatment of diabetic foot infections.
Clin Infect Dis
International Working Group on the Diabetic Foot, International Diabetes Federation: International Consensus on the Diabetic Foot [article online],
. Available from http://www.iwgdf.org/index.php?option=com_content&task=view&id=16&Itemid=26. Accessed 2 June 2008
Bernard L, Lavigne JP, Société de Pathologie Infectieuse de Langue Française: Management of diabetic foot infections.
Med Mal Infect
Sotto A, Richard JL, Jourdan N, Combescure C, Bouziges N, Lavigne JP: Miniaturized oligonucleotide arrays: a new tool for discriminating colonization from infection due to Staphylococcus aureus in diabetic foot ulcers.
Diabetes Care
Soussy CJ, Carret G, Cavallo JD, Antibiotic Susceptibility Testing Committee of the French Society for Microbiology: Antibiotic susceptibility testing, French Society for Microbiology [article online],
. Available from http://www.sfm.asso.fr. Accessed 14 May 2008
Jarraud S, Mougel C, Thioulouse J, Lina G, Meugnier H, Forey F, Nesme X, Etienne J, Vandenesch F: Relationships between Staphylococcus aureus genetic background, virulence factors, agr groups (alleles), and human disease.
Infect Immun
Tristan A, Ying L, Bes M, Etienne J, Vandenesch F, Lina G: Use of multiplex PCR to identify Staphylococcus aureus adhesins involved in human hematogenous infections.
J Clin Microbiol
Lina G, Boutite F, Tristan A, Bes M, Etienne J, Vandenesch F: Bacterial competition for human nasal cavity colonization: role of Staphylococcal agr alleles.
Appl Environ Microbiol
Charlebois ED, Bangsberg DR, Moss NJ, Moore MR, Moss AR, Chambers HF, Perdreau-Remington F: Population-based community prevalence of methicillin-resistant Staphylococcus aureus in the urban poor of San Francisco.
Clin Infect Dis
Kondo Y, Ito T, Ma XX, Watanabe S, Kreiswirth BN, 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
Sifri CD, Begun J, Ausubel FM, Calderwood SB: Caenorhabditis elegans as a model host for Staphylococcus aureus pathogenesis.
Infect Immun
Lavigne JP, Blanc-Potard AB, Bourg G, Moreau J, Chanal C, Bouziges N, O'Callaghan D, Sotto A: Virulence genotype and nematode-killing properties of extra-intestinal Escherichia coli producing CTX-M β-lactamases.
Clin Microbiol Infect
DeLong ER, DeLong DM, Clarke-Pearson DL: Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach.
Ferry T, Bes M, Dauwalder O, Meugnier H, Lina G, Forey F, Lina G, Forey F, Vandenesch F, Etienne J: Toxin gene content of the Lyon methicillin-resistant Staphylococcus aureus clone compared with that of other pandemic clones.
J Clin Microbiol
Dauwalder O, Thomas D, Ferry T, Debard AL, Badiou C, Vandenesch F, Etienne J, Lina G, Monneret G: Comparative inflammatory properties of staphylococcal superantigenic enterotoxins SEA and SEG: implications for septic shock.
J Leukoc Biol
van Wamel WJ, Rooijakkers SH, Ruyken M, van Kessel KP, van Strijp JA: The innate immune modulators staphylococcal complement inhibitor and chemotaxis inhibitory protein of Staphylococcus aureus are located on β-hemolysin-converting bacteriophages.
J Bacteriol
Verdier I, Durand G, Bes M, Taylor KL, Lina G, Vandenesch F, Fattom AI, Etienne J: Identification of the capsular polysaccharides in Staphylococcus aureus clinical isolates by PCR and agglutination tests.
J Clin Microbiol
Herbert S, Newell SW, Lee C, Wieland KP, Dassy B, Fournier JM, Wolz C, Döring G: Regulation of Staphylococcus aureus type 5 and type 8 capsular polysaccharides by CO2.
J Bacteriol
Luong TT, Lee CY: Overproduction of type 8 capsular polysaccharide augments Staphylococcus aureus virulence.
Infect Immun
Game FL, Boswell T, Soar C, Houghton E, Treece KA, Pound M, Jeffcoate WJ: Outcome of diabetic foot ulcers with and without Staphylococcus aureus (MRSA) (Abstract).
Diabet Med
Mizobuchi S, Minami J, Jin F, Matsushita O, Okabe A: Comparison of the virulence of methicillin-resistant and methicillin-sensitive Staphylococcus aureus.
Microbiol Immunol

Published ahead of print at http://care.diabetesjournals.org on 22 September 2008.

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Supplementary data