Isolates of the Iberian clone exhibited resistance against almost all antibiotics available for MRSA therapy including clindamycin, erythromycin, gentamicin, tobramycin, tetracycline, ciprofloxacin and rifampicin. From 1996 to 2003, the Iberian clone was gradually replaced by isolates of Clonal Complex 5 (ST125 and variants; Enzalutamide concentration SCCmec type IV) related to the Paediatric clone (ST5; SCCmec type IV) [4]. Unlike the Iberian clone, these strains showed only consistent resistance to tobramycin and ciprofloxacin combined with variable resistance to clindamycin and/or erythromycin. Similar trends have been observed in other hospitals in Spain and in other countries such as

France, Germany, Belgium or Portugal, with involvement of different clonal lineages [5–10]. MRSA isolates resistant to clindamycin, erythromycin, gentamicin, tobramycin, and ciprofloxacin were detected in 2004. These isolates showed reduced susceptibility to Fludarabine rifampicin (RIF-R), according to the Clinical and Laboratory Standards Institute (CLSI) criteria [11]. This new phenotype Everolimus of multiresistance differed from that of the Iberian clone on the low level RIF-R and on the tetracycline susceptibility. The frequency of the RIF-R

MRSA isolates rapidly increased from 2004 to 2006: 25% (59/237) of all MRSA clinical isolates in 2004, 33% (67/206) in 2005, and 45% (116/256) in 2006. The percentage of RIF-R MRSA decreased to 30% (111/378) in 2007 and 25% in 2008 (75/300). not Rifampicin

cannot be used as a single agent to treat MRSA infections because of the rapid selection of resistant mutants [12, 13]. However, combinations of rifampicin with other anti-staphylococcal agents such as quinolones [14] or fusidic acid [15] could prevent the emergence of rifampicin resistance during therapy [16]. Rifampicin interacts specifically with the RNA polymerase beta-subunit encoded by the gene rpoB [12]. Rifampicin resistance in S. aureus, as in other bacteria, is associated with mutations in particular regions (cluster I and II) of the gene rpoB [13, 17]. The objectives of the present study were: i) to characterise a collection of MRSA isolates expressing this new multiresistant pattern, and to determine whether they represented a novel genotype or they were the current representatives of a previously detected clone, ii) to determine the different levels of the rifampicin resistance by disk diffusion, microdilution and E-test, and iii) to analyse mutations in the rpoB gene related to rifampicin resistance. Methods Hospital setting The Hospital Universitari de Bellvitge in Barcelona, Spain, is a nearly 900-bed tertiary care teaching centre. It is the reference hospital for a geographical area with a population of approximately 1 million inhabitants.