Observations of that strain from Abu Dhabi [2] and in German patients with family ties to Turkey [14] as well as the present study might suggest

that this strain is common and widespread in the Middle East. PVL-positive CC30-IV is a strain mainly known from the Pacific islands, Samoa and New Zealand, but also from Abu Dhabi [2] and Kuwait [8]. An importation of that strain into Gulf countries appears to be likely due to the high numbers of immigrant labourers from Pacific countries such as the Philippines, as similarly noted in Denmark [36]. PVL-positive CC80-IV has been dubbed the European CA-MRSA strain as it is widespread although sporadically detected across several European countries. However, it appears to be more predominant in the Middle East and Maghreb (North African) countries being detected Ibrutinib chemical structure not only in Saudi Arabia but also in Abu Dhabi [2], Kuwait [37], Lebanon [9], Tunisia [11] and Algeria [12]. Other strains were rare being identified only in sporadic cases, accounting for less than 3% each. Some of the minor strains have been previously observed in other ERK inhibitor regions so that an importation might be likely. For others no, or only few, data on distribution or prevalence are available. Therefore it is not clear if they emerged locally or if they have been imported. For instance, CC1/ST772-V is known to mainly occur in India and Bangladesh, and cases in Europe

are usually linked to these countries [35, 38]. There might also be an epidemiological link to India for the isolate from this study, as there are high numbers of Indian workers, including healthcare workers, in Riyadh. CC5-IV is known to occur essentially worldwide. CC5-IV/SCCfus has been described only from Malta [22], so it would be interesting to check whether this strain has a wider distribution in the Mediterranean countries and the Middle East. CC6-IV has previously been observed not only in Australia, but also in Abu Dhabi [2]. Interestingly, CC6-MSSA has been found to be a common clone

in Middle Eastern camels [39] so that a local emergence of CC6-IV after inter-species transfer and acquisition of a SCCmec element appears to be possible. PVL-negative CC80-IV appear to be extremely scarce, and the few detected isolates might be deletion variants of the so-called European CA-MRSA clone. One of the two isolates identified in this study carried enterotoxin genes, FER which is also a rare feature among CC80. PVL-positive CC88-IV are known from Abu Dhabi and, sporadically, from Europe. CC97-V has been previously identified in Egypt, which warrants further study on its presence in the Middle East. Since CC97 MSSA are common among domestic animals, here again a possible transmission from livestock should be investigated. The MRSA strains found in Saudi Arabian patients showed a significantly high carriage of PVL genes (54.21%). Comparable high figures have been reported from Algeria [13] as well as from Abu Dhabi (41.9%, [2]).